Outcome following emergency surgery for refractory severe ulcerative colitis in a tertiary care centre in India

ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment

This is the second of a series of two articles reporting the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of adult patients with ulcerative colitis [UC]. The first article is focused on medical management, and the present article addresses medical treatment of acute severe ulcerative colitis [ASUC] and surgical management of medically refractory UC patients, including preoperative optimisation, surgical strategies, and technical issues. The article provides advice for a variety of common clinical and surgical conditions. Together, the articles represent an update of the evidence-based recommendations of the ECCO for UC.

[Surgical approach for colon perforation and traumatic ruptures at the multifield hospital]

OBJECTIVE

To analyze postoperative outcomes in patients with colon perforation and traumatic ruptures at the multifield hospital.

MATERIAL AND METHODS/

The study included 93 patients aged 24-85 years with colon perforation and traumatic ruptures. All patients were divided into 3 groups depending on the cause of colon perforation: group 1 - 43 (46.2%) patients with colon cancer, group 2 - 27 (29%) patients with ulcerative colitis, group 3 - 22 (23.6%) patients with traumatic ruptures following blunt abdominal trauma. Cause of colon perforation was unclear in 1 (1.1%) case. Diagnostic algorithm included routine clinical and laboratory methods and modern minimally invasive endoscopic surgical technologies (ultrasound, CT, MRI, colonoscopy, laparoscopy).

RESULTS/

Ninety (96.8%) out of 93 patients with colon perforation underwent surgery. Postoperative mortality was 41.5%, 46.1% and 31.8% in all groups, respectively. Overall postoperative mortality was 40%.

CONCLUSION

Bowel resection with colostomy is preferred for colon perforation regardless the cause of injury because this procedure ensures the best immediate results. Palliative suturing of perforations with colostomy or delivering the affected colon segment on anterior abdominal wall are accompanied by high mortality and should be used for strict indications in severely ill patients.

First United Arab Emirates consensus on diagnosis and management of inflammatory bowel diseases: A 2020 Delphi consensus

Ulcerative colitis and Crohn's disease are the main entities of inflammatory bowel disease characterized by chronic remittent inflammation of the gastrointestinal tract. The incidence and prevalence are on the rise worldwide, and the heterogeneity between patients and within individuals over time is striking. The progressive advance in our understanding of the etiopathogenesis coupled with an unprecedented increase in therapeutic options have changed the management towards evidence-based interventions by clinicians with patients. This guideline was stimulated and supported by the Emirates Gastroenterology and Hepatology Society following a systematic review and a Delphi consensus process that provided evidence- and expert opinion-based recommendations. Comprehensive up-to-date guidance is provided regarding diagnosis, evaluation of disease severity, appropriate and timely use of different investigations, choice of appropriate therapy for induction and remission phase according to disease severity, and management of main complications.

Hospital malnutrition in northeast and southeast Asia: A systematic literature review

BACKGROUND & AIMS

Hospital malnutrition is a prevalent yet frequently under-recognised condition that is associated with adverse clinical and economic consequences. Systematic reviews from various regions of the world have provided regional estimates of the prevalence of malnutrition and the magnitude of the associated health and economic burden; however, a systematic assessment of the prevalence and consequences of hospital malnutrition in northeast and southeast Asia has not been conducted.

METHODS

We performed a systematic literature search for articles on hospital malnutrition in 11 Asian countries published in English between January 1, 1997 and January 15, 2018. Studies reporting data on the prevalence, clinical consequences, or economic impact of hospital malnutrition in an adult inpatient population with a sample size ≥30 were eligible for inclusion.

RESULTS

The literature search identified 3207 citations; of these, 92 studies (N = 62,280) met the criteria for inclusion. There was substantial variability in study populations and assessment methods; however, a majority of studies reported a malnutrition prevalence of >40%. Malnutrition was associated with an increase in clinical complications, mortality, length of hospitalisation, hospital readmissions, and healthcare costs.

CONCLUSIONS

Hospital malnutrition is a highly prevalent condition among hospitalised patients in northeast and southeast Asia. Additionally, poor nutritional status is associated with increased morbidity and mortality and increased healthcare costs. Further research aimed at improving the identification and proactive management of hospitalised patients at risk for malnutrition is necessary to improve patient outcomes and alleviate the burden on local healthcare budgets.

