World Journal of Surgery

, Volume 35, Issue 3, pp 671–676 | Cite as

Trends in the Surgical Treatment of Ulcerative Colitis over Time: Increased Mortality and Centralization of Care

  • Michelle C. Ellis
  • Brian S. Diggs
  • John T. Vetto
  • Daniel O. Herzig



New medical therapies available to ulcerative colitis (UC) patients have influenced operative mortality for patients requiring colectomy. We sought to examine trends in treatment and outcome for UC patients treated surgically.


A review of 36,447 UC patients from the Nationwide Inpatient Sample was performed, comparing the pre-monoclonal antibody era (1990–1996) to the present-day era (2000–2006). Patients treated with total colectomy with ileostomy or proctocolectomy with ileal pouch were reviewed for outcome measures and practice setting (rural, urban non-teaching, urban teaching). Our main outcome measures were in-hospital mortality, length of stay, and total charges.


Total colectomy (n = 30,362) was performed five times more often than proctocolectomy (n = 6,085). When comparing the two study periods, mortality after total colectomy increased 3.8% to 4.6% (p = 0.0003). This difference was primarily due to increasing mortality in later years; when 1995–1996 was compared to 2005–2006, mortality increased from 3.6% to 5.6% (p < 0.0001). There were no deaths in the proctocolectomy group (p < 0.0001). The distribution by practice setting shifted over the two study periods, decreasing in rural (7.0% to 4.8%) and urban non-teaching (43.7% to 28.4%) centers, and increasing in urban teaching centers (49.3% to 66.8%). The total inflation-adjusted charges per patient increased significantly ($34,638 vs. $43,621; p < 0.0001).


The mortality rate after total colectomy is increasing, and the difference is accentuated in the years since widespread use of monoclonal antibody therapy. The care of these patients is being shifted to urban teaching centers and is becoming more expensive.


  1. 1.
    Langholz E, Munkholm P, Davidsen M et al (1994) Course of ulcerative colitis: analysis of changes in disease activity over years. Gastroenterology 107:3–11PubMedGoogle Scholar
  2. 2.
    Kunitake H, Hodin R, Shellito PC et al (2008) Perioperative treatment with infliximab in patients with Crohn’s disease and ulcerative colitis is not associated with an increased rate of postoperative complications. J Gastrointest Surg 12:1730–1736 (discussion 1736–1737)CrossRefPubMedGoogle Scholar
  3. 3.
    Lawson MM, Thomas AG, Akobeng AK (2006) Tumour necrosis factor alpha blocking agents for induction of remission in ulcerative colitis. Cochrane Database Syst Rev. 2006 Jul 19(3):CD005112Google Scholar
  4. 4.
    Russo EA, Harris AW, Campbell S et al (2009) Experience of maintenance infliximab therapy for refractory ulcerative colitis from six centres in England. Aliment Pharmacol Ther 29:308–314CrossRefPubMedGoogle Scholar
  5. 5.
    Schluender SJ, Ippoliti A, Dubinsky M et al (2007) Does infliximab influence surgical morbidity of ileal pouch-anal anastomosis in patients with ulcerative colitis? Dis Colon Rectum 50:1747–1753CrossRefPubMedGoogle Scholar
  6. 6.
    Selvasekar CR, Cima RR, Larson DW et al (2007) Effect of infliximab on short-term complications in patients undergoing operation for chronic ulcerative colitis. J Am Coll Surg 204:956–962 (discussion 962–963)CrossRefPubMedGoogle Scholar
  7. 7.
    Jarnerot G, Hertervig E, Friis-Liby I et al (2005) Infliximab as rescue therapy in severe to moderately severe ulcerative colitis: a randomized, placebo-controlled study. Gastroenterology 128:1805–1811CrossRefPubMedGoogle Scholar
  8. 8.
    Sandborn WJ, Rutgeerts P, Feagan BG et al (2009) Colectomy rate comparison after treatment of ulcerative colitis with placebo or infliximab. Gastroenterology 137:1250–1260 quiz 1520CrossRefPubMedGoogle Scholar
  9. 9.
    Aratari A, Papi C, Clemente V et al (2008) Colectomy rate in acute severe ulcerative colitis in the infliximab era. Dig Liver Dis 40:821–826CrossRefPubMedGoogle Scholar
  10. 10.
    Bressler B, Law JK, Al Nahdi Sheraisher N et al (2008) The use of infliximab for treatment of hospitalized patients with acute severe ulcerative colitis. Can J Gastroenterol 22:937–940PubMedGoogle Scholar
  11. 11.
    Mor IJ, Vogel JD, da Luz Moreira A et al (2008) Infliximab in ulcerative colitis is associated with an increased risk of postoperative complications after restorative proctocolectomy. Dis Colon Rectum 51:1202–1207 discussion 1207–1210CrossRefPubMedGoogle Scholar
  12. 12.
    Bordeianou L, Kunitake H, Shellito P et al (2009) Preoperative infliximab treatment in patients with ulcerative and indeterminate colitis does not increase rate of conversion to emergent and multistep abdominal surgery. Int J Colorectal Dis 25:401–404CrossRefPubMedGoogle Scholar
  13. 13.
    Longobardi T, Bernstein CN (2007) Utilization of health-care resources by patients with IBD in Manitoba: a profile of time since diagnosis. Am J Gastroenterol 102:1683–1691CrossRefPubMedGoogle Scholar
  14. 14.
    Bewtra M, Su C, Lewis JD (2007) Trends in hospitalization rates for inflammatory bowel disease in the united states. Clin Gastroenterol Hepatol 5:597–601CrossRefPubMedGoogle Scholar
  15. 15.
    Nguyen GC, Tuskey A, Dassopoulos T et al (2007) Rising hospitalization rates for inflammatory bowel disease in the United States between 1998 and 2004. Inflamm Bowel Dis 13:1529–1535CrossRefPubMedGoogle Scholar
  16. 16.
    Bernstein CN, Nabalamba A (2006) Hospitalization, surgery, and readmission rates of IBD in Canada: a population-based study. Am J Gastroenterol 101:110–118CrossRefPubMedGoogle Scholar
  17. 17.
    Cannom RR, Kaiser AM, Ault GT et al (2009) Inflammatory bowel disease in the United States from 1998 to 2005: has infliximab affected surgical rates? Am Surg 75:976–980PubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2010

Authors and Affiliations

  • Michelle C. Ellis
    • 1
  • Brian S. Diggs
    • 1
  • John T. Vetto
    • 2
  • Daniel O. Herzig
    • 1
  1. 1.Department of General SurgeryOregon Health and Science UniversityPortlandUSA
  2. 2.Division of Surgical OncologyOregon Health and Science UniversityPortlandUSA

Personalised recommendations