Outcomes following emergency surgery for acute colitis: open vs laparoscopic J.Livie1, E.Goodall1, M.Wilson2,C.Payne2 Department of Surgery2 Niinewells Hospital and Medical School1

Introduction Acute Colitis has many different causes This includes inflammatory bowel disease (IBD), ischaemia and pseudomembranous colitis Patients can present with a range of symptoms inc. abdo pain, fever, diarrhoea Patients can present to either the physicians and surgeons Acute Colitis or inflammation of the colon has many different causes These include inflammatory bowel disease, ischaemia and pseudomembranous colitis as a result of antibiotic use. Patients can present with a wide range of symptoms including abdominal pain, fever, and diarrhoea Patients may under the care of the physicians first prior to surgery, such as the gastroenterologists particularly in those who have known inflammatory bowel disease Surgery warranted if patients not responding to medical treatment eg IV steroids, infliximab infusions, antibiotics etc depending on cause.

Aims of the project Analyse outcomes following emergency surgery in Ninewells for acute colitis Open vs laparoscopic Primary outcome: 30 day mortality Secondary outcome: operative time and length of post-op stay

Methods Theatre lists were used initially to identify relevant patients Emergency surgery Acute Colitis Jan 2002 – Dec 2014 ICE, TOPAS and clinical portal Paper notes Also recorded: surgeon final pathology pre-op stoma review post-op clinics other operations Theatre lists were used to identify relevant patients who needed emergency surgery for acute colitis between January 2012 to December 2014. A range of clinical systems was used to gather the required information about each patient including ICE, TOPAS and clinical portal. Paper notes were also used if needed. The primary outcome was assessing 30 day mortality following the operation The secondary outcome was looking at whether operative time and length of stay varied was different depending on whether surgery was open vs laparoscopic Also recorded was the final pathology, whether there was pre-op stoma review, if the patient was seen in clinic post-operatively and who carried out this r/v (medics/surgeons/stoma nurse) and if they went on to have another op such as a completion protectomy

Results Variable Open (n=128) Laparoscopic (n=29) P-value Gender 50% male 59% male 0.42 Mean age (range) 50 (12-94) 36 (15-79) 0.0011 Mortality 30day 1year 5years 12.5% 14.8% 25.0% 0.0% 7.7% 0.04 0.03 0.30 Operating time (min) 177 (64-335) 247.4 (160-405) 0.0001 HDU post op 83.8% 23.1% HDU stay (nights) 3.1 2.3 0.43 Post op stay (nights) 16.2 (1-96) 13.1 (4-74) 0.24 Over the 12 year period, 157 operations took place, with the vast majority of these operations being open surgery. The mean age of surgery was older for those having a open operation, where as the mean age for a laparoscopic operation was younger at 36. Significantly, the mortality following a laparoscopic operation was 0% up to 1 year post op, where as the mortality for open surgery was a lot higher. ?Age or nature of surgery Although laparoscopic surgery was longer than an open operation. It is more difficult to do a laparoscopic emergency colectomy as the tissues are all inflamed, and surgeons are likely to be still on their 'learning curve'. It may be that over time we will see a reduction in operating time for laparoscopic colectomy. Patients were less likely to go to HDU post-operatively, however even if they did go to HDU they stayed similar lengths of stay with an open operation and their total post op stay was not found to be significantly reduced. All laparoscopic operations were carried out by specialist colorectal surgeons

Results continued Final pathology Pre-operative stoma review = 20.4% Ulcerative Colitis (84 – 52.9%) Crohn’s (41 – 26.1%) Ischaemic (19 – 12.1 %) Indeterminate IBD (7 – 4.5%) Pseudomembranous Colitis (3 – 1.9%) Other (4 – 2.5%) Pre-operative stoma review = 20.4% Post-op clinic review: surgery (61.1%), GI (53.5%), stoma nurse (46.5%) 29 patients went on to have a completion proctectomy, 18 patients went on to have pouch surgery Most of the operations were for inflammatory bowel disease, of which ulcerative colitis was more commonly operated on than crohn’s. Pre-operative stoma review was only documented in 1/5 of patients The vast majority of patients were followed up after their operation, with some of them being seen by both the surgeons and physicians

Conclusion Laparoscopic surgery associated with: Reduced mortality Less likely to require HDU post-operatively Longer operating time More emergency theatre time used, limiting access No improvement in overall length of postoperative stay Longer operation means occupying more emergency theatre time (potentially limiting access to theatre for other emergency cases).

Limitations Laparoscopic cohort – younger patients ?bias Ischaemic colitis patients included – expected higher mortality rates. laparoscopic cohort are younger, therefore may be 'self selected' by the operating surgeon which is effectively bias. You also need to make the point that you included ischaemic colitis patients, who are inherently older with more comorbidities and therefore expected higher mortality.

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