Surgery for Ulcerative Colitis in Elderly Persons
Changes in Indications for Surgery and Outcome Over Time
Gidon Almogy, MD; David B. Sachar, MD; Carol A. Bodian, DrPH; Adrian J. Greenstein, MD
Hypothesis:Medical therapy has changed the indica- tions for surgery over the last 4 decades. Advances in peri- operative care have significantly improved the out- come.
Design:The medical records of all patients 65 years and older who underwent surgery for ulcerative colitis dur- ing a 40-year period were analyzed retrospectively.
Setting:Tertiary referral center.
Patients:One hundred thirteen consecutive patients 65 years and older who underwent surgery for ulcerative co- litis between January 1, 1960, and June 30, 1999.
Main Outcome Measures:Changes in elective and urgent indications for surgery. Changes over time in out- come and the factors that brought about these changes.
Predictors of poor outcome in an elderly population with ulcerative colitis.
Results:One hundred thirteen patients were divided into 3 cohorts of 38, 38, and 37 consecutive patients admit-
ted to the hospital during the periods 1960 through 1984, 1985 through 1993, and 1994 through 1999, respec- tively. Indications for surgery and morbidity and mor- tality rates have changed with time. Dysplasia has re- placed carcinoma as a major indication for elective surgery (P=.001). Toxic megacolon has become significantly less common as an indication for urgent surgery (P = .001).
Surgery-associated adverse outcomes have decreased sig- nificantly from 50% (13% deaths, 37% major complica- tions) to 27% (3% deaths, 24% major complications) (P = .04). Male sex, an albumin level of 2.8 g/dL or less, and urgent surgery were found to be independent pre- dictors of poor outcome.
Conclusions:In our referral center, the indications for urgent and elective surgery have changed during the past 4 decades from toxic megacolon and carcinoma, to dis- ease refractory, to medical therapy and dysplasia, respec- tively. Morbidity and mortality have decreased dramati- cally over time. Urgent procedures, low levels of albumin, and male sex are all predictors of poor outcome.
Arch Surg. 2001;136:1396-1400
A
S THE ELDERLYpopulationhas increased, the recogni- tion of ulcerative colitis (UC) in the older patient has become of increasing importance. Previous studies have sug- gested that UC in elderly patients is a dif- ferent disease and follows a different pattern with a higher frequency of complications.1 The higher frequency of acute complica- tions such as toxic megacolon, free perfo- ration, and massive hemorrhage in older pa- tients leads to a correspondingly higher case- fatality rate.2It is unclear whether the higher mortality in elderly patients with UC, reach- ing 19% in some reports, is due to the dis- ease process itself or to the adverse effects of concomitant illnesses.3
Other studies have suggested that the occurrence of inflammatory bowel dis- ease in the elderly population is, in fact, associated with a favorable outcome.4 These contradictory observations may have
been due in part to misdiagnosis of con- ditions such as ischemic colitis and acute diverticulitis for UC, and also to the re- ferral bias inherent in reports from ter- tiary referral centers.5
The aim of this study was to summa- rize our surgical experience with an el- derly population suffering from UC in a referral hospital. We analyzed the changes over time in terms of population charac- teristics, indications for surgery, surgical procedures, and short-term outcome in pa- tients 65 years old and older who under- went surgery for UC. We further identi- fied predictors of an adverse outcome in this elderly population.
RESULTS
Overall 113 patients 65 years old and older had surgery for UC in the 40-year period from 1960 through 1999. The characteris- tics for all 3 groups are given inTable 1. ORIGINAL ARTICLE
From the Departments of Surgery (Drs Almogy and Greenstein), Medicine (Division of Gastroenterology) (Dr Sachar), and
Biomathematical Sciences (Dr Bodian), Mount Sinai Hospital and the Mount Sinai School of Medicine, New York, NY. Dr Almogy is now with the Department of Surgery, Hadassah University Hospital, Jerusalem, Israel.
The number of sugical procedures performed for all pa- tients with UC at our institution has significantly in- creased during the past 4 decades. The number of surgi- cal procedures performed for patients older than 65 years has also increased from 4.2 surgical procedures per year in group 2 to 6.2 surgical procedures per year in group 3.
The diagnosis of UC was made preoperatively in most cases. In 3 patients the preoperative diagnosis was missed;
1 was diagnosed preoperatively as having acute diver- ticulitis, 1 as having ischemic colitis, and 1 as having Crohn colitis.
