SURGICAL INFECTIONS

Volume 23, Number 2, 2022 Original Articles

ª Mary Ann Liebert, Inc.
DOI: 10.1089/sur.2021.126

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

Joseph D. Forrester,1 Kristin P. Colling,2 Jose J. Diaz,3 Bradley Faliks,4 Peter K. Kim,5
Jeffrey M. Tessier,6 Jamie Tung,1 and Jared M. Huston4,7

Abstract

Background: Clostridioides difficile infection (CDI) can result in life-threatening illness requiring surgery.
Surgical options for managing severe or fulminant, non-perforated C. difficile colitis include total abdominal
colectomy with end ileostomy or creation of a diverting loop ileostomy with antegrade vancomycin lavage.
Methods: The Surgical Infection Society’s Therapeutics and Guidelines Committee convened to develop gui-
delines for summarizing the current SIS recommendations for total abdominal colectomy versus diverting loop
ileostomy with antegrade lavage for severe or fulminant, non-perforated C. difficile colitis. PubMed, Embase,
and the Cochrane database were searched for pertinent studies. Severe infection was defined as laboratory
diagnosis of C. difficile infection with leukocytosis (white blood cell count of ‡15,000 cells/mL) or eleva-
ted creatinine (serum creatinine level >1.5 mg/dL). Fulminant infection was defined as laboratory diagnosis of
C. difficile infection with hypotension or shock, ileus, or megacolon. Perforation was defined as complete
disruption of the colon wall. Total abdominal colectomy was defined as resection of the ascending, transverse,
descending, and sigmoid colon with end ileostomy. For the purpose of the guideline, the terms subtotal col-
ectomy, total abdominal colectomy, and rectal-sparing total colectomy were used interchangeably. Diverting
loop ileostomy with antegrade enema was defined as creation of both a diverting loop ileostomy with intra-
operative colonic lavage and post-operative antegrade vancomycin unless otherwise specified. Evaluation of
the published evidence was performed using the Grades of Recommendation Assessment, Development and
Evaluation (GRADE) system. Using a process of iterative consensus, all committee members voted to accept or
reject each recommendation.
Results: We recommend that total abdominal colectomy be the procedure of choice for definitive therapy of
severe or fulminant, non-perforated C. difficile colitis. In select patients, colon preservation using diverting loop
ileostomy with intra-colonic vancomycin may be associated with higher rates of ostomy reversal and restoration
of gastrointestinal continuity but may lead to development of recurrent C. difficile colitis.
Conclusions: This guideline summarizes the current Surgical Infection Society recommendations regarding use
of total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for adults with severe or
fulminant, non-perforated C. difficile infection.

Keywords: antibiotic agents; Clostridioides; Clostridium; colectomy; ileostomy; infection

1
Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA.
2
Department of Trauma and Critical Care Surgery, St. Mary’s Medical Center, Essentia Health, Duluth, Minnesota, USA.
3
Program in Trauma, Department of Surgery, University of Maryland School of Medicine/R Adams Cowley Shock Trauma Center.
Baltimore, Maryland, USA.
4
Department of Surgery, 7Department of Science Education, Zucker School of Medicine at Hofstra/Northwell, Northwell Health,
Hempstead, New York, USA.
5
Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.
6
Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern, Dallas, Texas, USA.

