Colon-sparing surgery for : Translatable lessons for the international humanitarian surgeon?Clostridium difficile: Translatable lessons for the international humanitarian surgeon?

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The large multicenter study sponsored by the Eastern Association for the Surgery of Trauma (EAST) offers support to the principle that colon-sparing surgery reduces mortality for patients with severe Clostridium difficile-associated disease (CDAD).1 Surgery has often been considered as a last resort in patients with CDAD with extremely sick patients undergoing total colectomy and end ileostomy with predictably high morbidity and mortality.2 Loop ileostomy and intraoperative colonic lavage with warmed polyethylene glycol 3350/electrolyte solution via the ileostomy, and postoperative antegrade instillation of vancomycin via the ileostomy, has been shown to reduce morbidity when compared to resectional surgery.3,4 Such an approach works on the premise that because CDAD is a mucosal disease, the priority is to remove the source of disease and its associated contaminants rather than resect the bowel.
Amoebiasis is recognized as the second most common cause of death from a parasitic infection worldwide.5 The causative protozoan organism—Entamoeba histolytica—is an aggressive pathogen that can invade the colonic mucosa, leading to amoebic colitis. Amoebic colitis and CDAD are both characterized by worsening diarrhea, with epithelial destruction, neutrophil migration, patchy colonic ulceration, and necrosis that may lead to toxic megacolon and perforation.5–7 Both pathologies may result in pseudomembranous colitis.8 Up to 40% of people with diarrhea in some developing nations are infected with E. histolytica,9 and fulminant amoebic colitis is its most life-threatening complication, with mortality from 50% to 89%.10–12 The population most at risk for amoebiasis may also have other factors that predispose them to a less favorable outcome, from a high burden of intestinal parasites and consequent nutritional compromise13 to concurrent infection with HIV/AIDS.14 Emergency surgery is indicated for both amoebic colitis and CDAD when patients are not improving despite optimal medical therapy and have actual or impending necrosis, perforation, or overwhelming sepsis. Unfortunately, in patients with both diseases, surgery is often considered only when the patient is in extremis, and radical surgery is often associated with poor outcomes and also has implications for longer term quality of life when compared to loop ileostomy. For CDAD patients, the requirement for preoperative intubation, organ failure, and shock requiring vasopressors are independent predictors of postoperative death, which may make pre-emptive surgery more desirable during earlier stages of disease.2 Because amoebic colitis and CDAD share clinical and pathologic features, and have similar treatment strategies, there may be some justification in applying evidence derived from CDAD (such as the EAST study1) to the surgical management of amoebic colitis.
A report of 122 patients with amoebic colonic perforations from Mexico City was published in 201015; segmental or total colectomy was undertaken in the vast majority of patients and overall mortality was 40% (coincidentally, the observed mortality in the contemporary cohort of patients treated for CDAD by total colectomy in the recent EAST report was also 40%1). As for CDAD, an earlier, less radical, but effective surgical solution would be most welcome. There have been reports from India of improved outcomes for colon-sparing surgery in amoebic colitis as early as 1978,16 and again from South Africa in the 1980s.17,18 However, there have been no large-scale clinical evaluations of colon-sparing surgery in this context in the last few decades. Indeed, a definitive review of the management of amoebic colitis published in 2003 in the Lancet did not even mention intestinal surgery as a therapeutic option.5 The apparent sparsity in recorded evidence for surgical management of amoebic colitis may be compounded by a publication bias against diseases of poverty19 or manuscript submission bias from poorer countries.
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