Systematic review of rectal stump management during and after emergency total colectomy for acute severe ulcerative colitis

BACKGROUND

There is no consensus about the optimal management of the rectal stump after an emergency subtotal colectomy in patients with acute severe ulcerative colitis (ASUC). The aim was to perform a systematic review of the published literature on the surgical and medical management of the rectal stump after an emergency (sub) total colectomy in patients with ASUC.

METHODS

The following databases were searched, MEDLINE (PubMed), EMBASE and OVID SP, from January 1993 to March 2018. Studies that reported post-operative outcomes after surgical and/or medical management of the rectal stump after emergency (sub) total colectomy in adults with ASUC were included. Two independent assessors reviewed eligible articles.

RESULTS

A total of 11 studies met the inclusion criteria. All were case series and included 476 patients. Regarding surgical management, five studies reported on closed subcutaneous placement of the rectal stump, seven on intraperitoneal placement and two on the formation of a formal mucous fistula. The lowest reported pelvic sepsis rate was in patients with subcutaneous closure of the rectal stump (n = 144, 2%) and lowest wound infection rate was reported after intraperitoneal closure (n = 268, 7.8%). The highest rate of mortality was reported after intraperitoneal placement of the rectal stump (n = 268, 1.5%). There were insufficient data reported on medical management for any comparison.

CONCLUSION

Subcutaneous placement of the rectal stump was associated with the lowest morbidity and mortality rate, although data are of limited quality and insufficient to guide practice recommendations.

Optimal management of acute severe ulcerative colitis

Acute severe ulcerative colitis is a life-threatening medical emergency, which can be associated with significant morbidity and is preventable through prompt and effective management. Corticosteroids remain the cornerstone of initial therapy, although a third of patients will not respond. Further management hinges on timely decisions with use of rescue therapy with ciclosporin or infliximab, without compromising the health or safety of the patient, or timely surgery. Although such patients need specialist care, it is imperative that emergency care physicians are aware of the important principles of management of this condition to achieve successful outcomes. Risk stratification and the use of predictive models using clinical parameters have reduced the morbidity associated with this condition.We discuss current evidence and present a clinical approach to clinicians involved in the emergency care of patients with acute severe ulcerative colitis in this review.

Totally laparoscopic, multi-stage, restorative proctocolectomy for inflammatory bowel diseases. A prospective study on safety, efficacy and long-term results

BACKGROUND

Laparoscopic ileo-pouch-anal anastomosis (IPAA) has been reported as having low morbidity and several advantages.

AIMS

To evaluate safety, efficacy and long-term results of laparoscopic IPAA, performed in elective or emergency settings, in consecutive unselected IBD patients.

METHODS

All the patients received totally laparoscopic 2-stage (proctocolectomy and IPAA - stoma closure) or 3-stage (colectomy - proctectomy and IPAA - stoma closure) procedure according to their presentation.

RESULTS

From July 2007 to July 2016, 160 patients entered the study. 50.6% underwent a 3-stage procedure and 49.4% a 2-stage procedure. Mortality and morbidity were 0.6% and 24.6%. Conversion rate was 3.75%. 8.7% septic complications were associated with steroids and Infliximab treatment (p = 0.0001). 3-stage patients were younger (p = 0.0001), with shorter disease duration (p = 0.0001), minor ASA scores of 2 and 3 (p = 0.0007), lower inflammatory index and better nutritional status (p = 0.003 and 0.0001), fewer Clavien-Dindo's grade II complications (p = .0001), reduced rates of readmission and reoperation at 90 days (p = 0.03), and shorter hospitalization (p = .0001), but with similar pouch and IPAA leakage, compared to 2-stage patients. 8 years pouch failure and definitive ileostomy were 5.1% and 3.7%.

CONCLUSION

A totally laparoscopic approach is safe and feasible, with very low mortality and morbidity rates and very low conversion rate, even in multi-stage procedures and high-risk patients.

Chinese research into severe ulcerative colitis has increased in quantity and complexity

AIM

To investigate the current state of research output from Chinese studies into severe ulcerative colitis (SUC) using a bibliometric analysis of publications.