97
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C lostridioides difficile is a gram-positive, spore-
forming bacterium commonly associated with antibiotic
use that can cause human infection [1–3]. This pathogen is
the costliest health-care–associated infection (HAI) in the
United States and is the second most common HAI [4].
There were 223,900 Clostridioides difficile infections
(CDI) and 12,800 deaths reported in 2017, with be-
tween one and six billion dollars of excess attributable
healthcare expenditure [1,4]. Symptoms of disease exist
along a range, from asymptomatic disease to fulminant,
life-threatening colitis associated with mortality rates of up
to 80% [2,3].
Total abdominal colectomy with removal of the entire
colon and sparing of the rectum, combined with end ileost-
omy, has historically been the procedure of choice for severe
or fulminant CDI [2,3]. Diverting loop ileostomy with ante-
grade lavage of vancomycin-containing effluent has been
proposed as an alternative operative intervention for pati-
ents with severe or fulminant, non-perforated CDI [5]. To
address variability in practice patterns, the Surgical Infection
Society Therapeutics and Guidelines Committee convened
to develop guidance for operative intervention for patients
with severe or fulminant, non-perforated CDI.
Objectives
Our population, intervention, comparator, and outcome
(PICO) questions are defined as follows:
 Population: Adult patients (‡18 years of age) with se-
vere or fulminant, non-perforated CDI
 Intervention: Total abdominal colectomy
 Comparator: Diverting loop ileostomy with antegrade
lavage
 Outcomes: Restoration of gastrointestinal continuity,
hospital length of stay, CDI recurrence, mortality
The resulting PICO question was: In adult patients with
severe or fulminant, non-perforated CDI should total abdom-
inal colectomy or diverting loop ileostomy with antegrade la-
vage of vancomycin-containing effluent be performed to
improve restoration of gastrointestinal continuity, decrease
hospital length of stay, decrease infection recurrence, or reduce
mortality?
Identification of References
PubMed, Embase, and Cochrane databases were searched
by professional librarians and study investigators in Novem-
ber 2020. The following medical subject headings (MeSH)
terms were included: enterocolitis, pseudomembranous
colitis, Clostridioides difficile, Clostridium difficile, colitis,
surgery, colectomy, ileostomy alone and in various combi-
nations (Supplementary Appendix SA1). Only English lan-
guage articles were reviewed. Animal studies were excluded.
No year limit was placed on the articles to maximize capture
of potentially applicable studies. Case reports, commentaries,
operative technique descriptions, and animal studies were
excluded. Studies with a majority (‡50%) of pediatric pa-
tients in their study population were excluded. Upon com-
pletion of the electronic literature search, titles and abstracts
from citation lists were reviewed by two authors ( J.D.F.,
J.M.H.) to identify potentially relevant studies. Additional
studies were sought by examining the bibliographies of
FORRESTER ET AL.
studies identified as being adequate for full-text review. Any
disagreement about study inclusion was resolved by con-
sensus. Data was abstracted by three authors ( J.D.F., B.F.,
J.M.H.). In total, 1,668 studies were identified, with 13 being
used to inform this PICO (Fig. 1).
Data Extraction and Methodology
For qualitative synthesis, quality and certainty of published
evidence was evaluated using Grades of Recommendation
Assessment, Development and Evaluation (GRADE) defi-
nitions [6,7]. The GRADE framework was applied to all
quantified outcomes for assessment for risk of bias, publi-
cation inconsistency, imprecision, and indirectness [7]. To be
included in the qualitative synthesis an article had to have a
clear comparison between total abdominal colectomy versus
diverting loop ileostomy with antegrade lavage, with at least
one critical outcome reported. Using a process of iterative
consensus, all committee members voted to accept or reject
the recommendation.
Severe infection was defined as laboratory diagnosis of
CDI with leukocytosis (white blood cell count of ‡15,000
cells/mL) or elevated creatinine (serum creatinine level
>1.5 mg/dL) [3]. Fulminant infection was defined as labo-
ratory diagnosis of CDI with hypotension or shock, ileus, or
megacolon [3]. Perforation was defined as complete dis-
ruption of the colon wall. Total abdominal colectomy was
defined as resection of the ascending, transverse, descend-
ing, and sigmoid colon with end ileostomy. For the purpose
of the guideline, total abdominal colectomy, subtotal co-
lectomy, and rectal sparing total colectomy are terms used
interchangeably. Diverting loop ileostomy was defined as
open or laparoscopic creation of a diverting loop ileostomy
with intra-operative colonic lavage and post-operative
antegrade vancomycin unless otherwise specified. A pedi-
atric patient was defined as a patient younger than 18 years
of age. Bias identified in reviewed studies was described in
the qualitative assessment. This study was Institutional
Review Board exempt because all articles were publicly
available.
Results
Results for the PICO question (In adult patients with se-