Universal colitis was twice as prevalent as left- sided colitis. For both, there was little difference be- tween male and female patients (23 males and 27 fe- males with universal colitis; 11 males and 14 females with left-sided colitis). Two patients had benign strictures.
Table 1. Clinical Characteristics of the Patients*
Characteristic
Group 1 (n = 38)
Group 2 (n = 38)
Group 3 (n = 37)
Total (N = 113)
F/M ratio 15:23 22:16 19:18 56:57
Age at onset of disease, y 56 (20-84) 61 (33-80) 63 (20-83) 59 (20-84)
Duration of disease, y 16.5 (0.2-45) 7 (0.2-50) 12 (0.2-50) 9 (0.2-50)
Age at surgery, y 70.5 (65-84) 72 (65-86) 69 (65-84) 70 (65-86)
Postoperative LOS, d† 22.5 (4-76)‡ 11 (6-50) 9 (5-72) 13 (4-76)
*Data are given as median number of patients (range) unless otherwise indicated. Group 1 patients underwent surgery from 1960 through 1984; group 2, from 1985 through 1993; and group 3, from 1994 through 1999.
†LOS indicates length of stay.
‡Values are statistically significantly different from groups 2 and 3 by Wilcoxon rank sum test (P⬍.01).
PATIENTS, MATERIALS, AND METHODS
We retrospectively reviewed the medical records of 119 con- secutive patients aged 65 years and older who underwent surgery for the diagnosis of UC at Mount Sinai Hospital, New York, NY, between January 1, 1960, and June 30, 1999.
The medical records of 42 patients operated on between 1960 and 1984 were retrieved from computer files kept at Mount Sinai Hospital (A.J.G.). The medical records of pa- tients with UC who underwent surgery from 1985 through 1999 were retrieved from the medical records at Mount Si- nai Hospital.
The diagnosis of UC was established by recognized ra- diological, endoscopic, and histopathological criteria.6Six patients were excluded from the study. One patient had an exploratory laparotomy for metastatic colon cancer. Five patients initially diagnosed as having UC were found to suf- fer from different causes. One patient had ischemic coli- tis, 1 patient had collagenous colitis, 1 patient had idio- pathic toxic dilatation of the colon, 1 patient had Crohn colitis, and 1 patient had an indeterminate form of inflam- matory bowel disease.
All patients in this study were aged 65 years and older at the time of surgery. The 113 patients were divided into 3 cohorts of 38, 38, and 37 consecutive patients to analyze changes over time (groups 1 through 3, for the years 1960- 1984, 1985-1993, and 1994-1999, respectively). Informa- tion regarding the extent of disease, albumin level, and he- matocrit was unobtainable for most of the patients in group 1. Therefore, this group was available only for analysis of changes that occurred over time in indications for sur- gery, surgical procedures, and short-term outcome. Analy- sis of predictors of an adverse outcome was performed for the remaining 2 groups, for which the information was more easily available.
Complication and death rates were similar for patients who had the disease for 2 to 10 years and for patients suffering from UC for longer than 10 years. Therefore, these groups were combined; duration of disease was defined as short or long according to a cutoff of 2 years or less from the on- set of disease to the operative procedure. The number of patients with emergent indications for surgery was small.
We therefore grouped all patients with emergent indica- tions for surgery (eg, free perforation) and all patients with urgent indications for surgery (eg, toxic megacolon and fail- ure of medical therapy administered in the hospital) as hav- ing urgent indications for surgery.
The indications for surgery were defined as follows:
(1) refractory to medical therapy (persistent symptoms such as diarrhea, abdominal pain, rectal bleeding, and weight loss, despite maximal medical therapy, with or without ste- roid dependency); (2) toxic megacolon as previously de- scribed7and confirmed by the operative findings; and (3) dysplasia and invasive carcinoma that were diagnosed by accepted pathologic criteria.8
Only procedures performed at our institution were in- cluded in the study. Most patients underwent only 1 op- eration. For patients who underwent more than 1 opera- tion, statistical analysis was performed for the initial procedure.
Complications requiring intervention or those pro- longing the hospital stay were considered major compli- cations. Mortality was defined as death within 30 days of the operative procedure or directly related to the surgical procedure. Adverse outcome was defined as a major com- plication or death.
