回肠袢式造口术与全腹结肠切除术治疗艰难梭菌相关性结肠炎：住院期间以外的结局。

Diverting loop ileostomy versus total abdominal colectomy for clostridioides difficile colitis: outcomes beyond the index admission.

机构信息

Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada.

Jewish General Hospital, McGill University, 3755 Cote Ste Catherine, G-317, Montreal, QC, H3T 1E2, Canada.

出版信息

Surg Endosc. 2021 Jun;35(6):3147-3153. doi: 10.1007/s00464-020-07755-6. Epub 2020 Jun 29.

DOI:10.1007/s00464-020-07755-6

PMID:32601762

Abstract

INTRODUCTION

Diverting loop ileostomy (DLI) and colonic lavage has emerged as a valid alternative to total abdominal colectomy (TAC) for the surgical management of Clostridioides difficile colitis (CDC). However, little data are available on outcomes beyond the index admission. The objective of this study was to compare post-discharge outcomes between patients who underwent DLI and TAC for CDC.

METHODS

Adult patients who underwent DLI or TAC for CDC between 2011 and 2016 were identified from the Nationwide Readmissions Database, and only discharges between January and September in each calendar year were included to allow for a 90-day follow-up period for all cases. Ninety-day overall in-hospital mortality (index admission mortality plus 90-day post-discharge mortality) and 90-day unplanned readmissions were compared. To assess 6-month ileostomy reversal rates, the cohort was then truncated to exclude discharges after June in each calendar year. Multivariate regression was used to adjust for patient demographics and disease severity.

RESULTS

In total, 2070 patients were discharged between January and September of each included year: 1486 (71.8%) TAC compared to 584 (28.2%) DLI. Overall in-hospital mortality was higher among patients who underwent TAC (34.5% vs. 27.7%, p = 0.004); however, this association did not remain on multivariate regression (OR 1.14, 95% CI 0.91-1.43). Among the 1434 patients who were discharged alive, the 90-day unplanned readmission rate was similar in both groups (TAC: 26.1% vs. DLI: 23.1%, p = 0.26). After truncating the cohort to those patients discharged alive between January and June of each included year (n = 1016), patients who underwent DLI had a significantly greater 6-month ileostomy reversal rate (26.4% vs. 8.3%, p < 0.001). DLI was independently associated with higher odds of 6-month ileostomy reversal (OR 2.68, 95% CI 1.80-4.00).

CONCLUSIONS

In the surgical management of CDC, DLI is associated with equivalent mortality and unplanned readmission, but greater likelihood of 6-month ileostomy reversal, compared to TAC.

摘要

简介

对于艰难梭菌结肠炎（CDC）的外科治疗，转流回肠造口术（DLI）和结肠灌洗已成为全腹结肠切除术（TAC）的有效替代方法。然而，关于出院后的结果数据很少。本研究的目的是比较因 CDC 而行 DLI 和 TAC 的患者出院后的结果。

方法

从全国再入院数据库中确定了 2011 年至 2016 年期间因 CDC 而行 DLI 或 TAC 的成年患者，仅纳入每年 1 月至 9 月的出院患者，以便对所有病例进行 90 天的随访期。比较 90 天的院内总死亡率（指数入院死亡率加上 90 天的出院后死亡率）和 90 天的非计划性再入院率。为了评估 6 个月的回肠造口反转率，该队列随后被截断以排除每年 6 月以后的出院患者。使用多变量回归来调整患者的人口统计学和疾病严重程度。

结果

共有 2070 例患者在每年 1 月至 9 月期间出院：1486 例（71.8%）TAC 与 584 例（28.2%）DLI。行 TAC 的患者院内死亡率较高（34.5%比 27.7%，p=0.004）；然而，这种关联在多变量回归中并不存在（OR 1.14，95%CI 0.91-1.43）。在 1434 例存活出院的患者中，两组 90 天的非计划性再入院率相似（TAC：26.1%比 DLI：23.1%，p=0.26）。将队列截断为每年 1 月至 6 月期间存活出院的 1016 例患者后，行 DLI 的患者 6 个月的回肠造口反转率显著更高（26.4%比 8.3%，p<0.001）。DLI 与 6 个月回肠造口反转的几率更高独立相关（OR 2.68，95%CI 1.80-4.00）。