METHODS

The contents of the Chinese periodical databases WANFANG, VIP, and China National Knowledge Infrastructure were searched for all papers regarding UC or SUC published in last the 15 years (from 2001 to 2015). The number of publications in each year was recorded to assess the temporal trends of research output. All SUC related publications were downloaded and the complexity of this research was evaluated with methods described previously. The number of patients with SUC reported each year was recorded and their clinical characteristics were analyzed using information available in the relevant papers.

RESULTS

There were 13499 publications regarding UC published in Chinese medical journals between 2001 and 2015, of which 201 focused on SUC. The number of publications increased rapidly with more than half of all papers being published in the most recent 5-year period. There was a significant increase in analytical studies and clinical trials over the study period (P < 0.01), with research into the management of SUC, included pharmacotherapy, nutrition support as well as surgery, predominating. Almost half (46.2%) of the observational analytical studies and clinical trials focused on Traditional Chinese Medicine, with little research on the efficacy of cyclosporin and infliximab in disease management. About 6222 patients with SUC were reported in the 201 SUC relevant papers, with a ratio of male/female of 1.38. The number of patients reported in each 5-year period significantly increased. The colectomy rate and short-term mortality rate were 7.7% and 0.8% respectively. The most commonly employed operation was total proctocolectomy with ileal pouch-anal anastomosis.

CONCLUSION

The output and complexity of research related to SUC in China increased significantly over the previous 15 years, however few of these studies focused on salvage therapy.

Early colectomy in steroid-refractory acute severe ulcerative colitis improves operative outcome

PURPOSE

Up to a third of patients with acute severe ulcerative colitis (ASUC) fail to respond to intensive steroid therapy and eventually require a salvage colectomy. We have previously reported that the mortality of emergency colectomy can be decreased by offering it within the first week of intensive medical therapy. We implemented this policy and report the results of our experience.

METHODS

The clinical records of all patients with ASUC who underwent emergency colectomy after failure of medical therapy between January 2005 and July 2015 were extracted from a prospectively maintained database. The data were analysed with regard to duration of intensive medical therapy, timing of surgery, in-hospital mortality and post-operative complications.

RESULTS

Eighty-eight patients underwent emergency surgery for ASUC after failed medical therapy. Of these, 75 (85.2%) were operated within 7 days of initiation of intensive medical therapy [n = 51 (58%) were operated < 5 days]. One patient who was operated on day 8 following steroid therapy died postoperatively. The current post-operative mortality of 1.1% (1/88) was significantly lower than the mortality noted in the previously recorded retrospective case series [8/51 (15.6%); p = 0.001]. In addition, the incidence of overall (9/13 vs. 23/75; p = 0.012) and clinically significant (12/75 vs. 6/13; p = 0.022) complications was significantly higher in patients operated after 7 days as compared to those operated within 7 days.

CONCLUSION

The policy of early colectomy, within 7 days, in patients with ASUC who fail to respond to intensive steroid-based therapy improves perioperative outcomes with significantly low in-hospital mortality and morbidity.

Fecal calprotectin as an alternative to ulcerative colitis endoscopic index of severity to predict the response to corticosteroids of acute severe ulcerative colitis: A prospective observational study

BACKGROUND

Fecal calprotectin (FC) might be an alternative to ulcerative colitis endoscopic index of severity (UCEIS) to predict the response to corticosteroids (CS) in acute severe colitis (ASC).

METHODS

One hundred and seventeen ASC patients were prospectively enrolled. Demographic, clinical, laboratory and sigmoidoscopic data were documented. Multivariate and ROC analyses were performed to identify risk factors for non-response to CS, and the predictive accuracy of possible predictors was assessed.

RESULTS

Totally, 39 (33.33%) patients failed intravenous CS therapy. CS responders among mild (UCEIS 3-4), moderate (UCEIS 5-6) and severe (UCEIS 7-8) groups were 40/44 (90.91%) vs. 36/55 (65.45%) vs. 2/18 (11.11%) (p<0.001). UCEIS (OR=5.08; 95% CI, 1.93-8.66; p<0.001) and FC (OR=2.56; 95% CI, 1.17-3.55; p=0.022) were found to be independent risk factors for CS non-responders. Compared with C-reactive protein, platelet, hemoglobin and albumin, baseline FC had the strongest correlation with UCEIS (r=0.701, p<0.001). ROC analysis of UCEIS and baseline FC in predicting CS non-response showed an AUC of 0.85 and 0.76 respectively.

