TOTAL ABDOMINAL COLECTOMY VERSUS DIVERTING LOOP ILEOSTOMY AND ANTEGRADE COLONIC LAVAGE FOR FULMINANT CLOSTRIDIOIDES COLITIS: ANALYSIS OF THE NATIONAL INPATIENT SAMPLE 2016-2019
Tyler Mckechnie*, Yung Lee, Léa Tessier, Aristithes Doumouras, Dennis Hong, Cagla Eskicioglu
McMaster University, Hamilton, ON, Canada
Introduction: Patients with fulminant Clostridioides difficile infection (CDI) may require surgical intervention. If surgery is required, total abdominal colectomy (TAC) is the most common approach. Diverting loop ileostomy (DLI) with antegrade colonic lavage has been introduced as a colon-sparing surgical approach to fulminant CDI. Prior analyses of National Inpatient Sample (NIS) data suggested equivalent postoperative outcomes between groups but did not evaluate healthcare resource utilization. As such, we aimed to analyze a more recent NIS cohort to compare these two approaches in terms of both postoperative outcomes and healthcare resource utilization.
Methods: A retrospective analysis of the NIS from 2016 to 2019 was conducted. Adult patients who underwent either a TAC or DLI with antegrade colonic lavage for fulminant CDI were identified using the relevant International Classification of Diseases, 10th revision codes. The primary outcome was postoperative in-hospital morbidity. Secondary outcomes included postoperative in-hospital mortality, specific postoperative complications, total admission healthcare cost, and length of stay (LOS). Univariable and multivariable regressions were utilized to compare the two operative approaches. Subgroup analyses were performed for patients undergoing early intervention (i.e., intervention within three days of admission).
Results: In total, 886 patients underwent TAC and 409 patients underwent DLI with antegrade colonic lavage. Adjusted analyses demonstrated no difference between groups in terms of postoperative in-hospital morbidity (aOR 0.96, 95%CI 0.64-1.44, p=0.85) or postoperative in-hospital mortality (aOR 1.15, 95%CI 0.81-1.64, p=0.436). On adjusted analyses, patients undergoing TAC experienced significantly decreased total admission healthcare cost (MD 79,715.34, 95%CI 133,841-25,588, p=0.004) and shorter postoperative LOS (MD 4.06, 95%CI 6.96-1.15, p=0.006). Findings were similar in the subgroup of patients undergoing early intervention. Younger patients (aOR 0.98, 95%CI 0.97-0.99, p=0.003) and patients being managed at teaching hospitals (aOR 3.38, 95%CI 1.15-9.97, p=0.027) were significantly more likely to undergo DLI with antegrade colonic lavage.
Conclusions: There are minimal differences between TAC and DLI with antegrade colonic lavage for fulminant CDI in terms of postoperative morbidity and mortality. Healthcare resource utilization, however, is significantly improved when patients undergo TAC as evidenced by clinically important decreases in total admission healthcare cost and postoperative LOS. Future prospective comparative studies reporting long-term outcomes are required to determine whether one approach is more favourable in this setting.
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