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Clinical Challenges in Emergency General Surgery: C Diff - When to Pull the Operative Trigger · Behind The Knife: The Surgery Podcast

• Clinical Challanges_C Diff_ Final === Speaker: [00:00:00] Welcome back to Behind the Knife with the emergency general surgery team in Tiger Country here at Mizzou. I'm Dr. Dev, and today we're gonna be tackling one of the most lethal and sometimes frustrating disease processes we manage as acute care surgeons, fulminant Clostridium difficile infection. This is not just a medical disease, it's a surgical disease with a w- narrow window where timing, judgment, and experience determines survival. So with that, let's meet the team. Speaker 2: Hey, I'm Kevin Barto. I'm Speaker: a general surgeon here at Mizzou. Speaker 3: Hi, I'm, uh, Raymond Okeke. I'm the SCCM ACS fellow. Speaker 4: And my name's Desirae Fletcher. I'm a third-year general surgery resident here. Speaker 5: And I'm Jeff Cochenour, one of the acute care surgery faculty and trauma medical director. Speaker: Awesome. Desirae, so let's level set for our listeners. The CDC and the American Society of Colorectal Surgeons defines Clostridium difficile as diarrhea, which is classically more than three watery stools per day, with positive C. diff tox, uh, toxin testing. But the clinical important distinction for our surgeons is severity Speaker 4: Yep, that's [00:01:00] correct. So mild disease is typically a white count less than fifteen thousand and creatinine less than one point five, whereas severe disease is the opposite, greater than fifteen thousand white count and creatinine greater than one point five. So fulminant disease, uh, is defined by hypotension, sepsis, shock, ileus, megacolon, or ICU-level sickness. The mortality for fulminant disease can exceed fifty percent, especially once organ failure develops. Speaker: Yeah, and that's key. Fulminant Clostridioides difficile is not simply just bad diarrhea. It's systemic disease. It's colitis plus end-organ malperfusion. In other words, it's essentially shock, right? Without-- or sepsis without the septic shock. Right. Speaker 3: Right. So, uh, risk factors here include recent antibiotic exposure, especially clindamycin, fluoroquinolones, cephalosporins, beta-lactamase inhibitors, plus advanced age, immunosuppression, IBD, diabetes, CHF, tube feeds, PPI exposure, and recent hospitalization or GI surgery.[00:02:00] Speaker: Yeah, that's quite a bit. Why don't you give us some contemporary diagnostic framework? Speaker 3: Right. The big concept here is diagnostic stewardship. So testing should generally be limited to patients who had new unexplained diarrhea, so at least three watery stools in twenty-four hours. And unless you're worried about fulminant disease with ileus or megacolon or unexplained, uh, leukocytosis, the most important thing here is to not test formed stool. Speaker 4: Right. So how do we test this? Uh, so testing is either with NAAT or PCR testing is what formally sends. Um, or you can actually do a two-step method, which can help distinguish between silent carriers, asymptomatic, and then symptomatic C. diff. The two-step process typically involves a toxin assay, the glutamate dehydrogenase, plus the NAAT. But no test perfectly separates colonization from the true infection. Speaker: Yeah. So what about-- where does imaging fall in all this, Rachel? Speaker 3: Right. So your CT scan will show colonic wall thickening. It will show [00:03:00] pancolitis, thumb printing, ascites, ileus, or toxic megacolon. It's important, though, to note that a normal or non-specific CT does not rule out clinically important disease, as this is, again, largely a mucosal-based disease. Speaker: Right, exactly. I think that's a big take-home point. CT does support the-- does not in some cases can support the diagnosis, but it doesn't decide the operation. So with that, let's anchor all this with the ASGAR treatment recommendations. Speaker 4: Yeah, absolutely. So for non-fulminant CDI, oral vanc or fidaxomicin are first-line therapies. Metronidazole, Flagyl, is no longer preferred as first-line therapy for most patients. Uh, this is because it's been shown to have lower cure rates and higher recurrence when compared to vancomycin. Speaker 3: Exactly. For fulminant CDI, ASGARs recommends vancomycin, so five hundred milligrams PO or enterally four times a day or Flagyl five hundred milligrams, and that's IV every eight hours. You can add, uh, rectal [00:04:00] vancomycin if there's ileus present. So again, important to stop or narrow the inciting antibiotics when possible, resuscitate with fluids and replace electrolytes, avoid antimotility agents, and then consult surgery early. Speaker: Exactly. The last part is probably most key for our audience. Early surgical consultation is not failure of medical management, but it's really the safe and correct management. So with that, uh, let's take a quick pivot and try to get to the literature a little bit, and let's highlight some of the key EGS papers as well as, uh, the actual guidance from the American Society of Colorectal Surgeons. Speaker 4: Yep. So