Colectomy Not a Final Cure for Ulcerative Colitis, Data Show

HONOLULU – The widely held view that surgery is the “curative” option in patients with severe ulcerative colitis could not be further from the truth, according to the results of a large, population-based study presented at the annual meeting of the American College of Gastroenterology.

Indeed, colectomy wasn't the end of the story for the majority of ulcerative colitis patients who underwent the procedure in Olmsted County, Minn., during 1940-2001. The cumulative risk of additional gut surgery that wasn't part of a planned multistage procedure was 28% within the first year following colectomy, 53% at year 10, and 63% at year 20, reported Dr. Shamina Dhillon of the Mayo Clinic, Rochester, Minn.

Since 98% of all residents in largely rural Olmsted County receive their health care through the Mayo Clinic and centralized records are kept, it was possible for Dr. Dhillon to study the natural history of ulcerative colitis in the 378 patients diagnosed there with the disease during the study period. The total follow-up amounted to 6,360 patient-years.

The cumulative risk of colectomy following diagnosis of ulcerative colitis was 3% within 1 year, 16% at 10 years, 22% at 20 years, and 28% at 30 years. Also, 3% of patients underwent surgical lysis of adhesions within the first year after colectomy; the figures were 14% by year 10 and 17% by year 20.

Among the 35 patients who underwent ileal pouch-anal anastomosis, the cumulative 10-year rate of any subsequent surgery was 53%. Conversion to permanent ileostomy or diverting ileostomy after initial takedown occurred at a cumulative rate of 18% at year 10.

Patients who underwent proctocolectomy with Brooke ileostomy had a 17% risk of stomal revision by year 10, climbing to 27% at year 20. The cumulative risk of a stomal hernia repair was 9% at year 10 and 20% at year 20.

The few other large population-based studies addressing what happens to patients after diagnosis of ulcerative colitis have shown similarly high rates of multiple surgeries. The Stockholm (Sweden) County Registry, for example, showed a cumulative colectomy rate of 45% at 25 years following diagnosis of ulcerative colitis.

Within 15 years after colectomy, 22% of patients underwent additional surgery to relieve obstruction of the small intestine, Dr. Dhillon said.

The experiences in Stockholm and Olmsted counties underscore the importance of early and aggressive medical intervention in ulcerative colitis in order to help affected patients avoid undergoing surgery not once, but on multiple occasions, she added.

Her study received the 2005 ACG/Centocor Inflammatory Bowel Disease Abstract Award.

Many audience members expressed surprise at the high rate of unplanned repeat surgery, particularly in light of the Mayo Clinic's longstanding reputation for outstanding-quality medical and surgical management of inflammatory bowel disease.

Dr. Dhillon's study coinvestigator, Dr. William J. Sandborn, provided some additional perspective. “I think surgery is increasingly becoming a treatment of last resort. It's not curative,” said Dr. Sandborn, professor of medicine at the Mayo Medical School.

“Half of the patients with ileoanal anastomosis get pouchitis, and 10%-20% get permanently or temporarily rediverted after their initial surgery,” Dr. Sandborn continued.

“The median stool frequency in 24 hours in our study was eight, which means half of the patients who didn't have pouchitis had more than eight stools in 24 hours.

“Fecundity in young women–the ability to get pregnant without in vitro fertilization–is reduced by as much as 80%. So this is not a cure. It's a last-ditch effort to have something besides a stoma if no medicines work.”