American Surgical Association

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Minimally Invasive Temporary Loop Ileostomy, Colonic Lavage and Intracolonic Antegrade Vancomycin for Severe Complicated Clostrdium Difficile Disease
Brian Zuckerbraun, MD*1, John Alverdy, MD2, Richard L. Simmons, MD1
1University of Pittsburgh, Pittsburgh, PA;2University of Chicago, Chicago, IL

Clostridium difficile associated disease [CDAD] generally responds to antibiotics, but overall mortality is 4-10%. Mortality of 60-85% occurs in "severe complicated" disease. Subtotal colectomy saves some patients but most survivors require permanent ileostomy. Because morbidity in CDAD originates from colonic microbial toxins, we have initiated treatment of "severe complicated" CDAD with laparoscopic diverting loop ileostomy permitting intraoperative antegrade colonic lavage, plus post-op antegrade colonic vancomycin instillation. Methods: The Quality Improvement Committee and Total Quality Council approved this trial: Since June 2009, all patients [n=34] with severe complicated CDAD underwent loop ileostomy, intraoperative lavage with 8 liters of PEG 3350/electrolyte solution, plus 500mg vancomycin q8h for 10 days. The previous 34 patients [2006-09] treated by subtotal colectomy were used as a historical control. Results: the primary outcome was patient survival [79% with diverting ileostomy/washout compared to 53% in historical colectomy group; *p=0.03; OR 0.3 {0.1-0.9}] The colon was saved in 24/27 survivors. The laparoscopic approach was successful in 28/34 [82%] attempts; 6/28 required open loop ileostomy. Of patients followed 6 months, 10/18 [55%] have had their ileostomy reversed. The table shows that there were no statistical difference in age, sex, or preoperative status between the current series and the historical control group. Conclusions: Minimally invasive temporary diverting loop ileostomy facilitates colonic lavage and offers life and colon saving alternatives to subtotal colectomy in severe complicated CDAD. 
Table 1. Demographics and outcomes in patients with severe, complicated Clostridium difficile associated disease treated with ileostomy/colonic lavage v. colectomy.
Ileostomy/LavageColectomy
AGE62.11364.2 14
SEX59% male62% male
APACHE-II27.15.628.16.1
ICU31/34 (91%)31/34 (91%)
INTUBATED20/34 (59%)21/34 (62%)
VASOPRESSORS25/34 (74%)27/34 (79%)
IMMUNOSUPPRESION16/34 (47%)14/34 (41%)
DEATH7/34 (20.5%)*16/34 (47%)
‘Severe, complicated’ disease is characterized by a diagnosis of CDAD with any one of the following criteria: Sepsis, ventilatory failure, vasopressore requirement, worsening abdominal pain/distention, peritonitis, mental status changes, unexplained clinical deterioration.


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