Postoperative complications and mortality following colectomy for ulcerative colitis

miR-195 plays a role in steroid resistance of ulcerative colitis by targeting Smad7

An imbalance in pro- and anti-inflammation is an important mechanism of steroid resistance in UC (ulcerative colitis), and miRNAs may participate in this process. The present study aimed to explore whether miRNAs play a role in the steroid resistance of UC by regulating gene expression of the inflammation signal pathway. SS (steroid-sensitive) patients, SR (steroid-resistant) patients and healthy individuals were recruited. In vivo miRNA profiles of serum samples showed that miR-195 was decreased significantly in the SR group compared with the SS group (P<0.05). This result was confirmed by qPCR (quantitative real-time PCR) and miRNA ISH (in situ hybridization) in serum and colon tissue samples. Online software was used to identify Smad7 mRNA as a potential target of miR-195. The direct interaction of miR-195 and Smad7 mRNA was investigated using a biotinylated miR-195 pull-down assay. Overexpression of a miR-195 precursor lowered cellular levels of Smad7 protein; conversely, antagonism of miR-195 enhanced Smad7 translation without disturbing Smad7 mRNA levels. A luciferase reporter assay revealed a repressive effect of miR-195 via a single Smad7 3'-UTR target site, and point mutation of this site prevented miR-195-induced repression of Smad7 translation. Furthermore, increased levels of miR-195 led to a decrease in c-Jun and p65 expression. In contrast, transfection with anti-miR-195 led to increased levels of c-Jun and p65 protein. The decrease in miR-195 led to an increase in Smad7 expression and corresponding up-regulation of p65 and the AP-1 (activator protein 1) pathway, which might explain the mechanism of steroid resistance in UC patients.

Short- and Long-Term Outcomes of Acute Severe Ulcerative Colitis in Korea: The 1999-2005 Cohort

BACKGROUND

No previous studies have evaluated the long-term outcomes of acute severe ulcerative colitis (ASUC) in non-Caucasian populations. The purposes of this study were to evaluate the short- and long-term outcomes of Korean patients with ASUC.

METHODS

We retrospectively analyzed 99 Korean patients with ASUC who satisfied the criteria given by Truelove and Witts between 1999 and 2005. The short-term outcome parameter was the colectomy rate during index hospitalization, and the long-term outcome parameters were the rates of colectomy and rehospitalization after discharge from index hospitalization.

RESULTS

During index hospitalization, 16 of 99 patients (16.2%) underwent colectomy: 6 of 71 responders (8.5%) to intravenous steroids on day 3 versus 10 of 28 nonresponders (35.7%), as assessed using the Oxford index (P = 0.002). Among 83 patients who avoided colectomy during index hospitalization, 13 patients (15.7%) underwent colectomy during the median follow-up period of 10.6 years. The cumulative probability of colectomy tended to be lower in complete responders on day 7 of intravenous steroid therapy (CR7) than in others: 3.7% versus 13.9% at 5 years and 7.6% versus 18.2% at 10 years (P = 0.100). The cumulative probability of rehospitalization was significantly lower in CR7 than in other patients: 20.5% versus 37.5% at 5 years and 31.4% versus 48.2% at 10 years (P = 0.043).

CONCLUSIONS

Assessing the degree of response to intravenous steroids helps predict the short- and long-term outcomes in patients with ASUC. Korean patients with ASUC may have better clinical courses than Caucasians, as indicated by the lower colectomy rate.

Systematic Review: Sequential Rescue Therapy in Severe Ulcerative Colitis: Do the Benefits Outweigh the Risks?

BACKGROUND

The options for medical management of acute severe steroid-refractory ulcerative colitis (UC) are limited. Recent guidelines recommend against use of sequential rescue therapy in the setting of failed medical management with initial salvage therapy. A systematic review was conducted to assess outcomes of sequential rescue therapy with infliximab (IFX) and calcineurin inhibitors like cyclosporine (CsA) or tacrolimus (Tac) in patients with steroid-refractory UC.

METHODS

A literature search identified studies that investigated treatment with IFX and CsA or Tac in acute severe UC. Outcomes of interest included short-term symptomatic response to treatment, rates of remission, adverse drug reactions, serious infections, mortality, and colectomy at 3 and 12 months.

RESULTS

Overall, ten studies with 314 participants were eligible for inclusion. After sequential treatment, patients achieved short-term treatment response in 62.4% (95% confidence interval [CI], 57.0%-67.8%) of cases and remission in 38.9% (95% CI, 33.5%-44.3%). Colectomy rates were 28.3% (95% CI, 21.7%-34.5%) at 3 months and 42.3% (95% CI, 36.0%-48.6%) at 12 months. Adverse events were encountered by 23.0% (95% CI, 17.7%-28.3%) of patients, including serious infections in 6.7% (95% CI, 3.6%-9.8%) and mortality in 1% (95% CI, 0%-2.1%).

CONCLUSIONS

The risk of sequential therapy in steroid-refractory UC seems lower than initially reported. Caution must be exercised however because of very low-quality evidence. In contrast to recent guidelines, the current analysis does not support a decision for or against use of sequential rescue therapy, which should only be performed at specialized referral centers familiar with the use of calcineurin inhibition.

Predicting outcomes in acute severe ulcerative colitis

Response to corticosteroid treatment in acute severe ulcerative colitis (ASUC) has changed very little in the past 50 years. Predicting those at risk at an early stage helps stratify patients into those who may require second line therapy or early surgical treatment. Traditionally, risk scores have used a combination of clinical, radiological and biochemical parameters; established indices include the 'Travis' and 'Ho' scores. Recently, inflammatory bowel disease genetic risk alleles have been built into models to predict outcome in ASUC. Given the multifactorial nature of inflammatory bowel disease pathogenesis, in the future, composite scores integrating clinical, biochemical, serological, genetic and other '-omic' data will be increasingly investigated. Although these new genetic prediction models are promising, they have yet to supplant traditional scores, which remain the best practice. In this modern era of rescue therapies in ASUC, robust scoring systems to predict failure of ciclosporine and infliximab must be devised.

Intrapartum corticosteroid use significantly increases the risk of gestational diabetes in women with inflammatory bowel disease

BACKGROUND AND AIMS

Women with inflammatory bowel disease (IBD) may be at higher risk of adverse pregnancy outcomes. This study compared perinatal outcomes in women with and without IBD.

METHODS

The population-based Data Integration, Measurement, and Reporting (DIMR) administrative discharge database was used to identify women (≥18 years of age) in Alberta, Canada, with IBD who delivered a baby between 2006 and 2009 inclusive. Women without IBD were randomly sampled and matched in a 3:1 ratio to IBD cases by age at conception (±1 year). Odds ratios of gestational diabetes, preterm birth, low birth weight, cesarean section, and neonatal intensive care unit admission were calculated.

RESULTS

One hundred and sixteen IBD patients were age-matched to 381 pregnant women without IBD. Gestational diabetes, preterm birth, and cesarean section were more common in women with IBD compared with controls (6.9 versus 1.8%, p = 0.03; 12.9 versus 0.3%, p < 0.0001; 43.1 versus 21.0%, p = 0.009, respectively). On multivariate analysis, women with IBD were independently more likely to have gestational diabetes (odds ratio [OR] = 4.3; 95% confidence interval [CI] 1.2-16.3), preterm birth (OR = 19.7, 95% CI 2.2-173.9), and to deliver by cesarean section (OR = 2.7, 95% CI 1.6-4.6) after adjusting for age and smoking status.

