Early Colectomy Saves Lives in Toxic Megacolon due to Clostridium difficile Infection

Nasim Ahmed, MD, FACS; Yen-Hong Kuo, PhD

Disclosures

South Med J. 2020;113(7):345-349. 

In This Article

Abstract and Introduction

Abstract

Objective: The purpose of the study was to evaluate whether early colectomy in patients who have toxic megacolon due to Clostridium difficile colitis reduces mortality.

Methods: The study was performed using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2016. All patients 18 to 89 years of age who underwent colectomy for toxic megacolon resulting from C. difficile colitis were included in the study. Other variables included in the study were patient demography, comorbidities, and outcomes. Patients who underwent colectomy before the presentation of septic shock (early group) were compared with patients who underwent colectomy after the onset of septic shock (late group). The main outcome of the study is 30-day all-cause mortality. Because there were some significant differences found in patient baseline characteristics in the univariate analysis, the propensity score of each patient was calculated and pair-matched analysis was performed. All P values are reported as 2-sided, and P < 0.05 was considered statistically significant.

Results: One hundred sixty-three patients met the inclusion criteria of the study. Approximately 85% of the patients underwent total abdominal colectomy. The average age of the patients was 65 years old, 51% of the patients were female, and 66% of the patients were white. The overall 30-day mortality was approximately 39%. The mortality rate of patients who underwent colectomy early compared to late was 13 (21%) vs 28 (45%), P = 0.009. The absolute risk difference was 0.24 with 95% CI: 0.07–0.42.

Conclusions: There was a reduction of 24% in 30-day mortality when colectomies were performed before the development of septic shock.

Introduction

Clostridium difficile infection occasionally presents with one of the fulminant toxic colon conditions that results in the rapid deterioration of a patient's condition. Approximately 3% to 4% of patients infected with C. difficile progress to the fulminant course,[1,2] and this can result in sepsis and septic shock.[3] In most circumstances, conservative management failed to improve a patient's condition and often lead to multiple organ failure and death.[4]

Prior studies evaluated the role of colectomy in high virulent strain of C. difficile cases during an epidemic outbreak, and found that early colectomy had a lower mortality rate.[5,6] Similarly, another study showed a survival benefit with aggressive management and early operative intervention with colectomy.[7] The prediction of appropriate timing of colectomy in patients with a C. difficile colitis infection that resulted in a toxic condition was not always determined in a timely fashion despite the availability of many scoring criteria.[8–15] In addition, the lack of clear guidelines on the timing of colectomy occasionally left the decision of operative interventions at the discretion of a treating physician.

In most instances when patients underwent colectomy, they were found to be in septic shock with severe leukocytosis and high lactate levels. Although, the overall mortality was significantly less in the colectomy group compared with those who did not undergo colectomy (34% vs 57%), the mortality rate was still high.[5] As such, the present study was designed to explore the American College of Surgeons National Surgical Quality Improvement Program (NISQIP) database, and evaluate whether early colectomy before progressing into septic shock improves survival in patients who had toxic megacolon as a result of C. difficile colitis.

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