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

Game of clones: Battles in the field of carcinogenesis

Recent advances in bulk sequencing approaches as well as genomic decoding at the single-cell level have revealed surprisingly high somatic mutational burdens in normal tissues, as well as increased our understanding of the landscape of "field cancerization", that is, molecular and immune alterations in mutagen-exposed normal-appearing tissues that recapitulated those present in tumors. Charting the somatic mutational landscapes in normal tissues can have strong implications on our understanding of how tumors arise from mutagenized epithelium. Making sense of those mutations to understand the progression along the pathologic continuum of normal epithelia, preneoplasias, up to malignant tissues will help pave way for identification of ideal targets that can guide new strategies for preventing or eliminating cancers at their earliest stages of development. In this review, we will provide a brief history of field cancerization and its implications on understanding early stages of cancer pathogenesis and deviation from the pathologically "normal" state. The review will provide an overview of how mutations accumulating in normal tissues can lead to a patchwork of mutated cell clones that compete while maintaining an overall state of functional homeostasis. The review also explores the role of clonal competition in directing the fate of normal tissues and summarizes multiple mechanisms elicited in this phenomenon and which have been linked to cancer development. Finally, we highlight the importance of understanding mutations in normal tissues, as well as clonal competition dynamics (in both the epithelium and the microenvironment) and their significance in exploring new approaches to combatting cancer.

Staging Pouch Surgery in Ulcerative Colitis in the Biological Era

Restorative proctocolectomy, or ileal pouch anal anastomosis, is considered the standard treatment for intractable ulcerative colitis. When the pelvic pouch was first introduced in 1978, a two-stage procedure with proctocolectomy, construction of the pelvic pouch, and a diverting loop with subsequent closure were suggested. Over the decades that the pelvic pouch has been around, some principal technical issues have been addressed to improve the method. In more recent days the laparoscopic approach has been additionally introduced. During the same time-period the medical arsenal has developed far more with the increasing use of immune modulators and the introduction of biologicals. Staging of restorative proctocolectomy with a pelvic pouch refers to how many sessions, or stages, the procedure should be divided into. The main goal with restorative proctocolectomy is a safe operation with optimal short- and long-term function. In this paper we aim to review the present knowledge and views on staging of the pouch procedure in ulcerative colitis, especially with consideration to the treatment with biologicals.

Trends in Morbidity and Mortality Following Colectomy Among Patients with Ulcerative Colitis in the Biologic Era (2002-2013): A Study Using the National Inpatient Sample

BACKGROUND

Total abdominal colectomy (TAC) is a treatment modality of last recourse for patients with severe and/or refractory ulcerative colitis (UC). The goal of this study is to evaluate temporal trends and treatment outcomes following TAC among hospitalized UC patients in the biologic era.

METHODS

We queried the National Inpatient Sample (NIS) to identify patients older than 18 years with a primary diagnosis of ulcerative colitis (UC) who underwent TAC between 2002 and 2013. We evaluated postoperative morbidity and mortality as outcomes of interest. Logistic regression was used to explore factors associated with postoperative morbidity and mortality after TAC.

RESULTS

A weighted total of 307,799 UC hospitalizations were identified. Of these, 27,853 (9%) resulted in TAC. Between 2002 and 2013, hospitalizations for UC increased by over 70%; however, TAC rates dropped significantly from 111.1 to 77.1 colectomies per 1000 UC admissions. Overall, 2.2% of patients died after TAC. Mortality rates after TAC decreased from 3.5% in 2002 to 1.4% in 2013. Conversely, morbidity rates were stable throughout the study period. UC patients with emergent admissions, higher comorbidity scores and who had TAC in low volume colectomy hospitals had poorer outcomes. Regardless of admission type, outcomes were worse if TAC was performed more than 24 h after admission.

CONCLUSIONS

Despite increased hospitalizations for UC, rates of TAC have declined during the post-biologic era. For UC patients who undergo TAC, mortality has declined significantly while morbidity remains stable. Older age, race, emergent admissions and delayed surgery are predictive factors of both postoperative morbidity and mortality.

Hospitalization and surgery rates in patients with inflammatory bowel disease in Brazil: a time-trend analysis

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.