CONCLUSION

Intrapartum corticosteroid use significantly increases the risk of gestational diabetes in women with IBD. Furthermore, IBD patients are at higher risk of preterm delivery and are more likely to undergo cesarean section compared with a healthy age-matched population. The finding of a higher risk of gestational diabetes is a novel finding not previously reported in the IBD literature.

Colectomy is a risk factor for venous thromboembolism in ulcerative colitis

AIM: To compare venous thromboembolism (VTE) in hospitalized ulcerative colitis (UC) patients who respond to medical management to patients requiring colectomy.

METHODS: Population-based surveillance from 1997 to 2009 was used to identify all adults admitted to hospital for a flare of UC and those patients who underwent colectomy. All medical charts were reviewed to confirm the diagnosis and extract clinically relevant information. UC patients were stratified by: (1) responsive to inpatient medical therapy (n = 382); (2) medically refractory requiring emergent colectomy (n = 309); and (3) elective colectomy (n = 329). The primary outcome was the development of VTE during hospitalization or within 6 mo of discharge. Heparin prophylaxis to prevent VTE was assessed. Logistic regression analysis determined the effect of disease course (i.e., responsive to medical therapy, medically refractory, and elective colectomy) on VTE after adjusting for confounders including age, sex, smoking, disease activity, comorbidities, extent of disease, and IBD medications (i.e., corticosteroids, mesalamine, azathioprine, and infliximab). Point estimates were presented as odds ratios (OR) with 95%CI.

RESULTS: The prevalence of VTE among patients with UC who responded to medical therapy was 1.3% and only 16% of these patients received heparin prophylaxis. In contrast, VTE was higher among patients who underwent an emergent (8.7%) and elective (4.9%) colectomy, despite greater than 90% of patients receiving postoperative heparin prophylaxis. The most common site of VTE was intra-abdominal (45.8%) followed by lower extremity (19.6%). VTE was diagnosed after discharge from hospital in 16.7% of cases. Elective (adjusted OR = 3.69; 95%CI: 1.30-10.44) and emergent colectomy (adjusted OR = 5.28; 95%CI: 1.93-14.45) were significant risk factors for VTE as compared to medically responsive UC patients. Furthermore, the odds of a VTE significantly increased across time (adjusted OR = 1.10; 95%CI: 1.01-1.20). Age, sex, comorbidities, disease extent, disease activity, smoking, corticosteroids, mesalamine, azathioprine, and infliximab were not independently associated with the development of VTE.

CONCLUSION: VTE was associated with colectomy, particularly, among UC patients who failed medical management. VTE prophylaxis may not be sufficient to prevent VTE in patients undergoing colectomy.

Effect of preoperative biologic drugs on complications and function after restorative proctocolectomy with primary ileal pouch formation: systematic review and meta-analysis

BACKGROUND

Debate exists concerning the presumed risk of postoperative complications in patients with ulcerative colitis (UC) receiving preoperative infliximab (IFX). Meta-analyses are contrasting because of many confounders included into analysis. Our aim was to determine the impact of IFX on pouch-related postoperative complications in patients with UC undergoing surgery with primary ileal pouch-anal anastomosis.

METHODS

We performed a systematic review to identify studies comparing the outcomes of patients undergoing surgery for UC with or without previous IFX exposure. The primary end points were (1) early ileal pouch-anal anastomosis-related complications after surgery with primary pouch formation and (2) those occurring after ileostomy closure. Secondary end points were the effects of IFX on total, infectious, and noninfectious complications in patients with UC undergoing any type of surgery. Results are reported as pooled odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

Seven papers, including 162 patients receiving biologics and 468 controls all undergoing primary pouch formation, were included for the primary aim. Patients receiving IFX were more likely developing early (OR = 4.12; 95% CI, 2.37-7.15; P < 0.001) and post-ileostomy closure (OR = 2.27; 95% CI, 1.27-4.05; P = 0.005) ileal pouch-anal anastomosis-related complications. Number needed to harm was calculated to be 5 and 4, respectively. Having received at least 3 IFX effusions increased the risk of early complications (OR = 9.59; 95% CI, 2.92-31.44; P = 0.0002), whereas an interval of <12 weeks since last effusion did not (OR = 2.35; 95% CI, 0.98-5.64; P = 0.06). Meta-analyses of 14 studies reporting on any type of surgery found that IFX showed a trend toward higher total and infectious complications, but no significant differences were observed. Biologics were associated with lower surgical site infection (OR = 0.67; 95% CI, 0.45-0.99; P = 0.04).

CONCLUSIONS

IFX exposure increases early pouch-specific complications and complications after ileostomy closure in UC. Avoiding primary pouch formation could be a prudent approach.

Refractory distal ulcerative colitis: is proctocolectomy always necessary?

Refractory distal ulcerative colitis (RDUC) is defined as persistence of symptoms caused by endoscopically proven colonic inflammation located at the rectum or left colon despite oral/topical steroids and 5-ASA. RDUC affects a small subset of patients and is associated with chronic disabling symptoms and increased social/medical costs. Moreover, patients with long-standing ulcerative colitis (UC) carry an elevated risk of developing colorectal cancer and colonic mucosa high-grade dysplasia. Alternative medical strategies in steroid refractory disease are unlikely to provide durable remission in all patients, carry potential severe side effects and, as immunosuppressants, the risk of other neoplasms, and may increase the short-term complication rate when surgery is finally required. Restorative proctocolectomy with ileal pouch-anal anastomosis (RP-IPAA) allows the complete removal of the diseased rectum and colon, virtually eliminating the risk of malignant transformation and reestablishing intestinal continuity with continence preservation. Since the introduction of this surgical procedure, morbidity and mortality rates have been drastically reduced. Despite the still notable rate of surgical complications, long-term quality of life assessment has shown excellent results in nearly all patients who have undergone RP-IPAA, comparing well with the general population. Furthermore, when performed for distal UC, RP-IPAA produces similar surgical outcomes with respect to pancolitis. In conclusion, RP-IPAA should always be considered in patients with RDUC, and multidisciplinary counseling should provide patients clear information about the advantages of surgery and possible complications as well as the chance to achieve disease remission with medical therapy.

Inflammatory bowel disease cause-specific mortality: a primer for clinicians

BACKGROUND

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC) is perceived to harbor significant morbidity but limited excess mortality, thought to be driven by colon cancer, compared with the general population. Recent studies suggest mortality rates seem higher than previously understood, and there are emerging threats to mortality. Clinicians must be up to date and able to clearly convey the causes of mortality to arm individual patients with information to meaningfully participate in decisions regarding IBD treatment and maintenance of health.

METHODS

A MEDLINE search was conducted to capture all relevant articles. Keyword search included: "inflammatory bowel disease," "Crohn's disease," "ulcerative colitis," and "mortality."

RESULTS

CD and UC have slightly different causes of mortality; however, malignancy and colorectal cancer-associated mortality remains controversial in IBD. CD mortality seems to be driven by gastrointestinal disease, infection, and respiratory diseases. UC mortality was primarily attributable to gastrointestinal disease and infection. Clostridium difficile infection is an emerging cause of mortality in IBD. UC and CD patients have a marked increase in risk of thromboembolic disease. With advances in medical and surgical interventions, the exploration of treatment-associated mortality must continue to be evaluated.

CONCLUSIONS

Clinicians should be aware that conventional causes of death such as malignancy do not seem to be as significant a burden as originally perceived. However, emerging threats such as infection including C. difficile are noteworthy. Although CD and UC share similar causes of death, there seems to be some differences in cause-specific mortality.

