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International Journal of Colorectal Disease

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01-01-2020 | Colectomy | Review

Diverting loop ileostomy with colonic lavage as an alternative to colectomy for fulminant Clostridioides difficile: a systematic review and meta-analysis

Authors: Tyler McKechnie, Yung Lee, Jeremy E. Springer, Aristithes G. Doumouras, Dennis Hong, Cagla Eskicioglu

Published in: International Journal of Colorectal Disease | Issue 1/2020

Abstract

Purpose

Surgical consultation is recommended for all patients with fulminant Clostridioides difficile infection (CDI). If surgery is required, total abdominal colectomy (TAC) is most commonly performed. However, diverting loop ileostomy and colonic lavage have been recently developed as a potential colon-sparing approach to fulminant CDI. The aim of this review is to compare TAC and diverting loop ileostomy with colonic lavage for fulminant CDI.

Methods

Search of MEDLINE, EMBASE, CENTRAL, and PubMed was performed. Articles were eligible for inclusion if they compared TAC and diverting loop ileostomy with colonic lavage. The primary outcome was postoperative mortality, and the secondary outcome was postoperative complications. Quality of included studies was assessed using Newcastle-Ottawa Scale.

Results

From 64 relevant citations, 5 studies (4 retrospective cohorts, 1 case series) with 3683 patients were included. Compared to TAC, diverting loop ileostomy with colonic lavage did not significantly reduce overall mortality (RR 1.10, 95% CI 0.60 to 1.99, P = 0.77), rate of reoperation (RR 1.02, 95% CI, 0.63 to 1.63, P = 0.94), or overall postoperative complications (RR 0.51, 95% CI, 0.22 to 1.17, P = 0.11). Rates of colonic preservation with the use of diverting loop ileostomy with colonic lavage ranged from 76% to 100%.

Conclusion

There does not appear to be a survival advantage with the use of diverting loop ileostomy with colonic lavage compared to TAC for fulminant CDI. However, diverting loop ileostomy with colonic lavage results in increased rates of colonic preservation, restoration of intestinal continuity, and laparoscopic surgery. This review is limited by the small number of included studies.

Steele SR, McCormick J, Melton GB, Paquette I, Rivadeneira DE, Stewart D, Buie WD, Rafferty J (2015) Practice parameters for the management of Clostridium difficile infection. Dis Colon Rectum 58(1):10–24. https://doi.org/10.1097/DCR.0000000000000289 CrossRefPubMed

Bagdasarian N, Rao K, Malani PN (2015) Diagnosis and treatment of Clostridium difficile in adults: a systematic review. JAMA 313(4):398–408. https://doi.org/10.1001/jama.2014.17103 CrossRefPubMedPubMedCentral

Gerding DN, Gelone SP, Cornely OA et al (2014) Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials. Clin Infect Dis 59(3):345–354. https://doi.org/10.1093/cid/ciu313 CrossRefPubMed

Halabi WJ, Nguyen VQ, Carmichael JC, Pigazzi A, Stamos MJ, Mills S (2013) Clostridium difficile colitis in the United States: a decade of trends, outcomes, risk factors for colectomy, and mortality after colectomy. J Am Coll Surg 217(5):802–812. https://doi.org/10.1016/j.jamcollsurg.2013.05.028 CrossRefPubMed

Joseph B, Azim A, Zangbar B, Bauman Z, OʼKeeffe T, Ibraheem K, Kulvatunyou N, Tang A, Latifi R, Rhee P (2017) Improving mortality in trauma laparotomy through the evolution of damage control resuscitation: analysis of 1,030 consecutive trauma laparotomies. J Trauma Acute Care Surg 82(2):328–333. https://doi.org/10.1097/TA.0000000000001273 CrossRefPubMed

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

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

Dudukgian H, Gonzalez-Ruiz C, Etzioni DA, Kaiser AM (2010) C. difficile colitis—predictors of fatal outcome. J Gastrointest Surg 14(2):315–322CrossRefPubMed

Hayden DM, Pinzon MCM, Francescatti AB, Edquist SC, Malczewski MR, Jolley JM, Brand MI, Saclarides TJ (2013) Hospital readmission for fluid and electrolyte abnormalities following ileostomy construction: preventable or unpredictable? J Gastrointest Surg 17(2):298–303. https://doi.org/10.1007/s11605-012-2073-5 CrossRefPubMed

10.

Neal MD, Zuckerbraun BS, Hall DE, Simmons RL, Alverdy JC (2011) Diverting loop ileostomy and colonic lavage. Ann Surg 254(3):423–429. https://doi.org/10.1097/sla.0b013e31822ade48 CrossRefPubMed

11.

Hall BR, Leinicke JA, Armijo PR, Smith LM, Langenfeld SJ, Oleynikov D (2019) No survival advantage exists for patients undergoing loop ileostomy for clostridium difficile colitis. Am J Surg 217(1):34–39. https://doi.org/10.1016/j.amjsurg.2018.09.023 CrossRefPubMed

12.

Fashandi AZ, Martin AN, Wang PT, Hedrick TL, Friel CM, Smith PW, Hays RA, Hallowell PT (2017) 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 213(3):507–511. https://doi.org/10.1016/j.amjsurg.2016.11.036 CrossRefPubMed

13.

Ferrada P, Callcut R, Zielinski MD, Bruns B, Yeh DD, Zakrison TL, Meizoso JP, Sarani B, Catalano RD, Kim P, Plant V, Pasley A, Dultz LA, Choudhry AJ, Haut ER, EAST Multi-Institutional Trials Committee (2017) Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile-associated disease: an eastern association for the surgery of trauma multicenter trial. J Trauma Acute Care Surg 83(1):36–40. https://doi.org/10.1097/TA.0000000000001498 CrossRefPubMedPubMedCentral

14.

