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Page 2 of 6 Chouillard et al. Mini-invasive Surg 2021;5:9 I http://dx.doi.org/10.20517/2574-1225.2020.108

INTRODUCTION
Proximal fecal diversion through a loop ileostomy is commonly used to protect colorectal anastomosis.
Patients undergoing total mesorectal excision (TME) for rectal cancer are at higher risk of developing an
[1]
anastomotic leak . Diverting stomas were found to decrease both the clinical anastomotic leak rate and
[2]
the risk of re-operation in patients undergoing low anterior resection or TME . The temporary stoma
[3]
is usually closed 8 to 12 weeks after surgery, or even earlier when there are no clinical or radiological
signs of leak. Clostridium difficile infection (CDI) is a major cause of hospital-acquired infection that
[4,5]
continues to increase in incidence and severity among hospitalized patients . Symptoms range from mild
diarrhea to fulminant colitis causing severe sepsis, toxic megacolon, and even death. The major risk factors
for acquiring CDI are previous antibiotic exposure, severe underlying disease, older age, and immune
[4,5]
suppression . In this paper, we report on an unusual presentation of CDI in 2 patients who had an elective
reversal of ileostomy after TME for rectal cancer. The initial presentation of CDI mimicked more common
causes of postoperative intra-abdominal sepsis.

CASE REPORT
Case # 1
A 47-year-old woman, with an unremarkable past medical history was diagnosed with low rectal
[6]
adenocarcinoma. She underwent trans-anal TME with diverting loop ileostomy 10 weeks after
the completion of a neoadjuvant treatments, including 45-Gr external beam radiotherapy and
oral 5-fluorouracil. Her postoperative course was uneventful. Final pathology diagnosed a T1 N0
p
p
adenocarcinoma with an R0 resection. Fourteen days after resection, the patient underwent ileostomy
closure after digital exam, endoscopy, and a computerized tomography (CT) scan showed no evidence for
an anastomotic leak. She received one dose of intravenous antibiotics (cefuroxime 1 g IV) at the induction
of anesthesia. The immediate postoperative outcome was uneventful.

However, 3 weeks postoperatively, the patient started having lower abdominal pain and severe diarrhea
with over 10 bowel movements per day. Physical examination revealed a fever at 38.5 °C, a heart rate of
92 BPM, and blood pressure at 110/70 mmHg. Abdominal examination was within normal limits and
did not reveal any signs of superficial surgical site infections. Gynecological evaluation was negative for
3
sepsis. Serum blood tests revealed a leukocytosis with white blood count of 13,500/mm and an elevated
C-reactive protein (CRP) at 132 mg/L. Stool testing for Clostridium difficile toxin was negative. As
symptoms worsened with persistent fever, a pelvic magnetic resonance imaging (MRI) scan was performed
and revealed evidence suggestive for a leak of the colo-anal anastomosis [Figure 1].

A diagnostic laparoscopy was performed. More than 2 liters of clear liquid was found in the peritoneal
cavity that ultimately tested negative for bacteria, fungus, creatinine, bilirubin, or amylase. There were no
signs of intestinal perforation or ureteral injury; however, the colon was hypervascularized, thickened, and
dilated. A loop ileostomy was again performed.

Postoperatively, stool cultures became positive for Clostridium difficile (CD). Intravenous metronidazole
was administered for 48 h then orally for 10 more days. Clinical improvement occurred rapidly.

Case # 2
A 64-year-old man, with a past medical history of hypertension, type 2 diabetes mellitus, and coronary
artery disease, was diagnosed with low rectal adenocarcinoma. He underwent trans-anal TME with
diverting loop ileostomy, 11 weeks after neoadjuvant treatment, including 45-Gr external beam
radiotherapy and oral 5-fluorouracil. His initial postoperative course was uneventful. Pathology report
showed a T3 N0 adenocarcinoma with an R0 resection. Eight weeks after surgery, the patient had
p
p