from the American Society of Colorectal Surgeons, uh, early surgical consultation in fulminant C. diff is a strong recommendation. Indications for operative inte-intervention are refractory shock, so greater than twelve to twenty-four hours, a rising lactate trends, uh, typically greater than five, leukocytosis greater than fifty thousand, and organ failure. Uh, the key bottom [00:05:00] line with this is that delay equals mortality. Basically, waiting until multi-organ failure is established worsens po- post-op Speaker 3: mortality. Right. Uh, meta-analyses here have shown that subtotal cole- uh, colectomy actually reduces mortality compared to continued medical therapy in severe disease. Again, outcomes, however, remain poor overall, with about a thirty to fifty mortality, percent mortality. Speaker: Yeah. So with that, why don't we transition a bit? So what about the big debate in C. diff? Speaker 4: Yep. So kinda two arms, subtotal colectomy versus the loop ileostomy and lavage. Subtotal colectomy remains the gold standard and for source control. Loop ileostomy plus the antral vancomycin lavage is less invasive, however, there's highly mixed data on mortality benefit. Speaker: Yeah. So contemporary literature essentially suggests that ileostomy approach may work in select and less, maybe less sick patients, but in true fulminant shock, I think the answer will always safely be [00:06:00] colectomy remains the gold standard. But why don't we just unpack that a little bit and work a clinical in the end and bring our two senior surgeons on board? It's a forty-seven-year-old female. She has a history of decompensated cirrhosis. She's got a MELD of twenty-six with a history of chronic atrial fibrillation, heart failure with moderately reduced ejection fraction, around forty to forty-five percent, and type two diabetes. She just got back from a trip from Barcelona, and she's been having about three days of profuse watery diarrhea, cramping, abdominal pain, nausea, and vomiting. In the ER, her vitals were nineties over sixties, a heart rate of a hundred and twenty, temperature of thirty-seven point nine, uh, white count of twenty, creatinine of one eight, bicarb of eighteen, and an INR of two three. She had initial stool studies that were done in the ED that actually showed no C. diff, but enteropathogenic E. coli was positive, and at that point, she was started on Cipro and [00:07:00] admitted to the medicine ward. She started to look better just for a hot minute, though. About five days later, if we fast-forward, she had an abrupt change on the floor where she became febrile, hypotensive with maps less than fifty, altered mental status, and persistent diarrhea. At the time, her white count was found to be forty-five, with a lactate of four point five, creatinine of two eight, an INR of three two, and platelet count of eighty. Essentially, she was diagnosed to be in septic shock. And in all rapid manner, she was transferred to the medical ICU and started on goal-directed sepsis medical therapy with pressors and fluids, and she had a repeat PCR that was com-- uh, completed and positive now for C. diff. In the medical ICU, she got escalated appropriately medic-- uh, with medications. She was started on PO vancomycin and IV metronidazole. But during this time, she continued to spiral and was intubated for persistent hypoxia. And [00:08:00] following goal-directed fluid resuscitation, her acidosis started to level off, and her vasopressor requirements started to slowly reduce. During this time, the medical intensivist obtained a CT scan, and it showed diffuse colitis, primarily on the left side, without any evidence of megacolon or perforation. She did have massive third spacing, lots of ascites, edema, and asarco. At this point, finally, acute care surgery was consulted, and we're at the bedside. So let's take a quick pause here. You're the faculty. You've been told that there's no perforation, no megacolon. She's overall becoming a little bit more stable on vaso-vasopressors and acid and showing subtle signs of improvement in bac-- in bicarb and lactate. So the question to our panel and our senior surgeons is, would you operate right now, or would you keep pushing medical therapy? Is there something you would tell the medical intensivist that they haven't completed or should entertain? Speaker 2: So I think for me, looking at [00:09:00] this overall picture is you have a very medically complex patient with probably a surgical problem. I would say she has improved on most of your medical therapy. Nothing has significantly worsened over the last, uh, little bit of time. So at this point, I'd probably keep closely monitoring this patient, and if anything clinically changes, it would push me to go to the operating room. Again, no hard signs on CT scan, but at this point, again, we're treating the human and not the CT scan. Speaker: Yeah. Would you guys at this point consider maybe even adding rectal enemas, like mink enemas? Speaker 2: I think it, it's not harmful. It might be helpful. Speaker: Yeah. Well, she actually got-- She, she got that. They started the rectal enemas and waited about another