Colorectal cancer surveillance in patients with inflammatory bowel disease and primary sclerosing cholangitis: an economic evaluation

BACKGROUND

The cost-effectiveness of annual colonoscopy for detection of colorectal neoplasia among patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) is uncertain. The aim of this study was to determine whether annual colonoscopy among patients with IBD-PSC is cost-effective compared with less frequent intervals from the perspective of a publicly funded health care system.

METHODS

A cost-utility analysis using a Markov model was used to simulate a 35-year-old patient with a 10-year history of well-controlled IBD and a recent diagnosis of concomitant PSC. The following strategies were compared: no surveillance, colonoscopy every 5 years, biennial colonoscopy, and annual colonoscopy. Outcome measures included: costs, number of cases of dysplasia found, number of cancers found and missed, deaths, quality-adjusted life-years (QALYs) gained, and the incremental cost per QALY gained.

RESULTS

In the base-case analysis, no surveillance was the least expensive and least effective strategy. Compared with no surveillance, the cost per QALY of surveillance every 5 years was CAD $15,021. The cost per QALY of biennial surveillance compared with surveillance every 5 years was CAD $37,522. Annual surveillance was more effective than biennial surveillance, but at an incremental cost of CAD $174,650 per QALY gained compared with biennial surveillance.

CONCLUSIONS

More frequent colonoscopy screening intervals improve effectiveness (i.e., detects more cancers and prevents additional deaths), but at higher cost. Health systems must consider the opportunity costs associated with different surveillance colonoscopy intervals when deciding which strategy to implement among patients with IBD-PSC.

Rising post-colectomy complications in children with ulcerative colitis despite stable colectomy rates in United States

BACKGROUND AND AIMS

In children with ulcerative colitis, data on temporal colectomy trends and in-hospital post-colectomy complications are limited. Thus, we evaluated time trends in colectomy rates and post-colectomy complications in children with ulcerative colitis.

METHODS

We identified all children (≤18years) with a diagnosis code of ulcerative colitis (ICD-9: 556.X) and a procedure code of colectomy (ICD-9: 45.8 and 45.7) in the Kids' Inpatient Database for 1997, 2000, 2003, 2006 and 2009. The incidence of colectomies for pediatric ulcerative colitis was calculated and Poisson regression analysis was performed to evaluate the change in colectomy rates. In-hospital postoperative complication rates were assessed and predictors for postoperative complications were evaluated using multivariate logistic regression.

RESULTS

The annual colectomy rate in pediatric ulcerative colitis was 0.43 per 100,000person-years, which was stable throughout the study period (P>.05). Postoperative complications were experienced in 25%, with gastrointestinal (13%) and infectious (9.3%) being the most common. Postoperative complication rates increased significantly by an annual rate of 1.1% from 1997 to 2009 (P=.01). However, other independent predictors of postoperative complications were not identified. Patients with postoperative complications had significantly longer median length of stay (14.3days vs 8.2days; P<.001) and higher median hospital charges per patient (US $81,567 vs US $55,461; P<.001) compared to those without complications.

CONCLUSION

Colectomy rates across the United States in children with ulcerative colitis have remained stable between 1997 and 2009; however, in-hospital postoperative complication rates have increased.

Risk of colectomy in patients with ulcerative colitis under thiopurine treatment

BACKGROUND AND AIMS

Little is known about the risk factors of colectomy in patients with ulcerative colitis (UC) under thiopurine treatment. The aim of the study was to determine the prevalence and the predictive risk factors of colectomy in an extensive cohort of patients with UC treated with thiopurines in Spain.

METHODS

Among 5753 UC patients, we identified those diagnosed between 1980 and 2009 and treated with azathioprine or mercaptopurine (AZA/MP). We analyzed the age at diagnosis, familial history of IBD, extraintestinal manifestations (EIMs), disease extent, smoking status and treatment requirements (AZA/MP, cyclosporine (CsA) or anti-TNFα). Colectomies for dysplasia or cancer were excluded. Survival analysis and Cox proportional hazard regression were performed. Results were reported as hazard ratios (HR) with 95% CI.

RESULTS

Among the 1334 cases included, 119 patients (8.9%) required colectomy after a median time of 26 months (IQR 12-42) after AZA/MP initiation. Independent predictors of colectomy were: Extensive UC (HR 1.7, 95% CI: 1.1-2.6), EIMs (HR 1.5, 95% CI: 1.0-2.4), need for antiTNFα (HR 2.3, 95% CI: 1.5-3.4) and need for CsA (HR 2.4, 95% CI: 1.6-3.7). Patients requiring early introduction of AZA/MP had an increased risk of colectomy with a HR of 4.9 (95% CI: 3.2-7.8) when AZA/MP started in the first 33 months after UC diagnosis.

CONCLUSIONS

Nearly one-tenth of patients with UC under thiopurines require colectomy. Extensive UC, EIMs, need for CsA or anti-TNFα ever and an early need for AZA/MP treatment were associated with a higher risk of colectomy. These risk factors of colectomy could help to stratify risk in further controlled studies in UC.

The incidence rate of colectomy for medically refractory ulcerative colitis has declined in parallel with increasing anti-TNF use: a time-trend study

BACKGROUND

Medical therapy is standard treatment for ulcerative colitis with colectomy reserved for medically refractory disease or malignancy. The introductions of ciclosporin in 1994 and anti-TNF therapy in 2005 have extended medical management options.

AIM

To determine whether the colectomy incidence rate for medically refractory ulcerative colitis has changed since the introduction of anti-TNF therapy.

METHODS

Adult patients with a diagnosis of ulcerative colitis and who subsequently underwent an urgent or elective colectomy for medically refractory disease in Edmonton, Canada between 1 January 1998 and 31 December 2011 were identified. Log-linear regression was used to estimate the annual percent change in the total colectomy incidence rate (urgent and elective combined) and the urgent and elective incidence rates individually, before and after 2005, the year infliximab was approved for use in ulcerative colitis. Temporal trends of drug utilisation in this study population were also described.

RESULTS

During 1998-2011, 481 patients with ulcerative colitis underwent a colectomy for medically refractory disease. There was negligible change in the total colectomy incidence rate from 1998 to 2005, with an annual percent change of 4.4% (95% confidence interval (CI): -1.12% to 10.16%). From 2005-2011, following the approval and increasing use of anti-TNF therapy, the total colectomy incidence rate decreased by 16.1% (95% CI: -21.32% to -10.54%) every year to 0.9 per 100 ulcerative colitis patients in 2011.

CONCLUSION

The total incidence rate of colectomy for medically refractory ulcerative colitis has declined substantially since 2005, paralleling the increased use of anti-TNF therapy in this patient population.

Mortality after total colectomy in 3084 patients with inflammatory bowel disease: a population-based cohort study

BACKGROUND

A high post-operative mortality has been reported following colectomy in patients with inflammatory bowel disease (IBD), especially in some patient groups.

AIMS

To investigate the 40-day mortality following colectomy in patients with IBD. The secondary aim was to assess whether colectomised IBD patients have an increased mortality compared to the general population.

METHODS

This is a population-based register study of all patients with IBD in Sweden who underwent total colectomy in 2000-2010. The cohort was identified using international classification codes for ulcerative colitis (UC) and Crohn's disease (CD). Patients registered with both UC and CD before colectomy (UCCD) were analysed separately. Each patient was followed-up to the date of death, migration or 31st of December 2010, whichever came first. Kaplan-Meier survival curves, Cox proportional hazards models and relative mortality rates were used to describe mortality.

