BACKGROUND: 

Emergency surgery is often required for fulminant Clostridium difficile colitis. Total abdominal colectomy has been the treatment of choice despite high morbidity and mortality.

OBJECTIVE: 

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.

DATA SOURCES: 

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.

STUDY SELECTION: 

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).

MAIN OUTCOMES MEASURES: 

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.

RESULTS: 

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; I² = 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 (I² = 0%).

LIMITATIONS: 

A limitation is the observational nature of the included studies introducing an overall high risk of selection bias.

CONCLUSIONS: 

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.

中文翻译：

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腹部全结肠切除术与Loop回肠回肠联合结肠灌洗术治疗恶性梭状芽胞杆菌难治性结肠炎术后死亡率和发病率的Meta分析

背景： 

暴发性艰难梭菌结肠炎通常需要急诊手术。尽管高发病率和高死亡率，全腹结肠切除术仍是首选治疗方法。

目的： 

这项荟萃分析的目的是评估暴发性艰难梭菌性结肠炎患者的全腹结肠切除术和环回肠造口术联合结肠灌洗后的术后死亡率和发病率。

数据源： 

通过对PubMed，Cochrane Library，MEDLINE和CINAHL进行系统搜索，确定了比较全腹腔结肠切除术与loop回肠造口术治疗暴发性艰难梭菌性结肠炎的研究。

研究选择： 

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。

干预措施： 

将全腹腔结肠切除术（全结肠直肠切除术，末端回肠造口术）与loop回肠造口术（回肠loop回术在离回盲肠交界处不远，进行结肠灌洗）进行了比较。

主要指标： 

这项荟萃分析是根据《系统评价和荟萃分析指南》的“首选报告项目”进行的。主要结果是术后死亡率，定义为干预后30天内发生的死亡。次要终点是造口逆转，深静脉血栓形成/栓塞，手术部位感染，尿路感染，呼吸系统并发症，再次手术和不良事件发生率。采用随机效应模型的Mantel–Haenszel方法进行荟萃分析。

结果： 

纳入五项观察性研究（3项队列研究和2项数据库分析研究），总计3683例患者。全腹大肠切除术后的死亡率为31.3％，回肠回肠造瘘术后的死亡率为26.2％（OR = 1.36（95％CI，0.83-2.24）；p = 0.22；需要治疗/伤害的数字= 20；I ² = 55％）。与全腹结肠切除术相比，loop回肠造口术后的造口逆转率在统计学上和临床上均显着更高（80％vs 25％； OR = 0.08（95％CI，0.02–0.30）；p = 0.002；治疗/伤害所需的数量= 2）具有低异质性（I ² = 0％）。

局限性： 

局限性在于所纳入研究的观察性质，从而导致选择偏向总体较高。

结论： 

这项荟萃分析表明，与全腹结肠切除术相比，loop回肠造瘘术联合结肠灌洗治疗难治性艰难梭菌性结肠炎可能与相似的生存率和降低的手术部位感染率相关。尽管loop回肠造口术与结肠灌洗术的造口术逆转率更高，但这一发现仅基于两项研究的数据。