An audit of process and outcome for emergency colectomy in England and Wales

AIM

The aim of this work was to describe process and outcome for patients undergoing emergency colectomy for colitis in England and Wales.

METHOD

The National Emergency Laparotomy Audit (NELA) is a national audit including patients undergoing emergency laparotomy and laparoscopic resectional procedures. Data from adult patients under 65 years of age who underwent emergency subtotal colectomy or panproctocolectomy for colitis between 2013 and 2016 were analysed.

RESULTS

In total 1204 patients were included. Although approximately a third of patients underwent a colectomy within 5 days of admission [37% (440/1204)], 32% (383/1204) were admitted for more than 10 days prior to surgery. Colorectal surgeons were present at operation in 72% (869/1204) of cases and consultant surgeons attended 94% (1137/1204) of procedures. Laparoscopy was attempted in 32% (390/1204) of operations with wide institutional variation in its use (0-100% of cases). The overall 30-day inpatient mortality was 2.9% (35/1204). On multivariable regression analysis, age > 55 years [OR 3.59 (1.05-12.21), P = 0.041], female gender [OR 2.88 (1.27-6.52), P = 0.011] and American Society of Anesthesiologists grade 5 [OR 37.43 (2.72-514.52), P = 0.007] were associated with increased mortality.

CONCLUSION

There is a consultant-driven service that is largely delivered by specialist colorectal surgeons. Laparoscopy rates were high although there was wide variation in use across institutions. Preoperative delays were evident, and further work is necessary to determine the underlying reasons for these.

Variation in care of patients with elderly-onset inflammatory bowel disease in Ontario, Canada: A population-based cohort study

Background

Variation in health care, when not based on patient preference, may result in poorer care. We determined whether variation in health services utilization, gastroenterologist care and outcomes existed among patients with elderly-onset inflammatory bowel disease (IBD).

Methods

Patients with IBD (diagnosed ≥65 years) were identified from population-based health administrative data from Ontario, Canada (1999 to 2014). We assessed variation across multispecialty physician networks in gastroenterologist care and outcomes using multilevel logistic regression. Median odds ratios (MOR) described variation. We evaluated the association between gastroenterologist supply, specialist care and outcomes.

Results

In 4806 patients, there was significant variation in having ever seen a gastroenterologist (MOR 3.35, P < 0.0001), having a gastroenterologist as the primary IBD care provider (MOR 4.16, P < 0.0001), 5-year colectomy risk in ulcerative colitis (MOR 1.38, P = 0.01), immunomodulator use (MOR 1.47, P = 0.001), and corticosteroid use (MOR 1.26, P = 0.006). No variation in emergency department visits, hospitalizations or intestinal resection (Crohn’s) was noted. Patients in networks with fewer gastroenterologists were less likely to see a gastroenterologist (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.15 to 0.56), have a gastroenterologist as their primary care provider (OR 0.27, 95% CI 0.12 to 0.59), be hospitalized within 5 years (OR 0.82, 95% CI 0.69 to 0.98), and be prescribed biologics within 1 year (OR 0.50, 95% CI 0.28 to 0.89).

Conclusions

Utilization of gastroenterology care in patients with elderly-onset IBD varies greatly. Patients treated by gastroenterologists and in networks with more gastroenterologists have better outcomes. There is a need to ensure all individuals with IBD have equal access to and utilization of specialist care to ensure the best possible outcomes.

The Handling of the Rectal Stump Does Not Affect Severe Morbidity After Subtotal Colectomy For Ulcerative Colitis: A Retrospective Cohort Study

Background and Aims:

Colectomy due to ulcerative colitis is associated with complications. One severe complication is the risk for blow-out of the remaining rectal remnant. The aim of this study was to compare the frequency and severity of complications in patients with the rectal remnant left subcutaneously versus patients with the rectal remnant left intra-abdominally. A secondary aim was to identify risk factors for complications.

Materials and Methods:

Consecutive patients at two tertiary centers in Sweden were retrospectively reviewed regarding surgical procedures; complications classified according to Clavien–Dindo; and possible risk factors for complications such as preoperative medication, emergency surgery, and body mass index.

