Surgery is a real alternative to rescue therapy in patients with steroid-refractory ulcerative colitis

Abstract

Dear Editor: The life-time risk of a fulminant flare of ulcerative colitis, which is a potentially life-threatening condition, is approximately 15–20 %. The mainstay of conventional therapy is intravenous corticosteroids of 1 mg/bwkg, however approximately one third of the patients fail to respond to a 3to 5-day intensive intravenous regimen, which sets up an interdisciplinary challenge for the surgeon and internist alike. The three options to be considered are intravenous cyclosporin (CsA) therapy, infliximab (IFX) treatment or total proctocolectomy. With the introduction of CsA in the early 1990, the rate of urgent colectomies decreased, since 76 % to 86 % of the patients will initially respond to CsA rescue medication, thus avoiding colectomy in the short run. However, 88 % of patients initially responding to CsA rescue therapy will require colectomy upon 7 years of follow-up and CsA use is still restricted by potential serious adverse events. Colectomy and receiving even a temporary stoma are of the most fearful complications for patients with inflammatory bowel disease. The recommended surgical procedure is restorative proctocolectomy with ileal pouch anal anastomosis (IPAA), which is considered to be a cure for ulcerative colitis; however, reports on functional outcome and postoperative quality of life are contradictory and a variety of complications can occur after surgery. In steroid-refractory ulcerative colitis our therapeutic decision between medical rescue and colectomy remains theoretical in the lack of comparative data. The aim of our study was to evaluate and compare long-term disease outcome in patients with steroid-refractory colitis who either responded to CsA rescue therapy or had to be operated on due to failure of rescue medication. Data of 90 patients with steroid-refractory severe ulcerative colitis were analyzed, of whom 44 patients responded to CsA rescue therapy (CsA responders) and 46 patients underwent colectomy due to early or late failure of rescue therapy (colectomy group). Clinical disease severity was assessed by the Lichtiger score. CsA was introduced intravenously, 4 mg/bwkg initially, which was changed to oral administration after 1 week and maintained for 6–12 months (earlier discontinuation of the therapy was either due to side effects or loss of therapeutic effect); the dosing was continuously monitored by drug serum level. Twenty-six patients received corticosteroids and 17 patients were on immunomodulator therapy at the time of the initiation of CsA rescue. The indication of colectomy was severe disease activity with early failure of the rescue medication or relapse after rescue medication. The mean disease duration was 10 years at the time of surgery. Twenty-five patients K. Gecse :K. Farkas : Z. Szepes : F. Nagy : T. Wittmann : T. Molnar (*) First Department of Internal Medicine, University of Szeged, H-6720, Koranyi fasor 8, Szeged, Hungary e-mail: molnar.tamas@med.u-szeged.hu