Top

Published in:

20-04-2023 | Colectomy | Original Article

Total Abdominal Colectomy Versus Diverting Loop Ileostomy and Antegrade Colonic Lavage for Fulminant Clostridioides Colitis: Analysis of the National Inpatient Sample 2016–2019

Authors: Tyler McKechnie, Jigish Khamar, Yung Lee, Léa Tessier, Edward Passos, Aristithes Doumouras, Dennis Hong, Cagla Eskicioglu

Published in: Journal of Gastrointestinal Surgery | Issue 7/2023

Abstract

Background

When surgery is indicated for fulminant Clostridioides difficile infection (CDI), total abdominal colectomy (TAC) is the most common approach. Diverting loop ileostomy (DLI) with antegrade colonic lavage has been introduced as a colon-sparing surgical approach. Prior analyses of National Inpatient Sample (NIS) data suggested equivalent postoperative outcomes between groups but did not evaluate healthcare resource utilization. As such, we aimed to analyze a more recent NIS cohort to compare these two approaches in terms of both postoperative outcomes and healthcare resource utilization.

Methods

A retrospective analysis of the NIS from 2016 to 2019 was conducted. The primary outcome was postoperative in-hospital morbidity. Secondary outcomes included postoperative in-hospital mortality, system-specific postoperative complications, total admission cost, and length of stay (LOS). Univariable and multivariable regressions were utilized to compare the two operative approaches.

Results

In total, 886 patients underwent TAC and 409 patients underwent DLI with antegrade colonic lavage. Adjusted analyses demonstrated no difference between groups in postoperative in-hospital morbidity (aOR 0.96, 95%CI 0.64–1.44, p = 0.851) or in-hospital mortality (aOR 1.15, 95%CI 0.81–1.64, p = 0.436). Patients undergoing TAC experienced significantly decreased total admission cost (MD $79,715.34, 95%CI 133,841–25,588, p = 0.004) and shorter postoperative LOS (MD 4.06 days, 95%CI 6.96–1.15, p = 0.006).

Conclusions

There are minimal differences between TAC and DLI with antegrade colonic lavage for fulminant CDI in terms of postoperative morbidity and mortality. Healthcare resource utilization, however, is significantly improved when patients undergo TAC as evidenced by clinically important decreases in total admission cost and postoperative LOS.

Available only for authorised users

DePestel DD, Aronoff DM. Epidemiology of Clostridium difficile infection. J Pharm Pract. 2013;26(5):464-475. https://doi.org/10.1177/0897190013499521CrossRefPubMedPubMedCentral

Bagdasarian N, Rao K, Malani PN. Diagnosis and treatment of Clostridium difficile in adults. JAMA. 2015;313(4):398. https://doi.org/10.1001/jama.2014.17103CrossRefPubMedPubMedCentral

Ng KE. Updates in the management of Clostridium difficile for adults. US Pharmacist. 2019;44(4):912.

Johnson S, Louie TJ, Gerding DN, et al. Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials. Clinical Infectious Diseases. 2014;59(3):345-354. https://doi.org/10.1093/cid/ciu313CrossRefPubMed

Dallal RM, Harbrecht BG, Boujoukas AJ, et al. Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications. Ann Surg. 2002;235(3):363-372. https://doi.org/10.1097/00000658-200203000-00008CrossRefPubMedPubMedCentral

Sailhamer E, Carson K, Chang Y. Fulminant Clostridium difficile colitis: patterns of care and predictors of mortality. JAMA Surg. 2009;144(5):433-439. https://doi.org/10.1001/archsurg.2009.51CrossRef

Byrn J, Maun D, Gingold D. Predictors of mortality after colectomy for fulminant Clostridium difficile colitis. JAMA Surg. 2008;143(2):150-154. https://doi.org/10.1001/archsurg.2007.46CrossRef

Neal MD, Zuckerbraun BS, Hall DE, et al. Diverting loop ileostomy and colonic lavage. Ann Surg. 2011;254(3):423-429. https://doi.org/10.1097/sla.0b013e31822ade48CrossRefPubMed

Hall BR, Leinicke JA, Armijo PR, et al. No survival advantage exists for patients undergoing loop ileostomy for Clostridium difficile colitis. Am J Surg. 2019;217(1):34-39. https://doi.org/10.1016/j.amjsurg.2018.09.023CrossRefPubMed

10.

Juo YY, Sanaiha Y, Jabaji Z, et al. Trends in diverting loop ileostomy vs total abdominal colectomy as surgical management for Clostridium difficile colitis . JAMA Surg. 2019;90095(10):899-906. https://doi.org/10.1001/jamasurg.2019.2141CrossRef

11.

