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Original Investigation
Pacific Coast Surgical Association
July 3, 2019

Trends in Diverting Loop Ileostomy vs Total Abdominal Colectomy as Surgical Management for Clostridium difficile Colitis

Author Affiliations
  • 1Department of Surgery, University of California, Los Angeles, Los Angeles
JAMA Surg. 2019;154(10):899-906. doi:10.1001/jamasurg.2019.2141
Key Points

Question  What is the recent national trend in treating fulminant Clostridium difficile colitis with loop ileostomy vs total abdominal colectomy, and do they provide comparable short-term outcomes?

Findings  In this cohort study examining a national administrative database spanning 2011 to 2015, a gradual increase in the frequency of diverting loop ileostomy was observed for treating Clostridium difficile colitis. In-hospital mortality was not associated with the choice of procedure.

Meaning  Loop ileostomy, being a less invasive and organ-preserving procedure, is a viable surgical option for treating fulminant Clostridium difficile colitis and has been used increasingly frequently on a national level; however, the grounds for selection of surgical treatment need clarification.


Importance  Diverting loop ileostomy and colonic lavage has generated much interest since it was first reported as a potential alternative to total abdominal colectomy for treating Clostridium difficile colitis in 2011. To our knowledge, few studies have validated the benefit reported in the initial description, and the association of this new approach with practice patterns has not been described.

Objective  To examine the national adoption pattern and outcomes of diverting loop ileostomy vs total abdominal colectomy as treatment for fulminant C difficile colitis.

Design, Setting, and Participants  This retrospective cohort study used data from hospitals participating in the National Inpatient Sample database across the United States from January 2011 to September 2015 and included 3021 adult patients who underwent surgery for C difficile colitis during the study period, comprising 2408 subtotal colectomies and 613 loop ileostomies. The data were analyzed between November 2018 and April 2019.

Exposures  Loop ileostomy as surgery of choice.

Main Outcomes and Measures  In-hospital mortality.

Results  Of 2408 participants, 1416 (58.8%) were women, 1781 (78.4%) were white, and 627 (21.6%) were individuals of color and the mean (SD) age was 68.2 (14.8) years. During the overall study period, 613 patients (20.28%) underwent diverting loop ileostomy without total abdominal colectomy. The annual proportion of patients undergoing only diversion increased from 11.16% in 2011 to 25.30% in 2015. Significantly more loop ileostomies were performed within the first day of hospitalization, in contrast to subtotal colectomies (23.31% vs 12.21%; P < .01). There was no significant difference in in-hospital mortality rates between the 2 groups (25.98% vs 31.18%; P = .28).

Conclusions and Relevance  This study demonstrates the adoption of diverting loop ileostomy to treat C difficile colitis across the United States. While fulminant C difficile colitis remains a condition with high mortality rates, no significant difference in this outcome was observed between loop ileostomy and total abdominal colectomy. Loop ileostomy may represent a viable surgical alternative to total abdominal colectomy, although the grounds for selection of treatment need to be clarified.

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