Results:

307 patients were identified. Minor complications were more common than previously reported (85%–89%). Severe surgical complications were not related to the handling of the rectal remnant. Leaving the rectal remnant subcutaneously was associated with local wound problems. Risk factors for severe complications were emergency surgery and preoperative medication with 5-aminosalicylic acid.

Conclusion:

Minor complications after colectomy for ulcerative colitis are very common and need to be addressed. Leaving the rectal stump intra-abdominally seems safe and may be advantageous to reduce local wound morbidity.

The rectal remnant after total colectomy for colitis - intra-operative,post-operative and longer-term considerations

OBJECTIVES

Acute severe colitis requires surgery in around 30% of the cases. Total colectomy with ileostomy is the standard procedure with distinct advantages to a laparoscopic approach. Less agreement exists regarding the formation or configuration of the retained rectal stump and its short-term and long-term management. In this review, aspects of management of the rectal remnant, including perioperative considerations, potential complications, medical treatment, surveillance and implications for proctectomy and reconstructive surgery are explored.

METHODS

A thorough literature review exploring the PubMed and EMBASE databases was undertaken to clarify the evidence base surrounding areas of controversy in the surgical approach to acute severe colitis. In particular, focus was given to evidence surrounding management of the rectal remnant.

RESULTS

There is a paucity of high quality evidence for optimal management of the rectal stump following colectomy, and randomised trials are lacking. Establishment of laparoscopic colectomy has been associated with distinct advantages as well as the emergence of unique considerations, including those specific to rectal remnant management.

CONCLUSIONS

Early surgical involvement and a multidisciplinary approach to the management of acute severe colitis are advocated. Laparoscopic subtotal colectomy and ileostomy should be the operation of choice, with division of the rectum at the pelvic brim leaving a closed intraperitoneal remnant. If the rectum is severely inflamed, a mucus fistula may be useful, and an indwelling rectal catheter is probably advantageous to reduce the complications associated with stump dehiscence. Patients electing not to proceed to proctectomy should undergo surveillance for dysplasia of the rectum.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Colectomy prior to diagnosis of primary sclerosing cholangitis is associated with improved prognosis in a nationwide cohort study of 2594 PSC-IBD patients

BACKGROUND

Despite the close relationship between primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD), the association between colectomy and the prognosis of PSC remains controversial.

AIM

To explore whether colectomy prior to PSC-diagnosis is associated with transplant-free survival.

METHODS

A nationwide cohort study in Sweden including all patients aged 18 to 69 years in whom both PSC and IBD was diagnosed between 1987 and 2014 was undertaken. Each patient was followed from date of both PSC and IBD diagnoses until liver transplantation or death, or 31 December 2014. Patients with colon in situ, and colectomy prior to PSC-diagnosis were compared. Survival analyses were performed using the Kaplan-Meier method and multivariable Cox regression models.

RESULTS

Of the 2594 PSC-IBD patients, 205 patients were treated with colectomy before PSC-diagnosis. During follow-up, liver transplantations were performed in 327 patients and 509 died. The risk of liver transplantation or death was lower in patients treated with colectomy prior to PSC-diagnosis (HR 0.71, 95% CI 0.53-0.95) than in patients with colon in situ. Male gender, longer time between IBD and PSC-diagnosis and older age were all associated with an increased risk of liver transplantation or death. Colectomy after PSC-diagnosis was however not associated with an increased risk of liver transplantation or death during long-term follow-up.

CONCLUSIONS

In PSC-IBD patients, colectomy prior to PSC-diagnosis is associated with a decreased risk of liver transplantation or death.

An evolutionary perspective on field cancerization

Tumorigenesis begins long before the growth of a clinically detectable lesion and, indeed, even before any of the usual morphological correlates of pre-malignancy are recognizable. Field cancerization, which is the replacement of the normal cell population by a cancer-primed cell population that may show no morphological change, is now recognized to underlie the development of many types of cancer, including the common carcinomas of the lung, colon, skin, prostate and bladder. Field cancerization is the consequence of the evolution of somatic cells in the body that results in cells that carry some but not all phenotypes required for malignancy. Here, we review the evidence of field cancerization across organs and examine the biological mechanisms that drive the evolutionary process that results in field creation. We discuss the clinical implications, principally, how measurements of the cancerized field could improve cancer risk prediction in patients with pre-malignant disease.

