Surgery During Admission for an Ulcerative Colitis Flare: Should Pouch Formation Be Considered?

Up to 25% of patients with ulcerative colitis will require hospitalization for a disease flare and 10% of these patients will require semiurgent colectomy during the same admission. Limited evidence exists to guide decision-making on the safety of ileal pouch anal anastomosis (IPAA) in the semiurgent setting.

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2016 for patients with a diagnosis of ulcerative colitis undergoing semiurgent (hospitalization > 48 h before surgery) total proctocolectomy (TPC) with IPAA, semiurgent subtotal colectomy (STC), or elective TPC with IPAA. The association of semiurgent pouch formation with 30-d major morbidity and organ space infection was assessed against semiurgent STC and elective TPC with IPAA by univariate comparisons and multivariable logistic regression.

A total of 3763 patients (semiurgent TPC with IPAA = 101, semiurgent STC = 797, elective TPC with IPAA = 2865) were included. Semiurgent TPC with IPAA was associated with a higher rate of major morbidity (28% versus 20%, P = 0.04) and organ space infection (19% versus 8%, P < 0.01) than elective TPC. On multivariable analysis, semiurgent status did not significantly increase the odds major morbidity (adjusted odds ratio, 1.2; 95% confidence interval [CI], 0.7-1.9), but it was a risk factor for organ space infection (2.3; 1.4-4.0). Major morbidity did not significantly differ between semiurgent TPC with IPAA and semiurgent STC (adjusted odds ratio: 1.5; 95% CI: 0.9-2.5).

Semiurgent IPAA was associated with an increased risk of major morbidity and organ space infection. Subtotal colectomy should remain the preferred operation in the semiurgent setting.