Threshold for colectomy may be too high, warn experts

The clinical threshold for undertaking elective surgery to remove part or all of the colon (colectomy) for people with inflammatory bowel disease (IBD) may be too high, warn researchers in a study published on bmj.com.

IBD is a general term for chronic inflammation of the intestine and includes ulcerative colitis and Crohn's disease. Around a quarter of a million people in the UK are affected and many people will require colectomy at some stage. Currently there are about 2,000 total or partial colectomies performed each year in England for IBD.

Death rates following elective colectomy are typically quite low, at least in the short term, while delaying surgery carries increased risks. It is thought, increasingly, that the thresholds for elective colectomy may be too high. However, there is a lack of strong evidence about this.

So researchers from Swansea and Oxford used routinely collected hospital data throughout England to investigate mortality after colectomy for IBD, comparing those who underwent elective colectomy, emergency colectomy, or who were hospitalised for IBD but had no colectomy. The study included 23, 464 people who were hospitalised for more than three days for IBD, 5,480 of whom underwent colectomy, and traced all deaths up to three years after hospital admission.

They found improved long term survival for elective colectomy compared with emergency colectomy or no colectomy. The findings also confirmed a substantially increased risk of dying shortly after emergency colectomy.

At three years, the increased of risk of death in people who did not undergo colectomy was almost as high as that in people who underwent emergency colectomy. In contrast, survival among people who underwent elective colectomy was very similar to that in the general population.

Our study findings suggest that the threshold for elective colectomy for IBD in England is too high, say the authors.

It also illustrates that, whenever indicated and possible, it is preferable for colectomy to be undertaken electively, rather than risk the need for emergency surgery when it has a much poorer prognosis.

They believe that further research is now required to establish the threshold criteria and optimal timing for colectomy in people with poorly controlled IBD.

The idea that surgery for IBD should be the last resort is flawed, adds an accompanying editorial. These findings, even allowing for interpretation, should be a word of caution to those who promote it.