Survival of ileal pouch anal anastomosis constructed after colectomy or secondary to a previous ileorectal anastomosis in ulcerative colitis patients: a population-based cohort study

OBJECTIVES

Ileorectal anastomosis (IRA) affects bowel function, sexual function and reproduction less negatively than ileal pouch anal anastomosis (IPAA), the standard reconstruction after colectomy for ulcerative colitis (UC). In younger UC patients, IRA may have a role postponing pelvic surgery and IPAA. The aim of the present study was to investigate the survival of IPAA secondary to IRA compared to IPAA as primary reconstruction, as this has not previously been studied in UC.

PATIENTS AND METHODS

All patients with UC diagnosis between 1960 and 2010 in Sweden were identified from the National Patient Registry. From this cohort, colectomized patients reconstructed with primary IPAA and patients reconstructed with IPAA secondary to IRA were identified. The survival of the IPAA was followed up until pouch failure, defined as pouchectomy and ileostomy or a diverting ileostomy alone.

RESULTS

Out of 63,796 patients, 1796 were reconstructed with IPAA, either primarily (n = 1720) or secondary to a previous IRA (n = 76). There were no demographic differences between the groups, including length of follow-up (median 12.6 (IQR 6.7-16.6) years and 10.0 (IQR 3.5-15.9) years, respectively). Failure of the IPAA occurred in 103 (6.0%) patients with primary and in 6 (8%) patients after secondary IPAA (P = 0.38 log-rank). The 10-year pouch survival was 94% (95% CI 93-96) for primary IPAA and 92% (81-97) for secondary.

CONCLUSIONS

Patients choosing IRA as primary reconstruction do not have an increased risk of failure of a later secondary IPAA in comparison with patients with primary IPAA.

Subtotal colectomy for ulcerative colitis: lessons learned from a tertiary centre

AIM

Subtotal colectomy (STC) is a well-established treatment for complicated and refractory ulcerative colitis (UC). A laparoscopic approach offers potentially improved outcomes. The aim of the study was to report our experience with STC for UC in a single large centre.

METHOD

From January 2007 to May 2015, all consecutive patients undergoing STC for UC were retrospectively analysed from a prospectively managed database. Patients with known Crohn's disease or those undergoing one-stage procedures were excluded. Demographics, perioperative outcomes and second-stage procedures were analysed.

RESULTS

During the study period, 151 STCs were performed for UC [100 emergency (66%) and 51 elective (34%)]. Acute severe colitis refractory to therapy was the most common indication (62%). Overall, 117 laparoscopic (78%) and 34 open STCs were performed, with a conversion rate of 14.5%. Mortality and morbidity rates were 0.7% and 38%, respectively. Whilst operative time was shorter for open STC (by 75 min; P = 0.001), there were fewer complications (32% vs 62%; P = 0.002) and a shorter hospital stay (by 6.9 days; P = 0.0002) following laparoscopic STC. Fewer complications and shorter hospital stay were also observed after elective STC. Patients undergoing laparoscopic STC were more likely to undergo a restorative second-stage procedure than those having open STC (75% vs 50%; P = 0.03).

CONCLUSION

Laparoscopic STC for UC is feasible and safe, even in the emergency situation. A laparoscopic approach may offer advantages in terms of lower morbidity and reduced length of stay. Elective resection may offer similar advantages and is best performed whenever possible.

Swedish surgical outcomes study (SweSOS): An observational study on 30-day and 1-year mortality after surgery

BACKGROUND

The European Surgical Outcomes Study (EuSOS) revealed large variations in outcomes among countries. In-hospital mortality and ICU admission rates in Sweden were low, going against the assumption that access to ICU improves outcome. Long-term mortality was not reported in EuSOS and is generally poorly described in the current literature.

OBJECTIVE

To describe the characteristics of the Swedish subset of EuSOS and identify predictors of short and long-term mortality after surgery.

DESIGN

An observational cohort study.

SETTING

Six universities and two regional hospitals in Sweden.

PATIENTS

A cohort of 1314 adult patients scheduled for surgery between 4 April and 11 April 2011.

MAIN OUTCOME MEASURES

30-day and 1-year mortality.

