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Stephens IJB, Murphy B, Burns L, McCawley N, McNamara DA, Burke JP. Contemporary perioperative outcomes after total abdominal colectomy for ulcerative colitis in a tertiary referral centre. Eur J Gastroenterol Hepatol 2024; 36:578-583. [PMID: 38489595 DOI: 10.1097/meg.0000000000002755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Colectomy for ulcerative colitis (UC) is common despite therapeutic advances. Post-operative morbidity and mortality demonstrate an association between hospital volumes and outcomes. This single-centre retrospective study examines outcomes after emergency colectomy for UC. METHODS Patient demographics, perioperative variables and outcomes were collected in Beaumont Hospital between 2010 and 2023. Univariant analysis was used to assess relationships between perioperative variables and morbidity and length of stay (LOS). RESULTS A total of 115 patients underwent total abdominal colectomy with end ileostomy for UC, 8.7 (±3.8) per annum. Indications were refractory acute severe colitis (88.7%), toxic megacolon (6.1%), perforation (4.3%), or obstruction (0.9%). Over 80% of cases were performed laparoscopically. Pre-operative steroid (93%) and biologic (77.4%) use was common. Median post-operative LOS was 8 days (interquartile range 6-12). There were no 30-day mortalities, and 30-day post-operative morbidity was 38.3%. There was no association between time to colectomy ( P = 0.85) or biologic use ( P = 0.24) and morbidity. Increasing age was associated with prolonged LOS ( P = 0.01). Laparoscopic approach (7 vs. 12 days P =0.01, 36.8% vs. 45% P = 0.66) was associated with reduced LOS and morbidity. CONCLUSION This study highlights contemporary outcomes after emergency colectomy for UC at a specialist high-volume, tertiary referral centre, and superior outcomes after laparoscopic surgery in the biologic era.
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Affiliation(s)
- Ian J B Stephens
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
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2
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Giddings HL, Ng KS, Solomon MJ, Steffens D, Van Buskirk J, Young J. Reducing rate of total colectomies for ulcerative colitis but higher morbidity in the biologic era: an 18-year linked data study from New South Wales Australia. ANZ J Surg 2023; 93:2928-2938. [PMID: 37795917 DOI: 10.1111/ans.18713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND This study aims to investigate the trends in UC surgery in New South Wales (NSW) at a population level. METHODS A retrospective data linkage study of the NSW population was performed. Patients of any age with a diagnosis of UC who underwent a total abdominal colectomy (TAC) ± proctectomy between Jul-2001 and Jun-2019 were included. The age adjusted population rate was calculated using Australian Bureau of Statistics data. Multivariable linear regression modelled the trend of TAC rates, and assessed the effect of infliximab (listed on the Pharmaceutical Benefits Scheme for UC in Apr-2014). RESULTS A total of 1365 patients underwent a TAC ± proctectomy (mean age 47.0 years (±18.6), 59% Male). Controlling for differences between age groups, the annual rate of UC TACs decreased by 2.4% each year (95% CI 1.4%-3.4%) over the 18-year period from 1.30/100000 (2002) to 0.84/100000 (2019). An additional incremental decrease in the rate of TACs was observed after 2014 (OR 0.83, 95% CI 0.69-1.00). There was no change in the proportion of TACs performed emergently over the study period (OR 1.02, 95% CI 0.998-1.04). The odds of experiencing any perioperative surgical complication (aOR 1.54, 95% CI 1.01-2.33, P = 0.043), and requiring ICU admission (aOR 1.85, 95% CI 1.24-2.76, P = 0.003) significantly increased in 2014-2019 compared to 2002-2007. CONCLUSIONS The rate of TACs for UC has declined over the past two decades. This rate decrease may have been further influenced by the introduction of biologics. Higher rates of complications and ICU admissions in the biologic era may indicate poorer patient physiological status at the time of surgery.
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Affiliation(s)
- Hugh L Giddings
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Joe Van Buskirk
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Public Health Research Analytics and Methods for Evidence, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Le Cosquer G, Capirchio L, Rivière P, Denis MA, Poullenot F, Remue C, Zerbib F, Leonard D, Célérier B, Kartheuser A, Laharie D, Dewit O. Time trend in surgical indications and outcomes in ulcerative colitis-A two decades in-depth retrospective analysis. Dig Liver Dis 2023; 55:1338-1344. [PMID: 37029063 DOI: 10.1016/j.dld.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/20/2023] [Accepted: 03/10/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Recent data regarding the impact of biologics and new surgical techniques on the indications and outcomes of colectomy for ulcerative colitis (UC) are limited. AIMS The present study aimed at determining the trend of colectomy in UC by comparing colectomy indications and outcomes between 2000 and 2010 and 2011-2020. METHODS This observational retrospective study was conducted in two tertiary hospitals, including consecutive patients who underwent colectomy between 2000 and 2020. All data concerning UC history, treatment and surgeries were collected. RESULTS Among the 286 patients included, 87 underwent colectomy in 2001-2010 and 199 in 2011-2020. Patients' characteristics were similar between groups, except for prior biologic exposure (50.6 % vs. 74.9%; p<0.001). The indications of colectomy significantly decreased for refractory UC (50.6 % vs. 37.7%; p = 0.042), but were similar for acute severe UC (36.8 % vs. 42.2%; p = 0.390) and (pre)neoplastic lesions (12.6 % vs. 20.1%; p = 0.130). A widespread use of laparoscopy (47.7 % vs. 81.4%; p<0.001) was associated with fewer early complications (12.6 % vs. 5.5%; p = 0.038). CONCLUSION Over the last two decades, the proportion of surgery for refractory UC significantly decreased compared to other surgical indications while surgical outcomes improved despite larger exposure to biologics.