vere or fulminant, non-perforated CDI, should total abdom-
inal colectomy or diverting loop ileostomy with antegrade
lavage be performed to improve restoration of gastrointesti-
nal continuity, decrease hospital length of stay, decrease in-
fection recurrence, or reduce mortality?) are provided in
Table 1.
Qualitative Synthesis
In 2011, Neal et al. [5] performed a non-matched case
control study of patients undergoing diverting loop ileostomy
with antegrade lavage, compared with a historical cohort of
patients undergoing total abdominal colectomy, to determine
if a colon-preserving approach could serve as an alternative
to total abdominal colectomy in the treatment of fulminant
CDI. All patients with fulminant CDI from June 2009 to
January 2011 at a single center were included [5]. The pri-
mary end point was resolution of CDI as defined by resolution
of clinical symptoms and normalization of peripheral white
SURGICAL TREATMENT FOR C. DIFFICILE
FIG. 1. Flow diagram showing selection process of included articles. PICO = population, intervention, comparator, and
outcome.
blood cell count [5]. Additional end points assessed included
death or need for a repeat operation [5]. No power calculation
was performed, no matching was performed, Student t-test
and w2 test were used for analysis, and no multivariable anal-
ysis was performed [5].
Forty-two (50%) case patients were identified, with 42
(50%) historical control patients identified [5]. In the case
group, 35 (83%) patients had a diverting loop ileostomy; the
remaining seven (17%) required conversion to total abdom-
inal colectomy [5]. On univariable analysis, mortality was
less common in patients undergoing diverting loop ileostomy
compared with total abdominal colectomy (8 [19%] vs. 21
[50%]; p = 0.006, respectively) [5]. Weaknesses of this study
include it was a single-center series from a single surgeon,
without randomization or matched comparison group, and
no mention was made of how patients with perforation were
managed operatively. Using a historical control group with-
out matching for critically ill patient introduced bias because
there were considerable changes in the practice of critical
care over the intervening time period.
In 2012, Bhangu et al. [8] performed a systematic review
of studies published from 1986–2011 from the United States,
the United Kingdom, Canada, and Ireland comparing survi-
vors and non-survivors of emergency surgery for CDI. The
meta-analysis was performed in accordance with Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines and pooled odds ratios were calculated
99
with the Mantel-Haenszel method [8]. Sensitivity analysis
of non-randomized data was based on a quality rating along
the Newcastle-Ottawa scale and inter-study heterogeneity
was assessed [8]. Both prospective and retrospective studies
evaluating patients ‡18 years of age were included. Case
reports and reviews without original data were excluded [8].
Of the 1,433 patients identified, 1,247 (87%) underwent
subtotal colectomy. Forty-seven (3%) underwent diverting
loop ileostomy with antegrade vancomycin enema, 42 (89%)
of these were from a single-institution study [8]. On analysis
of high-quality studies, no difference in overall mortality was
seen between patients undergoing subtotal colectomy (odds
ratio [OR], 0.87; 95% confidence interval [CI], 0.09–2.29) or
other procedures [8]. Weaknesses included the low number
of patients undergoing diverting loop ileostomy, inclusion
of non-randomized data, the large number of retrospective
studies that were included, and limited long-term follow-up
data. No attempt was made to distinguish patients who had
contraindications to diverting loop ileostomy.
In 2015, Sartelli et al. [9] released World Society of
Emergency Surgery (WSES) guidelines for the management
of CDI in surgical patients. No systematic review criteria
were provided but GRADE hierarchy criteria were applied
[9]. Recommendations from this group included that resec-
tion of the entire colon should be considered to treat patients
with fulminant colitis (GRADE 1B) and that diverting loop
ileostomy with colonic lavage may be a useful alternative
 Table 1. Articles Reviewed for PICO
Patient/study inclusion TAC patients DLI patients Quality
Series/type Site criteria (n, %) (n, %) Outcomes assessed of evidence
Neal et al. [5] Single center Patients with fulminant CDI 42 (50) 42 (50) Clinical resolution of disease Low
Non-matched case-control Mortality
Need for repeat operation
Bhangu et al. [8] Multi-center Survivors of emergency 1247 (96) 47 (4) 30-day and in-hospital mortality Low
Systematic review and surgery for CDI
meta-analysis
Sartelli et al. [9,10] Multi-center Society guidelines Not specified Not specified Not specified Very low
Society guidelines
Fashandi et al. [12,13] Single center Patients undergoing surgical 13 (57) 10 (43) 30-day mortality Low
Retrospective cohort intervention for severe, 1-year mortality
complicated CDI Disease recurrence
Colon preservation
Return of intestinal continuity
Ferrada et al. [11] Multi-center Patients with CDI undergoing 77 (79) 21 (21) Estimated operative blood loss Low
Retrospective cohort surgery Operative transfusion volume
Operative crystalloid volume
Need for reoperation
Organ failure
Thromboembolic events
Infection

