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Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile–associated disease: An Eastern Association for the Surgery of Trauma multicenter trial

Ferrada, Paula MD; Callcut, Rachael MD, MSPH; Zielinski, Martin D. MD; Bruns, Brandon MD; Yeh, Daniel Dante MD; Zakrison, Tanya L. MD, MPH; Meizoso, Jonathan P. MD, MSPH; Sarani, Babak MD; Catalano, Richard D. MD; Kim, Peter MD; Plant, Valerie MD; Pasley, Amelia DO; Dultz, Linda A. MD, MPH; Choudhry, Asad J. MBBS; Haut, Elliott R. MD, PhDEAST Multi-Institutional Trials Committee

Journal of Trauma and Acute Care Surgery: July 2017 - Volume 83 - Issue 1 - p 36–40
doi: 10.1097/TA.0000000000001498
EAST Plenary Paper
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OBJECTIVES The mortality of patients with Clostridium difficile–associated disease (CDAD) requiring surgery continues to be very high. Loop ileostomy (LI) was introduced as an alternative procedure to total colectomy (TC) for CDAD by a single-center study. To date, no reproducible results have been published. The objective of this study was to compare these two procedures in a multicentric approach to help the surgeon decide what procedure is best suited for the patient in need.

METHODS This was a retrospective multicenter study conducted under the sponsorship of the Eastern Association for the Surgery of Trauma. Demographics, medical history, clinical presentation, APACHE score, and outcomes were collected. We used the Research Electronic Data Capture tool to store the data. Mann-Whitney (continuous data) and Fisher exact (categorical data) were used to compare TC with LI. Logistic regression was performed to determine predictors of mortality. A propensity score analysis was done to control for potential confounders and determine adjusted mortality rates by procedure type.

RESULTS We collected data from 10 centers of patients who presented with CDAD requiring surgery between July 1, 2010 and July 30, 2014. Two patients died during the surgical procedure, leaving 98 individuals in the study. The overall mortality was 32%, and 75% had postoperative complications. Median age was 64.5 years; 59% were male. Concerning preoperative patient conditions, 54% were on pressors, 47% had renal failure, and 36% had respiratory failure. When comparing TC and LI, there was no statistical difference regarding these conditions. Univariate preprocedure predictors of mortality were age, lactate, timing of operation, vasopressor use, and acute renal failure. There was no statistical difference between the APACHE score of patients undergoing either procedure (TC, 22 vs LI, 16). Adjusted mortality (controlled for preprocedure confounders) was significantly lower in the LI group (17.2% vs 39.7%; p = 0.002).

CONCLUSIONS This is the first multicenter study comparing TC with LI for the treatment of CDAD. In this study, LI carried less mortality than TC. In patients without contraindications, LI should be considered for the surgical treatment of CDAD.

LEVEL OF EVIDENCE Therapeutic study, level III.

From the Virginia Commonwealth University (P.F., V.P.), Richmond, Virginia; University of California San Francisco (R.C.), San Francisco, California; Mayo Clinic Rochester (M.D.Z., A.J.C.), Rochester, New York; University of Maryland School of Medicine (B.B., A.P.), Baltimore, Maryland; Massachusetts General Hospital (D.D.Y.), Boston, Massachusetts; University of Miami Miller School of Medicine (T.L.Z., J.P.M.), Miami, Florida; George Washington University (B.S.), Washington, DC; Loma Linda University and Medical Center (R.D.C.), San Bernardino, California; Albert Einstein College of Medicine (P.K.), New York, New York; The Johns Hopkins University School of Medicine (L.A.D., E.R.H.), Baltimore, Maryland.

Submitted: November 30, 2016, Revised: January 17, 2017, Accepted: March 3, 2017, Published online: April 20, 2017.

Drs. Ferrada and Callcut are co–first authors.

Address for reprints: Paula Ferrada, MD, FACS, Surgery Trauma, Critical Care and Emergency Surgery, Virginia Commonwealth University, PO Box 980454, Richmond, VA 23298–0454; Location/Delivery address: West Hospital, 15th Floor, East Wing, 1200 E Broad St, Richmond, VA 23298; email: pferrada@mcvh-vcu.edu.

© 2017 Lippincott Williams & Wilkins, Inc.