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Affiliation(s)
- Guillaume Le Cosquer
- Department of Gastroenterology, CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Lena Capirchio
- Department of Hepato-gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Pauline Rivière
- Department of Gastroenterology, CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Marie Armelle Denis
- Department of Hepato-gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Florian Poullenot
- Department of Gastroenterology, CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Christophe Remue
- Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Frank Zerbib
- Department of Gastroenterology, CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Daniel Leonard
- Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Bertrand Célérier
- Department of Digestive and Endocrine Surgery, CHU de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - Alex Kartheuser
- Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - David Laharie
- Department of Gastroenterology, CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Olivier Dewit
- Department of Hepato-gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
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Kariyawasam VC, Mourad FH, Mitrev N, Paramsothy S, Selinger CP, Katelaris PH, Jones B, McDonald C, Barr G, Chapman G, Cowlishaw J, Andrews J, Leong RW. Early thiopurine maintenance is associated with reduced proximal disease progression and colectomy rate in ulcerative colitis. Eur J Gastroenterol Hepatol 2021; 33:1524-1532. [PMID: 33731581 DOI: 10.1097/meg.0000000000002101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Thiopurines effectively maintain remission in ulcerative colitis patients. Whether early initiation of thiopurines after ulcerative colitis diagnosis decreases proximal disease progression and colectomy rates is not known. METHODS We conducted a cohort study of ulcerative colitis subjects recruited from 1970 to 2009. Early thiopurine maintenance was defined as commencement of azathioprine or mercaptopurine within 5 years of diagnosis and maintenance for at least 6 months. Propensity score matching was conducted to correct for confounders influencing early thiopurine introduction. Outcomes of interest were colectomy rate and endoscopic proximal disease extension. RESULTS 982 consecutive ulcerative colitis subjects (12 879 patient-years) were recruited with 116 requiring colectomy. Thiopurines initiation and maintenance increased over time with median time to thiopurine commencement decreasing from 23 years in the first decade to 2 years in the last decade (P < 0.0001). Multivariate analysis showed that early thiopurine maintenance significantly decreased the need for colectomy [hazard ratio, 0.13; 95% confidence interval (CI):0.03-0.55; P = 0.006]. The number of subjects needed to be treated to reduce one colectomy at 5 and 10 years was 18 (95% CI, 16- 36) and 12 (95% CI, 11-25). After propensity score matching, early thiopurine maintenance was significantly associated with decreased colectomy (hazard ratio, 0.10; 95% CI, 0.03-0.43; P = 0.002) and proximal progression of disease extent (hazard ratio, 0.26; 95% CI, 0.10-0.78; P = 0.015). CONCLUSION Early thiopurine maintenance for >6 months is significantly associated with reduced colectomy and proximal progression of disease extent in ulcerative colitis.
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Affiliation(s)
- Viraj C Kariyawasam
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Fadi H Mourad
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
| | - Nikola Mitrev
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
| | | | - Christian P Selinger
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Peter H Katelaris
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Brian Jones
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Charles McDonald
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
| | - Gavin Barr
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
| | - Grace Chapman
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
| | - James Cowlishaw
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
| | - Jane Andrews
- IBD Services, Department of Gastroenterology, Royal Adelaide Hospital, Adelaide, Australia
| | - Rupert W Leong
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
- Faculty of Medicine, The University of New South Wales, Sydney, Australia
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Soriano CR, Powell CR, Chiorean MV, Simianu VV. Role of hospitalization for inflammatory bowel disease in the post-biologic era. World J Clin Cases 2021; 9:7632-7642. [PMID: 34621815 PMCID: PMC8462259 DOI: 10.12998/wjcc.v9.i26.7632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/17/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
Treatment for inflammatory bowel disease (IBD) often requires specialized care. While much of IBD care has shifted to the outpatient setting, hospitalizations remain a major site of healthcare utilization and a sizable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. In this review, we approach IBD care from the population-level with a specific focus on hospitalization for IBD, including the shifts from inpatient to outpatient care, the balance of emergency and elective hospitalizations, regionalization of specialty IBD care, and contribution of surgery and endoscopy to hospitalized care.
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Affiliation(s)
- Celine R Soriano
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Charleston R Powell
- Department of Internal Medicine, Madigan Army Medical Center, Tacoma, WA 98431, United States
| | - Michael V Chiorean
- Department of Gastroenterology, Swedish Medical Center, Seattle, WA 98109, United States
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
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6
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Sninsky J, Barnes EL. Medical Management of Aggressive Inflammatory Bowel Disease: When Is the Time to Cut Your (and the Patient's) Losses? J Laparoendosc Adv Surg Tech A 2021; 31:905-910. [PMID: 34171979 DOI: 10.1089/lap.2021.0338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Despite a treatment armamentarium that continues to increase in terms of medical options for the therapy of Crohn's disease (CD) and ulcerative colitis (UC), a significant proportion of patients will require surgical intervention over their disease course. Surgery does not represent a failure of medical therapy in the treatment of patients with inflammatory bowel disease (IBD); rather, surgery represents an integral feature of the multidisciplinary approach to an individual patient. The timing, factors, and potential outcomes of each therapeutic decision in the pre-, peri- and postoperative periods must be weighed by each member of a multidisciplinary team with the goal of improving the quality of life for patients with IBD. In this article, we review the current evidence underlying approaches to the medical and surgical management of complications of CD and UC. We also outline opportunities for tailored decision-making and potentially earlier surgical intervention with the aim of improving long-term outcomes among patients with IBD.
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Affiliation(s)
- Jared Sninsky
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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7
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Palacio FGM, de Souza LMP, Moreira JPDL, Luiz RR, de Souza HSP, Zaltman C. Hospitalization and surgery rates in patients with inflammatory bowel disease in Brazil: a time-trend analysis. BMC Gastroenterol 2021; 21:192. [PMID: 33906627 PMCID: PMC8077865 DOI: 10.1186/s12876-021-01781-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/20/2021] [Indexed: 12/25/2022] Open
Abstract
Background The prevalence of inflammatory bowel disease (IBD) is increasing globally, and the disease is frequently managed surgically. The aim of this study was to investigate the time trends and geographic distribution of IBD hospitalizations, surgeries and surgical-associated lethality.
Methods Data from the Brazilian Health Public System were retrospectively collected regarding hospitalizations, in-hospital deaths, IBD-related surgical procedures and lethality from 2005 to 2015. Results This eleven-year period revealed decreases in the rates of hospitalization (24%), IBD-related surgeries (35%), and IBD-related surgical lethality (46%). Most surgeries were performed in Crohn’s disease patients, and the predominant procedure was small bowel resection, mostly in young adults. A higher prevalence of ulcerative was observed throughout the country. The highest hospitalization and surgical rates were observed in the more industrialized regions of the South and the Southeast and in the municipalities integrated with metropolitan regions (MRs). The highest surgical-related lethality rates were seen in the less-developed regions and in municipalities not integrated with MRs. The length of hospital stay showed a slight increase throughout the period. Conclusions Brazil follows the global trend of decreases in hospitalizations, lethality, surgeries, and surgical lethality associated with IBD. The unequal distribution of hospitalizations and surgeries, concentrated in the industrialized areas, but with a shift towards the Northeast and from urbanized to rural areas, indicates ongoing changes within the country. Reductions in the rates of IBD-related hospitalizations, surgeries and lethality suggest the effectiveness of decentralization and improvements in the quality of public health services and the advances in medical therapy during the study period. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-021-01781-x.