100
ICU length of stay
Hospital length of stay
Ventilator days
Mortality
Hall et al. [14] National Patients undergoing TAC 410 (90) 47 (10) Number of complications Very low
Retrospective cohort or DLI for CDI Cardiovascular complication
Respiratory complications
Any infectious complication
Thromboembolic complication
Surgical site infections
Renal failure
Re-admission
Re-operation
Length of stay
Mortality
Juo et al. [15] National Patients undergoing TAC 2,408 (80) 613 (20) In-hospital mortality Very low
Retrospective cohort or DLI for CDI Length of stay
Hemorrhage
Wound disruption
Abou-Khalil et al. [16] National Patients undergoing TAC 1,486 (72) 584 (28) In-hospital mortality Very low
Retrospective cohort or DLI for CDI 90-day unplanned re-admission
6-month leostomy reversal
(continued)
SURGICAL TREATMENT FOR C. DIFFICILE 101

PICO = population, intervention, comparator, and outcome; CDI = Clostridioides difficile colitis; TAC = total abdominal colectomy; DLI = diverting loop ileostomy with antegrade lavage;
of evidence
to resection of the entire colon (GRADE 2C) [9]. The only

Quality
referenced study comparing these two interventions was the
study by Neal et al. [5]. The 2015 WSES guidelines were

Low

Low
followed in 2019 by updated WSES guidelines [10]. The
2019 guidelines included search criteria and evaluated the
MEDLINE, Embase and Cochrane database from 2011–
2017, and GRADE criteria were again applied [10]. In ad-
dition to the study by Neal et al. [5], the study by Ferrada et al.
[11] was included in the 2019 update. Based on inclusion
Outcomes assessed

of this second study, the authors upgraded their recommen-

Respiratory complication
Thromboembolic events

Thromboembolic events
dation that diverting loop ileostomy with colonic lavage may
Urinary tract infections

Urinary tract infections

Surgical site infections

be a useful alternative to resection of the entire colon to

Acute renal failure

GRADE 1B [10]. Weaknesses of these guideline statements
30-day mortality
Ostomy reversal

Ostomy reversal
include absence of reported search criteria, lack of discus-
Re-operations

Re-operations
sion about why addition of the study by Ferrada et al. [11]
Pneumonia
increased the GRADE recommendation, high dependence on
Mortality

expert opinion, and low number of comparative studies.

In 2017, Fashandi et al. [12] performed a retrospective
cohort analysis of adult patients undergoing surgical inter-
vention for severe, complicated CDI at a single U.S. acade-
mic medical center to compare outcomes of patients treated
DLI patients

733 (20)

733 (20)

with diverting loop ileostomy and intra-operative colonic

(n, %)

lavage and antegrade vancomycin enemas with patients un-

dergoing total abdominal colectomy. Patients with concur-
rent inflammatory bowel disease or whose final pathology did
not demonstrate pseudomembranous colitis were excluded [12].
Between April 2011 and June 2015, 23 patients were iden-
TAC patients
Table 1. (Continued)

2,950 (80)

2,950 (80)

tified. Thirteen (57%) underwent subtotal colectomy and 10

(n, %)

(43%) underwent diverting loop ileostomy. There were no

short-term or long-term benefits of diverting loop ileostomy
identified [12]. Although the 30-day mortality was lower in
the subtotal colectomy group this was not significant (OR,
0.70; 95% CI, 0.11–4.54) [12]. Similarly, the one-year mor-
Patients with fulminant CDI

tality rate was higher in the subtotal colectomy group al-

undergoing TAC or DLI
Patient/study inclusion

Patients undergoing TAC

though this was not significant (OR, 1.29; 95% CI, 0.24–6.83)
[12]. There was no difference in the frequency of patients
who underwent a procedure to return intestinal continuity
criteria

or DLI for CDI

(p = 0.27) in either group [12]. From this same cohort,

Fashandi et al. [13] also published additional details on the
patients undergoing diverting loop ileostomy. In this cohort,
they identified that among patients undergoing diverting
loop ileostomy, 40% of patients had an episode of recur-
rent infection after restoration of intestinal continuity [13].
Weaknesses of this study include absence of a power anal-
ysis, absence of randomization, potential for performance
Multi-center

Multi-center

bias because of the small number of surgeons, and small sam-

ple size. Patients who underwent subtotal colectomy because
Site

of perforation were not identified.

