Diverting loop ileostomy with antegrade colonic lavage compared with colectomy in Clostridioides difficile colitis: A decade-long propensity score-matched analysis.

Abstract

Fulminant Clostridioides difficile colitis (CDC) carries high morbidity and mortality, often necessitating emergent surgical intervention. While total abdominal colectomy (TAC) remains the standard of care, diverting loop ileostomy with antegrade colonic lavage (DLI) has emerged as a colon-preserving alternative. This study aimed to compare outcomes between DLI and TAC and evaluate the safety of a DLI first approach, including cases that ultimately failed DLI. We performed a retrospective analysis of adult patients with CDC undergoing TAC or DLI between 2012 and 2021 using the National Inpatient Sample. Patients with abdominal compartment syndrome, colonic perforation, or alternative surgical indications were excluded. Patients who required TAC because of failed DLI trial were included in the DLI group. Propensity score matching was performed 1:1 to adjust for demographics, illness severity, and comorbidities. Outcomes assessed included mortality, discharge disposition, hospital length of stay, complications, and costs. A subgroup analysis compared patients with failed DLI with primary TAC. Of 6,618 patients undergoing surgery for CDC, 10.7% received DLI and 89.3% underwent TAC. After matching, 668 patients remained in each group. No significant difference was observed in mortality (24.4% DLI vs. 26.0% TAC, p = 0.600), although DLI patients had longer hospital stays and higher costs ( p < 0.05). Postoperative wound disruption and infection were significantly less common in the DLI group ( p < 0.05). Among patients with failed DLI (n = 116), outcomes including mortality, length of stay, and complications were comparable with primary TAC postmatching. Diverting loop ileostomy with antegrade colonic lavage appears to be a safe alternative to colectomy in select patients with fulminant CDC. Although it does not confer a survival benefit, it is associated with lower wound morbidity and does not worsen outcomes even when conversion to colectomy is required. These findings support the selective use of DLI as a colon-preserving surgical strategy. Therapeutic/Care Management; Level III.