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Affiliation(s)
- Flávia Gonçalves Musauer Palacio
- Departamento de Clínica Médica, Hospital Universitário, Universidade Federal Do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco 255, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-913, Brazil
| | - Lucila Marieta Perrotta de Souza
- Departamento de Clínica Médica, Hospital Universitário, Universidade Federal Do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco 255, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-913, Brazil
| | | | - Ronir Raggio Luiz
- Instituto de Estudos de Saúde Coletiva (IESC), Universidade Federal Do Rio de Janeiro, Rio de Janeiro, 21944-970, Brazil
| | - Heitor Siffert Pereira de Souza
- Departamento de Clínica Médica, Hospital Universitário, Universidade Federal Do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco 255, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-913, Brazil. .,D'Or Institute for Research and Education (IDOR), Rua Diniz Cordeiro 30, Botafogo, Rio de Janeiro, RJ, 22281-100, Brazil.
| | - Cyrla Zaltman
- Departamento de Clínica Médica, Hospital Universitário, Universidade Federal Do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco 255, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-913, Brazil
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Katsanos KH, Adamina M. Postoperative mortality after surgery for inflammatory bowel disease: The myth of Apollo and Artemis. Dig Liver Dis 2021; 53:52-53. [PMID: 33189589 DOI: 10.1016/j.dld.2020.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 10/15/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Ioannina School of Health Sciences, 45110 Ioannina, Greece.
| | - Michel Adamina
- Faculty of Medicine, University of Basel, Chief of Colorectal Surgery, Cantonal Hospital of Winterthur, 8401 Winterthur, Switzerland
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Guasch M, Vela E, Mañosa M, Clèries M, Cañete F, Parés D, Guarga À, Troya J, Calafat M, Domènech E. Postoperative mortality after surgery for inflammatory bowel disease in the era of biological agents: A population-based study in Southern Europe. Dig Liver Dis 2021; 53:54-60. [PMID: 33082087 DOI: 10.1016/j.dld.2020.09.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite the efficacy of biological agents, surgery is still required for a large percentage of patients with inflammatory bowel disease (IBD). AIMS To assess the postoperative mortality rates and associated risk factors in IBD patients in a population-based setting in the era of biological agents. METHODS This is a population-based longitudinal study including all patients diagnosed with IBD in Catalonia who underwent intestinal resection or colectomy between 2007 and 2016, identified from the Catalan Health Surveillance System database. Logistic regression was used to calculate the adjusted odds ratio for postoperative in-hospital and 30-day mortality. Data for Crohn's disease (CD) and ulcerative colitis (UC) were analysed separately. RESULTS A total of 1,660 interventions for CD (69%) and 738 for UC (31%) were performed at 55 centres. In-hospital and 30-day postoperative mortality rates were 2.1% and 2.5% for CD, and 5.4% and 6.4% for UC, respectively. In the multivariate logistic regression analysis, comorbidity was associated with in-hospital and 30-day postoperative mortality in CD and UC, whereas age was only associated with mortality in CD and a non-laparoscopic surgical approach with UC. CONCLUSIONS In the era of biologicals, the postoperative mortality rate for IBD depends mostly on co-morbidities and age.
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Affiliation(s)
- Montserrat Guasch
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Universitat Autònoma de Barcelona, Catalonia, Spain
| | - Emili Vela
- Unitat d'Informació i Coneixement, Servei Català de la Salut, Generalitat de Catalunya, Catalonia, Spain
| | - Míriam Mañosa
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid Spain
| | - Montserrat Clèries
- Unitat d'Informació i Coneixement, Servei Català de la Salut, Generalitat de Catalunya, Catalonia, Spain
| | - Fiorella Cañete
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid Spain
| | - David Parés
- Universitat Autònoma de Barcelona, Catalonia, Spain; Colorectal Surgery Unit, Department of General Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Àlex Guarga
- Gerència de Serveis Assistencials, Àrea d'Atenció Sanitària, Servei Català de la Salut, Generalitat de Catalunya, Catalonia, Spain
| | - José Troya
- Universitat Autònoma de Barcelona, Catalonia, Spain; Colorectal Surgery Unit, Department of General Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Margalida Calafat
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Eugeni Domènech
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Universitat Autònoma de Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid Spain.
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Endoscopic Step Up: A Colon-Sparing Alternative to Colectomy to Improve Outcomes and Reduce Costs for Patients With Advanced Neoplastic Polyps. Dis Colon Rectum 2020; 63:842-849. [PMID: 32118624 DOI: 10.1097/dcr.0000000000001645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The optimal strategy for colonic polyps not amenable to traditional endoscopic polypectomy is unknown. Endoscopic step up is a promising strategy for definitive treatment. OBJECTIVE The purpose of this study was to determine whether endoscopic step up leads to improved outcomes and decreased costs compared with planned colectomy for endoscopically unresectable colon polyps. DESIGN This was a retrospective review of a prospective database. SETTING The study was conducted at a tertiary referral center. PATIENTS Consecutive patients referred for endoscopically unresectable colon polyps 15 to 50 mm in size were included. INTERVENTIONS Patients underwent planned colectomy or endoscopic step up at the surgeon's discretion. Endoscopic step up began with diagnostic colonoscopy in the operating room. If the polyp was amenable to endoscopic removal, endoscopic mucosal resection or endoscopic submucosal dissection was performed with progression to combined endoscopic-laparoscopic surgery or laparoscopic colectomy, as indicated. MAIN OUTCOME MEASURES