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Am Fam Physician. 2008;78(7):online

Background: According to British statistics, about 15 percent of persons with ulcerative colitis require hospitalization every year, and about 40 percent of these persons undergo colectomy. Some experts recommend that around 85 percent of hospitalized patients who do not respond to medical therapy within three days of admission should also undergo surgery. Roberts and colleagues studied mortality data for the three years following hospital admission for inflammatory bowel disease to compare outcomes for patients with elective, emergency, or no colectomy.

The Study: The researchers identified all cases admitted for more than three days to any hospital in the Oxford region between 1968 and 1999 because of inflammatory bowel disease. With the availability of new national data systems, they were also able to identify all patients who met these criteria from 1998 to 2003. The medical records of each patient were tracked for at least three years to identify subsequent admissions, surgeries, and comorbidities. Mortality rates of patients undergoing elective or emergency colectomy were compared with those of patients not receiving colectomy during the index admission.

Results: In the 2,959 admissions between 1968 and 1999, the three-year case fatality rates for ulcerative colitis (6.1 percent) and Crohn disease (4.6 percent) in patients treated with elective colectomy were lower than those in patients treated with emergency colectomy (9.8 and 9.2 percent, respectively) and those not undergoing colectomy (12.7 and 9.8 percent, respectively), but the differences did not reach statistical significance. The improved case fatality rates following elective colectomy reached statistical significance in the larger and more recent data from all patients. For patients with ulcerative colitis, mortality rates leveled off to those of the general population within about two months of elective colectomy and four months of emergency colectomy. For Crohn disease, the mortality rates also leveled off to match the general population within two months of elective colectomy, but continued to worsen for patients treated with emergency or no colectomy. The improved mortality after elective colectomy was not changed by adjustment for comorbidities or by the inclusion of patients with three days or less of hospital stay. Following the index admission, 9.9 percent of patients with ulcerative colitis and 4.5 percent of patients with Crohn disease who did not originally undergo surgery were subsequently treated with colectomy.

Conclusion: The authors conclude that elective colectomy provides a significant survival benefit for patients with inflammatory bowel disease, and that the current criteria for recommending this surgery may be too strict.

editor's note: The role of surgery in treating inflammatory bowel disease is highly controversial. Despite recent improvements, medical therapy is effective in the long term for only up to 40 percent of severely affected patients. Traditionally, surgery has been offered solely as a last resort. Recent improvements in medical and surgical treatments mean that decisions for each patient should be made after a more in-depth analysis of the specific risks and potential benefits of different treatment strategies, rather than the traditional approach.

This analysis must include a careful exploration of the quality-of-life priorities of the patient and his or her family. Inflammatory bowel disease is uniquely distressing in its impact on basic bowel function, self-esteem, and ability to function. Surgery may entail a permanent colostomy and the small but real risk of adverse effects, including impaired sexual function. This study may not be directly applicable to the approximately 1.4 million patients in the United States with inflammatory bowel disease because it focuses on those English patients who were sufficiently ill to require a significant hospital stay, but it certainly raises the question of potential benefit from earlier surgery.—a.d.w.

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