Statistical analysis was performed using2tests and2 tests for trends, Fisher 2-tailed exact test, and the Wilcoxon rank sum test, as applicable. Statistical analysis for predic- tors of an adverse outcome was performed using multivar- iate logistic regression analysis. Results were considered sta- tistically significant when the P value was⬍.05.
INDICATIONS FOR SURGERY
While disease refractory to medical therapy has re- mained the main indication for elective surgery, the his- topathological findings of dysplasia has gradually re- placed carcinoma as a major indication for elective surgery (P = .001) (Figure 1). Toxic megacolon was the main indication for urgent surgery in group 1 (Figure 2). This has changed over time and most of the urgent surgical procedures for patients in groups 2 and 3 were per- formed owing to failure of medical therapy (P = .001).
SURGICAL PROCEDURES
A total of 123 surgical procedures were performed for 113 patients aged 65 years and older who had UC between 1960 and 1999 (Table 2). Eighty-one elective procedures and
42 urgent procedures were performed in the study pe- riod. Eleven patients had a second elective procedure, with completion proctectomy the most common procedure.
Total proctocolectomy with J-shaped ileal pouch–anal anas- tomosis was performed on 8 female and 6 male patients older than 65 years (median age, 68 years; age range, 65-74 years) with no mortality and minimal morbidity (1 pa- tient with a wound infection). These patients were oper- ated on starting in 1985, with most surgical procedures being performed during the last 6 years; all were elective.
MORTALITY
Mortality has decreased over time. Five patients (13%) in group 1, 3 patients (7.9%) in group 2, and 1 patient (2.7%) in group 3 died after surgery, but this trend did not reach statistical significance (P = .10). Of the 5 pa- tients who died during the early postoperative period in group 1, the cause of death was intra-abdominal sepsis in 4 patients and massive upper gastrointestinal tract hem- orrhage in 1 patient. Of the 3 deaths in group 2, 1 pa- tient died of intra-abdominal sepsis, 1 of pulmonary em- bolism, and 1 from massive upper gastrointestinal tract hemorrhage. Intra-abdominal sepsis was the cause of death for the only patient who died in group 3.
Toxic megacolon was associated with a high mor- tality rate in all 3 groups. Three (33%) of 9 patients in group 1, and 1 (50%) of 2 patients in both groups 2 and 3 died after undergoing surgery for toxic megacolon.
MORBIDITY
The major complications for all patients are given in Table 3. Six patients (16.6%) had more than 1 compli-
70
50 60
40
30
20
10
0
% of Patients
Refractory to Medical Therapy
Dysplasia Carcinoma Other†
∗
∗
Group 1 Group 2 Group 3
Figure 1. Changes over time in indications for elective surgery. There was an increase in the number of operations performed for dysplasia and a decrease in the number of operations performed for carcinoma over time (P⬍.01, 2 test). Group 1 indicates those patients operated on from 1960 through 1984;
group 2, those patients operated on from 1985 through 1993; and group 3, those patients operated on from 1994 through 1999. The asterisks indicate statistically significantly different from groups 2 and 3 by2test for trends;
dagger, 5 patients underwent surgery for benign strictures.
90
50 60 70 80
40 30 20 10 0
% of Patients
Toxic Megacolon
Refractory to Medical Therapy
Other†
∗
∗
Group 1 Group 2 Group 3
Figure 2. Changes over time in indications for urgent surgery. The number of operations performed for failure of medical therapy increased, while the number of operations performed for toxic megacolon decreased over time (P⬍.01, 2test). Group 1 indicates those patients operated on from 1960 through 1984; group 2, those patients operated on from 1985 through 1993;
and group 3, those patients operated on from 1994 through 1999. The asterisks indicate statistically significantly different from groups 2 and 3 by
2for trends; dagger, 5 patients who had perforation of the colon.
Table 2. Elective and Urgent Procedures*
Variable Group 1 Group 2 Group 3
Elective Procedures Partial resections of the colon
Segmental resection 6 1 1†
Completion proctectomy without anastomosis
6 3 4
Subtotal colectomy and end ileostomy 8 7 8 Total proctocolectomy
Without anastomosis 7 6 8
With J-shaped ileal pouch−anal anastomosis‡
0 4 10
Exteriorization of the bowel (ileostomy or colostomy)
2 0 0
Total§ 29 21 31
Urgent Procedures
Subtotal colectomy with end ileostomy 6 13 8†
Total proctocolectomy with end ileostomy 6 5 2 Exteriorization of the bowel
(ileostomy or colostomy)
2 0 0
Total 14 18 10
*Data are given as the number of patients. Group 1 patients underwent surgery from 1960 through 1984; group 2, from 1985 through 1993; and group 3, from 1994 through 1999.