twenty-four hours. About the next day, though, her lactate was still hanging around two to three point five, and her pH was still acidotic, metabolic primarily, seven point two eight. However, later that afternoon, she [00:10:00] started developing guarding, a little bit more per-- and localized peritonitis in the pelvis and right and left lower abdomen you guys know the answer at this point. She was taken to the operating room under our service, and we did perform a subtotal colectomy, which she did have a favorable outcome, which I'll talk about here shortly towards the end. But I want this to be kind of a transition point for us to talk about when to operate and the salient steps of the operations that we need to do. The American Society of Colorectal Surgery states that surgery, surgery should typically be reserved for perforation or severe colitis that fails to improve with medical therapy. But the problem with all recommendations and even textbooks is that there's just no clear black-and-white algorithm. We should probably talk-- It's more gray, and we should probably talk more about the physiology and kind of what triggers us as surgeons at the bedside to early, to intervene early or wait. So, Dr. Copenhaver, what are your triggers? Speaker 5: Primarily the [00:11:00] word kiddo and dart when it comes to thoracic decompression. Speaker: That's great. Speaker 5: Okay, uh- That's Speaker: great. Let's, let's go back to EGS. Speaker 5: So, uh, you know, it is a difficult question to answer. Um, I think most patients are gonna deserve at least twenty-four to forty-eight-ish hours of medical therapy, uh, and you're gonna see how to, um, how, how they respond. Uh, I think more important than any single collection of data points are gonna be the patient's data points over time, right? What, what's the trend? Uh, any patient that exhibits persistent or worsened acidosis or organ dysfunction, certainly more likely to, to move towards operation. Mm-hmm. Uh, I think exam, uh, although it's part of the equation, every one of these patients, it's difficult. It's limited. They're often already sedated. They're mechanically ventilated. Can you gauge worsened distension volume [00:12:00] overload? Anytime I think that there's a concern for intra-abdominal hypertension in addition to the abnormal physiology, then we're probably headed to the operating room. Speaker: So I think the teachable point is, you know, you don't have to operate on everyone early, but it's important to identify the patient who is crossing the line from severe C. diff to that medically refractory fulminant C. diff that's just festering before they become unsalvageable. Speaker 5: Exactly. Speaker: Yeah. Speaker 2: So again, I think timing is everything. Uh, you're looking at both physiology and exam, and that exam can be difficult. Uh, so in this case, again, this, this is an ill patient, had a white count of forty-five, lactate of four point five, had some pressor requirement, and the question is, should that have been enough? Or did the team do the right thing and wait to have peritoneal signs? And then another question is, did this patient, uh, with cirrhosis, did it cloud [00:13:00] judgment or change the urgency and approach? Again, MELD was twenty-six, INR three point two, and platelet count of eighty. This is a patient who may not survive surgery, but also this patient definitely won't survive without it. So the question becomes, does cirrhosis push you toward, number one, earlier surgery or, number two, a delayed surgery? Speaker: Yeah. I think listening to Cochenour talk and Honestly, listening to this patient and being actively involved in her care, my humble opinion is we wait before she becomes unsalvageable. And being less, uh, conservative and going to the OR early is probably the best bet. Again, for this case, a subtotal colectomy with end ileostomy was performed, which is what the, uh, American Society of Colorectal Surgeons does recommend for severe complicated or fulminant Clostridium difficile. And as we go through that, and as a patient is in extremis and peritonitic, and maybe we have [00:14:00] waited a little too long, unfortunately, on this case, we are now speed walking ourselves to the operating room. And, and Dr. Oppenheimer and Dr. Barto, I really would like us to have you guys walk us through the way that you handle the operation. What do you do? What do you tell the residents and the fellows, our young surgeons like, uh, myself, how to safely perform this operation in an expedited manner to get them through to resuscitation and continue their medical therapy? Speaker 2: So for me, uh, this is not a time to be cute. So it's, uh, gonna be a midline laparotomy. This is a source control operation. We're not here to make a fancy ostomy or some fancy oncologic resection. So the goal is to safely remove the diseased colon, limit your operative time, try to avoid as much bleeding as you can, and get the patient back to the ICU. Speaker: How much colon are you taking out? Speaker 5: Uh, I'm taking out everything I can get my hands on. Uh, quick mobilization getting both the, uh, right [00:15:00] and the