J. N. Cohan1,3, P. Bacchetti2, M. G. Varma1, E. Finlayson1,3 1University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 2University Of California – San Francisco,Department Of Epidemiology And Biostatistics,San Francisco, CA, USA 3University Of California – San Francisco,Institute For Health Policy Studies,San Francisco, CA, USA
Introduction: Historically, older patients with ulcerative colitis were not considered candidates for ileal pouch-anal anastomosis (IPAA). However, evidence from several single-center studies suggests that IPAA can be performed in selected older patients with surgical outcomes similar to those in younger patients. In order to evaluate whether this finding is generalizable, we used a national database including patient data from 374 US hospitals to examine outcomes after IPAA.
Methods: Using the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) database, we identified all patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with IPAA from 2005-2012. We examined the associations of age and frailty trait count with length of stay and major surgical complication count using multivariate linear and negative binomial regression. In both models, we adjusted for important procedure and patient characteristics (see table footnote). The frailty trait count includes frailty traits present in the NSQIP database that are frequently used in frailty indices: diabetes, hypertension, congestive heart failure, functional status, and ≥10% body weight loss over six months prior to surgery.
Results: IPAA was performed in 2493 patients with ulcerative colitis. Thirty-day mortality was 0.002% (N=7). Patients older than age 50 were more likely to have diabetes (20.4% vs 2.6%), hypertension (32.9% vs 8.0%), blood transfusion (6.8% vs 3.6%), ≥1 frailty trait (39.7% vs 14.2%), and American Society of Anesthesiologists class 3-4 (35.4% vs 17.6%) than younger patients (all p≤0.001). The majority of patients had no serious postoperative complications (age <50: 79.5%, age 50-59: 80.4%, age ≥60: 79.1%). After adjusting for important procedure and patient characteristics, age ≥60 was associated with a minor (15%) increase in number of complications (p=0.40) and with a 0.8 day increase in length of stay (p=0.036). The average adjusted length of stay was 7.4 days in patients age <50, 7.7 days in patients age 50-59, and 8.2 days in patients age ≥ 60. Frailty trait count ≥1 was associated with small increases that did not reach statistical significance (Table).
Conclusion: Among patients with ulcerative colitis undergoing IPAA in the NSQIP database, advanced age and frailty were associated with only slightly increased postoperative complications, but the effect of age ≥60 on length of stay was close to a full day. These findings suggest that IPAA may be a safe surgical option for older patients with ulcerative colitis. Future work should evaluate functional outcomes in older patients across a spectrum of hospitals.