In 2017, Ferrada et al. [11] performed a prognostic retro-
spective multicenter study comparing total abdominal co-
lectomy to diverting loop ileostomy for patients with
C. difficile-associated disease. No clear inclusion or exclu-
sion criteria were reported. Adjusted mortality accounting for
need for re-operation was compared between groups, and
Systematic review and

Systematic review and

ICU = intensive care unit.

Trejo-Avila et al. [18]
Felsenreich et al. [17]

proportional increase in mortality associated with reoperation

was reported [11]. Multivariable logistic regression was used
meta-analysis

meta-analysis

to determine predictors of mortality and a propensity score

analysis was used to control for potential confounders [11].
Series/type

Ninety-eight patients were identified between July 2010

and July 2014 [11]. Seventy-seven (79%) underwent total
abdominal colectomy whereas 21 (21%) underwent diverting
loop ileostomy [11]. Adjusted mortality was lower in the
102
diverting loop ileostomy group (17% vs. 40%; p = 0.002),
although no odds of mortality of total abdominal colectomy
was reported that could be compared with the other reported
predictors of overall mortality [11]. Weaknesses of this study
include retrospective study design and small sample size, no
power calculation was reported, patients were not random-
ized, which could have introduced significant selection bias,
and failure to identify total abdominal colectomy cases per-
formed for perforation.
In 2019, Hall et al. [14] performed a retrospective review
of the National Surgical Quality Improvement Database,
comparing outcomes between patients undergoing total ab-
dominal colectomy or diverting loop ileostomy for CDI.
Patients were included if they had a post-operative diagnosis
of enterocolitis caused by Clostridium difficile by Inter-
national Classification of Diseases, Clinical Modification
(ICD-CM) diagnostic codes (ICD-9-CM and ICD-10-CM).
Surgical procedures were identified through Current Proce-
dural Terminology (CPT) codes [14]. Patients were excluded
if they had outlying (95th percentile) length of stay, age, or
operative time [14].
There were 457 patients identified from 2011–2016 [14].
Of these, 410 (90%) underwent total abdominal colectomy
and 47 (10%) underwent diverting loop ileostomy [14]. There
was no statistical difference between mean length of stay,
re-admission rates, and mortality was similar between the
two intervention groups [14]. Interestingly, the predicted pre-
operative morbidity based on pre-operative variables was
higher in the total abdominal colectomy group compared
with the diverting loop ileostomy group (62% – 15% vs.
37% – 16%; p < 0.0001), suggesting considerable selection
bias may exist among patients undergoing total abdominal
colectomy [14]. Weaknesses included potential for consid-
erable selection bias, failure to account for CDI-specific
disease severity, no application of a correction for the large
number of comparisons performed, dependence on billing
codes rather than collected clinical data, lack of specificity
in the dataset for antegrade lavage, and the study was
underpowered.
In 2019, Juo et al. [15] performed a retrospective cohort
analysis of the National Inpatient sample from January 2011
to September 2015 to evaluate trends in use of total abdom-
inal colectomy and diverting loop ileostomy as surgical
management for C. difficile colitis. Adult patients (‡18 years)
were identified by a discharge diagnosis of C. difficile colitis
as defined by ICD-9, with a concomitant diagnosis of to-
tal abdominal colectomy or diverting loop ileostomy [15].
Admission with a diagnosis of ulcerative colitis, Crohn dis-
ease, ischemic colitis, cancer, or lower gastrointestinal hem-
orrhage were excluded [15]. Primary outcome was in-hospital
mortality, with secondary outcomes of length of stay, hem-
orrhage, and wound disruption [15]. Multivariable logistic
regression was used for analysis [15].
There were 3,021 patients identified, 2,408 of whom (80%)
underwent total abdominal colectomy and 613 of whom
(20%) underwent diverting loop ileostomy [15]. No differ-
ence was identified between total abdominal colectomy and
diverting loop ileostomy for in-hospital mortality (31% vs.