RESULTS

In the cohort of 3084 patients, 2424 were diagnosed with UC, 326 with CD and 334 with UCCD. The 40-day, 1-year and 3-year mortality was 1.3%, 3.1% and 6.0%, respectively. The highest 40-day mortality was seen in patients ≥59 years of age (4.4%). Colectomy at the primary hospitalisation for IBD did not significantly increase the risk of post-operative mortality, nor did hospital volume. The relative survival after 3 years was 0.99, 0.98, 0.97 and 0.90 in those <30, 30-43, 44-58 and ≥59 years old, respectively.

CONCLUSION

The 40-day mortality following total colectomy in IBD patients in Sweden is low, except in patients ≥59 years old.

Postoperative complications and emergent readmission in children and adults with inflammatory bowel disease who undergo intestinal resection: a population-based study

BACKGROUND

Although the nature and frequency of postoperative complications after intestinal resection in patients with inflammatory bowel disease have been previously described, short-term readmission has not been characterized in population-based studies. We therefore assessed the risk of postoperative complications and emergent readmissions after discharge from an intestinal resection.

METHODS

We used a Canadian provincial-wide inpatient hospitalization database to identify 2638 Crohn's disease (CD) and 559 ulcerative colitis (UC) admissions with intestinal resection from 2002 to 2011. We identified the cumulative risk of in-hospital complication and emergent readmission within 90 days after discharge along with predictors for both outcomes using a Poisson regression for binary outcomes.

RESULTS

The cumulative risks of in-hospital postoperative complications and 90-day emergent readmission were 23.8% and 12.6%, respectively in CD and 33.3% and 11.1%, respectively in UC. The predictors for in-hospital postoperative complications for CD and UC included older age, comorbidities, and open laparatomy for CD, additional predictors included emergent admission, stoma surgery, and concurrent resection of both small and large bowel. The predictors for 90-day readmission for CD included a postoperative complication (risk ratio, 1.61; 95% confidence interval, 1.30-2.01), emergent admission (risk ratio, 1.39; 95% confidence interval, 1.12-1.73), and stoma formation (risk ratio, 1.49; 95% confidence interval, 1.15-1.93) at the hospitalization requiring surgery.

CONCLUSIONS

Readmission and postoperative complications are common after intestinal resection in CD and UC. Clinicians should closely monitor surgical patients who required emergent admission, undergo surgery with stoma formation, or develop in-hospital postoperative complications to anticipate need for readmission or interventions to prevent readmission.

Clostridium difficile infection worsens the prognosis of ulcerative colitis

BACKGROUND

The impact of Clostridium difficile infections among ulcerative colitis (UC) patients is well characterized. However, there is little knowledge regarding the association between C difficile infections and postoperative complications among UC patients.

OBJECTIVE

To determine whether C difficile infection is associated with undergoing an emergent colectomy and experiencing postoperative complications.

METHODS

The present population-based case-control study identified UC patients admitted to Calgary Health Zone hospitals for a flare between 2000 and 2009. C difficile toxin tests ordered in hospital or 90 days before hospital admission were provided by Calgary Laboratory Services (Calgary, Alberta). Hospital records were reviewed to confirm diagnoses and to extract clinical data. Multivariate logistic regression analyses were performed among individuals tested for C difficile to examine the association between C difficile infection and emergent colectomy and diagnosis of any postoperative complications and, secondarily, an infectious postoperative complication. Estimates were presented as adjusted ORs with 95% CIs.

RESULTS

C difficile was tested in 278 (58%) UC patients and 6.1% were positive. C difficile infection was associated with an increased risk for emergent colectomy (adjusted OR 3.39 [95% CI 1.02 to 11.23]). Additionally, a preoperative diagnosis of C difficile was significantly associated with the development of postoperative infectious complications (OR 4.76 [95% CI 1.10 to 20.63]).

CONCLUSION

C difficile diagnosis worsened the prognosis of UC by increasing the risk of colectomy and postoperative infectious complications following colectomy. Future studies are needed to explore whether early detection and aggressive management of C difficile infection will improve UC outcomes.

Cytomegalovirus infection and postoperative complications in patients with ulcerative colitis undergoing colectomy

BACKGROUND

Ulcerative colitis (UC) can be complicated by reactivation of cytomegalovirus (CMV). CMV reactivation may change the course of UC and may require antiviral treatment. Some risk factors of CMV reactivation have previously been identified, whereas the association between CMV reactivation and postoperative complications has not been examined systematically.

METHODS

Patients with UC operated with colectomy due to active UC were studied (n = 77). Patient and disease characteristics, as well as postoperative complications were recorded and CMV was detected by immunohistochemical examination of multiple sections from the colectomy specimen.

RESULTS

CMV was found in nine (11.7%) colectomy specimens. CMV-positive patients received significantly higher doses of corticosteroids at colectomy than CMV-negative patients (61.1 ± 23 vs 32.5 ± 32 mg/day, p = 0.01). CMV-positive patients were also older, had a higher risk of severe complications, higher American Society of Anesthesiologists (ASA) score, longer preoperative stay, and a higher rate of acute surgery. Complications occurred in 30 (39%) patients after surgery, 8(10.4%) of whom were serious. Two CMV-positive patients (2.6%) died in-hospital after the colectomy. High ASA score was associated with the occurrence of serious complications.

CONCLUSION

A relatively small proportion of patients with UC operated by colectomy were CMV positive. CMV positivity was associated with old age, high dose of corticosteroids at operation, high ASA score, acute surgery, and severe postoperative complications. Patients with such characteristics may be at risk of CMV infection and may require special management.

Defining quality indicators for best-practice management of inflammatory bowel disease in Canada

BACKGROUND

There is a paucity of published data regarding the quality of care of inflammatory bowel disease (IBD) in Canada. Clinical quality indicators are quantitative end points used to guide, monitor and improve the quality of patient care. In Canada, where universal health care can vary significantly among provinces, quality indicators can be used to identify potential gaps in the delivery of IBD care and standardize the approach to interprovincial management.

METHODS

The Emerging Practice in IBD Collaborative (EPIC) group generated a shortlist of IBD quality indicators based on a comprehensive literature review. An iterative voting process was used to select quality indicators to take forward. In a face-to-face meeting with the EPIC group, available evidence to support each quality indicator was presented by the EPIC member aligned to it, followed by group discussion to agree on the wording of the statements. The selected quality indicators were then ratified in a final vote by all EPIC members.

RESULTS

Eleven quality indicators for the management of IBD within the single-payer health care system of Canada were developed. These focus on accurate diagnosis, appropriate and timely management, disease monitoring, and prevention or treatment of complications of IBD or its therapy.

CONCLUSIONS

These quality indicators are measurable, reflective of the evidence base and expert opinion, and define a standard of care that is at least a minimum that should be expected for IBD management in Canada. The next steps for the EPIC group involve conducting research to assess current practice across Canada as it pertains to these quality indicators and to measure the impact of each of these indicators on patient outcomes.

Cost-effectiveness analysis of chromoendoscopy for colorectal cancer surveillance in patients with ulcerative colitis

BACKGROUND

Recent studies report that the risk of colorectal cancer (CRC) among patients with ulcerative colitis (UC) may be lower than previously estimated. Although white-light endoscopy (WLE) with random biopsies is recommended for dysplasia detection in patients with UC, several studies reported increased detection of dysplasia by chromoendoscopy.

