From the Guidelines
For operative indications of C. difficile, surgical management is necessary for severely ill patients, and subtotal colectomy with preservation of the rectum is the recommended procedure. This is based on the evidence from 1, which provides a strong recommendation with moderate quality of evidence. The study suggests that subtotal colectomy with preservation of the rectum is the preferred surgical approach for patients with fulminant CDI.
Some key points to consider for operative indications of C. difficile include:
- Fulminant CDI may be characterized by hypotension or shock, ileus, or megacolon, and requires prompt surgical intervention.
- Subtotal colectomy with preservation of the rectum is the recommended surgical procedure, as it has been shown to provide survival benefits compared to medical therapy alone 1.
- Diverting loop ileostomy with colonic lavage followed by antegrade vancomycin flushes is an alternative approach that may lead to improved outcomes, although the evidence for this is weaker 1.
- The decision to operate should be made on a case-by-case basis, taking into account the severity of the patient's condition and the potential risks and benefits of surgery.
It's worth noting that the evidence for operative indications of C. difficile is based on studies such as 1 and 1, which provide recommendations for the treatment of fulminant CDI. However, the most recent and highest quality study, 1, also supports the use of surgical management for severely ill patients, and provides guidance on the recommended surgical procedures. Overall, the recommendation for subtotal colectomy with preservation of the rectum is based on the strongest and most recent evidence available 1.
From the Research
Indications for Surgical Intervention in C. difficile Infection
The following are indications for surgical intervention in C. difficile infection:
- Severe or fulminant colitis, which has a high potential for poor outcome 2
- Toxic megacolon, bowel perforation, septic shock, and death 3, 4
- Failure of medical management, which may be indicated by surrogate parameters such as respiratory and/or renal insufficiency, age greater than 60 years, peripheral vascular disease, congestive heart failure, and coagulopathy 2
- Refractory CDI, which may benefit from surgical interventions such as colectomy or diverting loop ileostomy with colonic lavage 5, 6
Surgical Options
Surgical options for C. difficile infection include:
- Open total abdominal colectomy with end ileostomy, which is typically the preferred surgical strategy 2
- Diverting loop ileostomy with colonic lavage, which may be considered for less severe or recurrent presentations 2
- Fecal microbiota transplantation (FMT), which is a promising therapy that can safely produce cure rates between 70 and 90% in patients with severe or fulminant CDI 5, 6
Patient Selection
Patient selection for surgical intervention is crucial, as some patients may not be good candidates for surgery due to underlying medical conditions. The following patient populations may benefit from surgical intervention: