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Early Versus Delayed Surgery in Patients With Medically Refractory Ulcerative Colitis Superimposed by Clostridium difficile Infection
Emre Gorgun*, Nuri Okkabaz, Cigdem Benlice, Feza H. Remzi, Luca Stocchi
Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
Background: Medically refractory ulcerative colitis (UC) superimposed by Clostridium difficile infection (CDI) is recently more frequently observed and can cause an increase in length of stay, hospital costs, morbidity and mortality. Limited data exist regarding the optimal timing of surgery in this group of patients. In this study we aimed to investigate the safety and outcomes of early colectomy in patients with medically refractory UC superimposed by CDI. We also aimed to compare the outcomes of these patients to their counterparts where colectomy is delayed until the initial CDI treatment with antibiotics was complete.
Methods: All patients who underwent total abdominal colectomy due to active, refractory UC between January 2003 and January 2013 were reviewed for coexisting CDI. Patients were enrolled into two groups: Group A (n=13); who completed full 10 days course of antibiotic therapy for CDI followed by total abdominal colectomy and end ileostomy; Group B (n=21); who underwent upfront surgery without any delay for antibiotics. Demographics, comorbidities, body mass index (BMI) and UC-related parameters were compared. Intraoperative complications, the need for intensive care unit stay (ICU), mortality, 30-day reoperation and readmission rates, surgical site infection rate (SSI), return to bowel function and were assessed. The impact of two different approaches on future restorative attempts was also evaluated.
Results: Both groups were similar in terms of demographics, BMI, comorbidities, medical treatment of UC, operation time, estimated blood loss and ICU requirement. There was no statistically difference in terms of wound infection [(30.8% vs. 9.5%), p=0.11], ileus [(30.8% vs. 14.3%), p=0.25], return to bowel function [2.23 (±1.8) vs. 2.14 (±1.3) days; p=0.73], reoperation [1 (7.7%) vs. 2 (9.5%), p=0.85] and readmission rates [0 vs. 2 (9.5%), p=0.15]. Intraoperative splenic injury was observed in one (7.7%) patient in group A (p=0.16). Restorative proctocolectomy was completed for 9 (69.2%) patients in group A and in 18 (85.7%) patients in group B within a follow-up time of 12 month (p=0.25).
Conclusion: Early colectomy can safely be performed in patients with medically refractory ulcerative colitis superimposed by Clostridium difficile infection with no difference in postoperative complications. Further randomized studies may potentially reveal superiority of upfront surgery. Table. Characteristics and outcomes of patients who underwent early or delay surgery | Antibiotherapy (N=13) | Surgery (N=21) | P value | | Age | 44.3 (19.2) | 43.5 (20.1) | 0.9 | | Male gender | 9 (69.2%) | 12 (57.1%) | 0.47 | | Previous CDI | 2 (15.4%) | 2 (9.5%) | 0.61 | | BMI, kg/m2 | 23.7 (3.0) | 22.6 (3.8) | 0.4 | | Operative time, min | 137.8 (59.3) | 105.3 (43.3) | 0.12 | | Reoperation | 1 (7.7%) | 2 (9.5%) | 0.85 | | Readmission | 0 (0%) | 2 (9.5%) | 0.15 | | Wound infection | 4 (30.8%) | 2 (9.5%) | 0.11 | | Ileus | 4 (30.8%) | 3 (14.3%) | 0.25 | | Return to bowel function | 2.23 (1.8) | 2.14 (1.3) | 0.73 | | Estimated blood loss | 238 (227.9) | 140.8 (116.4) | 0.18 | | Intensive care unit | 1 (7.7%) | 4 (19%) | 0.34 |
Values are reported as mean (SD) or absolute values (%).
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