ESCP 2017: Multidisciplinary decision-making for colectomy: the difficult patient 

By Maria Dalby (article) and Peter Mas Mollinedo (interviews)

The decision to perform a colectomy in patients with ulcerative colitis (UC) should not be made lightly. Such a decision should always be made within a multi-disciplinary team setting, and surgery should be considered not only for patients who are refractory to medical therapy or who need surgery, but also for…

Miss Nicola Fearnhead (Addenbrookes Hospital, Cambridge) and Mr Janindra Warusavitarne (St Mark’s Hospital, London) discuss the importance of the multidisciplinary team in the management of IBD and how partnerships can continue to be improved.

The decision to perform a colectomy in patients with ulcerative colitis (UC) should not be made lightly. In a presentation at the joint ESCP/ECCO symposium at ESCP 2017, Professor Willem Bemelman from Amsterdam stressed that such a decision should always be made within a multi-disciplinary team setting, and surgery should be considered not only for patients who are refractory to medical therapy or who need surgery, but also for patients where surgery may be an alternative to maintenance biological therapy.

Professor Bemelman highlighted two clinical scenarios that pose a particular challenge in terms of deciding to perform a colectomy, namely patients admitted to hospital with acute severe colitis and patients who are treated as outpatients. Under a treatment algorithm proposed by van Assche et al in 2011,¹ infliximab or cyclosporine should be initiated in patients who present with acute severe colitis where indications for emergency surgery such as perforation, severe bleeding and toxic megacolon have been excluded, and who fail to respond to intravenous corticosteroids. The response should be assessed by the surgical team after 5-7 days and if negative, a total colectomy followed by second stage proctectomy and ileal pouch-anal anastomosis (IPAA) should be performed. Adhering to this timeline is of the utmost importance as a prolonged pre-operative hospital stay increases the risk of post-operative morbidity and mortality² – the objective should be to save the patient’s life, rather than the colon. The decision to proceed to colectomy should be based primarily on the patient’s clinical condition; the so-called Travis score is still valid, which states that patients with a stool frequency of >8/day, or >3/day with a C-reactive protein (CRP) level of >45mg/dl after three days of intravenous corticosteroids have an 85% risk of having a colectomy.³ Another key predictor of colectomy is the albumin level, as hypoalbuminemia has been shown to correlate with non-response to biologic therapy⁴ as well as with septic complications.⁵

Another scenario where the decision whether or not to operate may be difficult to make is for patients with moderate to severe UC who are managed as outpatients. This category includes patients who may have narrowly escaped surgery following treatment for acute severe colitis, or patients with chronic refractory and relapsing disease. Although these patients can be managed with medical therapy, the disease is having a tremendous impact on their lives and their ability to work and socialise. Studies have shown that a narrow escape from surgery in the acute setting is highly predictive of a future colectomy: two out of three patients who receive infliximab or cyclosporine after failing to respond to intravenous steroids in the acute setting will have a colectomy within three years.^{6, 7} Male patients, older patients and patients with pancolitis are at particularly high risk of having a colectomy following treatment for acute severe colitis;⁷ in addition, the Mayo endoscopy score has been shown to correlate with colectomy rates in patients treated with infliximab and can be used to guide the decision-making process.⁸

Patients with chronic moderate to severe UC are typically capable of sustaining multiple drug cycles, but over time the increasing burden of side effects, loss of response, fatigue and intolerance will create a level of disutility for the patient that is likely to outweigh that of having a colectomy and a stoma. A study involving 297 UC patients who underwent restorative proctocolectomy or started anti-TNF treatment at Professor Bemelman’s centre between 2010 and 2015 showed that although patients in the pouch group reported higher stool frequency and more perianal skin irritation than patients in the anti-TNF group, no difference was seen in generic quality of life as measured with the EQ-5D tool.⁹ Furthermore, patients in the pouch group scored significantly higher on the general health items on the SF-36 questionnaire, suggesting that UC patients who have undergone surgery are less inclined to feel that they have a chronic disease. Concluding, Professor Bemelman’s advised clinicians to face up to the realities of the condition and to strive to save the quality of life of the patient, rather than the colon.

References

1. Van Assche G, Vermeire S, Rutgeerts P. Management of acute severe ulcerative colitis. Gut 2011;60:130-3.
2. Bartels SA, Gardenbroek TJ, Bos L, et al. Prolonged preoperative hospital stay is a risk factor for complications after emergency colectomy for severe colitis. Colorectal Dis 2013;15:1392-8.
3. Travis SP, Farrant JM, Ricketts C, et al. Predicting outcome in severe ulcerative colitis. Gut 1996;38:905-10.
4. Ho GT, Mowat C, Goddard CJ, et al. Predicting the outcome of severe ulcerative colitis: development of a novel risk score to aid early selection of patients for second-line medical therapy or surgery. Aliment Pharmacol Ther 2004;19:1079-87.
5. Huang W, Tang Y, Nong L, et al. Risk factors for postoperative intra-abdominal septic complications after surgery in Crohn’s disease: A meta-analysis of observational studies. J Crohns Colitis 2015;9:293-301.
6. Duijvis NW, Ten Hove AS, Ponsioen CI, et al. Similar Short- and Long-term Colectomy Rates with Ciclosporin and Infliximab Treatment in Hospitalised Ulcerative Colitis Patients. J Crohns Colitis 2016;10:821-7.
7. Al-Darmaki A, Hubbard J, Seow CH, et al. Clinical Predictors of the Risk of Early Colectomy in Ulcerative Colitis: A Population-based Study. Inflamm Bowel Dis 2017;23:1272-1277.
8. Colombel JF, Rutgeerts P, Reinisch W, et al. Early mucosal healing with infliximab is associated with improved long-term clinical outcomes in ulcerative colitis. Gastroenterology 2011;141:1194-201.
9. van Gennep S, Sahami S, Buskens CJ, et al. Comparison of health-related quality of life and disability in ulcerative colitis patients following restorative proctocolectomy with ileal pouch-anal anastomosis versus anti-tumor necrosis factor therapy. Eur J Gastroenterol Hepatol 2017;29:338-344.