Elective colectomy associated with improved survival in ulcerative colitis

1. In this matched cohort study, patients with advanced ulcerative colitis who underwent elective colectomy had improved overall survival compared to matched patients who were managed with long-term medical therapy.

2. Sensitivity analysis showed that age greater than 50 was particularly associated with a mortality benefit from surgery compared to medical therapy.

Evidence Rating Level: 2 (Good)

Study Rundown: Ulcerative colitis, a disease characterized by long-term inflammation of the large intestine, affects approximately one million Americans, and can lead to long-term illness and death. Advanced ulcerative colitis is typically treated with either strong anti-inflammatory medications or surgical removal of the large intestine (i.e., colectomy). This cohort study compared mortality in patients with advanced ulcerative colitis who either underwent elective colectomy or long-term medical therapy to treat their disease. Patients were “matched” in terms of age, sex, and factors associated with disease severity. Overall, patients who underwent elective surgery had decreased mortality rates compared to matched patients who were treated medically. When subgroups were analyzed separately, this finding was particularly strong in patients who were 50 years or older. This study only used data from Medicare and Medicaid patients, potentially limiting its generalizability. Furthermore, the study’s design did not allow for full accounting of all possible confounding factors. Nonetheless, these results suggest that, especially among older patients with advanced ulcerative colitis, colectomy may be associated with decreased overall mortality when compared to long-term medical therapy.

Click to read the study, published today in the Annals of Internal Medicine

Relevant Reading: Risk of Surgery for Inflammatory Bowel Diseases Has Decreased Over Time: A Systematic Review and Meta-analysis of Population-Based Studies.

In-Depth [retrospective cohort study]: This retrospective, matched cohort study compared 830 patients who underwent elective colectomy with 7,541 demographic- and disease-severity-matched patients undergoing long-term medical management for advanced ulcerative colitis. All patients were Medicare and/or Medicaid beneficiaries. Overall, colectomy was associated with significantly decreased mortality compared to long-term medical management after adjusting for comorbidities (HR 0.67, 95%CI 0.52-0.87). This corresponded to 34 versus 54 deaths per 1000 person-years for colectomy and medical management, respectively. Notably, in subgroup analysis, surgery was best associated with improved mortality in patients aged greater than 50 years old (HR 0.60, 95%CI 0.45-0.79). Statistical significance for mortality benefit disappeared in sensitivity analysis that excluded relatively well patients from the overall study population, but mortality benefit remained significant in patients over age 50.

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