CONCLUSIONS

Baseline FC levels correlated significantly with UCEIS in ASC, and both were useful in predicting short-term outcome of CS treatment. Baseline FC levels could be used as an alternative of UCEIS to guide the decision of early salvage therapy or colectomy and reduce the adverse effects of long-term futile CS usage.

A retrospective analysis of 20-year data of the surgical management of ulcerative colitis patients in Taiwan: a study of Taiwan Society of Inflammatory Bowel Disease

Background/Aims

With the recent progress in medical treatment, surgery still plays a necessary and important role in treating ulcerative colitis (UC) patients. In this study, we analyzed the surgical results and outcomes of UC in Taiwan in the recent 20 years, via a multi-center study through the collaboration of Taiwan Society of IBD.

Methods

A retrospective analysis of surgery data of UC patients from January 1, 1995, through December 31, 2014, in 6 Taiwan major medical centers was conducted. The patients' demographic data, indications for surgery, and outcome details were recorded and analyzed.

Results

The data of 87 UC patients who received surgical treatment were recorded. The median post-operative follow-up duration was 51.1 months and ranged from 0.4 to 300 months. The mean age at UC diagnosis was 45.3±16.0 years and that at operation was 48.5±15.2 years. The 3 leading indications for surgical intervention were uncontrolled bleeding (16.1%), perforation (13.8%), and intractability (12.6%). In total, 27.6% of surgeries were performed in an emergency setting. Total or subtotal colectomy with rectal preservation (41.4%) was the most common operation. There were 6 mortalities, all due to sepsis. Emergency operation and low pre-operative albumin level were significantly associated with poor survival (P=0.013 and 0.034, respectively).

Conclusions

In the past 20 years, there was no significant change in the indications for surgery in UC patients. Emergency surgeries and low pre-operative albumin level were associated with poor survival. Therefore, an optimal timing of elective surgery for people with poorly controlled UC is paramount.

Mortality associated with medical therapy versus elective colectomy in ulcerative colitis: a cohort study

BACKGROUND

Ulcerative colitis (UC) can be treated with surgery or medications. Patients often must choose between long-term immunosuppressant therapy or total colectomy. Whether one of these treatment approaches has a mortality benefit is uncertain.

OBJECTIVE

To determine whether patients with advanced UC treated with elective colectomy have improved survival compared with those treated with medical therapy.

DESIGN

Retrospective matched cohort study.

SETTING

Data from all 50 states for Medicaid beneficiaries (2000 to 2005), Medicare beneficiaries (2006 to 2011), and dual-eligible persons (2000 to 2011).

PATIENTS

830 patients with UC pursuing elective colectomy and 7541 matched patients with UC pursuing medical therapy.

MEASUREMENTS

The primary outcome was time to death. Cox proportional hazards models were used to compare the survival of patients with advanced UC treated with elective colectomy or medical therapy. The models controlled for significant comorbid conditions through matched and adjusted analysis.

RESULTS

The mortality rates associated with elective surgery and medical therapy were 34 and 54 deaths per 1000 person-years, respectively. Elective colectomy was associated with improved survival compared with long-term medical therapy (adjusted hazard ratio [HR], 0.67 [95% CI, 0.52 to 0.87]), although this result did not remain statistically significant in all sensitivity analyses. Post hoc analysis by age group showed improved survival with surgery in patients aged 50 years or older with advanced UC (HR, 0.60 [CI, 0.45 to 0.79]; P = 0.032 for age-by-treatment interaction).

LIMITATIONS

Retrospective nonrandomized analysis is subject to residual confounding. The source cohort was derived from different databases throughout the study. Sensitivity and secondary analyses had reduced statistical power.

CONCLUSION

Elective colectomy seemed to be associated with improved survival relative to medical therapy among patients aged 50 years or older with advanced UC.

PRIMARY FUNDING SOURCE

National Institutes of Health and Agency for Healthcare Research and Quality.

