Surgical Management of Worsening Pseudomembranous Colitis
The appropriate surgical procedure for a patient with worsening pseudomembranous colitis requiring urgent laparotomy is total abdominal colectomy with ileostomy (option b).
Rationale for Total Abdominal Colectomy
The evidence strongly supports total abdominal colectomy as the definitive procedure for fulminant pseudomembranous colitis requiring surgery:
Patients who underwent total abdominal colectomy with ileostomy recovered promptly, while those who had segmental resection or no resection deteriorated postoperatively and died within 48 hours to 12 days 1
Subtotal colectomy with ileostomy achieved a mortality rate of only 14%, compared to 100% mortality in patients who underwent left hemicolectomy (segmental resection) 2
The best surgical results were consistently obtained with subtotal colectomy and ileostomy, as simple decompression or segmental resection does nothing to alter the underlying disease process 3
Why Other Options Are Inadequate
Segmental colectomy (options a, d, e) is contraindicated:
- All patients who underwent segmental resection in the reviewed series either died or required subsequent total colectomy 1
- Segmental approaches fail to address the diffuse nature of C. difficile colitis affecting the entire colon 3
Diverting colostomy alone (option c) is insufficient:
- Simple decompression procedures do not alter the underlying disease process and are associated with poor outcomes 3
- The toxic colonic mucosa continues to produce systemic toxicity even with diversion 2
Critical Surgical Considerations
The external appearance of the colon is often deceptively normal and should not influence the decision to perform total colectomy:
- Two patients in one series had only colonic edema at laparotomy but no other gross pathological changes; both deteriorated postoperatively and died 1
- Even when the colon appears relatively normal externally, the mucosal disease is extensive and life-threatening 2
Timing is critical:
- Extremely aggressive forms of pseudomembranous colitis exist where the usual waiting period for medical treatment can be lethal 4
- Surgical intervention should be performed when patients develop signs of organ failure, peritonitis, or worsening clinical status despite appropriate medical therapy 2
Surgical Approach Selection
Open laparotomy is recommended for hemodynamically unstable patients:
- In the setting of peritonitis or toxic megacolon in hemodynamically unstable patients, an open approach allows for faster source control 5
Laparoscopic approach may be considered in stable patients:
- If the patient is hemodynamically stable and local expertise exists, laparoscopic total abdominal colectomy can be performed with minimal morbidity and shorter hospital stays 6
- However, given the worsening clinical picture described in this question, open surgery is likely more appropriate 5
Common Pitfalls to Avoid
- Do not be misled by relatively normal-appearing colon at laparotomy - proceed with total colectomy regardless of external appearance 1, 2
- Do not attempt segmental resection or primary anastomosis - these approaches have unacceptably high mortality rates in fulminant pseudomembranous colitis 1, 3
- Do not delay surgery once the decision is made - rapid deterioration can occur within hours in fulminant cases 4