RESULTS

A total of 303 patients were lost to follow-up, leaving 1011 for analysis; 69% of patients were classified as American Society of Anesthesiologists' physical status 1 or 2, and 68% of surgical procedures were elective. The median length of stay in postanaesthesia care units (PACUs) was 175 min (interquartile range 110-270); 6.6% of patients had PACU length of stay of more than 12 h and 3.6% of patients were admitted to the ICU postoperatively. Thirty-day mortality rate was 1.8% [95% confidence interval (CI) 1.0-2.6] and 8.5% (CI 6.8-10.2) at 1 year (n = 18 and 86). The risk of death was higher than in an age and sex-matched population after 30 days (standardised mortality ratio 10.0, CI 5.9-15.8), and remained high after 1 year (standardised mortality ratio 3.9, CI 3.1-4.8). Factors predictive of 30-day mortality were age, American Society of Anesthesiologists' physical status, number of comorbidities, urgency of surgery and ICU admission. For 1-year mortality, age, number of comorbidities and urgency of surgery were independently predictive. ICU admission and long stay in PACU were not significant predictors of long-term mortality.

CONCLUSION

Mortality rate increased almost five-fold at 1 year compared with 30-day mortality after surgery, demonstrating a significantly sustained long-term risk of death in this surgical population. In Sweden, factors associated with long-term postoperative mortality were age, number of comorbidities and surgical urgency.

Disease patterns in late-onset ulcerative colitis: Results from the IG-IBD "AGED study"

BACKGROUND

Late-onset UC represents an important issue for the near future, but its outcomes and relative therapeutic strategies are yet poorly studied.

AIM

To better define the natural history of late-onset ulcerative colitis.

METHODS

In a multicenter retrospective study, we investigated the disease presentation and course in the first 3 years in 1091 UC patients divided into 3 age-groups: diagnosis ≥65years, 40-64 years, and <40years. Disease patterns, medical and surgical therapies, and risk factors for disease outcomes were analyzed.

RESULTS

Chronic active or relapsing disease accounts for 44% of patients with late-onset UC. Across all age-groups, these disease patterns require 3-6 times more steroids than remitting disease, but immunomodulators and, to a lesser extent, biologics are less frequently prescribed in the elderly. Advanced age, concomitant diseases and related therapies were found to be inversely associated with the use of immunomodulators or biologics, but not with surgery.

CONCLUSIONS

The conclusion that late-onset UC follows a mild course may apply only to a subset of patients. an important percentage of elderly patients present with more aggressive disease. Since steroid use and surgery rates did not differ in this subgroup, lower use of immunosuppressive therapy and biologics may reflect concerns in prescribing these therapies in the elderly.

Patient optimization for surgery relating to Crohn's disease

The majority of patients with Crohn's disease require abdominal surgery during their lifetime, some of whom will require multiple operations. Postoperative complications are seen more frequently in patients requiring abdominal surgery for Crohn's disease than in patients requiring abdominal surgery for other conditions. In this article, we review the evidence supporting preoperative optimization, discussing strategies that potentially improve surgical outcomes and reduce perioperative morbidity and mortality. We discuss the roles of adequate cross-sectional imaging, nutritional optimization, appropriate adjustments of medical therapy, management of preoperative abscesses and phlegmons, smoking cessation and thromboembolic prophylaxis. We also review operation-related factors, and discuss their potential implications with respect to postoperative complications. Overall, the literature suggests that preoperative management has a major effect on postoperative outcomes.

The Fate of Reconstructive Surgery Following Colectomy for Inflammatory Bowel Disease in Sweden: A Population-based Cohort Study

BACKGROUND AND AIMS

Previous studies describing the cumulative failure rate after reconstructive surgery in patients with inflammatory bowel disease have been restricted to specific hospitals, and the generalizability of these results in a population-based setting is unknown. The aim of this study was to investigate the cumulative failure rate and risk factors for failure after reconstructive surgery in patients with inflammatory bowel disease.

METHODS

The study cohort includes all patients with inflammatory bowel disease in Sweden who underwent colectomy in 2000 through 2013 who were later treated with reconstructive surgery with ileal pouch-anal anastomosis or ileorectal anastomosis. Each patient was followed from admission for reconstructive surgery until admission for failure (a diverting stoma or permanent stoma), date of death, migration or December 31, 2013. Cumulative failure distributions were obtained with the Kaplan-Meier method, and multivariable Cox regression models were used to calculate the risk of failure.

