From the Guidelines
Surgery for Clostridioides difficile (C. diff) colitis is indicated in severe, life-threatening cases that fail to respond to medical management, with the primary indications including toxic megacolon, bowel perforation, peritonitis, septic shock unresponsive to antibiotics, and severe colitis with organ failure that doesn't improve with standard therapy. The decision to operate should be based on a multidisciplinary approach, considering the high mortality of emergency colectomy against the even higher mortality of delaying necessary surgical intervention in fulminant disease 1.
Indications for Surgery
- Toxic megacolon (colon dilation >7cm with systemic toxicity)
- Bowel perforation
- Peritonitis
- Septic shock unresponsive to antibiotics
- Severe colitis with organ failure that doesn't improve with standard therapy
- Persistent symptoms despite 48-72 hours of maximal medical therapy, particularly with rising lactate levels (>5 mmol/L), severe leukocytosis (>25,000 cells/mm³), or hypotension requiring vasopressors
Surgical Procedure
The standard surgical procedure is subtotal colectomy with end ileostomy, though loop ileostomy with colonic lavage may be an option in select cases, as it has been shown to be a useful alternative to resection of the entire colon, with reduced mortality and preservation of the colon in most patients 1.
Timing of Surgery
Early surgical consultation is crucial, as mortality increases significantly when surgery is delayed, and patients presenting with organ failure need prompt intervention since the timing of surgical intervention is the key for survival of patients with fulminant colitis 1. A risk scoring system can be used to identify high-risk patients who may benefit from early surgical intervention, with factors such as age, white blood cell count, cardiorespiratory failure, and diffuse abdominal tenderness on physical examination being taken into account 1.
Medical Management Before Surgery
Before considering surgery, patients should receive maximal medical therapy, including high-dose vancomycin (500 mg, 6 hourly), oral and/or by enema, in combination with intravenous metronidazole (500 mg, 8 hourly) 1. The vancomycin dosage is 500 mg orally 4 times per day and 500 mg in approximately 100 mL normal saline per rectum every 6 hours as a retention enema, as recommended by the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) 1.
From the Research
Indications for Surgery in C Diff Colitis
- Fulminant CDI with no improvement six or more days after initiating medical therapy is an indication for surgical intervention 2
- Severe CDI colitis that is unresponsive to medical therapy may require surgical intervention, such as total abdominal colectomy or diverting loop ileostomy with colonic lavage 3
- Surgical options are considered when there is a high risk of mortality or significant morbidity due to CDI 3
Surgical Procedures
- Total abdominal colectomy was once the only procedure of choice, but diverting loop ileostomy with colonic lavage is emerging as a viable alternative 3
- The choice of surgical procedure depends on the severity of the disease, the patient's overall health, and the presence of any underlying medical conditions
Medical Therapy Before Surgery
- Vancomycin is recommended as first-line therapy for an initial episode of mild/moderate or severe CDI, with consideration of fidaxomicin for patients at particularly high risk for recurrence 2
- Fecal microbiota transplantation and targeted therapy against toxin B (bezlotoxumab) are also playing an increasingly important role in the management of CDI 3, 4, 5, 6