Patients with inflammatory bowel disease (IBD) were about five to eight times more likely to die after emergency intestinal resection as opposed to elective surgery, a large meta-analysis found.
Overall mortality rates after emergency intestinal resection were 5.3% for patients with ulcerative colitis (UC) and 3.6% for patients with Crohn’s disease (CD), said Dr. Sunny Singh and his associates at the University of Calgary in Alberta, Canada. In contrast, only 0.6%-0.7% of patients died after elective resection, the researchers reported in the October issue of Gastroenterology (2015 Jun 5. doi: 10.1053/j.gastro.2015.06.001).
Clinicians should optimize medical management to avoid emergency resection, seek ways to reduce associated mortality, and use the data when counseling patients and weighing medical and surgical management options, they added.
Intestinal resection is less common among patients with IBD than in decades past, but almost half of CD patients undergo the surgery within 10 years of diagnosis, as do 16% of UC patients, according to another meta-analysis (Gastroenterology 2013;145:996-1006). Past studies have reported divergent rates of death after these surgeries, the researchers noted. To better understand mortality rates and relevant risk factors, they reviewed 18 original research articles and three abstracts published between 1990 and 2015, all of which were indexed in Medline, EMBASE, or PubMed. The studies included 67,057 UC patients and 75,971 CD patients from 15 countries.
Rates of mortality after elective resection were significantly lower than after emergency resection, whether patients had CD (elective, 0.6%; 95% confidence interval, 0.2%-1.7%; emergency, 3.6%; 1.8%-6.9%) or UC (elective, 0.7%; 0.6%-0.9%; emergency, 5.3%; 3.8%-7.3%), the researchers found. Death rates did not significantly differ based on disease type. Postoperative mortality dropped significantly after the 1990s among CD patients only, perhaps because emergency surgery has become less common in Calgary since 1997, the researchers said. However, they were unable to compare changes in death rates over time by surgery type, they said.
Several factors could explain the high fatality rates after emergency intestinal resection, the researchers said. Patients tended to have worse disease activity and higher rates of intestinal obstruction, intra-abdominal abscess, toxic megacolon, preoperative clostridial diarrhea, venous thromboembolism, malnourishment, or prolonged treatment with intravenous corticosteroids, they said. General surgeons are more likely to perform emergency resections than elective cases, which are typically handled by more experienced colorectal surgeons, they added. Emergency resections also are less likely to be performed laparoscopically than are elective resections, they noted. “The low risk of death associated with elective intestinal resections for CD and UC could be used as a quality assurance benchmark to compare outcomes between hospitals and surgeons,” they added.
The research was funded by the Canadian Institute of Health Research, Alberta-Innovates Health-Solutions, the Alberta IBD Consortium. Dr. Singh reported no conflicts of interest. Senior author Dr. Gilaad Kaplan and four coauthors disclosed speaker, advisory board, and funding relationships with a number of pharmaceutical companies.