Better Data Shed More Light on Ulcerative Colitis Surgery

By Reuters Staff

July 01, 2020

NEW YORK (Reuters Health) - An inflammatory bowel disease (IBD) surgery registry that adds IBD-specific variables to general quality measurements for restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) performed for ulcerative colitis (UC) allows a better interpretation of predictive factors for delayed pouch formation, according to a new study.

There is little consensus about RPC-IPAA measurements, and the the ACS National Surgical Quality Improvement Program (NSQIP) cannot accurately classify RPC-IPAA staged approaches, Dr. Samuel Eisenstein of UC San Diego Health, in La Jolla, California, and colleagues note in The American Journal of Surgery.

The procedure is often performed in a staged manner as the operation is complex. Patients may require the initial surgical intervention when they are medically refractory, may be receiving multiple immunosuppressive medications, and experiencing other sequelae.

"Currently," the authors add, "much of the North American literature comparing RPC-IPAA staged approaches has been limited to single-center retrospective cohorts."

To help reduce these limitations the team formed the NSQIP-IBD Collaborative as a working group of clinicians and surgical quality experts from 11 sites in the U.S. The aim was to "collect more granular data specific to IBD surgical patients."

This effort, the authors say, is the first to use NSQIP data to generate a disease-specific surgical-outcomes database with statistical validity. To examine one aspect of its utility, they explored potential preoperative predictors of whether patients received immediate or delayed pouch construction.

Of more than 1,800 IBD operations between 2017 and 2019 the researchers focused on 430 patients who received index surgery or completed pouches; 28% received immediate pouches and the remaining 72% had delayed pouches.

Compared with immediate IPAA recipients, patients receiving index subtotal colectomy (STC) were more likely to be taking steroids, and have lower serum albumin and hematocrit and higher white blood cell counts. Index STCs were also more likely to be completed at higher-volume centers.

Patients receiving delayed IPAAs, by contrast, were less likely to be on biologics or steroids. However, delayed pouch formation did not significantly predict complication severity. The researchers also point out that, "Overall standard NSQIP did not properly capture 99% of all ileostomies."

The researchers conclude, "While NSQIP has proven to be a strong foundation for outcomes-based operation research nationwide and was the foundation for our own database, large-scale studies of IBD surgeries such as RPC-IPAA cannot be reliably conducted without the disease specific variables that our Collaborative has been able to collect. This study can serve as a model for not just IBD operation, but also for continued improvement of NSQIP and other large databases."

Dr. Eisenstein did not respond to requests for comments.

SOURCE: The American Journal of Surgery, online June 12, 2020.