The Epidemiology of Colectomy in Ulcerative Colitis
The Epidemiology of Colectomy in Ulcerative Colitis
OBJECTIVES: Previous studies have reported colectomy rates of over 50% in ulcerative colitis (UC), although changes in management may have influenced the rates of colectomy in the modern era. We sought to determine the incidence of colectomy in UC and identify risk factors associated with early colectomy (EC) and late colectomy (LC).
METHODS: We used the University of Manitoba Inflammatory Bowel Disease Epidemiology Database, a population-based data set including UC patients with up to 25 years of post diagnosis follow-up. We tracked the occurrence of total colectomy in all patients with known UC, subdivided into EC (≤90 days from diagnosis date) and LC (>90 days from diagnosis). Survival curves were created and stratified by age, sex, era of diagnosis, and inpatient/hospital diagnosis. Cox proportional hazards modeling was used to determine which risk factors were predictive of either EC or LC.
RESULTS: Among 3,752 patients with UC, 367 underwent colectomy. The 5-, 10- and 20-year actuarial risk of requiring colectomy was 7.5%, 10.4%, and 14.8%, respectively. Male sex (hazard ratio (HR): 63, 95% confidence interval (CI): 1.58–4.36) and being initially diagnosed during a hospitalization (HR: 12.46, 95% CI: 7.40–21.0) were predictive of EC after adjustment for confounders. In-hospital diagnosis was predictive of LC, whereas being diagnosed more recently was protective against LC (HR: 0.96, 95% CI: 0.93–0.98).
CONCLUSIONS: The cumulative incidence of colectomy in UC is lower than previously reported, and appears to be decreasing further among more recently diagnosed cohorts of patients. Male sex and hospitalization at the time of diagnosis are major risk factors for EC and LC.
Ulcerative colitis (UC) is a chronic inflammatory disease of unknown etiology affecting the colon. The clinical course of UC can be quite variable from person to person; some patients may remain completely asymptomatic or have indolent disease with minimal symptoms, whereas at the other extreme, patients can have symptoms that significantly interfere with daily functioning and quality of life. Although the majority of persons with UC are able to achieve long-term control of symptoms through medical therapy, colectomy has remained a mainstay of therapy for patients who fail to respond to medical management, develop colon cancer or dysplasia, or have intolerable side effects or complications related to drug therapy.
Although subjects who undergo colectomy may be able to re-establish bowel continuity through performance of ileoanal pouch surgery, a significant proportion will be left with an ileostomy. Furthermore, even subjects who do undergo successful ileoanal pouch surgery are left with increased bowel frequency, and complications are common, including the development of pouchitis in up to 50% and decreased fertility in women. Moreover, patients undergoing colectomy have a complication rate of 30%, and a mortality rate of 2–4%, which may be even higher in patients who are undergoing colectomy urgently. So while colectomy can provide significant relief of symptoms and obviate the need for potentially toxic medical therapies, there are significant risks of associated morbidity and mortality. Furthermore, even though patients who have undergone colectomy report a quality of life comparable to the general population, the majority of patients with UC report fear or anxiety about the possibility of one day requiring a colectomy.
Previous studies assessing the likelihood of requiring colectomy have reported rates as high as 65% at 25 years. However, much of the data on the long-term risk of colectomy emerged from cohorts who were diagnosed and followed in the 1970s and 1980s, and given advances in medical management that may reduce the need for surgical intervention, it is reasonable to believe that colectomy rates may be decreasing. A precise and accurate assessment of current risks for colectomy in UC patients will assist patients and providers in making well-informed decisions in the management of their disease. Therefore, we aimed to use a population-based cohort of patients with UC in order to determine the risk of undergoing colectomy, both early and later in the course of disease, and to identify risk factors that predict the need for colectomy.
Abstract and Introduction
Abstract
OBJECTIVES: Previous studies have reported colectomy rates of over 50% in ulcerative colitis (UC), although changes in management may have influenced the rates of colectomy in the modern era. We sought to determine the incidence of colectomy in UC and identify risk factors associated with early colectomy (EC) and late colectomy (LC).
METHODS: We used the University of Manitoba Inflammatory Bowel Disease Epidemiology Database, a population-based data set including UC patients with up to 25 years of post diagnosis follow-up. We tracked the occurrence of total colectomy in all patients with known UC, subdivided into EC (≤90 days from diagnosis date) and LC (>90 days from diagnosis). Survival curves were created and stratified by age, sex, era of diagnosis, and inpatient/hospital diagnosis. Cox proportional hazards modeling was used to determine which risk factors were predictive of either EC or LC.
RESULTS: Among 3,752 patients with UC, 367 underwent colectomy. The 5-, 10- and 20-year actuarial risk of requiring colectomy was 7.5%, 10.4%, and 14.8%, respectively. Male sex (hazard ratio (HR): 63, 95% confidence interval (CI): 1.58–4.36) and being initially diagnosed during a hospitalization (HR: 12.46, 95% CI: 7.40–21.0) were predictive of EC after adjustment for confounders. In-hospital diagnosis was predictive of LC, whereas being diagnosed more recently was protective against LC (HR: 0.96, 95% CI: 0.93–0.98).
CONCLUSIONS: The cumulative incidence of colectomy in UC is lower than previously reported, and appears to be decreasing further among more recently diagnosed cohorts of patients. Male sex and hospitalization at the time of diagnosis are major risk factors for EC and LC.
Introduction
Ulcerative colitis (UC) is a chronic inflammatory disease of unknown etiology affecting the colon. The clinical course of UC can be quite variable from person to person; some patients may remain completely asymptomatic or have indolent disease with minimal symptoms, whereas at the other extreme, patients can have symptoms that significantly interfere with daily functioning and quality of life. Although the majority of persons with UC are able to achieve long-term control of symptoms through medical therapy, colectomy has remained a mainstay of therapy for patients who fail to respond to medical management, develop colon cancer or dysplasia, or have intolerable side effects or complications related to drug therapy.
Although subjects who undergo colectomy may be able to re-establish bowel continuity through performance of ileoanal pouch surgery, a significant proportion will be left with an ileostomy. Furthermore, even subjects who do undergo successful ileoanal pouch surgery are left with increased bowel frequency, and complications are common, including the development of pouchitis in up to 50% and decreased fertility in women. Moreover, patients undergoing colectomy have a complication rate of 30%, and a mortality rate of 2–4%, which may be even higher in patients who are undergoing colectomy urgently. So while colectomy can provide significant relief of symptoms and obviate the need for potentially toxic medical therapies, there are significant risks of associated morbidity and mortality. Furthermore, even though patients who have undergone colectomy report a quality of life comparable to the general population, the majority of patients with UC report fear or anxiety about the possibility of one day requiring a colectomy.
Previous studies assessing the likelihood of requiring colectomy have reported rates as high as 65% at 25 years. However, much of the data on the long-term risk of colectomy emerged from cohorts who were diagnosed and followed in the 1970s and 1980s, and given advances in medical management that may reduce the need for surgical intervention, it is reasonable to believe that colectomy rates may be decreasing. A precise and accurate assessment of current risks for colectomy in UC patients will assist patients and providers in making well-informed decisions in the management of their disease. Therefore, we aimed to use a population-based cohort of patients with UC in order to determine the risk of undergoing colectomy, both early and later in the course of disease, and to identify risk factors that predict the need for colectomy.
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