Ferrada P, Callcut R, Zielinski MD, et al. Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile -associated disease: An Eastern Association for the Surgery of Trauma multicenter trial. Journal of Trauma and Acute Care Surgery. 2017;83(1):36-40. https://doi.org/10.1097/TA.0000000000001498CrossRefPubMed

12.

McKechnie T, Lee Y, Springer JE, et al. Diverting loop ileostomy with colonic lavage as an alternative to colectomy for fulminant Clostridioides difficile: a systematic review and meta-analysis. Int J Colorectal Dis. 2020;35(1):1-8. https://doi.org/10.1007/s00384-019-03447-3CrossRefPubMed

13.

Felsenreich DM, Gachabayov M, Rojas A, et al. Meta-analysis of postoperative mortality and morbidity after total abdominal colectomy versus loop ileostomy with colonic lavage for fulminant Clostridium difficile colitis. Dis Colon Rectum. 2020;63(9):1317-1326. https://doi.org/10.1097/DCR.0000000000001764CrossRefPubMed

14.

Shellito AD, Russell MM. Diverting loop ileostomy for Clostridium difficile colitis: a systematic review and meta-analysis. Am Surg. 2020;86(10):1269-1276. https://doi.org/10.1177/0003134820964213CrossRefPubMed

15.

DeAngelis EJ, Zebley JA, Ileka IS, et al. Trends in utilization of laparoscopic colectomy according to race: an analysis of the NIS database. Surg Endosc. Published online 2022. https://doi.org/10.1007/s00464-022-09381-wCrossRef

16.

Acosta CJ, Goldberg D, Amin S. Evaluating the impact of frailty on periprocedural adverse events and mortality among patients with GI bleeding. Gastrointest Endosc. 2021;94(3):517-525.e11. https://doi.org/10.1016/j.gie.2021.03.021CrossRefPubMed

17.

Edigin E, Asotibe J, Eseaton PO, et al. Coexisting psoriasis is associated with an increased risk of hospitalization for patients with inflammatory bowel disease: an analysis of the National Inpatient Sample database. Journal of Investigative Medicine. 2021;69(4):857-862. https://doi.org/10.1136/jim-2020-001689CrossRef

18.

Luhn P, Kuk D, Carrigan G, et al. Validation of diagnosis codes to identify side of colon in an electronic health record registry. BMC Med Res Methodol. 2019;19(1). https://doi.org/10.1186/s12874-019-0824-7

19.

Quan H, Drösler S, Sundararajan V, et al. Adaptation of AHRQ patient safety indicators for use in ICD-10 administrative data by an international consortium. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). 2008.

20.

Storesund A, Haugen AS, Hjortås M, et al. Accuracy of surgical complication rate estimation using ICD-10 codes. British Journal of Surgery. 2019;106(3):236-244. https://doi.org/10.1002/bjs.10985CrossRefPubMed

21.

LaPar DJ, Bhamidipati CM, Mery CM, et al. Primary payer status affects mortality for major surgical operations. Ann Surg. 2010;252(3):544-551. https://doi.org/10.1097/SLA.0b013e3181e8fd75CrossRefPubMed

22.

Abou-Khalil M, Garfinkle R, Alqahtani M, et al. Diverting loop ileostomy versus total abdominal colectomy for Clostridioides difficile colitis: outcomes beyond the index admission. Surg Endosc. 2021;35(6):3147-3153. https://doi.org/10.1007/s00464-020-07755-6.CrossRefPubMed

23.

Fashandi AZ, Martin AN, Wang PT, et al. An institutional comparison of total abdominal colectomy and diverting loop ileostomy and colonic lavage in the treatment of severe, complicated Clostridium difficile infections. Am J Surg. 2017;213(3):507-511. https://doi.org/10.1016/j.amjsurg.2016.11.036.CrossRefPubMed

24.

Forrester JD, Colling KP, Diaz JJ, et al. Surgical infection society guidelines for total abdominal colectomy versus diverting loop ileostomy with antegrade intra-colonic lavage for the surgical management of severe or fulminant, non-perforated Clostridioides difficile colitis. Surg Infect (Larchmt). 2022;23(2):97-104. https://doi.org/10.1089/sur.2021.126.CrossRefPubMed

25.

Steele SR, McCormick J, Melton GB, et al. Practice parameters for the management of Clostridium difficile infection. Dis Colon Rectum. 2015;58(1):10-24. https://doi.org/10.1097/DCR.0000000000000289.CrossRefPubMed

26.

Pepin J, Alary ME, Valiquette L, et al. Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis. 2005;40(11):1591-7. https://doi.org/10.1086/430315.CrossRefPubMed

27.

