Elective colectomy may be advisable for elderly with ulcerative colitis

Last Updated: 2015-07-13

By Will Boggs MD

NEW YORK (Reuters Health) - Elective colectomy improves survival compared with medical therapy in older patients with advanced ulcerative colitis, a retrospective study suggests.

"Physicians, including many gastroenterologists, have often viewed surgical therapy as an option of last resort in ulcerative colitis care," Dr. Meenakshi Bewtra, from the University of Pennsylvania, Philadelphia, told Reuters Health by email. "With the new knowledge from this study, we hope that physicians will be more empowered to begin a dialogue about surgery earlier in their patients' course of treatment."

Dr. Bewtra's team used U.S. Medicare and Medicaid data on 8,371 adults, ages 18 to 80, with advanced ulcerative colitis, including 830 who underwent elective colectomy. Each surgical patient was matched with up to 10 medically treated controls.

The patients had either been hospitalized or were taking steroids or immunosuppressive drugs.

Overall, mortality rates were 34 deaths per 1000 person-years with elective colectomy, compared with 54 per 1000 person-years with medical therapy, according to the July 13 Annals of Internal Medicine online report.

There appeared to be no survival benefit with elective colectomy in patients younger than 50 years, but among older patients, elective colectomy reduced mortality by 40%.

"These results should be interpreted with caution," the researchers noted, "given that these analyses were performed post hoc and involved a smaller sample size and low absolute number of deaths (78 total)."

"In younger patients with ulcerative colitis that is refractory to medication, elective surgery can be beneficial in reducing morbidity and mortality," they added. "Thus, our findings should not be interpreted as indicating that surgery should be universally avoided in this younger population."

"Many ulcerative colitis patients are afraid of surgical therapy," Dr. Bewtra said. "This study should help them to understand that the benefits of surgery may extend beyond just reducing the symptoms of uncontrolled UC, and colectomy options may be something they should discuss with their gastroenterologist or a colorectal surgeon. They can certainly learn more about this option so they understand the choices fully. This is especially important for patients who are not responding, or not responding completely, to medical therapy or are worried about the potential risks of the medications used to control UC."

Dr. David Sachar from The Mount Sinai Medical Center in New York City, whose editorial was published with the paper, told Reuters Health by email, "These findings will not influence physicians to recommend surgery simply on the grounds of statistically improved survival in a heterogeneous retrospective cohort, but they should help dissuade physicians from relentlessly pursuing medical therapy at the expense of patients' quality of life."

"The principal message, as I have stated in the editorial and elsewhere, is that the therapeutic goal in every case of UC is not the avoidance of surgery but the restoration of health and well-being, be it by medical or surgical means," he said. "We are, after all, not so much in the business of saving colons as of saving lives, including quality of life."

"Surgery is not a 'failure of medical therapy,'" Dr. Sachar concluded. "It is, in fact, not any kind of 'failure' at all; it is simply a 'treatment,' and in certain selected cases the treatment of choice."

Dr. Alan C. Moss, from Beth Israel Medical Center's Center for Inflammatory Bowel Disease in Boston, told Reuters Health by email, "Repeated treatment of older patients with steroids for relapsing colitis may not be the best strategy for them. Although steroids make patients feel better, they do not heal the mucosa in most patients, and lead to a false sense of security that their colitis is under control. The physiologic toll of chronic inflammation and steroids can be prevented by elective colectomy, (which) should be offered as a valid option to these patients. Too often we try overlapping courses of immunosuppressives as many patients are afraid of colectomy and the thoughts of having an ostomy."

"For the population of patients who never maintain remission, and have numerous courses of steroids for flare-ups, a colectomy is an important option to consider," Dr. Moss said. "Particularly in older patients, the toll of chronic illness and immunosuppressive agents may not be worth keeping their colon. However, for patients in clinical remission on nonsteroidal therapy, there is not sufficient data here to encourage them to have an elective colectomy."

Dr. Gilaad Kaplan, from the University of Calgary's Inflammatory Bowel Disease Clinic in Alberta, Canada, told Reuters Health by email, "Deciding between medical and surgical management in patients with ulcerative colitis is a difficult choice. In the current paper, the authors focused on 'advanced' ulcerative colitis, which they defined as patients with UC who were hospitalized, prescribed corticosteroids, or an immunosuppressant (i.e., cyclosporine, tacrolimus, azathioprine, 6-mercaptopurine, or infliximab). The majority of patients with ulcerative colitis do not meet the authors' definition of 'advanced.'"

"This study's provocative findings that elective colectomy was associated with fewer deaths than medical management among patients with advanced ulcerative colitis should be interpreted cautiously due to inherent biases of analyzing Medicare/Medicaid databases," Dr. Kaplan said. "Future studies should reevaluate these findings in the context of the changing paradigm of ulcerative colitis management, which includes wider use of infliximab and the advent of newer agents like vedolizumab."

The National Institutes of Health and the Agency for Healthcare Research and Quality funded this research. Three authors reported a number of disclosures.

SOURCE: http://bit.ly/1Mq6HSJ

Ann Intern Med 2015.