• Daniel Moritz Felsenreich, Mahir Gachabayov, Aram Rojas, Rifat Latifi, and Roberto Bergamaschi.
• Division of General Surgery, Department of Surgery, Vienna Medical University, Vienna, Austria.
• Dis. Colon Rectum. 2020 Sep 1; 63 (9): 1317-1326.

BackgroundEmergency surgery is often required for fulminant Clostridium difficile colitis. Total abdominal colectomy has been the treatment of choice despite high morbidity and mortality.ObjectiveThe aim of this meta-analysis was to evaluate postoperative mortality and morbidity after total abdominal colectomy and loop ileostomy with colonic lavage in patients with fulminant C difficile colitis.Data SourcesStudies comparing total abdominal colectomy to loop ileostomy for fulminant C difficile colitis were identified by a systematic search of PubMed, Cochrane Library, MEDLINE, and CINAHL.Study SelectionRelevant records were detected and screened using a cascade system (title, abstract, and/or full text article).Intervention(S)Total abdominal colectomy (rectal-sparing resection of the entire colon with end ileostomy) was compared to loop ileostomy (exteriorization of an ileal loop not far from the ileocecal junction for colonic lavage).Main Outcomes MeasuresThis meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines. Primary outcome was postoperative mortality, defined as death occurring within 30 days after the intervention. Secondary end points were the rates of ostomy reversal, deep venous thrombosis/embolism, surgical site infection, urinary tract infection, respiratory complications, reoperations, and adverse events. Mantel-Haenszel method with random-effects model was used for meta-analysis.ResultsFive observational studies (3 cohort and 2 database analysis studies) totaling 3683 patients were included. Postoperative mortality rate was 31.3% after total abdominal colectomy and 26.2% after loop ileostomy (OR = 1.36 (95% CI, 0.83-2.24); p = 0.22; number needed to treat/harm = 20; I = 55%). Ostomy reversal rate was both statistically and clinically significantly higher after loop ileostomy as compared with total abdominal colectomy (80% vs 25%; OR = 0.08 (95% CI, 0.02-0.30); p = 0.002; number needed to treat/harm = 2) with low heterogeneity (I = 0%).LimitationsA limitation is the observational nature of the included studies introducing an overall high risk of selection bias.ConclusionsThis meta-analysis suggests that loop ileostomy with colonic lavage for fulminant C difficile colitis may be associated with similar survival and decreased surgical site infection rates as compared with total abdominal colectomy. Although loop ileostomy with colonic lavage was associated with higher ostomy reversal rates, this finding was based on the data from only 2 studies.

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