The primary outcome was 30-day adverse events. We also examined length of stay, hospital charges, insurer payments, and polyp recurrence. RESULTS A total of 52 patients underwent planned colectomy (48 laparoscopic), and 38 underwent endoscopic step up (28 endoscopic mucosal resection, 2 endoscopic submucosal dissection, 6 combined endoscopic-laparoscopic surgery, and 2 colectomy). Compared with planned colectomy, endoscopic step-up patients had fewer complications (13% vs 33%; p = 0.03) and shorter length of stay (median, 0 vs 4 d; p < 0.001). There was 1 readmission in the endoscopic step-up group and 5 in the planned colectomy group. Endoscopic step-up patients had lower hospital costs ($4790 vs $13,004; p < 0.001) and insurer payments ($2431 vs $19,951; p < 0.001). One-year polyp recurrence-free survival was 84% (95% CI, 67%-93%) in endoscopic step-up patients. All of the recurrences were benign, <1 cm, and managed endoscopically. LIMITATIONS The study was limited by its nonrandomized design and short follow-up. CONCLUSIONS An endoscopic step-up approach to colon polyps is associated with less morbidity, decreased healthcare costs, and colon preservation in 95% of patients. Additional studies are needed to evaluate long-term quality of life and polyp recurrence in this group. See Video Abstract at http://links.lww.com/DCR/B188. ENDOSCOPIC STEP UP UNA ALTERNATIVA A COLECTOMíA PARA PRESERVACIóN DE COLON CON LOS PROPóSITOS DE MEJORAR RESULTADOS Y REDUCIR COSTOS EN PACIENTES CON PóLIPOS NEOPLáSICOS AVANZADOS: Se desconoce la estrategia óptima para los pólipos de colon no susceptibles a la polipectomia endoscópica tradicional. Endoscopic Step Up es una estrategia prometedora para el tratamiento definitivo.Determinar si Endoscopic Step Up produce mejores resultados y menores costos en comparación con la colectomía programada para pólipos de colon endoscópicamente no resecables.Revisión retrospectiva de una base de datos prospectiva.Centro de referencia de tercer nivel.Pacientes consecutivos remitidos para pólipos de colon endoscópicamente irresecables de tamaño 15-50 mm.Los pacientes se sometieron a colectomía programada o Endoscópico Step Up a discreción del cirujano. Endoscopic Step Up comenzó con una colonoscopia diagnóstica en el quirófano. Si el pólipo era susceptible de extirpación endoscópica, la resección endoscópica de la mucosa o la disección submucosa endoscópica se realizaba con progresión a cirugía endoscópica-laparoscópica combinada o colectomía laparoscópica, según a cosnideraciones clínicas en el transoperatorio.El resultado primario fue los eventos adversos a 30 días. Duración de la estadía hospitalaria, los cargos hospitalarios, los pagos de las aseguradoras y la recurrencia de pólipos también fueron examinados.Un total de 52 pacientes se sometieron a colectomía programada (48 laparoscópicas) y 38 se sometieron a Endoscopic Step Up (28 resección endoscópica de la mucosa, 2 disección submucosa endoscópica, 6 cirugía endoscópica-laparoscópica combinada y 2 colectomía). En comparación con la colectomía programada los pacientes endoscópicos Step Up tuvieron menos complicaciones (13% versus 33%, p = 0.03) y una estadía hospitalaria más corta (mediana 0 versus 4 días, p <0.001). Hubo 1 reingreso hospitalario en el grupo Endoscopic Step Up y 5 en el grupo de colectomía programada. Los pacientes endoscópicos Step Up tuvieron costos hospitalarios más bajos ($ 4,790 versus $ 13,004, p <0,001) y pagos de la aseguradora ($ 2,431 versus $ 19,951, p <0,001). La supervivencia libre de recurrencia de pólipos a un año fue del 84% (IC 95% 67-93) en pacientes endoscópicos Step Up. Todas las recurrencias fueron benignas, <1 cm, y manejadas endoscópicamente.Diseño no aleatorizado y seguimiento corto.El abordaje endoscópico Step Up para pólipos de colon se asocia con menos morbilidad, disminución de los costos de atención médica y preservación del colon en el 95% de los pacientes. Se ocupan más estudios para evaluar la calidad de vida a largo plazo y la recurrencia de pólipos en este grupo. Consulte Video Resumen en http://links.lww.com/DCR/B188. (Traducción-Dr Adrián Ortega Robles).
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Justiniano CF, Aquina CT, Becerra AZ, Xu Z, Boodry CI, Swanger AA, Monson JRT, Fleming FJ. Postoperative Mortality After Nonelective Surgery for Inflammatory Bowel Disease Patients in the Era of Biologics. Ann Surg 2019; 269:686-691. [PMID: 29232213 DOI: 10.1097/sla.0000000000002628] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of the study was to analyze recent trends in the rate of nonelective surgery and corresponding mortality for inflammatory bowel disease (IBD) patients since the rise of biologic use. BACKGROUND Modern biologic therapy has improved outcomes for IBD, but little is known about the impact on mortality rates after nonelective surgery. METHODS New York's Statewide Planning & Research Cooperative System was queried for hospital admissions for ulcerative colitis (UC) with concurrent colectomy and Crohn disease (CD) with concurrent small bowel resection or colectomy from 2000 to 2013. Mixed-effects analyses assessed patient, surgeon, and hospital-level factors and hospital-level variation associated with 30-day mortality after nonelective surgery. RESULTS Between 2000 to 2006 and 2007 to 2013, the number of unscheduled IBD-related admissions increased by 50% for UC and 41% for CD, but no change in the proportion of nonelective surgery cases was observed (UC=38% vs 38%; CD=45% vs 42%) among 15,837 intestinal resections (UC=5,297; CD=10,540). Nonelective surgery mortality rates between 2000 to 2006 and 2007 to 2013 were high and increased for UC (10.2% vs 15%) but decreased for CD (3.3% vs 2.2%). Nonelective surgery in 2007 to 2013 was associated with an 82% increased risk of 30-day mortality in UC cases (odds ratio: 1.82; confidence interval: 1.19-2.62). After controlling for patient-level factors, large hospital-level variation was observed with 23-fold difference in mortality for both UC and CD. CONCLUSIONS Although nonelective IBD surgery rates have remained stable, associated 30-day mortality for UC has doubled in recent years despite advances in medical management. Current clinical decision-making and care pathways must be further evaluated to improve outcomes in this high-risk population.
