Division of General Surgery, Department of Surgery, Vienna Medical University, Vienna, Austria.
Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.
Dis Colon Rectum. 2020 Sep;63(9):1317-1326. doi: 10.1097/DCR.0000000000001764.
Emergency surgery is often required for fulminant Clostridium difficile colitis. Total abdominal colectomy has been the treatment of choice despite high morbidity and mortality.
The aim of this meta-analysis was to evaluate postoperative mortality and morbidity after total abdominal colectomy and loop ileostomy with colonic lavage in patients with fulminant C difficile colitis.
Studies comparing total abdominal colectomy to loop ileostomy for fulminant C difficile colitis were identified by a systematic search of PubMed, Cochrane Library, MEDLINE, and CINAHL.
Relevant records were detected and screened using a cascade system (title, abstract, and/or full text article).
INTERVENTION(S): Total abdominal colectomy (rectal-sparing resection of the entire colon with end ileostomy) was compared to loop ileostomy (exteriorization of an ileal loop not far from the ileocecal junction for colonic lavage).
This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines. Primary outcome was postoperative mortality, defined as death occurring within 30 days after the intervention. Secondary end points were the rates of ostomy reversal, deep venous thrombosis/embolism, surgical site infection, urinary tract infection, respiratory complications, reoperations, and adverse events. Mantel-Haenszel method with random-effects model was used for meta-analysis.
Five observational studies (3 cohort and 2 database analysis studies) totaling 3683 patients were included. Postoperative mortality rate was 31.3% after total abdominal colectomy and 26.2% after loop ileostomy (OR = 1.36 (95% CI, 0.83-2.24); p = 0.22; number needed to treat/harm = 20; I = 55%). Ostomy reversal rate was both statistically and clinically significantly higher after loop ileostomy as compared with total abdominal colectomy (80% vs 25%; OR = 0.08 (95% CI, 0.02-0.30); p = 0.002; number needed to treat/harm = 2) with low heterogeneity (I = 0%).
A limitation is the observational nature of the included studies introducing an overall high risk of selection bias.
This meta-analysis suggests that loop ileostomy with colonic lavage for fulminant C difficile colitis may be associated with similar survival and decreased surgical site infection rates as compared with total abdominal colectomy. Although loop ileostomy with colonic lavage was associated with higher ostomy reversal rates, this finding was based on the data from only 2 studies.
艰难梭菌结肠炎爆发时通常需要进行急诊手术。尽管总腹部结肠切除术的发病率和死亡率很高，但它一直是治疗的首选。
本荟萃分析旨在评估在爆发性艰难梭菌结肠炎患者中，总腹部结肠切除术和带有结肠灌洗的回肠造口术的术后死亡率和发病率。
通过系统搜索 PubMed、Cochrane 图书馆、MEDLINE 和 CINAHL，确定了比较总腹部结肠切除术与回肠造口术治疗爆发性艰难梭菌结肠炎的研究。
使用级联系统（标题、摘要和/或全文文章）检测和筛选相关记录。
总腹部结肠切除术（直肠保留切除整个结肠，末端回肠造口术）与回肠造口术（将靠近回盲肠交界处的回肠袢外置，用于结肠灌洗）进行比较。
本荟萃分析按照系统评价和荟萃分析的首选报告项目进行。主要结局是术后 30 天内发生的死亡率，定义为干预后死亡。次要终点是造口还纳率、深静脉血栓形成/栓塞、手术部位感染、尿路感染、呼吸道并发症、再次手术和不良事件。使用 Mantel-Haenszel 法和随机效应模型进行荟萃分析。
纳入了 5 项观察性研究（3 项队列研究和 2 项数据库分析研究），共计 3683 名患者。总腹部结肠切除术的术后死亡率为 31.3%，回肠造口术的术后死亡率为 26.2%（OR=1.36（95%CI，0.83-2.24）；p=0.22；需要治疗/危害的数量=20；I=55%）。与总腹部结肠切除术相比，回肠造口术的造口还纳率无论在统计学上还是临床上都显著更高（80% vs 25%；OR=0.08（95%CI，0.02-0.30）；p=0.002；需要治疗/危害的数量=2），且异质性较低（I=0%）。
研究的局限性在于纳入的研究具有观察性，总体上存在较高的选择偏倚风险。
本荟萃分析表明，对于爆发性艰难梭菌结肠炎，带有结肠灌洗的回肠造口术与总腹部结肠切除术相比，可能具有相似的生存率和较低的手术部位感染率。尽管带有结肠灌洗的回肠造口术与更高的造口还纳率相关，但这一发现仅基于来自 2 项研究的数据。
