Kidane Biniam, Lung Kalvin, McCreery Greig, El-Khatib Chadia, Ott Michael C, Hernandez-Alejandro Roberto, Vinden Chris, Gray Daryl, Parry Neil G, Leslie Kenneth A, Mele Tina S
1 Division of General Surgery, Western University , London, Ontario, Canada .
2 Division of Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, Western University , London, Ontario, Canada .
Surg Infect (Larchmt). 2018 Jan;19(1):78-82. doi: 10.1089/sur.2017.147. Epub 2017 Dec 11.
Severe Clostridium difficile infections (CDI) can lead to significant impediments to effective treatment. We developed a novel treatment protocol utilizing bedside gastrointestinal lavage (GIL) for the management of patients with severe, complicated CDI. We describe the development and early outcomes of non-operative bedside GIL in hospitalized patients with severe, complicated CDI following the Idea, Development, Exploration, Assessment, Long Term Study (IDEAL) framework at the Idea stage. We compared our results with those of a cohort of patients managed with colectomy.
We conducted a retrospective cohort study of hospitalized patients with severe, complicated CDI who failed conventional medical therapy and were referred for surgical consultation at two academic tertiary-care hospitals between January 2009 and January 2015. After surgical assessment, the attending surgeon decided to proceed either with bedside GIL or directly to colectomy. Bedside GIL involved nasojejunal tube insertion followed by flushing with 8 L of polyethylene glycol 3350/electrolyte solution over 48 h. Both patient groups received standard medical treatment with vancomycin 500 mg q 6 h enterally and metronidazole 500 mg intravenously three times daily for 14 d. The main outcomes of interest were the incidence of colectomy, complications, and mortality rate.
Nineteen and seventeen patients underwent GIL and direct colectomy, respectively. There were no significant differences between the groups in terms of demographics, American Society of Anesthesiologists class, disease severity, need for intensive care unit admission, mechanical ventilation, vasopressor use, serum lactate concentration, or proportion presenting with hypotension, acute kidney injury, or a white blood cell count >16,000/mcL or <4,000/mcL (p > 0.1). The in-hospital mortality rate was 26% (5/19) and 41% (7/17) for the GIL and colectomy groups, respectively (p = 0.35). Only one patient in the GIL group failed the protocol, requiring colectomy. There were no significant differences in complications in the two groups.
Bedside GIL appeared to be safe for the treatment of patients with severe, complicated CDI who had failed conventional medical therapy. It did not appear to increase the risk of morbidity or death compared with the traditional strategy of proceeding directly to colectomy.
严重艰难梭菌感染（CDI）会给有效治疗带来重大阻碍。我们开发了一种新颖的治疗方案，利用床边胃肠灌洗（GIL）来管理严重、复杂的CDI患者。我们按照“理念、开发、探索、评估、长期研究”（IDEAL）框架的理念阶段，描述了非手术床边GIL在住院严重、复杂CDI患者中的开发及早期结果。我们将我们的结果与一组接受结肠切除术治疗的患者的结果进行了比较。
我们对2009年1月至2015年1月期间在两家学术三级医疗中心住院的严重、复杂CDI患者进行了一项回顾性队列研究，这些患者常规药物治疗失败并被转诊进行手术咨询。经过手术评估后，主刀医生决定进行床边GIL或直接进行结肠切除术。床边GIL包括插入鼻空肠管，然后在48小时内用8升聚乙二醇3350/电解质溶液冲洗。两组患者均接受标准药物治疗，万古霉素500毫克，每6小时口服一次，甲硝唑500毫克，静脉注射，每日三次，共14天。主要关注的结果是结肠切除术的发生率、并发症和死亡率。
分别有19例和17例患者接受了GIL和直接结肠切除术。两组在人口统计学、美国麻醉医师协会分级、疾病严重程度、入住重症监护病房的需求、机械通气、血管活性药物使用、血清乳酸浓度，或出现低血压、急性肾损伤或白细胞计数>16,000/微升或<4,000/微升的比例方面无显著差异（p>0.1）。GIL组和结肠切除术组的院内死亡率分别为26%（5/19）和41%（7/17）（p=0.35）。GIL组中只有1例患者治疗方案失败，需要进行结肠切除术。两组并发症无显著差异。
床边GIL对于治疗常规药物治疗失败的严重、复杂CDI患者似乎是安全的。与直接进行结肠切除术的传统策略相比，它似乎没有增加发病或死亡风险。
