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Indications for surgery in Ulcerative Colitis – Is it time to rethink
- Chelliah R Selvasekar (19 November 2007)
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The survival benefit of elective colectomy in inflammatory bowel disease (IBD): Fact or fiction?
- Muhammad F Dawwas (21 November 2007)
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Chelliah R Selvasekar, Consultant Colorectal Surgeon Mid Cheshire Hospital, Crewe CW1 4QJ
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I read with interest the article by Roberts et al on the clinical outcome in patients with inflammatory bowel disease.1 Ulcerative colitis is a disease of young age and it is well known that 25-30% of patients will need colectomy in their life time.2 Proctocolectomy offers the complete cure for the colonic manifestation of the disease and restoration with ileal pouch anal anastomosis (IPAA) enables patients to maintain normal quality of life without stoma even after 20 years of follow up.3 Surgery eliminates the disease, avoids future risk of cancer, the need for surveillance and the medication needed to induce and maintain remissions.3 Nowadays, Proctocolectomy with IPAA can be safely performed using the laparoscopic approach and the short term results are comparable to open approach with the additional benefit of the minimally invasive technique.4 We have shown that with the introduction of biological treatment in the management of ulcerative colitis, the short-term complications following IPAA are higher and this in turn may compromise the long-term results of IPAA.5 It was difficult to prove in this study if this was a direct cause and effect relation or is it due to the severity of the disease or if the patients were nutritionally compromised to account for the statistically significant post operative complications. At the same time, the long-term side effects of biologics in patients with inflammatory bowel disease are not known. This paper by Roberts et al1 gives a clear indication that colorectal surgeons trained in performing IPAA should work closely with other members of the inflammatory bowel disease team to identify patients early who would benefit immensely from colectomy and restorative surgery to regain normal quality of life and avoid complications from emergency surgery or from non-intervention. Reference List 1.Roberts SE, Williams JG, Yeates D, Goldacre MJ. Mortality in patients with and without colectomy admitted to hospital for ulcerative colitis and Crohn's disease: record linkage studies. BMJ 2007; 335: 1033. 2.Carter MJ, Lobo AJ, Travis SP. Guidelines for the management of inflammatory bowel disease in adults. Gut 2004; 53 Suppl 5: V1-16. 3.Hahnloser D et al. Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis. Br J Surg 2007; 94: 333-40. 4.Larson DW et al. Safety, feasibility, and short-term outcomes of laparoscopic ileal-pouch-anal anastomosis: a single institutional case- matched experience. Ann Surg 2006; 243: 667-70. 5.Selvasekar CR et al. Effect of infliximab on short-term complications in patients undergoing operation for chronic ulcerative colitis. J Am Coll Surg 2007; 204: 956-62. Competing interests: None declared |
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Muhammad F Dawwas, Specialist Registrar Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ
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The study by Roberts and colleagues of mortality among hospital admissions for IBD 1 has a number of noteworthy limitations. Firstly, the observation that IBD patients undergoing an elective colectomy had a lower mortality than those either treated medically or requiring emergency colectomy, does not inofitself amount to “strong evidence suggesting that the threshold for elective colectomy is too high”. This is because IBD patients who electively undergo colectomy are usually those with chronic relapsing disease or malignancy risk whereas those requiring hospital admission for either medical management or emergency colectomy are usually far sicker with severe acute or fulminant disease.2 Those are therefore very different subgroups of patients with entirely distinct indications for colectomy and, consequently, it does not follow that lowering the threshold for elective surgery would necessarily reduce the numbers of those being admitted with severe acute disease. Secondly, the authors’ method of risk-adjustment for comorbidity is flawed given the poor accuracy and completeness of secondary medical diagnostic (vs. procedure) coding in the Hospital Episode Statistics database.3 Furthermore, their risk model neither included well-established predictors of the need for colectomy, such as IBD disease extent and race, 4,5 nor took the severity of comorbid disease into account, thereby making the highly counterintuitive assumption that patients with mild and severe comorbid disease have the same mortality risk. It is therefore perfectly plausible that patients treated medically were in fact high-risk surgical candidates who were destined to experience a poor prognosis and therefore appropriately not offered surgery. This contention is further supported by the authors own observation that patients managed conservatively during their index hospital admission had a similarly high mortality irrespective of whether they subsequently underwent colectomy. In conclusion, no evidence exists to change the current practice of consigning surgery in IBD to the treatment of last resort.2 REFERENCES 1. Roberts SE, Williams JG, Yeates D, Goldacre MJ. Mortality in patients with and without colectomy admitted to hospital for ulcerative colitis and Crohn's disease: record linkage studies. BMJ. 2007;335:1033. 2. Carter MJ, Lobo AJ, Travis SP; IBD Section, British Society of Gastroenterology. Guidelines for the management of inflammatory bowel disease in adults. Gut. 2004;53 Suppl 5:V1-16. 3. Aylin P, Alves B, Cook A, Bennett J, Bottle A, Best N, Catena B, Elliott P. Analysis of Hospital Episode Statistics for the Bristol Royal Infirmary Inquiry. Available at: http://www.bristol- inquiry.org.uk/Documents/hes_(Aylin).pdf. (accessed on 20/11/2007) 4. Nguyen GC, Laveist TA, Gearhart S, Bayless TM, Brant SR. Racial and geographic variations in colectomy rates among hospitalized ulcerative colitis patients. Clin Gastroenterol Hepatol. 2006;4:1507-1513. Erratum in: Clin Gastroenterol Hepatol. 2007;5:765. 5. Hoie O, Wolters FL, Riis L, Bernklev T, Aamodt G, Clofent J, Tsianos E, Beltrami M, Odes S, Munkholm P, Vatn M, Stockbrügger RW, Moum B; European Collaborative Study Group of Inflammatory Bowel Disease. Low colectomy rates in ulcerative colitis in an unselected European cohort followed for 10 years. Gastroenterology. 2007;132:507-15. Competing interests: None declared |
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