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Affiliation(s)
- Carla F Justiniano
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | | | - Adan Z Becerra
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
- Department of Public Health Sciences, Division of Epidemiology, University of Rochester Medical Center, Rochester, NY
| | - Zhaomin Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Courtney I Boodry
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Alex A Swanger
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group, University of Central Florida, College of Medicine, Orlando, FL
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
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Sharara AI, Al Awadhi S, Alharbi O, Al Dhahab H, Mounir M, Salese L, Singh E, Sunna N, Tarcha N, Mosli M. Epidemiology, disease burden, and treatment challenges of ulcerative colitis in Africa and the Middle East. Expert Rev Gastroenterol Hepatol 2018; 12:883-897. [PMID: 30096985 DOI: 10.1080/17474124.2018.1503052] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Ulcerative colitis is an idiopathic, chronic, inflammatory bowel disorder characterized by an unpredictable course of alternating cycles of relapse and remission. Traditionally viewed as a disease of Western countries, the prevalence of ulcerative colitis is reported to be increasing in the developing world. In these regions, there is the potential to further explore the etiology of the disease, mainly through genetic studies. With this in mind, we consider available data relating to the epidemiology, clinical manifestations, and disease course of ulcerative colitis in Africa and the Middle East. Current treatment approaches in these countries are also reviewed and discussed in the context of new, small molecule, orally administered therapies. Areas covered: Available data on the epidemiology, clinical manifestations, and risk factors of ulcerative colitis in Africa and the Middle East are reviewed using a PubMed database search. Expert commentary: Epidemiologic studies from African and Middle Eastern countries suggest disease trends similar to the West, and an important health and economic burden. The management of ulcerative colitis within these developing countries is challenging, with the need to improve early diagnosis, access to healthcare, and patient education, along with facilitation of access to treatment options and improvement of medication adherence.
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Affiliation(s)
- Ala I Sharara
- a Division of Gastroenterology , American University of Beirut Medical Center , Beirut , Lebanon
| | | | - Othman Alharbi
- c Gastroenterology Division , King Khalid University Hospital, King Saud University , Riyadh , Kingdom of Saudi Arabia
| | - Hisham Al Dhahab
- d Department of Gastroenterology , Royal Hospital , Muscat , Oman
| | | | - Leonardo Salese
- f Department of Gastroenterology , Inflammation and Immunology Medical Affairs, Pfizer Inc , Collegeville , PA , USA
| | - Ena Singh
- f Department of Gastroenterology , Inflammation and Immunology Medical Affairs, Pfizer Inc , Collegeville , PA , USA
| | - Nancy Sunna
- g Department of Inflammation and Immunology , Pfizer Inc , Amman , Jordan
| | | | - Mahmoud Mosli
- h Department of Medicine , King Abdulaziz University , Jeddah , Kingdom of Saudi Arabia
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Aquina CT, Fleming FJ, Becerra AZ, Hensley BJ, Noyes K, Monson JR, Temple LK, Cellini C. Who gets a pouch after colectomy in New York state and why? Surgery 2018; 163:305-310. [DOI: 10.1016/j.surg.2017.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/30/2017] [Accepted: 07/31/2017] [Indexed: 02/08/2023]
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Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Hensley BJ, Noyes K, Monson JR, Fleming FJ. Missed Opportunity. Ann Surg 2016; 264:127-34. [DOI: 10.1097/sla.0000000000001389] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Alexakis C, Pollok RCG. Impact of thiopurines and anti-tumour necrosis factor therapy on hospitalisation and long-term surgical outcomes in ulcerative colitis. World J Gastrointest Surg 2015; 7:360-9. [PMID: 26730281 PMCID: PMC4691716 DOI: 10.4240/wjgs.v7.i12.360] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 09/22/2015] [Accepted: 11/10/2015] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis (UC) is a chronic inflammatory condition affecting the large bowel and is associated with a significant risk of both requirement for surgery and the need for hospitalisation. Thiopurines, and more recently, anti-tumour necrosis factor (aTNF) therapy have been used successfully to induce clinical remission. However, there is less data available on whether these agents prevent long-term colectomy rates or the need for hospitalisation. The focus of this article is to review the recent and pertinent literature on the long-term impact of thiopurines and aTNF on long-term surgical and hospitalisation rates in UC. Data from population based longitudinal research indicates that thiopurine therapy probably has a protective role against colectomy, if used in appropriate patients for a sufficient duration. aTNF agents appear to have a short term protective effect against colectomy, but data is limited for longer periods. Whereas there is insufficient evidence that thiopurines affect hospitalisation, evidence favours that aTNF therapy probably reduces the risk of hospitalisation within the first year of use, but it is less clear on whether this effect continues beyond this period. More structured research needs to be conducted to answer these clinically important questions.
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Hardt J, Kienle P. Occult and Manifest Colorectal Carcinoma in Ulcerative Colitis: How Does It Influence Surgical Decision Making? VISZERALMEDIZIN 2015; 31:252-7. [PMID: 26557833 PMCID: PMC4608634 DOI: 10.1159/000438811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background The incidence of colorectal cancer (CRC) among patients with ulcerative colitis (UC) is increased compared to the general population. The diagnosis of CRC potentially influences surgical decision making in patients with UC. Methods This review considers clinical studies, systematic reviews, and guidelines on the surgical therapy of CRC in UC. We searched the bibliographic databases The Cochrane Library and Medline (applying MeSH terms such as ‘Colitis, Ulcerative/surgery’, ‘Colorectal Neoplasms’, and ‘Proctocolectomy, Restorative’) with no restriction on language, date, or country. Search results as well as references of relevant publications were independently screened by both authors of this review. Results The surgical gold standard for proven CRC in UC is oncological proctocolectomy, if possible preferably as a restorative procedure with formation of an ileal pouch-anal anastomosis. Mucosectomy and hand-sewn anastomosis is the preferred option for fashioning the anastomosis in these patients, especially in case of dysplasia or cancer in the rectum, although the available data is not conclusive. In highly selected cases of patients with histologically confirmed sporadic CRC without dysplasia in multiple random biopsies and without relevant inflammation, a conventional limited oncological resection is adequate. If UC patients with rectal cancer require radiotherapy, it should be performed in a neoadjuvant setting because of the high risk of radiation-induced pouch failure. Conclusion Although restorative proctocolectomy is clearly the gold standard therapy for patients with CRC in UC, surgical decision making has to take into account the various settings and patient factors.