Management of acute severe ulcerative colitis

The management strategy of acute severe ulcerative colitis has evolved over the past decade from being entirely restricted to twin choices of intravenous steroids or colectomy to include colon rescue therapies like cyclosporin as well as infliximab. However it still remains a medical emergency requiring hospitalization and requires care from a multidisciplinary team comprising of a gastroenterologist and a colorectal surgeon. The frame shift in management has been the emphasis on time bound decision making with an attempt to curtail the mortality rate to below 1%. Intravenous corticosteroids are the mainstay of therapy. Response to steroids should be assessed at day 3 of admission and partial/non-responders should be considered for alternative medical therapy/surgery. Medical rescue therapies include intravenous cyclosporin and infliximab. Cyclosporin is administered in a dose of 2 mg/kg per day and infliximab is administered as a single dose intravenous infusion of 5 mg/kg. Approximately 75% patients have short term and 50% patients have long term response to cyclosporin. Long term response to cyclosporin is improved in patients who are thiopurine naïve and are started on thiopurines on day 7. Infliximab also has a response rate of approximately 70% in short term and 50% in long term. Both cyclosporin and infliximab are equally efficacious medical rescue therapies as demonstrated in a recent randomized control trial. Patients not responding to infliximab or cyclosporin should be considered for colectomy.

Assessing patient preferences for treatment options and process of care in inflammatory bowel disease: a critical review of quantitative data

Inflammatory bowel disease (IBD), consisting of both Crohn's disease (CD) and ulcerative colitis (UC), are chronic inflammatory conditions of the intestinal tract. As there is no cure for either CD or UC, patients with these conditions face numerous treatment decisions regarding their disease. The aim of this review is to evaluate literature regarding quantitative studies of patient preferences in therapy for IBD with a focus on the emerging technique of stated preference and its application in IBD. Numerous simple survey-based studies have been performed evaluating IBD patients' preferences for medication frequency, mode of delivery, potential adverse events, etc., as well as variations in these preferences. These studies are limited, however, as they are purely descriptive in nature with limited quantitative information on the relative value of treatment alternatives. Time trade-off and standard-gamble studies have also been utilized to quantify patient utility for various treatment options or outcomes. However, these types of studies suffer from inaccurate assumptions regarding patient choice behavior. Stated preference is an emerging robust methodology increasingly utilized in health care that can determine the relative utility for a therapy option as well as its specific attributes (such as efficacy or adverse side effects). Stated preference techniques have begun to be applied in IBD and offer an innovative way of examining the numerous therapy options these patients and their providers face.

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.

Indian Society of Gastroenterology consensus on ulcerative colitis

In 2010, the Indian Society of Gastroenterology's Task Force on Inflammatory Bowel Diseases undertook an exercise to produce consensus statements on ulcerative colitis. This consensus, produced through a modified Delphi process, reflects our current understanding of the definition, diagnostic work up, treatment and complications of ulcerative colitis. The consensus statements are intended to serve as a reference point for teaching, clinical practice, and research in India.

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.

The Asia-Pacific consensus on ulcerative colitis

Inflammatory bowel disease (IBD) is increasing in many parts of the Asia-Pacific region. There is a need to improve the awareness of IBD and develop diagnostic and management recommendations relevant to the region. This evidence-based consensus focuses on the definition, epidemiology and management of ulcerative colitis (UC) in Asia. A multi-disciplinary group developed the consensus statements, reviewed the relevant literature, and voted on them anonymously using the Delphi method. The finalized statements were reviewed to determine the level of consensus, evidence quality and strength of recommendation. Infectious colitis must be excluded prior to diagnosing UC. Typical histology and macroscopic extent of the disease seen in the West is found in the Asia-Pacific region. Ulcerative colitis is increasing in many parts of Asia with gender distribution and age of diagnosis similar to the West. Extra-intestinal manifestations including primary sclerosing cholangitis are rarer than in the West. Clinical stratification of disease severity guides management. In Japan, leukocytapheresis is a treatment option. Access to biologic agents remains limited due to high cost and concern over opportunistic infections. The high endemic rates of hepatitis B virus infection require stringent screening before initiating immune-suppressive agents. Vaccination and prophylactic therapies should be initiated on a case-by-case basis and in accordance with local practice. Colorectal cancer complicates chronic colitis. A recent increase in UC is reported in the Asia-Pacific region. These consensus statements aim to improve the recognition of UC and assist clinicians in its management with particular relevance to the region.

Laparoscopic vs. open total abdominal colectomy for severe colitis: impact on recovery and subsequent completion restorative proctectomy

PURPOSE

This study was designed to compare short-term outcomes of laparoscopic vs. open total abdominal colectomy and end ileostomy for severe ulcerative colitis and to evaluate the impact of the initial surgical approach on subsequent operations for three-stage restorative proctocolectomy.

