The threshold for deciding elective surgery for inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease is too high says a new UK report. The result is that surgery is treated as a last resort resulting in too many emergency operations with poorer survival rates than if earlier elective surgery had been performed.

The study is published in the Online First issue of the BMJ (British Medical Journal), and is the work of Dr Stephen E Roberts, Senior Lecturer in Epidemiology in the School of Medicine at Swansea University, Wales, UK, and colleagues from Swansea and Oxford.

Roberts and colleagues suggested that the threshold for deciding to undertake elective surgery to take away part or all of the colon (colectomy) in patients with inflammatory bowel disease (IBD) may be too high.

In the UK there are about a quarter of a million people living with IBD who will need a colectomy sooner or later. in England, about 2,000 colectomies are performed every year because of IBD.

Experts have previously suggested that delaying surgery has increased risk, and it is known that death rates for elective colectomy are low. However, it has not been clear if this is due to the threshold criteria for when surgery should be performed being too high, resulting in delayed decisions to operate and more emergency operations.

Roberts and colleagues investigated hospital records throughout England (from 1998 to 2003) to find the mortality rate following colectomy for IBD. They compared rates of elective colectomy, emergency colectomy and rates of hospitalization for IBD that was not followed by colectomy.

The researchers gathered records on a total of 23,464 patients who had spent more than three days in hospital because of IBD and of whom 5,480 had a colectomy. They also traced records on the participants who died up to three years after being admitted to hospital.

The results showed that:

  • Long term survival for elective colectomy was better than that for emergency or no colectomy.
  • There was a substantially greater risk of dying shortly after emergency colectomy.
  • At three years, the increased risk of death among patients who did not have a colectomy was almost as high as among those who had an emergency colectomy.
  • However, patients who had elective colectomies has a similar rate of survival as the general population.
  • Adjustment for other illnesses occuring in the patients did not affect the results.

The researchers conclude that:

“In England, the clinical threshold for elective colectomy in people with inflammatory bowel disease may be too high. Further research is now required to establish the threshold criteria and optimal timing of elective surgery for people with poorly controlled inflammatory bowel disease.”

The authors said their findings supported the idea that whenever possible, it was better to opt for elective colectomy rather than incur delay and risk emergency colectomy which has a poorer prognosis.

They called for further studies to establish the threshold criteria and help define the right timing for people with badly controlled IBD to have an elective colectomy.

An accompanying editorial said the findings should act as a word of caution to those who promoted surgery for IBD as a last resort.

“Mortality in patients with and without colectomy admitted to hospital for ulcerative colitis and Crohn’s disease: record linkage studies.”
Stephen E Roberts, John G Williams, David Yeates, and Michael J Goldacre.
BMJ, Oct 2007; doi:10.1136/bmj.39345.714039.55.

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Written by: Catharine Paddock