Outcome following emergency surgery for refractory severe ulcerative colitis in a tertiary care centre in India

BMC Gastroenterology Outcome following emergency surgery for refractory severe ulcerative colitis in a tertiary care centre in India Sujoy Pal 1 Peush Sahni 1 Girish K Pande 1 Subrat K Acharya 0 Tushar K Chattopadhyay 1 0 Department of Gastroenterology & Human Nutrition Unit, All India Institute of Medical Sciences , Ansari Nagar, New Delhi-110029 , India 1 Department of GI Surgery & Liver Transplantation, All India Institute of Medical Sciences , Ansari Nagar, New Delhi-110029 , India Background: Steroid-based intensive medical therapy for severe ulcerative colitis is successful in 60-70% of such patients. Patients with complications or those refractory to medical therapy require emergency colectomy for salvage. Little is known about the impact of timing of surgical intervention and surgical outcomes of such patients undergoing emergency surgery in India where the diagnosis is often delayed or missed in patients who are poor, malnourished and non-compliant to medical treatment. Methods: The clinical records of all patients undergoing emergency surgery for severe ulcerative colitis or its complication in the Department of GI surgery AIIMS, New Delhi, India, between January 1985 and December 2003 were retrieved and data pertaining to demographic features, duration of intensive medical therapy, presence of complications, time from admission to emergency surgery, surgical procedure, in-hospital morbidity and mortality and follow up status extracted. Results: A total of 72 patients underwent emergency surgery (Subtotal colectomy: 60; ileostomy alone under local anaesthesia: 12). Poor nutritional status was seen in 61% of the patients. Twenty-one patients (29%) underwent emergency surgery for complications of severe ulcerative colitis such as colonic perforation (spontaneous 6, iatrogenic 4), massive lower gastrointestinal haemorrhage (5), toxic megacolon (4) and large bowel obstruction (2). The remaining patients (n = 51) underwent emergency surgery following failed intensive therapy; 17 underwent surgery 5 days (Group I) and 34 were operated >5 days (Group II) after initiation of intensive therapy. In this group all the post-operative deaths (n = 8) occurred in those who were operated after 5 days. The difference in mortality in these two groups (i.e. surgical intervention or >5 days) was statistically significant {0/17 (Group I) vs 8/34 (Group II); p = 0.03}. Overall, 12 patients died (in-hospital mortality: 16.7%). The mortality was higher (10/43; 23.3%) in our early experience (i.e. 1985-1995) when compared to our subsequent experience (2/29; 6.9%) (1996-2003). A total of 48 patients (including 3 awaiting a restorative procedure) are alive on follow up (66.7%; 3 patients lost to follow up). A restorative procedure could be successfully completed in 81% of the survivors of the emergency procedure. Conclusion: To optimize the outcome, a combined team of physicians and surgeons should be involved in the management of patients with severe ulcerative colitis with focus on nutritional support, correction of metabolic derangements, close clinical monitoring and timely assessment for the need for emergency surgery. This retrospective analysis shows that improved results can be achieved with experience and by following a policy of early surgical intervention within 5 days, especially in patients who have failed intensive medical therapy. - Background It is known that about 20% of patients with ulcerative colitis, suffer from severe acute relapse and its associated complications at some point in the course of their illness [1,2]. Overall, 510% of patients with ulcerative colitis present with a severe first attack. The relapse-free interval in a given patient remains unpredictable. However, longterm prospective cohort studies have shown that virtually all patients will relapse and develop acute exacerbation at some point in the course of their illness [1,2]. Intensive medical treatment (Oxford regimen) is successful in 60%70% of patients suffering from severe ulcerative colitis, but the rest require emergency surgery either for a complication or because they fail to respond to medical therapy [3-6]. Among those who respond to intensive medical therapy, a colectomy will be required in up to 50% within a year and in at least 75% at around 5 years of follow up [6,7]. Emergency surgery in anaemic, nutritionally depleted, immunosuppressed and toxic patients has a high morbidity and mortality [8,9]. Little is known about the outcome of patients with acute severe ulcerative colitis undergoing emergency surgery in India. We hypothesized that Indian patients with ulcerative colitis may behave differently because they are poor (have difficulty in purchasing drugs) and often illiterate (do not understand the importance of continuing medication and follow up) and the diagnosis is often delayed because of the high incidence of infective diarrhoea and dysentery. We therefore analyzed our experience of emergency surgery in patients with ulcerative colitis focusing on two main issues, i.e. the timing of surgery and the immediate as well as long term outcome following emergency surgery. Methods All patients undergoing emergency surgery for severe ulcerative colitis or its complication in the Department of GI Surgery, All India Institute of Medical Sciences, New Delhi, between January 1985 and December 2003 had a pre-designed proforma filled. The details recorded included demographic features of the patients, duration of intensive medical therapy during the index admission, presence of complications (toxic megacolon, perforation, lower gastrointestinal haemorrhage, intestinal obstruction and colorectal cancer), time from initiation of intensive therapy to emergency operation, indication for emergency surgery, type of surgical procedure, postoperative complications, in-hospital mortality, delayed deaths during follow up, outcome of any further operative procedures and current status. The collected data was retrospectively analyzed. A severe episode of ulcerative colitis was defined according to Truelove and Witt's criteria [3] as: >6 bloody stools/ day, fever 38C, tachycardia > 100/min, anemia and/or an erythrocyte sedimentation rate > 30 mm in 1st hour.[3] All patients diagnosed to have severe ulcerative colitis were admitted in the Gastroenterology department of our institution and were managed jointly, from the time of the admission, by a team comprising of physicians and surgeons. Nutritional status at admission was judged by a combination of subjective clinical assessment, body weight record (labeled underweight when <10th percentile of their expected weight as per sex and height) and serum albumin levels <3.0 g/dl was considered low. Intensive medical therapy included parenteral steroids (100 mg hydrocortisone intravenously 6 hourly), nil by mouth, nasogastric aspiration, intravenous crystalloids and electrolytes, parenteral nutritional support, blood transfusions and broad spect (...truncated)