†Value includes 1 laparoscopic procedure.
‡Value includes 8 patients with protective loop ileostomy.
§Values include 11 patients who underwent a second elective procedure.
cation. Three patients in group 1 required emergency sur- gery for their complications—2 for wound evisceration and 1 for anastomotic breakdown. None of the patients in group 2 required emergency procedures for their com- plications. One patient in group 3 had to be returned to the operating room for early nonresolving small-bowel obstruction.
ADVERSE OUTCOME
To analyze the overall adverse outcome, deaths and ma- jor complications were grouped together. Surgery- associated adverse outcome has decreased significantly over time from 50% to 27% (P = .04) (Table 4). To bet- ter understand the decrease in complications and deaths, we analyzed the data to see if the decrease over time was uniform for all 3 groups for factors such as age, sex, du- ration of disease, indication for surgery, extent of dis- ease, and urgency of surgery (Table 4). We identified sev- eral factors that have changed over time: (1) The complication rate for patients aged 75 years and older at surgery has significantly decreased (P=.03), whereas the decrease for younger patients was less notable. (2) The complication rate for patients with duration of disease of longer than 2 years has significantly decreased over time (P=.02), while there was no change for patients with a short duration of disease (duration ofⱕ2 years). (3) There was a significant decrease in the complication rate for female patients over time (P = .046) but not for male patients. The decrease in complication rate was compa- rable for both elective and urgent surgery.
PREDICTORS OF ADVERSE OUTCOME
We analyzed the rate of adverse outcome as a function of age, sex, duration of disease, extent of disease, albu- min level, hematocrit, indication for surgery, and ur- gency of surgery. We performed a multivariate regres- sion analysis only for patients in groups 2 and 3, as these
data for patients in group 1 were incomplete, to identify independent predictors of adverse outcome. Using a step- wise logistic regression procedure, male sex (P=.03; odds ratio=3.7) and albumin level of 2.8 g/dL or less (P=.001;
odds ratio = 7.2) were found to be independent predic- tors of poor outcome. However, data for the albumin level were missing for 7 of the 75 patients (groups 2 and 3), so the analysis was repeated without considering the al- bumin level. Then, elective surgery was found to corre- late inversely with the complication rate (P = .01; odds ratio = 0.24). Age at surgery of 75 years or older, dura- tion of disease for 2 years or less, extent of disease, and toxic megacolon were not found to be predictors of an adverse outcome.
COMMENT
Acute complications, namely, toxic megacolon, free per- foration, and uncontrolled bleeding were considered the major indications for urgent surgery in patients older than 60 years who had UC.9The reported incidence of toxic megacolon in patients with UC has ranged from 1.6%10 to 22%.11The overall mortality rate varies greatly but has been reported to be as high as 20%.12Our data show that toxic megacolon has become much less common as an in- dication for surgery. This is probably because of earlier di- agnosis, more aggressive treatment including nasointes- tinal decompression, broad-spectrum antibiotics, parenteral nutrition, and the use of high-dose intravenous steroids.
Although significantly less prevalent than in the past as an indication for surgery, toxic megacolon is still associ- ated with a fatality rate of 37.5% (5 of 12 patients) in our series. This high fatality rate has not improved over time.
Restorative proctocolectomy has become the pro- cedure of choice for younger patients with UC. Im- Table 3. Major Complications*
Complication Group 1 Group 2 Group 3
Wound
Infection 6 (16) 1 (3) 3 (8)
Dehiscence 0 0 1 (3)
Evisceration 2 (5)† 0 0
Abdominal
Sepsis 2 (5) 0 1 (3)
Anastomotic leak 1 (3)† 0 0
Small-bowel obstruction
Resolving 1 (3) 0 5 (14)
Nonresolving 0 0 1 (3)†
Pulmonary
Embolism 0 1 (3) 0
Pneumonia 1 (3) 2 (5) 0
Acute myocardial infarction 2 (5) 0 0
Urinary tract infection 3 (8) 3 (8) 0
*Data are given as number (percentage) of patients. Group 1 patients underwent surgery from 1960 through 1984; group 2, from 1985 through 1993; and group 3, from 1994 through 1999. Four patients in group 1 and 2 patients in group 3 had 2 major complications.