RESULTS

Of the 1809 patients with inflammatory bowel disease treated with colectomy and reconstructive surgery, 83% had ulcerative colitis. During follow-up, 270 patients failed, and the cumulative failure rate was 4.1%, 13.2%, and 15.3% after 1, 3, and 5 years, respectively. The risk of failure was lower after treatment with ileal pouch-anal anastomosis than with ileorectal anastomosis [hazard ratio (95% confidence interval): 0.72 (0.56-0.93)]. Gender, hospital volume, and timing of reconstruction were not significantly associated with the risk of failure.

CONCLUSIONS

The 5-year cumulative failure rate in a nationwide setting was 15.3%, and hospital volume was not associated with the risk of failure.

Colectomy rates in patients with ulcerative colitis following treatment with infliximab or ciclosporin: a systematic literature review

This review aimed to compile all available published data on colectomy rates following treatment using infliximab or ciclosporin in adult ulcerative colitis patients and to analyse colectomy rates, timing to colectomy and postcolectomy mortality for each treatment. We systematically reviewed the literature after 1990 reporting colectomy rates in ulcerative colitis patients treated with infliximab or ciclosporin, excluding articles on paediatric patients, patients with indeterminate colitis or Crohn's disease and bowel surgery not related to ulcerative colitis. We presented weighted mean colectomy rates and mortality rates. Cox's regression was used to assess time to colectomy adjusting for colitis severity, patient age and sex. We tabulated 78 studies reporting on ciclosporin and/or infliximab and colectomy rates or postcolectomy mortality rates. Not all studies reported data in a standardized manner. Infliximab had a significantly lower colectomy rate than ciclosporin at 36 months when analysing all studies, studies directly comparing infliximab and ciclosporin and studies using severe colitis patients, but not at 3, 12 or 24 months. Severity and age were key indicators in the likelihood of undergoing colectomy after treatment. Postcolectomy mortality rates were less than 1.5% for both drugs. This review indicates that long-term colectomy rates following infliximab are significantly lower than ciclosporin in the longer term, and that postcolectomy mortality following infliximab and ciclosporin is very low. However, many key data items were missing from research articles, reducing our ability to establish with more confidence the actual impact of these two drugs on colectomy rates and postcolectomy mortality rates.

Probability, rate and timing of reconstructive surgery following colectomy for inflammatory bowel disease in Sweden: a population-based cohort study

AIM

Many patients with inflammatory bowel disease (IBD) need colectomy, but the rate of reconstructive surgery with restoration of intestinal continuity is unknown. The aim of this study was to investigate the probability, rate and timing of reconstructive surgery after colectomy in patients with IBD in a population-based setting.

METHOD

The study cohort included all patients with IBD in Sweden who underwent colectomy from 2000 to 2009. Each patient was followed from admission for colectomy to admission for reconstructive surgery, date of death, migration or 31 December 2010. Kaplan-Meier survival curves and multivariable Poisson regression models were used to describe the probability, rate and timing of reconstructive surgery.

RESULTS

Out of 2818 IBD patients treated with colectomy, 61.0% were male and 78.9% had ulcerative colitis. No reconstructive surgery had been performed in 1595 (56.6%) patients by the end of follow-up. Of the remaining 1223 patients, 526 underwent primary reconstructive surgery and 697 had a secondary reconstruction following a median interval of 357 days from primary surgery in the form of colectomy. The probability of reconstructive surgery was dependent on age (55.6% and 18.1% at ages 15-29 and ≥ 59 years, respectively), and the chance of reconstructive surgery was higher in hospitals that performed more than 13 colectomies for IBD per year [incidence rate ratio and 95% confidence interval 1.27 (1.09-1.49)].

CONCLUSION

Fewer than half of the patients having a colectomy for IBD underwent subsequent reconstructive surgery. Older age and low hospital volume were risk factors for no reconstructive surgery.

Postoperative Mortality Among Patients With Inflammatory Bowel Diseases: A Systematic Review and Meta-analysis of Population-Based Studies

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.