Pépin J, Valiquette L, Alary ME, et al. Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. CMAJ. 2004;171(5):466-72. https://doi.org/10.1503/cmaj.1041104.CrossRefPubMedPubMedCentral

28.

Vardakas KZ, Polyzos KA, Patouni K, et al. Treatment failure and recurrence of Clostridium difficile infection following treatment with vancomycin or metronidazole: a systematic review of the evidence. Int J Antimicrob Agents. 2012;40(1):1-8. https://doi.org/10.1016/j.ijantimicag.2012.01.004.CrossRefPubMed

29.

Halabi WJ, Nguyen VQ, Carmichael JC, et al. Clostridium difficile colitis in the United States: a decade of trends, outcomes, risk factors for colectomy, and mortality after colectomy. J Am Coll Surg. 2013;217(5):802-12. https://doi.org/10.1016/j.jamcollsurg.2013.05.028.CrossRefPubMed

30.

Fakhry SM, Martin B, Al Harakeh H, et al. Proportional costs in trauma and acute care surgery patients: dominant role of intensive care unit costs. J Am Coll Surg. 2013;216(4):607–14; discussion 614–6. https://doi.org/10.1016/j.jamcollsurg.2012.12.031.

31.

Bayer-Oglesby L, Zumbrunn A, Bachmann N. Social inequalities, length of hospital stay for chronic conditions and the mediating role of comorbidity and discharge destination: a multilevel analysis of hospital administrative data linked to the population census in Switzerland. PLOS ONE. 2022;17(8):e0272265. 0.1371/journal.pone.0272265CrossRefPubMedPubMedCentral

32.

Sasmal PK, Mishra TS, Rath S, et al. Port site infection in laparoscopic surgery: a review of its management. World J Clin Cases. 2015;3(10):864-71. https://doi.org/10.12998/wjcc.v3.i10.864.CrossRefPubMedPubMedCentral

33.

Mehboob A, Perveen S, Iqbal M, et al. Frequency and complications of ileostomy. Cureus. 2020;12(10):e11249. https://doi.org/10.7759/cureus.11249.CrossRefPubMedPubMedCentral

34.

Hayden DM, Pinzon MC, Francescatti AB, et al. Hospital readmission for fluid and electrolyte abnormalities following ileostomy construction: preventable or unpredictable? J Gastrointest Surg. 2013;17(2):298-303. https://doi.org/10.1007/s11605-012-2073-5.CrossRefPubMed

35.

Justiniano CF, Temple LK, Swanger AA, et al. Readmissions with dehydration after ileostomy creation: rethinking risk factors. Dis Colon Rectum. 2018;61(11):1297-1305. https://doi.org/10.1097/DCR.0000000000001137.CrossRefPubMedPubMedCentral

36.

Anaraki F, Vafaie M, Behboo R, et al. Quality of life outcomes in patients living with stoma. Indian J Palliat Care. 2012;18(3):176-80. https://doi.org/10.4103/0973-1075.105687.CrossRefPubMedPubMedCentral

Title: Total Abdominal Colectomy Versus Diverting Loop Ileostomy and Antegrade Colonic Lavage for Fulminant Clostridioides Colitis: Analysis of the National Inpatient Sample 2016–2019
Authors: Tyler McKechnie
Jigish Khamar
Yung Lee
Léa Tessier
Edward Passos
Aristithes Doumouras
Dennis Hong
Cagla Eskicioglu
Publication date: 20-04-2023
Publisher: Springer US
Keywords: Colectomy
Colectomy
Ileostomy
Clostridioides Difficile
Published in: Journal of Gastrointestinal Surgery / Issue 7/2023
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI: https://doi.org/10.1007/s11605-023-05682-0

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Total Abdominal Colectomy Versus Diverting Loop Ileostomy and Antegrade Colonic Lavage for Fulminant Clostridioides Colitis: Analysis of the National Inpatient Sample 2016–2019

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 7/2023

A Rare Cause of Lower Gastrointestinal Bleeding: Behcet’s Disease

The Impact of Laparoscopic Sleeve Gastrectomy on Thyroid Functions in Egyptian Patients with Obesity

Tumor Deposit Is an Independent Factor Predicting Early Recurrence and Poor Prognosis in Gastric Cancer

Autologous Fat Grafting: an Emerging Treatment Option for Complex Anal Fistulas

Liquid Biopsy by ctDNA in Liver Transplantation for Colorectal Cancer Liver Metastasis

The Significance of Tumor Locations in Patients with Gallbladder Carcinoma After Curative-Intent Resection