26%; p = 0.28), length of stay (mean 16 days [interquartile
range, 10–24 days] vs. 18 [11–33] days; no p value reported)
or post-operative hemorrhage (2% vs. 2%; p = 0.99) [15].
Diverting loop ileostomy was associated with increased
FORRESTER ET AL.
wound disruption (6% vs. 2%; p = 0.04) and surgical site
infection (9% vs. 4%; p = 0.01) [15]. Weaknesses of the study
include failure to account for the large number of compari-
sons in significance estimations, inability to assess tempo-
rality between intervention and suspected outcome, potential
for selection and coding bias, lack of ability to differentiate
between fulminant and non-fulminant colitis, and depen-
dence upon an administrative database.
In 2020, Abou-Khalil et al. [16] performed a retrospective
review of the Nationwide Readmission Database evaluat-
ing 2070 inpatient admissions for adult patients undergoing
diverting loop ileostomy or total abdominal colectomy for
CDI in the United States from 2011–2016. Patients with a
concurrent colorectal procedural or diagnostic code were ex-
cluded. One-thousand four hundred eighty-six (72%) patients
underwent total abdominal colectomy, and 584 (28%) under-
went diverting loop ileostomy [16]. Outcomes assessed in-
cluded in-hospital mortality, 90-day unplanned re-admission,
and six-month ileostomy reversal [16].
There was no difference between in-hospital mortality
(OR, 1.14; 95% CI, 0.91–1.43) or 90-day unplanned re-
admission (OR, 0.85; 95% CI, 0.65–1.12) between patients
undergoing total abdominal colectomy and diverting loop
ileostomy [16]. Patients undergoing diverting loop ileostomy
had greater odds of ileostomy reversal (OR, 2.69; 95% CI,
1.8–4.0) and shorter median time-to-reversal compared
with those who underwent total abdominal colectomy (26%
vs. 8%; p < 0.001) [16]. Limitations include lack of a priori
power calculation, inability to identify if antegrade enema
was administered in addition to diverting loop ileostomy,
dependence on billing codes rather than clinical data, trun-
cated follow-up, and potential for coding errors.
In 2020, Felsenreich et al. [17] published a systematic
review and meta-analysis comparing post-operative mortal-
ity and morbidity after total abdominal colectomy to loop
ileostomy with colonic lavage in patients with fulminant
C. difficile colitis. This review included studies from 2011–
2019 from the United States and Europe [17]. PRISMA and
Meta-analyses Of Observational Studies in Epidemiology
(MOOSE) guidelines were observed [17]. Observational
or experimental comparative studies comparing total abdom-
inal colectomy with diverting loop ileostomy were included
[17]. Non-comparative studies, reviews, technical notes, and
correspondence were not included [17]. The primary out-
come assessed was post-operative mortality (death within
30 days of operation); secondary end points included rates
of ostomy reversal, venous thromboembolic events, surgical
site infections, urinary tract infections, respiratory compli-
cations, re-operations, and a composite adverse events end
point [17]. The Mantel-Haenszel method with a random ef-
fects model was used for analysis with heterogeneity assessed
with Cochran x2 and I2 [17]. The Newcastle-Ottawa Quality
Assessment Scale was applied [17].
Five observational studies were identified, containing
3,683 patients [17]. Two thousand nine hundred fifty patients
(80%) received total abdominal colectomy and 733 (20%)
receiving diverting loop ileostomy [17]. The authors reported
no increased mortality rate after total abdominal colectomy
(OR, 1.36; 95% CI, 0.83–2.24) compared with diverting
loop ileostomy [17]. Ostomy reversal rate was lower after
total abdominal colectomy compared with diverting loop
ileostomy (OR, 0.08; 95% CI, 0.02–0.3) [17]. Whereas total
SURGICAL TREATMENT FOR C. DIFFICILE
abdominal colectomy was associated with greater odds of
adverse events (OR, 1.84; 95% CI, 1.16–2.92), this was lar-
gely driven by higher rates of respiratory complications and
surgical site infections among patients undergoing total ab-
dominal colectomy [17]. Weaknesses of this review included
not specifically removing patients with perforation from the
total abdominal colectomy group, observational nature of