left, uh, freed, uh, and then often using some sort of an energy device, uh, to just quickly move from, uh, wherever we've elected to divide terminal ileum and then just motoring our way around. Uh, most of the mesentery you're gonna leave behind. Again, as, uh, Dr. Barto just said, this is not an oncologic resection, so you're usually able to stay up towards the colon. But it's, it's probably one of, one of the most I don't know, uh, take the training wheels off maybe, uh, case where you have to... every move has got to be with a purpose so that you can get this operation done in a timely, uh, manner. Speaker 2: And I think another key here is sometimes the colon can fool you. Again, this is a mucosal disease, and sometimes I've seen you look inside and some of the colon looks pretty normal. But I agree with Jeff that a subtotal colectomy i- is, is what is needed. And according to the ASGARS point, again, gross appearance can [00:16:00] underestimate disease. Again, this is a mucosal-based disease. Uh, and then in some patients who did not receive the subtotal colectomy, reoperation for additional resection has been reported with a very high mortality. So I agree. I think we, we try to take as much as you can get out in a, a most efficient manner. Speaker: Yeah. So if I can ask you guys some, like, really more detailed kind of technical points in the OR. You know, it's one thing to be able to speak and say all the right things, like, in an oral board and in preparation. It's another thing when you're actually in the, you know, in the trenches and actually in the OR and doing the procedure. You know, I've, I've seen enough at this point now that- A lot of, a lot of these patients their colon, their tissues are just very friable. There's massive edema, especially in somebody like this with decompensated liver disease. Everything's hemorrhagic, kind of, oozing, and there's massive ascites, and sometimes a retroperitoneal might be popping into your face with a heavy hematoma when you're doing that [00:17:00] dissection. And then don't forget that splenic flexure, right? And how do you deal with the rectal stump? Do you guys do anything different? Like, what-- Do you use the same staplers every time, the same energy devices every time? Do you tackle the terminal ileum first, or do, or do you mobilize the sigmoid and take it off the rectosigmoid junction then go backwards? Do y'all do anything specific to expedite your operations? Speaker 2: So again, for me, I'm a midline laparotomy. Obviously, you start with exposure and a rapid assessment. Uh, if you can get the small bowel away, I, I'd certainly do that. I start on the right side. I think, uh, it's the most consistent anatomy. And again, your goal is to take the colon out, and my typical operative plan is to give an end ileostomy. I think it's easiest to divide the terminal ileum right away and use that as a handle. I'm also a very heavy stapler use, and so I tend to use a vascular load on my stapler to take most of my vascular pedicles, and it [00:18:00] makes it really fast and, and a, a much more hemostatic operation. I'm not digging through and chopping through with an energy device. I will say the splenic flexure is tricky. Don't be afraid to extend your incision as high as you need to, to get, to get all the way around the spleen or the splenic flexure, because you certainly don't wanna be taking out a spleen in addition to your colon in this, uh, pretty unstable human. Jeff, you got any other tips? Speaker 5: No, I think you know, the, the colon's likely gonna be-- it's gonna be distended. It's gonna be friable. Uh, you're gonna have to be careful with how you handle it. But again, every movement has to be with a purpose. Uh, so you've gotta not be afraid to, uh, pull it medially as you're taking down the lateral attachments. You still have to be careful as you come around hepatic flexure, for instance. Uh, don't, don't be so in a hurry that you pull up new edema or make, uh, silly errors Uh, I think if, if patients have, uh, big fat, uh, omentum, [00:19:00] uh, hanging off the transverse, sometimes taking an extra five or 10 minutes with an energy device to get that out of your way can be helpful. Uh, but just, I've already said it several times, but just moving with a purpose and continuing to progress is really the, the hallmark of, of a successful operation. Speaker 2: I would also say Dr. Debbi asked about s- you know, different staplers. Yeah. I, I would let the tissue tell you what to use. Yeah. So, um, across the rectum, I typically would use a thicker stapler load. Across the TI, obviously a thinner stapler load, and these are things I have planned out before I start the operation, and I tell my team, "I want all the stapler loads and all the colors," because I know it's, it's not a one-size-fits-all operation. Speaker: Yeah. Yeah, this is the case where you don't wanna be waiting for your scrub tech or your nurse to be going out and getting different loads because they're across the OR. The more you can communicate beforehand- Yeah ... as much as you have, you can get into Speaker 2: problems. You know the, you know the operation you're gonna do- Yeah ... and you know the tools you're gonna need, so [00:20:00] communicate that up front. Yeah. 