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

15.

Moher D, Liberati A, Tetzlaff J, Altman DG, Prisma Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 151(4):264–269. https://doi.org/10.1371/journal.pmed.1000097 CrossRefPubMed

16.

Wells GA, Shea B, O’Connell D, J Peterson, V Welch, M Losos, P Tugwell (2009) The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa Hospital Research Institute. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp

17.

Wan X, Wang W, Liu J, Tong T (2014) Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 14(1):135. https://doi.org/10.1186/1471-2288-14-135 CrossRefPubMedPubMedCentral

18.

Higgins J, Green S, Jüni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA (2011) Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Br Med J. https://doi.org/10.1136/bmj.d5928 CrossRefPubMedPubMedCentral

19.

Justiniano C, Temple L, Swanger A, Xu Z, Speranza JR, Cellini C, Salloum RM, Fleming FJ (2018) Readmissions with dehydration after ileostomy creation: rethinking risk factors. DCR. 61(11):1297–1305. https://doi.org/10.1097/DCR.0000000000001137 CrossRef

20.

Anaraki F, Vafaie M, Behboo R, Maghsoodi N, Esmaeilpour S, Safaee A (2012) Quality of life outcomes in patients living with stoma. Indian J Palliat Care 18(3):176–180. https://doi.org/10.4103/0973-1075.105687 CrossRefPubMedPubMedCentral

21.

Arsan C, Gonzalez OY, Gillespie TL (2016) A fatal case of Clostridium difficile enterocolitis following diverting loop ileostomy reversal. Surg Infect Case Reports 1(1):16–18. https://doi.org/10.1089/crsi.2016.29004.ca CrossRef

22.

Fashandi AZ, Ellis SR, Smith PW, Hallowell PT (2016) Overwhelming recurrent Clostridium difficile infection after reversal of diverting loop ileostomy created for prior fulminant C. difficile colitis. Am Surg 82(8):E194–E195PubMed

23.

Braga M, Vignali A, Gianotti L, Zuliani W, Radaelli G, Gruarin P, Dellabona P, di Carlo V (2002) Laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome. Ann Surg 236(6):759–767. https://doi.org/10.1097/00000658-200212000-00008 CrossRefPubMedPubMedCentral

24.

Gash K, Chambers W, Ghosh A, Dixon AR (2011) The role of laparoscopic surgery for the management of acute large bowel obstruction. Color Dis 13(3):263–266. https://doi.org/10.1111/j.1463-1318.2009.02123.x CrossRef

25.

Farinella E, Cirocchi R, La Mura F et al (2009) Feasibility of laparoscopy for small bowel obstruction. World J Emerg Surg 4(1):1–9. https://doi.org/10.1186/1749-7922-4-3 CrossRef

26.

Tseng J, Loper B, Jain M, Lewis AV, Margulies DR, Alban RF (2017) Predictive factors of mortality after colectomy in ischemic colitis: an ACS-NSQIP database study. Trauma Surg Acute Care Open 2(1):e000126. https://doi.org/10.1136/tsaco-2017-000126 CrossRefPubMedPubMedCentral

27.

De Silva S, Ma C, Proulx MC et al (2011) Postoperative complications and mortality following colectomy for ulcerative colitis. Clin Gastroenterol Hepatol 9(11):972–980. https://doi.org/10.1016/j.cgh.2011.07.016 CrossRefPubMed

28.

Bhangu A, Nepogodiev D, Gupta A, Torrance A, Singh P (2012) Systematic review and meta-analysis of outcomes following emergency surgery for Clostridium difficile colitis. Br J Surg 99:1501–1513CrossRefPubMed

29.

McEllistrem MC, Carman RJ, Gerding DN, Genheimer CW, Zheng L (2004) A Hospital outbreak of Clostridium difficile disease associated with isolates carrying binary toxin genes. Clin Infect Dis 40(2):265–272. https://doi.org/10.1086/427113 CrossRefPubMed

30.

Rubin M, Bodenstein L, Kent K (1995) Severe Clostridium difficile colitis. DCR. 38(4):350–354

31.

Belmares J, Gerding DN, Parada JP, Miskevics S, Weaver F, Johnson S (2007) Outcome of metronidazole therapy for Clostridium difficile disease and correlation with a scoring system. J Inf Secur 55(6):495–501. https://doi.org/10.1016/j.jinf.2007.09.015 CrossRef

32.

Van Der Wilden GM, Chang Y, Cropano C et al (2014) Fulminant clostridium difficile colitis: prospective development of a risk scoring system. J Trauma Acute Care Surg 76(2):424–430. https://doi.org/10.1097/TA.0000000000000105 CrossRefPubMed

Title: Diverting loop ileostomy with colonic lavage as an alternative to colectomy for fulminant Clostridioides difficile: a systematic review and meta-analysis
Authors: Tyler McKechnie
Yung Lee
Jeremy E. Springer
Aristithes G. Doumouras
Dennis Hong
Cagla Eskicioglu
Publication date: 01-01-2020
Publisher: Springer Berlin Heidelberg
Keywords: Colectomy
Colectomy
Ileostomy
Clostridioides Difficile
Published in: International Journal of Colorectal Disease / Issue 1/2020
Print ISSN: 0179-1958
Electronic ISSN: 1432-1262
DOI: https://doi.org/10.1007/s00384-019-03447-3

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Diverting loop ileostomy with colonic lavage as an alternative to colectomy for fulminant Clostridioides difficile: a systematic review and meta-analysis

Abstract

Purpose

Methods

Results

Conclusion

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Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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