METHODS

Perioperative demographic and outcome data for patients with severe ulcerative colitis who underwent laparoscopic (n = 37) or open (n = 41) total abdominal colectomy at the initial stage of a three-stage restorative proctocolectomy were compared. Each stage was analyzed independently by using two-tailed t-tests and analysis of covariance.

RESULTS

Patients who underwent laparoscopic total abdominal colectomy had higher serum albumin (P = 0.0003), less inpatient narcotic usage (P = 0.0143), faster return of bowel function (P = 0.0001), and shorter length of stay (P = 0.039). There were no differences in perioperative parameters for the restorative proctectomy and ileostomy closure. The laparoscopic total abdominal colectomy patients underwent subsequent restorative proctectomy 49 days sooner (P = 0.0044) and ileostomy closure 17 days sooner (P = 0.00003) than the open total abdominal colectomy patients.

CONCLUSIONS

Laparoscopic abdominal colectomy for severe ulcerative colitis in selected patients is safe and is associated with short-term benefits that may lead to faster recovery and progression to completion of restorative proctocolectomy.

Impact of hospital volume on postoperative morbidity and mortality following a colectomy for ulcerative colitis

BACKGROUND & AIMS

Postoperative morbidity and mortality following a colectomy for ulcerative colitis (UC) has been primarily reported from tertiary care referral centers that perform a high volume of operations; however, the postoperative outcomes among nonselected hospitals are not known. We set out to evaluate postoperative morbidity and mortality using a nationally representative database and to determine the factors that influenced outcomes.

METHODS

We analyzed the 1995-2005 Nationwide Inpatient Sample to identify 7108 discharges for UC patients who underwent a total abdominal colectomy. The effects of hospital volume on postoperative morbidity and mortality were evaluated in logistic regression models adjusting for demographic and clinical factors.

RESULTS

Postoperative mortality and morbidity rates were 2.3% and 30.8%, respectively. Most operations were performed in low-volume hospitals that had an increased risk of death (adjusted odds ratio [aOR], 2.42; 95% confidence interval [CI]: 1.26-4.63). In-hospital mortality was increased in patients who were admitted emergently (aOR, 5.40; 95% CI: 3.48-8.40), aged 60-80 years (aOR, 8.70; 95% CI: 3.30-22.92), and those with Medicaid (aOR, 4.29; 95% CI: 2.13-8.66). Emergently admitted UC patients whose surgery was performed 6 days after their admission had significantly increased likelihood of in-hospital death (aOR, 2.12; 95% CI: 1.13-3.97).

CONCLUSIONS

Postoperative mortality was lowest in hospitals that performed the highest volume of operations. Increasing the proportion of total colectomies performed in high-volume hospitals may improve clinical outcomes for patients with UC.

Outcomes of the rectal remnant following colectomy for ulcerative colitis

OBJECTIVE

Controversy surrounds the optimal surgical management of the distal rectal remnant during colectomy for ulcerative colitis (UC) and the potential benefit from the placement of a rectal catheter for remnant drainage. This study reviews the clinical outcomes of patients who have undergone colectomy for UC with intra-peritoneal closure of the rectal remnant.

METHOD

Analysis of prospective data lodged on Lothian Surgical Audit databases from patients treated in a tertiary coloproctology unit over 11 years.

RESULTS

One hundred and fifty-nine patients were identified, the mean age was 41.9 years, 63% were men. Failure of maximal medical therapy necessitated surgery for 78.1% patients, while 12.6% had acute perforation and 11.9% had toxic megacolon. Complications included five (3.1%) stump dehiscences, eight (5.0%) intra-abdominal/pelvic collections, four (2.5%) significant wound infections, three (1.9%) small bowel obstructions and three (1.9%) deaths. Within the follow-up period, 62.3% patients had an ileo-pouch anal anastomosis (IPAA), 7.5% patients had a completion proctectomy, 10.1% patients within the series had a retained rectal remnant after 1 year follow up, the remaining patients had less than 1 year follow up.

CONCLUSION

The intra-peritoneal rectal stump following colectomy for UC is associated with low rates of pelvic sepsis and a high proportion of patients successfully proceeding to IPAA.