OBJECTIVE

To analyze the cost effectiveness of chromoendoscopy relative to WLE or no endoscopy for CRC surveillance in patients with UC.

DESIGN

Decision-analytic state-transition (Markov) model with Monte Carlo simulation.

SETTING

To simulate the clinical course of chronic UC, we estimated dysplasia and CRC incidence and progression, endoscopic test characteristics, stage-specific mortality rates, and costs from published literature and Medicare reimbursement data.

PATIENTS

Patients from a population-based age distribution with ulcerative colitis for ≥8 years.

INTERVENTION

We compared 3 different strategies at various surveillance intervals: chromoendoscopy with targeted biopsies, WLE with random biopsies, and no surveillance. The robustness of the model was assessed by using probabilistic sensitivity analysis. One-way sensitivity analyses were performed to evaluate individual variables, and 3-dimensional analysis was used to examine the effects of varying screening intervals.

MAIN OUTCOME MEASUREMENTS

Incremental cost-effectiveness ratio (ICER).

RESULTS

Chromoendoscopy was found to be more effective and less costly than WLE at all surveillance intervals. However, compared with no surveillance, chromoendoscopy was cost effective only at surveillance intervals of at least 7 years, with an ICER of $77,176. Chromoendoscopy was the most cost effective strategy at sensitivity levels >0.23 for dysplasia detection and cost <$2200, regardless of the level of sensitivity of WLE for dysplasia detection. The estimated population lifetime risk of developing CRC ranged from 2.5% (annual chromoendoscopy) to 5.9% (chromoendoscopy every 10 years).

LIMITATIONS

Estimates used for the model are based on best available data in the literature.

CONCLUSION

Chromoendoscopy is both more effective and less costly than WLE and becomes cost effective relative to no surveillance when performed at intervals of ≥7 years.

Challenges in designing a national surveillance program for inflammatory bowel disease in the United States

This review describes the history of U.S. government funding for surveillance programs in inflammatory bowel diseases (IBD), provides current estimates of the incidence and prevalence of IBD in the United States, and enumerates a number of challenges faced by current and future IBD surveillance programs. A rationale for expanding the focus of IBD surveillance beyond counts of incidence and prevalence, to provide a greater understanding of the burden of IBD, disease etiology, and pathogenesis, is provided. Lessons learned from other countries are summarized, in addition to potential resources that may be used to optimize a new form of IBD surveillance in the United States. A consensus recommendation on the goals and available resources for a new model for disease surveillance are provided. This new model should focus on "surveillance of the burden of disease," including (1) natural history of disease and (2) outcomes and complications of the disease and/or treatments.

The potential benefits and disadvantages of laparoscopic surgery for ulcerative colitis: A review of current evidence

Up to 35% of patients with ulcerative colitis will require surgery during the course of their disease. Nowadays, a total colectomy with ileal pouch-anal anastomosis is the preferred procedure, which can be performed open or via laparoscopic approach. Since the early '90s, minimally invasive techniques have gained popularity, but the extend of restorative procedures in these patients has restricted the use of laparoscopic approaches mainly to elective procedures in specialised centres. This review discusses the benefits and disadvantages of laparoscopic surgery when compared to open surgery. It presents the current evidence on short-term and long-term post-operative results, functional outcome, fecundity, and costs, for both elective and emergency indications. In addition, the value of new techniques (including single port surgery) and alternative laparoscopic approaches (e.g. ileo-rectal anastomosis, Kock-pouch and appendectomy) will be discussed.

Preoperative use of anti-TNF therapy and postoperative complications in inflammatory bowel diseases: a meta-analysis

BACKGROUND AND AIMS

About one-third of inflammatory bowel disease (IBD) patients still require surgery. A growing number of them receive anti-tumor necrosis factor (TNF) therapy before surgery. The present meta-analysis studied the risk of postoperative complications in IBD patients treated with anti-TNF.

METHODS

MEDLINE was searched (up to January 2012) to identify observational studies reporting the prevalence of postoperative complications in IBD patients. The prevalence of overall, infectious, and non-infectious postoperative complications was extracted for all studies, and according to preoperative anti-TNF treatment where reported. Pooled prevalence, as well as odds ratios (ORs), with 95% confidence intervals (CIs) was calculated.

RESULTS

The search identified 86 citations. Twenty-one studies, containing 4251 subjects, reported the prevalence of postoperative complications according to preoperative anti-TNF treatment. Pooled prevalence of any postoperative complication was 21%, 35%, and 26% in Crohn's disease (CD), ulcerative colitis (UC) or inflammatory bowel disease unspecified (IBD-U) and IBD, respectively. The prevalence of any postoperative complication was increased in IBD patients who underwent preoperative anti-TNF therapy (OR: 1.25; 95% CI: 1.02-1.53). Pooled prevalence of infectious postoperative complications was 16%, 17%, and 15% in CD, UC/IBD-U and IBD, respectively. The prevalence of infectious postoperative complications was increased in CD patients who underwent preoperative anti-TNF therapy (OR: 1.45; 95% CI: 1.03-2.05). The confounding effect of concomitant therapies could not be studied.

CONCLUSIONS

Preoperative anti-TNF use slightly increases the occurrence of overall postoperative complications in IBD patients, and particularly infectious complications in CD patients. Postoperative complications are not increased in UC.

The positioning of colectomy in the treatment of ulcerative colitis in the era of biologic therapy

The position of surgery in the treatment of ulcerative colitis (UC) has changed in the era of biologics. Several important questions arise in determining the optimal positioning of surgery in the treatment of UC, which has long been a challenge facing gastroenterologists and surgeons. Surgery is life-saving in some patients and leads to better bowel function and better quality of life in most patients. The benefits of surgery, however, must be weighed against the potential surgical morbidity and compromised functioning that clearly can occur. The introduction of biologic therapy has added further complexity to decisions about medical management, surgery, and the relative timing of these choices. Appropriate medical management of UC may induce and maintain remission and may prevent surgery. However, medical management also carries risks of adverse effects, and recent data suggest that delay of surgery during ineffective medical therapy can increase the chances of negative surgical outcomes. To make individualized timely treatment decisions, early collaboration between gastroenterologists and surgeons is important and more data on predictors of treatment response and positive outcomes are needed. Early identification of patients who would benefit from biologic therapy or surgery is challenging.

Prolonged preoperative hospital stay is a risk factor for complications after emergency colectomy for severe colitis

AIM

Risk factors for postoperative complications in patients undergoing emergency colectomy for severe colitis in inflammatory bowel disease have hardly been studied. Therefore, this study aimed to define predictors of a complicated postoperative course in these patients.

METHOD

A retrospective review was performed of 71 consecutive patients who underwent emergency colectomy for severe colitis between 1999 and 2012 at a tertiary referral centre. Complications were graded according to the Clavien-Dindo classification. Patients with a complication Grade II or higher were compared with those with no complications or a Grade I complication.

RESULTS

Nineteen patients (26.7%) had at least one postoperative complication classified as Clavien-Dindo Grade II or higher. In the group with postoperative complications, patients had a higher age (mean 45 vs 35 years, P = 0.020) and a higher body mass index (BMI) (mean 25.9 vs 21.0 kg/m(2), P = 0.006). Length of preoperative hospital stay (median 15 vs 6 days, P = 0.032) was longer in the group with postoperative complications. During the study period, the preoperative hospital stay decreased by 0.8 days per study year (95% CI 0.2-1.5 days, P < 0.001). This did not influence the complication rate over time, however.