†Complication that requires urgent surgery be performed.
Table 4. Changes Over Time in Complication and Death Rates by Patient and Disease Characteristics*
Variable
Group 1 (n = 38)
Group 2 (n = 38)
Group 3 (n = 37)
P Value Patients with major
complications or deaths, all patients
19/38 (50) 10/38 (26) 10/37 (27) .04†
Sex
Female 7/15 (47) 3/22 (14) 3/19 (16) .046†
Male 12/23 (52) 7/16 (44) 7/18 (39) .40
Type of surgery
Elective 9/24 (38) 2/19 (11) 5/27 (19) .12 Urgent 10/14 (71) 8/19 (42) 5/10 (50) .20 Duration of disease, y
⬎2 16/32 (50) 7/32 (22) 6/26 (23) .02†
ⱕ2 3/6 (50) 3/6 (50) 4/11 (36) .56
Age at surgery, y
ⱖ75 6/7 (86) 4/9 (44) 3/10 (30) .03†
⬍75 13/31 (42) 6/29 (21) 7/27 (26) .17
*Data are given as number (percentage) of patients. The numerator indicates the number of patients with the characteristic; the denominator, the total number of patients sampled. Group 1 patients underwent surgery from 1960 through 1984; group 2, from 1985 through 1993; and group 3, from 1994 through 1999.
†Groups 2 and 3 are statistically significantly different from group 1 by2tests for trends.
proved perioperative care and surgical techniques have brought about a decrease in morbidity and mortality and, thus, have made these procedures possible. Some au- thors believe that the surgical stress associated with re- storative proctocolectomy in the elderly population is pro- hibitively high.13Recent reports, however, have shown that there is no increase in surgical morbidity and mor- tality among older patients undergoing restorative proc- tocolectomy.14The median age of patients in these re- ports was between 55 and 56 years. Since 1985, we have performed total proctocolectomies with J-shaped ileal pouch–anal anastomosis pullthroughs for 14 patients older than 65 years (median age, 68 years; age range, 65-74 years) with minimal morbidity and no mortality. We be- lieve that restorative proctocolectomy should be consid- ered with caution for a select and limited number of el- derly patients, omitting those with findings of significant comorbidity and poor overall nutritional status, as re- flected in low serum albumin levels.
It was commonly believed that older patients had higher complication rates.15In fact, mortality rates in pa- tients requiring urgent surgery were reported to be as high as 50%.9,16,17However, the number of elderly patients who underwent surgery in these reports was small. Recent re- ports have shown a decrease in mortality and morbidity rates.14,18To our knowledge, we present the largest series of elderly patients with UC who underwent surgery. Our data show that the mortality rate is lower than 3%. This improvement in outcome is secondary to better results for female patients, for patients aged 75 years and older, for elective procedures, and for patients who have a longer duration from the onset of disease to the surgical proce- dure. Better perioperative care and improvements in an- esthesia also account for the increase in survival.
Previous reports have suggested that the proportion of male to female patients is higher in elderly patients who have UC.1Male patients also seem to have more limited and less aggressive disease.19However, most patients in these reports were not referred for surgery. In this study, male patients aged 65 years and older who underwent sur- gery for UC had significantly higher complication and death rates than female patients. Female patients also seemed to do better over time. These sex differences were not due to differences in the age at surgery, duration of disease, indication for surgery, extent of disease, or the propor- tion of patients requiring urgent surgery. It is unclear whether elderly male patients with UC who require sur- gery have a different disease process, as some have sug- gested, or whether other factors, as yet unknown, make elderly male patients more prone to complications.
CONCLUSIONS
We reviewed our 40-year surgical experience with 113 patients aged 65 years and older who have UC. Over the
past 4 decades the indications for urgent and elective sur- gery have changed. Failure of medical therapy has re- placed toxic megacolon as the main indication for ur- gent surgery at our institution. The complication and death rates have decreased significantly over time; the current overall mortality for patients aged 65 years and older is less than 3%. Urgent procedures, low levels of albumin, and male sex are predictors of an adverse out- come in the elderly population. Low complication and death rates should be expected for elective procedures in the elderly population.
Corresponding author and reprints: Gidon Almogy, MD, Department of Surgery, Hadassah University Hospital, PO Box 12000, Jerusalem, Israel (e-mail: galmogy
@hotmail.com).
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