'Cause that way nobody's running to find things. Speaker: How do you deal with your rectal stump? Do you, do you guys staple it and then oversew or cut it and sew it? With the fibral tissue and that thickness, just speaking from experience from just last year, um, I had one rectal stump blow out from a similar infection, and I've been stapling across. But you know, I've heard multiple M&Ms and multiple other senior surgeons, some people talk about just cutting it and then oversewing it in two layers or oversewing their staple lines. Seems like voodoo, but do you guys do anything different? Speaker 2: I make sure I have the correct staple load for the thickness of the tissue, that the stump is vascularized. You haven't taken all the mesentery and leave a long stump, and then I staple it and don't touch it again. Yeah. Speaker 5: I think most of the time the, the bad foment disease tends to make the colon look abnormal higher up. So by, by the time you get that far down, usually it's [00:21:00] not that difficult. And I think, you know, what, what you said, KB, that, that using whatever load that you normally would use across the rectum, if it's large, then, I mean, you just have to, you have to be prepared for a plan B. Yeah. Like, what you typically do is probably not gonna be safe. Don't, don't try to squeeze your usual, uh, square peg into a round hole. Speaker: Yeah. No, that's, that's, that's been kind of a hard learning point, trying to get out of your comfort zone and, and move and do what the patient needs. That kind of dovetails into this last point. This patient's erotic, right? She's acidotic, she's hypothermic, she's, um, she's bleeding from all of her orifices. She's on multiple pressors. You're trying to get this colon out safely and efficiently. What do you consider damage control? Like, and, and what are your steps for that damage control? Speaker 5: And so I, I think this is a great example of, uh, what is, uh, classically known as a trick question. Um, we're already doing a damage control [00:22:00] operation. We've already sort of, you know, kind of flirted with failure to rescue and, you know, depending on how abnormal their physiology is. So, the one parallel I'll say, uh, which was expertly discussed in one of our prior episodes, is when you get done doing a really difficult coecystectomy, all the bleeding dries up, right? In this operation, when you get yourself down to almost complete the colectomy, it's amazing oftentimes how often the physiology starts to improve so getting that disease colon out, it may be difficult, they may be sick, but I can't remember a time where I've bailed because they're ill because the one thing that's gonna make them better is finishing the operation. So you just, you gotta go, baby, go, uh, and be mindful. Uh, you have really close communication with your anesthesia colleagues, but I don't think there's a stopping [00:23:00] point. Speaker: I think a good principle that the TV guys are saying, and I think I'm getting from this, is don't let that perfect colectomy kill you. Don't, don't wait and be-- Uh, don't try to be cute. Don't try to be perfect. Be safe, be efficient, but get it out safely and, uh, get the patient back to the ICU as soon as possible to complete their resuscitation and medical care. So let's, let's pivot just for a minute or change gears. While we're here, let's just spend a few minutes on that most elusive topic and debate fulminant C. diff and the operative debate being, um, subtotal colectomy versus diverting loop ileostomy with antegrade colonic lavage, uh, using vancomycin. When it comes to this debate, there's a really good episode, I believe it's six forty-eight, for our EGS journal review that goes over this exact topic in a little bit more detail. It's broken down for, you know, our listeners in that episode, but I'd like to go over it in broad strokes for everybody to listen to and us to have a l- a discussion as it pertains to [00:24:00] this patient. So just to recap, the loop ileostomy approach really gained its traction with the Pittsburgh group in twenty eleven. Um, what they approved by doing that antegrade lavage with vancomycin enemas was a lower mortality compared to historical colectomy cohorts. And they touted the fact of colonic preservation and quicker s- uh, quicker time for potential reversal However, since then, a lot of data has come out, things have changed, and clinical practices has evolved. So let's kinda hit the pro sides of the loop ileostomy first. Raymond, let's make an argument. Speaker 3: All right. So for the loop ileostomy, it's less of a physiologic insult, uh, than a colectomy. Uh, you can avoid a large laparotomy and, uh, a dissection, especially in patients who are unstable. You can preserve the colon, which again, gives that potential quality of life benefit, and you can do a, um, an, an antegrade lavage and a [00:25:00] direct intraluminal vancomycin delivery. So essentially, you are providing intraluminal treatment for an intraluminal disease. So essentially, in