CONCLUSION

Factors increasing the risk of complications after emergency colectomy for severe colitis were a higher age, a higher BMI and a longer preoperative hospital stay.

Total abdominal colectomy for severe ulcerative colitis: does the laparoscopic approach really have benefit?

BACKGROUND

It is still unknown to what extent the reported morbidity and recovery benefits of laparoscopic total abdominal colectomy (TAC) for severe ulcerative colitis (UC) are associated with patient selection bias. This study aimed to evaluate whether laparoscopic TAC has any advantages over open surgery after control for perioperative confounding factors.

METHODS

Patients undergoing TAC for UC during 2006-2010 were identified. Demographics, disease characteristics, and perioperative outcomes were compared between laparoscopic and open TAC. Postoperative recovery and 30-day complications were further assessed by covariate-adjusted multivariate regression models. The outcomes of different laparoscopic techniques were compared. A subgroup analysis including surgeons who routinely used both laparoscopic and open techniques was also performed.

RESULTS

Of the 412 eligible patients, the 197 patients undergoing laparoscopic TAC were significantly younger and had a decreased Charlson Comorbidity Index and ASA score, increased hemoglobin and serum albumin levels, and a smaller proportion of extensive colitis and urgent cases. Unadjusted analyses showed that intraoperative morbidity, postoperative mortality, and rates for readmission and reoperation were similar. Laparoscopic TAC was associated with a longer operative time but a decrease in blood loss, overall morbidity, ileus, and thromboembolism, as well as a faster return to bowel function and a shorter hospital stay. After covariate adjustments, laparoscopic surgery remained associated with a reduction in the time to stoma function, incidence of postoperative ileus, and hospital stay compared with open TAC. The rates of postoperative morbidity, readmission, and reoperation did not differ regardless whether the conventional multitrocar technique, hand-assisted procedure, or single-incision technique was used. Laparoscopic TAC among surgeons using both open and laparoscopic techniques was associated with recovery benefits similar to those observed in the overall study population.

CONCLUSION

The data suggest that laparoscopic TAC retains recovery advantages over open surgery even after adjustments for confounders.

A review of mortality and surgery in ulcerative colitis: milestones of the seriousness of the disease

Standardized mortality rates in ulcerative colitis (UC) are no different than that in the general population. Patients who are older and have more comorbidities have increased mortality. Emergent colectomy still carries 30-day mortality rates of approximately 5%. In more recent studies, UC surgery rates at 10 years from diagnosis are nearly 3% in Hungary, <10% in referral center studies from Asia, approximately 10% in Norway, the European Cohort Study of Inflammatory Bowel Diseases and Manitoba, Canada, and nearly 17% in Olmsted County, Minnesota. These rates are for the most part lower than reported colectomy rates from studies completed before 1990. Short-term colectomy rates in severe hospitalized UC have remained stable at 27% for several years. Generally, children seem to have higher rates of extensive colitis at diagnosis than adults. There also seems to be higher rates of colectomy in children than in adults (i.e., at least 20% at 10 years), and perhaps, this reflects a higher rate of extensive disease. Acute severe colitis in patients with UC still represents a condition with a high early colectomy rate and a measurable mortality rate.

Infliximab as rescue therapy in hospitalised patients with steroid-refractory acute ulcerative colitis: a long-term follow-up of 211 Swedish patients

BACKGROUND

Rescue therapy with infliximab (IFX) has been proven effective in a steroid-refractory attack of ulcerative colitis (UC). The long-term efficacy is not well described.

AIM

To present a retrospective study of IFX as rescue therapy in UC. Primary end points were colectomy-free survival at 3 and 12 months.

METHODS

In this multicentre study, 211 adult patients hospitalised between 1999 and 2010 received IFX 5 mg/kg as rescue therapy due to a steroid-refractory, moderate-to-severe attack of UC. Exclusion criteria were duration of current flare for >12 weeks, corticosteroid treatment for >8 weeks before hospitalisation, previous IFX therapy or Crohn's disease.

RESULTS

Probability of colectomy-free survival at 3 months was 0.71 (95% CI, 0.64-0.77), at 12 months 0.64 (95% CI, 0.57-0.70), at 3 years 0.59 (95% CI, 0.52-0.66) and at 5 years 0.53 (95% CI, 0.44-0.61). Steroid-free, clinical remission was achieved in 105/211 (50%) and 112/209 (54%) patients at 3 and 12 months respectively. Of 75 colectomies during the first year, 48 (64%) were carried out during the first 14 days, 13 (17%) on days 15-90 and 14 (19%) between 3 and 12 months. There were three (1.4%) deaths during the first 3 months.

CONCLUSIONS

Infliximab is an effective rescue treatment, both short- and long-term, in a steroid-refractory attack of UC. Most IFX failures underwent surgery during the first 14 days, which calls for studies on how to optimise induction treatment with IFX. Serious complications, including mortality, were rare.

Meta-analysis: peri-operative anti-TNFα treatment and post-operative complications in patients with inflammatory bowel disease

BACKGROUND

The impact of peri-operative use of TNFα antagonists on post-operative complications such as infection and wound healing is controversial.

AIM

To conduct a systematic review and meta-analysis to assess the impact of peri-operative use of TNFα antagonists on post-operative complications such as infection and wound healing in patients with inflammatory bowel disease (IBD).

METHODS

A literature search identified studies that investigated post-operative outcomes in patients with IBD using TNFα antagonists. The primary outcome was the rate of post-operative infectious complications. Secondary outcomes included the rates of non-infectious complications and total complications. Odds ratios (OR) with 95% confidence intervals (CI) are reported.

RESULTS

Overall, 18 studies with 4659 participants were eligible for inclusion. Patients with IBD using preoperative anti-TNFα therapies had significant increases in post-operative infectious [OR 1.56 (95% CI, 1.09-2.24)], non-infectious [OR 1.57 (95% CI, 1.14-2.17)] and total complications [OR 1.73 (95% CI, 1.23-2.43)]. Studies limited to patients with Crohn's disease demonstrated a statistically significant increase in infectious (OR 1.93, 95% CI 1.28-2.89) and total (OR 2.19, 95% CI 1.69-2.84) complications, and a trend towards increase in non-infectious complications (OR 1.73, 95% CI 0.94-3.17). Studies of patients with ulcerative colitis did not demonstrate significant increases in infectious (OR 1.39, 95% CI 0.56-3.45), non-infectious (OR 1.40, 95% CI 0.68-2.85), or total complications (OR 1.10, 95% CI 0.81-1.47).

CONCLUSION

Anti-TNFα therapies appear to increase the risk of post-operative complications. The increase in risk is small, and may well reflect residual confounding rather than a true biological effect. Nevertheless, physicians should exercise caution when continuing biological therapies during the peri-operative period.

Weekend hospitalisations and post-operative complications following urgent surgery for ulcerative colitis and Crohn's disease

BACKGROUND

There is increasing complexity in the management of patients with acute severe exacerbation of inflammatory bowel disease [IBD; Crohn's disease (CD), ulcerative colitis (UC)] with frequent requirement for urgent surgery.

AIM

To determine whether a weekend effect exists for IBD care in the United States.

METHODS

We used data from the Nationwide Inpatient Sample (NIS) 2007, the largest all-payer hospitalisation database in the United States. Discharges with a diagnosis of CD or UC who underwent urgent intestinal surgery within 2 days of hospitalisation were identified using the appropriate ICD-9 codes. The independent effect of admission on a weekend was examined using multivariate logistic regression adjusting for potential confounders.

