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Comment & Response
November 6, 2019

Loop Ileostomy a Viable Alternative for Clostridium Difficile Colitis?—Reply

Author Affiliations
  • 1Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, University of California, Los Angeles
JAMA Surg. Published online November 6, 2019. doi:https://doi.org/10.1001/jamasurg.2019.4699

In Reply We appreciate the comments rendered by Kanemoto et al and Ng et al in response to our study1 reporting surgical trends in the management of Clostridium difficile colitis. We used the National Inpatient Sample, the largest all-payor administrative database available in the United States, to derive the study cohort.

We agree with Kanemoto et al in that a more definitive study with stringent criteria is required to formally compare the outcomes of diverting ileostomy plus colonic lavage and subtotal colectomy. We also agree that the National Inpatient Sample has deficiencies, much like any other clinical or administrative database. Many issues impede the execution of a randomized trial for comparative efficacy of these surgical therapies. Owing to the rarity of complicated C difficile, we have thus far relied on retrospective multicenter trials such as the one by Ferrada et al.2 However, as both Kanemoto et al and Ng et al have pointed out, the nonrandomized nature of this study might lead to substantial bias arising from confounders such as the difference in quality of care between hospitals.

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