the right patient, you can convert a lethal disease into a recoverable one without removing the colon. Speaker 2: And I would say a counterpoint to that is when you look at more recent data, there's really no consistent mortality benefit across studies. I do think there is a significant selection bias. Many of those studies exclude the sickest patients, and then oftentimes a failure require to delay colectomy, and that's not a trivial problem to have. So I don't think we're comparing apples to apples. We're comparing selected patients against the sickest patients. Speaker: Yeah. So hey, Jeff, why don't you tell us why the gold standard is colectomy? Speaker 5: Because it's the right operation. The, the point I think to be underscored is that, uh, if, if you get away with it, then the patient potentially gets better. Uh, if they don't, they potentially die, and, and I, I would argue in our experience [00:26:00] More often than not, the patients didn't have a very robust, uh, response, and we were going back to complete it. So we-- colon is the problem, the colon needs to be removed. Speaker: Yep. Toxin-producing colon, get it out. It's simple. Loop ileostomy tends to treat the mucosal lumen, and colectomy treats the disease, simply put. Um, let's make this practical. Raymond, tell us, tell us who gets what. Speaker 3: All right. So for a loop ileostomy, it, it can be a reasonable option if your patient is not in refractory shock, if they have limited vasopressor requirements, if there's no peritonitis, there's no perforation, there's no toxic megacolon, they have-- they're in an early disease trajectory, and you have a younger patient with a better physiologic reserve. Speaker 5: And I'll contrast, uh, colectomy, uh, is definitely the right answer, uh, obvious for any patient with, uh, evidence of perforation, uh, or exam evidence of peritonitis. As we discussed earlier, a little more subtle, but still a good [00:27:00] indication for colectomy would be a persistent or worsening, uh, acidosis, multi-organ dysfunction syndrome, uh, or they still require a significant volume of fluid. Colectomy. Speaker: Yeah. I, I can-- I sometimes feel like it might be a slippery slope when talking about loop ileostomy, and it seems like there might be a risk that it could potentially delay definitive care. Speaker 2: Yeah, and that's the danger. If you use it in the wrong patient, you've just delayed the inevitable colectomy and subsequently increased the mortality. Speaker: Um, when you look at, uh, the ASGE guidelines, it kind of reflects this nuance in a little bit more black and white matter. They say that subtotal colectomy remains the gold standard recommendation, and that loop ileostomy is a weak recommendation with low-quality evidence, and you should consider it selectively but just don't do it routinely. I think the safe board answer when preparing is clear. It's subtotal colectomy. But in the real world, uh, the answer is really more [00:28:00] nuanced and somewhat gray, and I think loop ileostomy is truly gonna be a tool, but it's not a replacement for source control. So with that, I think we've done a pretty good job, guys. Let's-- Why don't we close out with some rapid-fire questions? Desira, with fulminant C. diff, what, uh, what kind of diagnosis do you use? Speaker 4: So it's clinical and physiologic, not just radiographic. Speaker: Right. Raymond, tell us about the best initial medical management for fulminant disease. Speaker 3: So it's high-dose enteral vancomycin plus IV metronidazole with rectal vancomycin if there's an ileus present. Speaker: Solid. Desira, what's the gold standard operation? Speaker 4: Subtotal colectomy, rectal stump closure, and end ileostomy creation. Speaker: Why not segmental colectomy, Raymond? Speaker 3: So C. diff is mucosal and diffuse, so essentially the outside of the colon can lie to you. Speaker: What about loop ileostomy? Speaker 4: Selective option, weak evidence, and not for a crashing patient. Speaker: And Raymond, finish us off with the biggest mistake. Speaker 3: Right. Waiting for perforation, megacolon or [00:29:00] irreversible organ failure. Don't do that. Speaker: Solid. All right. Well, fulminant C. diff is one of the few diseases in EGS where the hardest decision is not what operation to do, it's when to stop hoping medical therapy works. The colon is the source, the physiology is the warning, and time is the enemy. The question isn't, "Can I save the colon?" The better question should be, "Can I save the patient?" So with that, I wanna thank everyone for hanging out with us here in Tiger Country at Mizzou. Dominate the Speaker 4: day.[00:30:00] [00:31:00] Speaker: Welcome back to Behind the Knife with the emergency general surgery team [00:32:00] in Tiger Country here at Mizzou. I'm Dr. Dev, and today we're gonna be tackling one of the most lethal and sometimes frustrating disease processes we manage as acute care surgeons, fulminant Clostridium difficile infection. This is not just a medical disease. It's a surgical disease with a wi- narrow window where timing, judgment, and experience determines survival. So with that, let's meet the team