RESULTS

Our study included 7,112 urgent intestinal surgeries in IBD patients, 21% of which occurred following weekend admissions. There was no difference in disease severity between weekend and weekday admissions. Post-operative complications were more common following weekend than weekday hospitalisations in UC [odds ratio (OR) 1.71, 95% confidence interval (CI) 1.01-2.90]. The most common post-operative complication was post-operative infections (Weekend 30% vs. weekday 20%, P = 0.04). The most striking difference between weekend and weekday hospitalisations was noted for needing repeat laparotomy (OR 11.5), mechanical wound complications (OR 10.03) and pulmonary complications (OR 2.22). In contrast, occurrence of any post-operative complication in CD was similar between weekday and weekend admissions.

CONCLUSION

Patients with UC hospitalised on a weekend undergoing urgent surgery within 2 days have an increased risk for post-operative complications, in particular mechanical wound complications, need for repeat laparotomy and post-operative infections.

Prognosis following emergency surgery for ulcerative colitis in elderly patients

Purpose

Since 2000, the incidence of ulcerative colitis (UC) in patients over 60 years old has been rapidly increasing. We reviewed our surgical experience of elderly patients with UC treated at our hospital.

Methods

Patients aged 60 years or older at the time of surgery were defined as “elderly”. The medical records of all elderly patients who underwent surgery for UC during a 26-year period were retrospectively analyzed.

Results

The prognosis of elderly patients who underwent emergency surgery was extremely poor: 8 (26.7 %) of 30 such patients died within 30 postoperative days (PODs), whereas only 1 (0.88 %) of 114 who underwent elective surgery died within 30 PODs. Respiratory tract infection and sepsis resulting from methicillin-resistant Staphylococcus aureus or mycotic infection were the most common causes of death after emergency surgery.

Conclusion

The prognosis of elderly UC patients undergoing emergency surgery is very poor; thus, physicians and surgeons should collaborate to treat severe and fulminant disease, to optimize the timing of surgery. Early decisions about emergency surgery for UC will reduce postoperative mortality, especially in elderly patients.

Infliximab versus cyclosporine as rescue therapy in acute severe steroid-refractory ulcerative colitis: a systematic review and meta-analysis

PURPOSE

Acute severe colitis affects 25 % of patients with ulcerative colitis (UC). Up to 30-40 % of these patients are resistant to intensive steroid therapy and therefore require rescue therapy to prevent emergent colectomy. Data comparing rescue therapy using infliximab and cyclosporine are limited and equivocal. This study evaluates the outcomes of UC patients receiving infliximab or cyclosporine as rescue therapy in acute severe steroid-refractory exacerbations.

METHODS

Electronic databases (PubMed, EMBASE, and Cochrane database) were searched for studies directly comparing infliximab and cyclosporine in UC, and references of included studies were screened. Two independent reviewers identified relevant studies and extracted data. Meta-analyses were performed using the random effect model. Outcome measures included 3- and 12-month colectomy rates, adverse drug reactions, and postoperative complications.

RESULTS

Six retrospective cohort studies describing 321 patients met the inclusion criteria. The meta-analysis did not show significant differences between infliximab and cyclosporine in the 3-month colectomy rate (odds ratio (OR) = 0.86, 95 % confidence interval (CI) = 0.31-2.41, p = 0.775), in the 12-month colectomy rate (OR = 0.60, 95 % CI = 0.19-1.89, p = 0.381), in adverse drug reactions (OR = 0.76, 95 % CI = 0.34-1.70, p = 0.508), and in postoperative complications (OR = 1.66, 95 % CI = 0.26-10.50, p = 0.591). Funnel plot revealed no publication bias.

CONCLUSIONS

Infliximab and cyclosporine are comparable when used as rescue therapy in acute severe steroid-refractory UC. Randomized trials are required to further evaluate these agents.

The surgical management of active ulcerative colitis complicated by Clostridium difficile infection

INTRODUCTION

Clostridium difficile stool toxin is detected in 5-20 % of patients with acute exacerbations of ulcerative colitis (UC). There is little data regarding the safety of surgery for UC with concurrent C. difficile.

METHODS

A retrospective review was performed of 23 patients undergoing colectomy for refractory UC complicated by C. difficile infection between January 2002 and June 2012. Patients were stratified into those who completed a full antibiotic course for C. difficile infection prior to surgery (group A, n = 7) and those who proceeded directly to surgery (group B, n = 16). The primary endpoints of perioperative mortality, ICU requirement, reoperation, readmission, and surgical site infection were assessed within 30 days after surgery.

RESULTS

Postoperatively, no mortalities, ICU admissions, readmission, or reoperations occurred. One group A patient developed a superficial wound infection, which resolved with a course of outpatient antibiotics (14 vs. 0 %, p = 0.12). Average days until return of bowel function and average length of postoperative stay were comparable between group A and B (3.9 vs. 3.6 days, p = 0.70; 7.0 vs. 6.9 days, p = 0.87; respectively). Ninety-one percent of patients subsequently underwent ileal pouch-anal anastomosis.

CONCLUSION

Colectomy for ulcerative colitis complicated by C. difficile can be performed safely without completing a course of antibiotic therapy.

Cyclosporine in patients with severe steroid refractory ulcerative colitis in the era of infliximab. Review article

Corticosteroids are the mainstay of therapy for severe ulcerative colitis. However, at least a third of patients fail to respond and face a colectomy. In these, rescue therapy with cyclosporine or infliximab (IFX), aimed at avoiding surgery, has been used in recent years. Of the two options, infliximab is largely preferred in both Sweden and Norway, whereas cyclosporine (CyA) is generally regarded as difficult to use, rather toxic and showing limited long-term efficacy. In light of some new recent data, herein, we provide an update of the literature in the field. It appears that there are theoretical and practical arguments on each side, and as of today, the choice between IFX or CyA for rescue therapy cannot be made on strong evidence. Thus, the best choice of medical rescue therapy will depend on the results of ongoing RCTs as well as future research in the field.

Strategies for the care of adults hospitalized for active ulcerative colitis

Ulcerative colitis is a chronic inflammatory disease of the colon; as many as 25% of patients with this disease require hospitalization. The goals of hospitalization are to assess disease severity, exclude infection, administer rapidly acting and highly effective medication regimens, and determine response. During hospitalization, patients should be given venous thromboembolism prophylaxis and monitored for the development of toxic megacolon. Patients who do not respond to intravenous corticosteroids should be considered for rescue therapy with infliximab or cyclosporine. Patients who are refractory to medical therapies or who develop toxic megacolon should be evaluated promptly for colectomy. Patients who do respond to medical therapies should be discharged on an appropriate maintenance regimen when they meet discharge criteria. We review practical evidence-based management principles and propose a day-by-day algorithm for managing patients hospitalized for ulcerative colitis.

Decreasing colectomy rates for ulcerative colitis: a population-based time trend study

OBJECTIVES

Colectomy rates for ulcerative colitis (UC) have been inconsistently reported. We assessed temporal trends of colectomy rates for UC, stratified by emergent vs. elective colectomy indication.

METHODS

From 1997 to 2009, we identified adults hospitalized for a flare of UC. Medical charts were reviewed. Temporal changes were evaluated using linear regression models to estimate the average annual percent change (AAPC) in surgical rates. Logistic regression analysis compared: (i) UC patients responding to medical management in hospital to those who underwent colectomy; (ii) UC patients who underwent an emergent vs. elective colectomy; and (iii) temporal trends of drug utilization.