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Affiliation(s)
- Julia Hardt
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Peter Kienle
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Singh S, Al-Darmaki A, Frolkis AD, Seow CH, Leung Y, Novak KL, Ghosh S, Eksteen B, Panaccione R, Kaplan GG. Postoperative Mortality Among Patients With Inflammatory Bowel Diseases: A Systematic Review and Meta-analysis of Population-Based Studies. Gastroenterology 2015; 149:928-37. [PMID: 26055136 DOI: 10.1053/j.gastro.2015.06.001] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 05/02/2015] [Accepted: 06/01/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS There have been varying reports of mortality after intestinal resection for the inflammatory bowel diseases (IBDs). We performed a systematic review and meta-analysis of population-based studies to determine postoperative mortality after intestinal resection in patients with IBD. METHODS We searched Medline, EMBASE, and PubMed, from 1990 through 2015, to identify 18 articles and 3 abstracts reporting postoperative mortality among patients with IBD. The studies included 67,057 patients with ulcerative colitis (UC) and 75,971 patients with Crohn's disease (CD), from 15 countries. Mortality estimates stratified by emergent and elective surgeries were pooled separately for CD and UC using a random-effects model. To assess changes over time, the start year of the study was included as a continuous variable in a meta-regression model. RESULTS In patients with UC, postoperative mortality was significantly lower among patients who underwent elective (0.7%; 95% confidence interval [CI], 0.6%-0.9%) vs emergent surgery (5.3%; 95% CI, 3.8%-7.4%). In patients with CD, postoperative mortality was significantly lower among patients who underwent elective (0.6%; 95% CI, 0.2%-1.7%) vs emergent surgery (3.6%; 95% CI, 1.8%-6.9%). Postoperative mortality did not differ for elective (P = .78) or emergent (P = .31) surgeries when patients with UC were compared with patients with CD. Postoperative mortality decreased significantly over time for patients with CD (P < .05) but not UC (P = .21). CONCLUSIONS Based on a systematic review and meta-analysis, postoperative mortality was high after emergent, but not elective, intestinal resection in patients with UC or CD. Optimization of management strategies and more effective therapies are necessary to avoid emergent surgeries.
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Affiliation(s)
- Sunny Singh
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Ahmed Al-Darmaki
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra D Frolkis
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Yvette Leung
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Subrata Ghosh
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Bertus Eksteen
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada.
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Sacchi M, Yeung TM, Spinelli A, Mortensen NJ. Assessment of the quality of patient-orientated internet information on surgery for ulcerative colitis. Colorectal Dis 2015; 17:511-4. [PMID: 25510335 DOI: 10.1111/codi.12870] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 09/20/2014] [Indexed: 02/08/2023]
Abstract
AIM This study examines the quality of websites providing information on ulcerative colitis, including treatment options and surgery. METHOD Two search engines (Google and Yahoo) and the search term 'surgery for ulcerative colitis' were used. The first 50 sites obtained with each search engine were assessed. Sites were evaluated for content and scored using the DISCERN instrument, which evaluates the quality of health information on treatment choices. RESULTS One hundred sites were examined, of which 14 were duplicates. Of the remainder, 58 provided patient-orientated information for adults and one site provided information for surgery in children. The other 27 sites included six scientific articles, three blogs, three links, six resources for clinicians, five fora, two video links and two dead links. Of the 58 websites that provided patient information for adults, only 26 (44.8%) had been updated within the last 2 years. Only 13/58 (22.4%) were affiliated to hospitals and clinics. Most sites (38/58, 65.5%) were associated with private companies with commercial interests. Although most websites contained information on symptoms and treatment options for ulcerative colitis, 37 (63.8%) did not describe any of the risks of surgery. Overall, only seven (12.1%) websites were identified as being 'good' or 'excellent' using the DISCERN criteria. CONCLUSION The quality of patient information on surgery for ulcerative colitis is highly variable. There is potential for internet provision of valuable information and clinicians should guide patients with to access high-quality websites.
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Affiliation(s)
- M Sacchi
- Colon and Rectal Surgery Unit, Department of General Surgery, Humanitas Research Hospital, Rozzano, Italy
| | - T M Yeung
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - A Spinelli
- Colon and Rectal Surgery Unit, Department of General Surgery, Humanitas Research Hospital, Rozzano, Italy.,Department of Biotechnologies and Translational Medicine, University of Milano, Milan, Italy
| | - N J Mortensen
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
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Øresland T, Bemelman WA, Sampietro GM, Spinelli A, Windsor A, Ferrante M, Marteau P, Zmora O, Kotze PG, Espin-Basany E, Tiret E, Sica G, Panis Y, Faerden AE, Biancone L, Angriman I, Serclova Z, de Buck van Overstraeten A, Gionchetti P, Stassen L, Warusavitarne J, Adamina M, Dignass A, Eliakim R, Magro F, D'Hoore A. European evidence based consensus on surgery for ulcerative colitis. J Crohns Colitis 2015; 9:4-25. [PMID: 25304060 DOI: 10.1016/j.crohns.2014.08.012] [Citation(s) in RCA: 232] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
PURPOSE Proctocolectomy has been a curative option for patients with severe ulcerative colitis. In recent years, there has been a growing use of medical salvage therapy in the management of patients with moderate to severe ulcerative colitis. We aimed at reviewing the role of surgical management in a time of intensified medical management on the basis of published trial data. The aim was to determine the efficacy of aggressive medical versus surgical management in achieving multifaceted treatment goals. METHODS A comprehensive search of Pubmed, Medline, the Cochrane database was performed. Abstracts were evaluated for relevance. Selected articles were then reviewed in detail, including references. Recommendations were then drafted based on evidence and conclusions in the selected articles. RESULTS The majority of patients with UC will not need surgery. However, steroid-refractoriness and steroid-dependence signal a subset of patients with more challenging disease. Biological therapy has been shown to achieve short-term improvement and temporarily reduce the need for a colectomy. However, there is a substantial financial and medical price to pay because a high fraction of these salvaged patients will still need a curative colectomy but may be exposed to the negative impact of prolonged immunosuppression, chronic illness, and a higher probability to require 3 rather than 2 operations. Proctocolectomy with ileo-anal pouch anastomosis-performed in 1, 2, or 3 steps depending on the patient's condition-remains the surgical procedure of choice. Even though it has its share of possible complications, it has been associated with excellent long-term outcomes and high levels of satisfaction, such that in the majority of patients they become indistinguishable from unaffected normal individuals. CONCLUSIONS The current data demonstrate that use of medical salvage therapy in the treatment of UC will likely continue to grow and evolve. Consensus is being developed to better define and predict failure of medical therapy and clarify the role of the different treatment modalities. For many patients, sacrificing the nonresponsive diseased colon is an underused or unnecessarily delayed chance to normalize their health and life. Biologicals in many instances may have to be considered the bridge to that end.
