Diverting Loop Ileostomy for Clostridium Difficile Colitis: A Systematic Review and Meta-analysis

Area of Science:

• Surgical Gastroenterology
• Infectious Diseases
• Critical Care Medicine

Background:

• Fulminant Clostridium difficile infection (CDI) presents a significant mortality risk.
• Surgical management options for severe CDI include total abdominal colectomy (TAC) and diverting loop ileostomy (DLI) with colonic lavage.
• The comparative efficacy and safety of DLI versus TAC for fulminant CDI remain debated.

Purpose of the Study:

• To evaluate the available evidence comparing the outcomes of diverting loop ileostomy (DLI) and total abdominal colectomy (TAC) for fulminant Clostridium difficile infection (CDI).
• To assess the impact of DLI on mortality rates in patients with severe CDI.

Main Methods:

• A systematic literature search was conducted on MEDLINE for studies published between 1999 and 2019.
• Included studies focused on the surgical treatment of CDI using DLI or TAC.
• Meta-analysis of pooled mortality data from five eligible studies (four retrospective, one prospective matched cohort) involving 3683 patients.

Main Results:

• A total of 3683 patients were analyzed; 733 (20%) underwent DLI and 2950 (80%) underwent TAC.
• The overall mortality rate across both procedures was 30.3%.
• No statistically significant difference in pooled mortality was observed between DLI and TAC (OR: 0.73; 95% CI, 0.45-1.2; P = 0.22).

Conclusions:

• Diverting loop ileostomy (DLI) with colonic lavage appears to be a potentially viable surgical alternative to total abdominal colectomy (TAC) for fulminant Clostridium difficile infection (CDI), with comparable mortality.
• Fulminant CDI continues to be associated with high mortality regardless of surgical approach.
• Further research is warranted to identify specific patient characteristics that may guide the routine selection of DLI over TAC for severe CDI.