RESULTS

From 1997 to 2009, colectomy rates significantly dropped for elective colectomies with an AAPC of -7.4% (95% confidence interval (CI): -10.8%, -3.9%). The rate of emergent colectomies remained stable with an AAPC of -1.4% (95% CI: -4.8%, 2.0%). Azathioprine/6-mercaptopurine prescriptions increased from 1997 to 2009 (odds ratio (OR)=1.15; 95% CI: 1.09-1.22) and infliximab use increased after 2005 (OR=1.68; 95% CI: 1.25-2.26). A 13% per year risk adjusted reduction in the odds of colectomy (OR=0.87; 95% CI: 0.83-0.92) was observed in UC patients responding to medical management compared with those who required colectomy. Emergent colectomy patients had a shorter duration of flare (<2 weeks vs. 2-8 weeks, OR=5.31; 95% CI: 1.58-17.81) and underwent colectomy early after diagnosis (<1 year vs. 1-3 years, OR=5.48; 95% CI: 2.18-13.79).

CONCLUSIONS

From 1997 to 2009, use of purine anti-metabolites increased and elective colectomy rates in UC patients decreased significantly. In contrast, emergent colectomy rates were stable, which may have been due to rapid progression of disease activity.

Meta-analysis: effect of preoperative infliximab use on early postoperative complications in patients with ulcerative colitis undergoing abdominal surgery

BACKGROUND

Infliximab is widely used in severe and refractory ulcerative colitis (UC). The results of clinical studies are inconsistent on whether preoperative infliximab use increases early postoperative complications in UC patients.

AIM

To determine the clinical safety and efficacy of preoperative infliximab treatment in UC patients with regard to short-term outcomes following abdominal surgery.

METHODS

PubMed, Embase databases were searched for controlled observational studies comparing postsurgical morbidity in UC patients receiving infliximab preoperatively with those not on infliximab. The primary endpoint was total complication rate. Secondary endpoints included the rate of infectious and non-infectious complications. We calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs) as summary measures.

RESULTS

A total of 13 studies involving 2933 patients were included in our meta-analysis. There was no significant association between infliximab therapy preoperatively and total (OR = 1.09, 95% CI: 0.87-1.37, P = 0.47), infectious (OR = 1.10, 95% CI: 0.51-2.38, P = 0.81) and non-infectious (OR = 1.10, 95% CI: 0.76-1.59, P = 0.61) postoperative complications respectively. Infliximab might be a protective factor against infection for the use within 12 weeks prior to surgery (OR = 0.43, 95% CI: 0.22-0.83, P = 0.01). No publication bias was found.

CONCLUSION

Preoperative infliximab use does not increase the risk of early postoperative complications in patients with ulcerative colitis undergoing abdominal surgery.

Postoperative complications following colectomy for ulcerative colitis in children

BACKGROUND AND AIMS

Colectomy rates for ulcerative colitis (UC) and data on postcolectomy complications in children are limited. Thus, we assessed colectomy rates, early postcolectomy complications, and clinical predictors in children with UC undergoing a colectomy.

METHODS

Children (18 years old or older) with UC who underwent colectomy from 1983 to 2009 were identified (n=30). All of the medical charts were reviewed. The diagnostic accuracy of International Classification of Diseases codes for UC and colectomy were validated. The primary outcome was postoperative complications defined as Clavien-Dindo classification grade II or higher. The yearly incidence of colectomies for pediatric UC was calculated and temporal trends were evaluated.

RESULTS

The sensitivity and positive predictive value of UC and colectomy International Classification of Diseases codes were 96% and 100%, respectively. The median ages at UC diagnosis and colectomy were 10.9 and 12.1 years, respectively. All of the children had pancolitis and 63% underwent emergent colectomy. Postoperatively, 33% experienced at least 1 complication. Patients with emergent colectomy were more likely to have a postoperative complication compared with patients with elective colectomy (90% vs 50%; P=0.03). For emergent colectomy, postoperative complications were associated with a disease flare of ≥2 weeks before admission (60% vs 0%; P=0.03) and >2 weeks from admission to colectomy (78% vs 22%; P=0.04). The average annual rate of pediatric colectomy was 0.059/100,000 person-years and stable from 1983 to 2009 (P>0.05).

CONCLUSIONS

Colectomy UC was uncommon and rates have remained stable. Postcolectomy complications were common, especially in patients undergoing emergent colectomy. Optimizing timing of colectomy may reduce postoperative complications.

Postoperative complications following colectomy for ulcerative colitis: a validation study

Background

Ulcerative colitis (UC) patients failing medical management require colectomy. This study compares risk estimates for predictors of postoperative complication derived from administrative data against that of chart review and evaluates the accuracy of administrative coding for this population.

Methods

Hospital administrative databases were used to identify adults with UC undergoing colectomy from 1996–2007. Medical charts were reviewed and regression analyses comparing chart versus administrative data were performed to assess the effect of age, emergent operation, and Charlson comorbidities on the occurrence of postoperative complications. Sensitivity, specificity, and positive/negative predictive values of administrative coding for identifying the study population, Charlson comorbidities, and postoperative complications were assessed.

Results

Compared to chart review, administrative data estimated a higher magnitude of effect for emergent admission (OR 2.52 [95% CI: 1.80–3.52] versus 1.49 [1.06–2.09]) and Charlson comorbidities (OR 2.91 [1.86–4.56] versus 1.50 [1.05–2.15]) as predictors of postoperative complications. Administrative data correctly identified UC and colectomy in 85.9% of cases. The administrative database was 37% sensitive in identifying patients with ≥ 1Charlson comorbidity. Restricting analysis to active comorbidities increased the sensitivity to 63%. The sensitivity of identifying patients with at least one postoperative complication was 68%; restricting analysis to more severe complications improved the sensitivity to 84%.

Conclusions

Administrative data identified the same risk factors for postoperative complications as chart review, but overestimated the magnitude of risk. This discrepancy may be explained by coding inaccuracies that selectively identifying the most serious complications and comorbidities.

Nationwide linkage analysis in Scotland to assess mortality following hospital admission for Crohn's disease: 1998-2000

BACKGROUND

Although population-based studies of patients with Crohn's disease (CD) suggest only a modestly increased mortality, recent data have raised concerns regarding the outcome of CD patients requiring hospitalisation.

AIM

To determine the mortality and contributory factors in 1595 patients hospitalised for CD in Scotland between 1998 and 2000.

METHODS

The Scottish Morbidity Records database and linked datasets were used to assess longitudinal patient outcome, and to explore associations between 3-year mortality and age, sex, comorbidity, admission type and social deprivation. The standardised mortality ratio (SMR) at 3 years from admission was calculated with reference to the Scottish population.

RESULTS

The SMR was 3.31 (95% confidence interval 2.80-3.89). This was increased in all patients, other than those <30 years at presentation, and was highest in patients aged 50-64 years (SMR 4.84 [3.44-6.63]). On multivariate analysis, age >50, admission type, comorbidity, social deprivation and length of admission were significantly associated with mortality. Other than age, admission type was the strongest factor predictive of death. Three-year crude mortality was 0.3% for elective surgical, 8.7% for emergency surgical, 8.3% for elective nonsurgical and 12.7% for emergency nonsurgical admission (P < 0.001).

CONCLUSIONS

The study demonstrates high mortality rates in patients hospitalised during 1998-2000 for CD, especially in patients over 50. Elective surgery is associated with lower mortality than emergency surgery or medical therapy. Further study is needed to determine whether these patterns have changed following the introduction of biological treatment.