Severe steroid-unresponsive ulcerative colitis - Outcomes of restorative proctocolectomy in patients undergoing cyclosporin treatment

PURPOSE: The recent introduction of the immune suppressor cyclosporin for t reatment of steroid-refractory ulcerative colitis has required surgeons to perform a colectomy in those patients who eventually fail this rescue treat ment, thus raising questions as to the safety of surgery as per formed in p atients with a heavily manipulated immune system. To assess the rates of mo rtality and morbidity in this setting, we studied a cohort of consecutive p atients who had surgery after failing cyclosporin for refractory ulcerative colitis at sur center. METHODS: Between January 1991 and December 1996, 25 patients with ulcerative colitis underwent restorative proctocolectomy per formed in three steps (21 patients) and in two steps (4 patients). Seventee n of the 25 patients (68 percent) mere initial nonresponders to a dose of 2 mg/kg/day of intravenous cyclosporin and underwent surgery immediately, th e remaining 8 (32 percent) relapsed as outpatients on oral cyclosporin and were readmitted for surgery. RESULTS: There was no operative mortality. Nin e patients of the 25 developed postoperative (early) complications (36 perc ent). The three-step operation subset had a 28 percent complication rate, t he two-step 75 percent. Three patients needed reoperation. A total of 11 pa tients (44 percent) reported with late complications: two patients required surgical treatment, one for obstruction and one for pouch-perianal fistula . Three cases of pouchitis were recorded. No patient required pouch removal . CONCLUSION: Given the absence of postoperative mortality and a low overal l complication rate, restorative proctocolectomy can safely be performed in patients who fail rescue treatment with a dose of 2 mg/kg of cyclosporin f or steroid-refractory ulcerative colitis. Corollary evidence in this articl e hints but does not prove that the three-step procedure is safer than the two-step operation.