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Chhaya V, Saxena S, Cecil E, Chatu S, Subramanian V, Curcin V, Majeed A, Pollok RC. The impact of timing and duration of thiopurine treatment on colectomy in ulcerative colitis: a national population-based study of incident cases between 1989-2009. Aliment Pharmacol Ther 2015; 41:87-98. [PMID: 25382737 DOI: 10.1111/apt.13017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 10/02/2014] [Accepted: 10/19/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND The role of thiopurines in altering the risk of colectomy in ulcerative colitis (UC) remains unclear. AIMS To examine predictors of colectomy in UC and determine the impact of thiopurines on the risk of colectomy. METHODS We constructed a population-based cohort of incident cases of UC in the United Kingdom between 1989 and 2009. We determined trends in thiopurine usage and colectomy for three defined cohorts: era 1 (1989-1995), era 2 (1996-2002), era 3 (2003-2009). We used Cox regression to determine predictors of colectomy and quantified the impact of duration and timing of thiopurine use on the risk of colectomy. RESULTS We identified 8673 incident cases of UC. 5-year colectomy rates increased from 4.2%, 5.1% to 6.9% (P = 0.001) for era 1, era 2 and era 3, respectively, despite increasing thiopurine use. This was not significant after adjustment for predictors of colectomy (P = 0.06). There was a higher risk of colectomy in men (HR 1.44, 95% CI: 1.19-1.73), those diagnosed at an early age (HR 1.35, 95% CI: 1.04-1.75; 16-24 vs. 25-64) and early steroid users (HR 1.94, 95% CI: 1.59-2.37). 5-ASA users were less likely to require a colectomy (HR 0.35, 95% CI: 0.28-0.44). Amongst thiopurine users, those treated for greater than 12 months had a 71% reduction in risk of colectomy (HR 0.29, 95% CI: 0.21-0.40). Early thiopurines offered no additional benefit. CONCLUSIONS Thiopurine exposure for greater than 12 months reduces the likelihood of colectomy by 71%. Young men and those requiring steroids within 3 months of diagnosis are at greatest risk of colectomy, and most likely to benefit from sustained thiopurine use.
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Affiliation(s)
- V Chhaya
- Department of Gastroenterology, St George's University Hospital, London, UK
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Nordenvall C, Ekbom A, Bottai M, Smedby KE, Nilsson PJ. Mortality after total colectomy in 3084 patients with inflammatory bowel disease: a population-based cohort study. Aliment Pharmacol Ther 2014; 40:280-7. [PMID: 24943679 DOI: 10.1111/apt.12844] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 04/19/2014] [Accepted: 05/28/2014] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- C Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Division of Coloproctology, Center for Digestive Disease, Karolinska University Hospital, Stockholm, Sweden
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Byrne BE, Mamidanna R, Vincent CA, Faiz O. Population-based cohort study comparing 30- and 90-day institutional mortality rates after colorectal surgery. Br J Surg 2014; 100:1810-7. [PMID: 24227369 PMCID: PMC4065361 DOI: 10.1002/bjs.9318] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2013] [Indexed: 12/19/2022]
Abstract
Background Surgical mortality results are increasingly being reported and published in the public domain as indicators of surgical quality. This study examined how mortality outlier status at 90 days after colorectal surgery compares with mortality at 30 days and subsequent intervals in the first year after surgery. Methods All adults undergoing elective and emergency colorectal resection between April 2001 and February 2007 in English National Health Service (NHS) Trusts were identified from administrative data. Funnel plots of postoperative case mix-adjusted institutional mortality rate against caseload were created for 30, 90, 180 and 365 days. High- or low-mortality unit status of individual Trusts was defined as breaching upper or lower third standard deviation confidence limits on the funnel plot for 90-day mortality. Results A total of 171 688 patients from 153 NHS Trusts were included. Some 14 537 (8·5 per cent) died within 30 days of surgery, 19 466 (11·3 per cent) within 90 days, 23 942 (13·9 per cent) within 180 days and 31 782 (18·5 per cent) within 365 days. Eight institutions were identified as high-mortality units, including all four units with high outlying status at 30 days. Twelve units were low-mortality units, of which six were also low outliers at 30 days. Ninety-day mortality correlated strongly with later mortality results (rs = 0·957, P < 0·001 versus 180-day mortality; rs = 0·860, P < 0·001 versus 365-day mortality). Conclusion Extending mortality reporting to 90 days identifies a greater number of mortality outliers when compared with the 30-day death rate. Ninety-day mortality is proposed as the preferred indicator of perioperative outcome for local analysis and public reporting.
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Affiliation(s)
- B E Byrne
- Centre for Patient Safety and Service Quality, Imperial College London, St Mary's Campus, and
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Chhaya V, Pollok R. The impact of thiopurines on surgical outcomes in inflammatory bowel disease: do they make a difference? F1000PRIME REPORTS 2013; 5:50. [PMID: 24273651 PMCID: PMC3816845 DOI: 10.12703/p5-50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Ulcerative colitis and Crohn's disease together are known as inflammatory bowel disease (IBD). Surgery is considered for more severe disease and is a dreaded consequence for patients. Thiopurines have proven efficacy in the induction and maintenance of remission of IBD, but the long-term need for surgery remains uncertain with conflicting results from the available studies. The timing and duration of thiopurines also appears to play a pivotal role in the management of these conditions and may also affect the need for surgery. Data from Denmark, Canada, Hungary and the UK appear to suggest a reduction in surgery rates prior to the introduction of anti-tumor necrosis factor (TNF) therapy. The authors aim to review the more recent literature evaluating the surgery rates in IBD and changes in disease trends over time. We ask whether increasing thiopurine prescribing has had an effect on the surgery rates in the era of biologic therapy and whether more aggressive treatment approaches have altered the natural history of IBD.
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Moore HB, Moore EE, Nehler MR, Cicutto LC, Bacon AW, Travis C, Schulick RD. Bridging the gap from T to K: integrated surgical research fellowship for the next generation of surgical scientists. J Am Coll Surg 2013; 218:279-82. [PMID: 24315889 DOI: 10.1016/j.jamcollsurg.2013.10.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 10/28/2013] [Indexed: 12/28/2022]
Affiliation(s)
- Hunter B Moore
- Department of Surgery, University of Colorado, Aurora, CO; Clinical Science Graduate Program, University of Colorado, Aurora, CO.