included studies that introduced high risk of selection bias,
lack of standardized definitions of interventions, inclusion of
patients from administrative databases, inability to ensure
that exclusively fulminant cases were included, and failure to
report on recurrent disease.
Also in 2020, Trejo-Avila et al. [18] performed a sys-
tematic review and meta-analysis comparing diverting loop
ileostomy with total abdominal colectomy for the treatment
of C. difficile colitis (18). PubMed, Embase, Cochrane, and
Web of Science databases were searched for randomized and
non-randomized studies comparing diverting loop ileostomy
to total abdominal colectomy for fulminant CDI [18]. Studies
from 2011–2019, from the United States and Europe were
included [18]. PRISMA and MOOSE guidelines were ap-
plied, and the study was registered with the International
Prospective Register of Systematic Reviews (PROSPERO)
[18]. Risk of bias was assessed according to the Cochrane
handbook, and quality of articles was assessed using GRADE
criteria [18]. Any randomized controlled trial or comparative
study was included; review articles, editorials, case reports,
case series, and non-comparative studies were excluded [18].
Meta-analysis was performed for end points of mortality and
post-operative complications including thromboembolic
events, pneumonia, acute renal failure, urinary tract infec-
tions and re-operations [18]. The Mantel-Haenszel method
was used for dichotomous variables [18]. Heterogeneity was
assessed with Higgins I2 and fixed effects were used if het-
erogeneity was absent, with random-effects applied if het-
erogeneity was found (18).
Five observational studies were identified: all were non-
randomized, one was prospective and four were retrospec-
tive. These same studies were identified by Felsenreich et al.
[18]. Similar to Felsenreich et al. [18], mortality between
procedures was found to be equivalent (OR, 0.73; 95% CI,
0.45–1.20). Odds of post-operative thromboembolic events
(OR, 0.45; 95% CI 0.14–1.43), acute renal failure (OR, 1.71;
95% CI, 0.91–3.23), surgical site infection (OR, 0.95; 95%
CI, 0.11–8.59), pneumonia (OR, 0.98; 95% CI, 0.36–2.66),
urinary tract infections (OR, 0.81; 95% CI, 0.26–2.52), and
overall re-operation rate (OR, 0.95; 95% CI, 0.50–1.82) were
found to be equivalent between studies [18]. Odds of ostomy
reversal was higher after diverting loop ileostomy (OR,
12.55; 95% CI, 3.31–47.55) [18]. A weakness of this review
was that all five studies were considered to be ‘‘at serious risk
of bias’’ by the authors according to the Risk Of Bias In Non-
randomized Studies-of Interventions (ROBINS-I) tool [18].
Recommendation
Management of severe or fulminant C. difficile colitis is
challenging and the timing of when a surgical team may be
notified about a worsening patient exists along a spectrum.
Acknowledging the selection bias in reviewed articles, we
recommend that total abdominal colectomy be the procedure
of choice for definitive therapy of severe or fulminant, non-
103
perforated C. difficile colitis based on low-quality evidence
supporting any benefit of diverting loop ileostomy to reduce
hospital length of stay, infection recurrence, or mortality.
Colon preservation using diverting loop ileostomy with intra-
colonic vancomycin could be considered in select patients
and may be associated with higher rates of ostomy reversal
or restoration of gastrointestinal continuity, but can lead to
development of recurrent C. difficile colitis. The severity of
disease at time of consultation, patient preference, and co-
morbidities of the patient may influence a surgeon’s decision
to perform a total abdominal colectomy versus diverting
ileostomy with antegrade lavage.
Acknowledgments
The authors would like to thank Chris Stave for his as-
sistance in developing search terms and use of Covidence.
Funding Information
No funding was received for this work.
Author Disclosure Statement
No conflicts of interest are reported for any author.
Supplementary Material
Supplementary Appendix SA1
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Address correspondence to:
Dr. Joseph D. Forrester
Division of General Surgery
Department of Surgery
Stanford University
H3591
300 Pasteur Drive
Stanford, CA 94305
USA
E-mail: jdf1@stanford.edu