The Natural History of Surgery for Ulcerative Colitis in a Population-Based Cohort from Olmsted County, Minnesota

Purpose: To describe the “natural history” and long term outcomes of surgical therapy in a population-based cohort of ulcerative colitis. Methods: All Olmsted County, MN residents diagnosed with UC between 1940 and 2001 have been identified. Community medical records were reviewed to ascertain all surgeries, including abdominal surgery, lysis of adhesions, perianal surgery, abscess drainage, stomal revision, and stomal hernia repair. Ileostomy takedown after first stage of ileal pouch-anal anastomosis (IPAA) was not counted as a subsequent surgery. The cumulative incidences of proctocolectomy from time of diagnosis and subsequent surgeries from time of colectomy were estimated using the Kaplan-Meier method. Results: The 378 incidence cases of UC (56.1% male) were followed for a total of 6,360 person-years (median follow-up per patient, 15.1 years; range, 0.1 – 58 years). Eighty-one (21%) underwent a surgical procedure for UC, of whom fifty-six (69%) underwent more than one procedure. See table for actuarial rates of colectomy and post-colectomy surgeries (95% CI). In those undergoing proctocolectomy with Brooke ileostomy, the cumulative risk of stomal revision was 17% at year 10 and 27% at year 20, and cumulative risk of a stomal hernia repair was 9% at year 10 and 20% at year 20. The cumulative risk of any subsequent surgery in patients with Brooke ileostomy at year 10 was 39%, versus 53% among IPAA patients. The cumulative risk of conversion to permanent ileostomy or diverting ileostomy in IPAA patients after initial takedown was 18% at year 10, while the cumulative risk of conversion to permanent ileostomy only was 8% at year 10.Table: Cumulative Risk of Colectomy and Subsequent Surgery in UC CohortConclusions: In this population-based cohort of UC patients, the cumulative risk of colectomy after UC diagnosis was 16% at year 10 and 28% after 30 years of disease. The cumulative risk of requiring a subsequent surgery after colectomy was greater than 50% after 10 years. These results highlight the need for early medical intervention in ulcerative colitis.