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Aurora, CO; Denver Health Medical Center, Denver, CO
| | - Mark R Nehler
- Department of Surgery, University of Colorado, Aurora, CO
| | - Lisa C Cicutto
- Clinical Science Graduate Program, University of Colorado, Aurora, CO
| | - Anthony W Bacon
- Department of Surgery, University of Colorado, Aurora, CO; Clinical Science Graduate Program, University of Colorado, Aurora, CO
| | - Claire Travis
- Department of Surgery, University of Colorado, Aurora, CO
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Musch E, Lutfi T, von Stein P, Zargari A, Admyre C, Malek M, Löfberg R, von Stein OD. Topical treatment with the Toll-like receptor agonist DIMS0150 has potential for lasting relief of symptoms in patients with chronic active ulcerative colitis by restoring glucocorticoid sensitivity. Inflamm Bowel Dis 2013; 19:283-92. [PMID: 22605641 DOI: 10.1002/ibd.23019] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with chronic active ulcerative colitis (UC) are regarded as treatment failures and represent an area of high unmet medical need, as normally the only remaining option is colectomy. METHODS We treated a total of eight chronic active severe UC outpatients with the immunomodulatory agent DIMS0150 as an add-on to current therapies. Seven patients received a single topical dose of 30 mg and one special case subject received three doses with 4 weeks between dosing occasions. All patients were classed as treatment failures and were elected for colectomy. Efficacy evaluation was determined in terms of colitis activity index, endoscopic improvement, and histologic disease activity assessed primarily at week 12 with a follow-up period of over 2 years. Glucocorticoid sensitivity was assayed by in vitro measurement of interleukin 6. RESULTS All patients demonstrated a pronounced and rapid reduction in their colitis activity index within 1 week following a single intracolonic administration via colonoscope of the agent DIMS0150. Further improvements were evident at week 4, resulting in a clinical response rate for the single-dose treatment of 71%, with 43% in clinical remission. By week 12 the clinical response and remission rates had reached 82% and 71%, respectively. A follow-up period of over 2 years posttreatment indicated that all but one of the treated patients had avoided the need for colectomy, with the longest patient being in symptom-free remission for over 27 months. Treatment with DIMS0150 restored glucocorticoid sensitivity. CONCLUSIONS DIMS0150 may have the potential to be an effective agent to treat chronic active UC patients with the prospect to avoid colectomy on a long-term basis and is currently the subject of a clinical phase III study (EudraCT number: 2011-003130-14).
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Affiliation(s)
- Eugen Musch
- Clinic of Colo-Proctology and Intestine Center the Marienhospital, Bottrop, Germany
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Targownik LE, Singh H, Nugent Z, Bernstein CN. The epidemiology of colectomy in ulcerative colitis: results from a population-based cohort. Am J Gastroenterol 2012; 107:1228-35. [PMID: 22613902 DOI: 10.1038/ajg.2012.127] [Citation(s) in RCA: 202] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Previous studies have reported colectomy rates of over 50% in ulcerative colitis (UC), although changes in management may have influenced the rates of colectomy in the modern era. We sought to determine the incidence of colectomy in UC and identify risk factors associated with early colectomy (EC) and late colectomy (LC). METHODS We used the University of Manitoba Inflammatory Bowel Disease Epidemiology Database, a population-based data set including UC patients with up to 25 years of post diagnosis follow-up. We tracked the occurrence of total colectomy in all patients with known UC, subdivided into EC (≤90 days from diagnosis date) and LC (>90 days from diagnosis). Survival curves were created and stratified by age, sex, era of diagnosis, and inpatient/hospital diagnosis. Cox proportional hazards modeling was used to determine which risk factors were predictive of either EC or LC. RESULTS Among 3,752 patients with UC, 367 underwent colectomy. The 5-, 10- and 20-year actuarial risk of requiring colectomy was 7.5%, 10.4%, and 14.8%, respectively. Male sex (hazard ratio (HR): 2.63, [corrected] 95% confidence interval (CI): 1.58-4.36) and being initially diagnosed during a hospitalization (HR: 12.46, 95% CI: 7.40-21.0) were predictive of EC after adjustment for confounders. In-hospital diagnosis was predictive of LC, whereas being diagnosed more recently was protective against LC (HR: 0.96, 95% CI: 0.93-0.98). CONCLUSIONS The cumulative incidence of colectomy in UC is lower than previously reported, and appears to be decreasing further among more recently diagnosed cohorts of patients. Male sex and hospitalization at the time of diagnosis are major risk factors for EC and LC.
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Affiliation(s)
- Laura E Targownik
- Section of Gastroenterology, Department of Internal Medicine, University of Manitoba IBD Clinical and Research Centre, Winnipeg, Canada.
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Abstract
PURPOSE OF REVIEW The relationship between surgery and biologic agents in the management of patients with inflammatory bowel disease continues to be a source of interest for both surgeons and clinicians. RECENT FINDINGS The role of biologic agents in patients with varying presentations of Crohn's disease or ulcerative colitis continues to evolve. However, the currently available biologic therapies are clearly not the panacea we have desired because they have only marginally decreased the frequency with which operative intervention is required and may have increased the risk for infectious postoperative complications in the nonelective setting. Compared to surgery, biologic agents are also significantly more costly and may not provide any greater gain in quality of life. SUMMARY Future studies must focus on the use of surgery and emerging biologic agents as complementary therapies designed to safely control inflammatory disease while providing objective value.
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Jen MH, Saxena S, Bottle A, Aylin P, Pollok RCG. Increased health burden associated with Clostridium difficile diarrhoea in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2011; 33:1322-31. [PMID: 21517920 DOI: 10.1111/j.1365-2036.2011.04661.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clostridium difficile (C. difficile) infection in hospitals in developed countries continues to be a major public health hazard despite increased control measures including review of antibiotic policies and hygiene measures. Patients with colitis are thought to be particularly vulnerable to C. difficile associated diarrhoea (CDAD). Identifying the clinical burden among hospitalised patients admitted with inflammatory bowel disease is an essential first step towards identifying and treating severe C. difficile infection in such individuals. AIM To determine excess morbidity and in-hospital mortality associated with hospital acquired CDAD in patients with inflammatory bowel disease (IBD-CDAD-HAI) admitted to NHS hospitals in England compared with those admitted for inflammatory bowel disease alone. METHODS Time trends study of all admissions to NHS hospitals between 2002/03 and 2007/08. We developed case definitions for IBD-CDAD-HAI patients. The primary outcomes were in-hospital mortality and length of stay. The secondary outcome was gastrointestinal surgery. RESULTS Patients in the IBD-CDAD-HAI group were more likely to die in hospital (adjusted OR 6.32), had 27.9 days longer in-patient stays and higher gastrointestinal surgery rates (adjusted OR 1.87) than patients admitted for inflammatory bowel disease alone. CONCLUSION Patients with inflammatory bowel disease admitted to NHS hospitals in England with co-existent C. difficile infection are at risk of greater in-hospital mortality and morbidity than patients admitted for inflammatory bowel disease alone.
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Affiliation(s)
- M-H Jen
- Dr Foster Unit at Imperial College, Department of Primary Care and Public Health, Imperial College Healthcare Trust, London, UK.
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