The management of ulcerative colitis (UC) has undergone a profound transformation over the past two decades, largely driven by the expansion of therapeutic options, notably the advent of advanced therapies such as biologics and small molecules 1. While these agents have significantly improved control of inflammation, their effect on surgical outcomes remains a matter of debate. Indeed, population-based studies have yielded conflicting results; some reported a reduction in colectomy rates 2 while others failed to demonstrate a substantial impact 3. In this context, the population-based cohort study by Couch et al. using comprehensive English healthcare datasets offers valuable longitudinal insights 4. The authors analysed 39,198 patients with incident UC diagnosed between 2003 and 2020 and reported a substantial decline in both elective (from 2.6% to 1.3%) and emergency colectomy rates (from 3.27% to 2.27%) within 5 years of diagnosis. This evolution coincided with a marked increase in the use of advanced therapies (from 2.27% to 15.61%) over the same period. Additionally, postoperative mortality—particularly after elective surgery (1.58%) – was low, reinforcing the safety of current surgical practices. These trends are consistent with the clinical perception of a reduced need for colectomy, particularly for refractory UC, in the biologic era. However, the observed decline in emergency colectomy rates is somewhat surprising, as previous data suggested limited impact of biologics on the course of acute severe UC 5. The study also underscores a positive but insufficient shift in corticosteroid prescribing patterns. Although steroid exposure declined from 50.9% to 43.9% at 5 years, this remained extremely high. These findings echo persistent concerns regarding steroid overuse in UC, particularly in primary care and highlight the ongoing need to implement effective steroid-sparing strategies and earlier therapeutic escalation 6, 7. Despite its large sample size, long-term follow-up and real-world generalizability, this study has some limitations. The observed association between exposure to advanced therapies and increased colectomy risk (aHR > 3 for elective, > 4 for emergency) probably reflects confounding by indication, as these therapies are generally reserved for patients with more severe disease. Furthermore, the relatively low proportion of patients receiving advanced therapies (< 20%) suggests underreporting, probably due to missing data on subcutaneous or oral advance therapies not captured in the dataset, as acknowledged by the authors 8. Finally, colectomy outcomes were not stratified by surgical indication (e.g., acute severe UC, dysplasia or medically refractory disease), limiting the ability to assess whether the biologic era has shifted the underlying reasons for surgery, as reported in other cohorts 9, 10. This distinction is critical, as both surgical indications and postoperative complications differ substantially by context. In conclusion, this robust and representative English cohort has confirmed the ongoing evolution of UC care: increased adoption of advanced therapies, reduced need for colectomy and modest progress in steroid stewardship. Future studies should aim to disentangle surgical indications, integrate complete therapeutic exposure data and evaluate patient-centred outcomes to further refine UC management strategies in the modern era. Guillaume Le Cosquer: writing – original draft, writing – review and editing, conceptualization. David Laharie: writing – review and editing, supervision. G.L.C. declares lecture, transport or fees from Abbvie, Janssen, Takeda, Eli Lilly and Company, and Pfizer. D.L. declares lecture, transports or fees from AbbVie, Alfasigma, Amgen, Celltrion, Ferring Pharmaceuticals, Janssen, Eli Lilly and Company, Medac, Merck Sharpe & Dohme, Pfizer, Roche, Sandoz and Takeda. This article is linked to Couch et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70319 and https://doi.org/10.1111/apt.70362. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Cosquer et al. (Thu,) studied this question.