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Early Surgical Intervention for Acute Ulcerative Colitis Is Associated with Improved Postoperative Outcomes

  • Original Article
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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Timing of surgical intervention for acute ulcerative colitis has not been fully examined during the modern immunotherapy era. Although early surgical intervention is recommended, historical consensus for “early” ranges widely. The purpose of this study was to evaluate outcomes according to timing of urgent surgery for acute ulcerative colitis.

Methods

All non-elective total colectomies in ulcerative colitis patients were identified in the National Inpatient Sample from 2002 to 2014. Procedures, comorbidities, diagnoses, and in-hospital outcomes were collected using International Classification of Disease, 9th Revision codes. An operation was defined as early if within 24 hours of admission. Results were compared between the early versus delayed surgery groups.

Results

We found 69,936 patients that were admitted with ulcerative colitis, and 2650 patients that underwent non-elective total colectomy (3.8%). Early intervention was performed in 20.4% of patients who went to surgery. More early operations were performed laparoscopically (28.1% versus 23.3%, p = 0.021) and on more comorbid patients (Charlson Index, p = 0.008). Median total hospitalization costs were $20,948 with an early operation versus $33,666 with a delayed operation (p < 0.001). Delayed operation was an independent risk for a complication (OR = 1.46, p = 0.001). Increased hospitalization costs in the delayed surgery group were statistically significantly higher with a reported complication (OR = 3.00, p < 0.001) and lengths of stay (OR = 1.26, p < 0.001).

Conclusion

Delayed operations for acute ulcerative colitis are associated with increased postoperative complications, increased lengths of stay, and increased hospital costs. Further prospective studies could demonstrate that this association leads to improved outcomes with immediate surgical intervention for medically refractory ulcerative colitis.

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Acknowledgements

The authors appreciate biostatistical and data management support from Joseph K. Canner, MS.

Funding

I.L.L.’s contribution to this manuscript was supported by a National Institutes of Health/National Cancer Institute T32 training grant (5T32CA126607) and an American Society of Colon and Rectal Surgeons General Surgery Resident Research Initiation Grant (GSRRIG-131).

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Authors and Affiliations

  1. Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA

    Ira L. Leeds, Sophia Y. Chen, Jonathan E. Efron, Susan L. Gearhart, Bashar Safar & Sandy H. Fang

  2. Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Brindusa Truta & Alyssa M. Parian

Authors
  1. Ira L. Leeds
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  2. Brindusa Truta
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  3. Alyssa M. Parian
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  4. Sophia Y. Chen
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  5. Jonathan E. Efron
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  6. Susan L. Gearhart
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  7. Bashar Safar
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  8. Sandy H. Fang
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Contributions

Study design: I.L.L, S.Y.C., J.E.E., S.L.G., B.S., S.H.F.

Data acquisition and analysis: I.L.L., S.Y.C.

Interpretation of data: I.L.L, B.T., A.M.P., S.Y.C., J.E.E., S.L.G., B.S., S.H.F.

Drafting work: I.L.L., S.Y.C., S.H.F.

Critical revision: B.T., A.M.P., J.E.E., S.L.G., B.S.

Final approval and accountability: I.L.L, B.T., A.M.P., S.Y.C., J.E.E., S.L.G., B.S., S.H.F.

Corresponding author

Correspondence to Sandy H. Fang.

Ethics declarations

This study design was reviewed and approved by the Johns Hopkins Medicine Institutional Review Board.

Appendix

Appendix

We performed propensity score matching described below and repeated a portion of the statistical analysis on high-level findings to confirm that observed differences were not due to limitations of conventional logistic regression analysis. This mirrored analysis is described through the series of complementary tables below. Propensity score assignment and 1:1 nearest neighbor matching with replacement was performed using the teffects package within Stata® 14.2 (StataCorp, College Station, TX). Covariates matched included sex, race, age, income quartile, and Charlson Comorbidity Index group. Patients unable to be matched were excluded from further analysis. A total of 325 patients from the delayed surgery group were individually matched to 539 patients in the early surgery group.

Fig. 1
figure 1

Distribution of aggregate covariate similarity pre- and postpropensity score matching when modeling in-hospital mortality

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Fig. 2
figure 2

Distribution of aggregate covariate similarity pre- and postpropensity score matching when modeling the risk of in-hospital complication

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Table 5 Patient demographic and baseline characteristics for total colectomies, propensity-weighted sample, 2002–2014 (n = 863)
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Table 6 Multivariable logistic regression with propensity score matching for in-hospital death and in-hospital complication rate
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Leeds, I.L., Truta, B., Parian, A.M. et al. Early Surgical Intervention for Acute Ulcerative Colitis Is Associated with Improved Postoperative Outcomes. J Gastrointest Surg 21, 1675–1682 (2017). https://doi.org/10.1007/s11605-017-3538-3

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  • DOI: https://doi.org/10.1007/s11605-017-3538-3

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