Biologics or Surgery—Which Is Better for the Treatment of Ulcerative Colitis?

Biologics or Surgery—Which Is Better for the Treatment of Ulcerative Colitis?

Lazarev Mark, Regueiro Miguel
US Gastroenterology - Volume-4 Issue 1
Published: March 2009
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Ulcerative colitis (UC) is a disease that has a prevalence of 35–100 per 100,000 people. While UC can often be controlled with 5-aminosalicylic acid (5-ASA) products and immunomodulators such as azathioprine and mercaptopurine (6-MP), some patients continue to have active colitis requiring corticosteroids. Approximately 15% of UC patients will require hospitalization and treatment with intravenous (IV) steroids at some point in their lifetime; 25% of these are corticosteroid-refractory and will require a colectomy. Infliximab has recently emerged as another treatment option for the induction and maintenance of remission in moderate to severe UC.

Management of Ulcerative Colitis—The Surgical Option
A proctocolectomy is a cure for UC. The surgical options include a conventional Brooke ileostomy, a continent (Kock pouch) ileostomy, and an ileal pouch–anal anastomosis (IPAA). The IPAA is the most frequently performed surgery for UC. A proctocolectomy with IPAA is a cure, but there are potential lifestyle changes and complications that can occur.

To start, patients need to be educated that bowel habits range from three to 10 bowel movements per day following IPAA. Usually, this is an improvement for most patients who undergo surgery for severe colitis. Patients usually have continence of bowel movements, but incontinence and seepage, especially nocturnal, may occur in some.

Pouchitis is one of the most common post-surgical complications for IPAA and is probably related to bacterial stasis in the pouch reservoir. The main symptoms are diarrhea and abdominal pain. In the largest study, of 1,043 UC patients, the five-year cumulative risk of developing one or more episodes of pouchitis that required treatment was 36% in patients without primary sclerosing cholangitis (PSC) and 61% in patients with PSC.1 Occasionally, pouchitis can become chronic and refractory to medical therapy.

Another complication of IPAA surgery is decreased fecundity among female patients. Generally, women with UC have normal fertility levels. Olsen et al. reported their findings on decreased fecundity in female UC patients undergoing IPAA. Structured phone interviews concerning reproductive behavior and waiting times to pregnancy were performed on 290 female patients with UC.2 Rates of fecundity were the same prior to diagnosis and before IPAA surgery. However, after surgery the fecundity ratio (fecundability rate compared with reference population) dropped to 20% (p<0.0001). This issue needs to be discussed with female UC patients of child-bearing age who are contemplating surgery. Of note, patients who undergo permanent or temporary end-ileostomy do not seem to have decreased fecundability rates.

Rarer complications of IPAA include small-bowel obstruction (20%), pouch–vaginal fistula (4%), impotence (1.5%), and death (<0.5%). Overall, the cumulative risk of complications at five years is 68%.3 In terms of costs, Thompson et al. found increased inpatient and overall healthcare utilization costs for patients with UC following colectomy.4Finally, an equal percentage of respondents who had undergone a colectomy for UC reported that their lives were better before surgery compared with after surgery.5

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