Medical vs Surgical Management

Ulcerative Colitis

Quality of Life

 

Quality of life (QOL) is a subjective index of health perception and function.  It embraces physical, social and emotional performance.  QOL has not had a prominent role in clinical trials of inflammatory bowel disease (IBD) studies until recently.  The adverse effects of ulcerative colitis (UC) are caused by intestinal and extra-intestinal complications.  They impact on self image, employment, sexual and family relationships, and psychological functions. 

 

These attributes of health related QOL are gaining increasing interest in research trials.  The following study has yielded results comparable to other studies performed on patients with UC who have been managed medically and surgically, and subsequently evaluated with respect to the QOL.

 

The Departments of Surgery and Gastroenterology, Bombay Hospital and Medical Research Centre, Mumbai, through the authors of Sheetal Shah, T. Satyendra and Deepak Amarapurkar assembled an article regarding the health related quality of life (HRQOL) about individuals affected by UC.  The assessment is that HRQOL plays an increasing important role in the evaluation of therapeutic interventions in various chronic diseases including IBD.

 

HRQOL assessment was done with standard IBD quality of life questionnaire in 30 patients with UC of which 15 patients were being treated medically and 15 had failed medical treatment and undergone surgery.  These were compared with a group of 15 apparently healthy control subjects.  Of the medically managed patients, nine patients had ileostomies and six had ileal and rectal anastomosis with or without pouch.

 

The medically controlled patients with UC have a reasonably good QOL.  The QOL in patients who do not respond to medical treatment is very poor.  The QOL improves considerably after surgery and is comparable to the medically treated group.  The QOL in patients with an ileostomy is better than patients undergoing ileoanal anastomosis with or without pouch.

 

In spite of many technological advances, achieving a cure of disease is not possible in many chronic conditions.  UC is one of them.  As cure is not possible, various treatment modalities including surgery are used.  HRQOL considers the various aspects physical, social, emotional and perception.  HRQOL assesses the world health organization's concept of health—physical, mental and social.  Health is more than the absence of disease.

 

HRQOL assessment can be general or disease specific.  HRQOL measures needs of individual patients or groups of patients determining the quality of care defining the natural history of the disease; evaluating various treatments; and calculating the cost effectiveness of different treatment regimens.  The study was designed to assess quality of life in patients with UC as compared to apparently healthy individuals; those medically treated; and surgically treated patients.

 

Thirty patients with UC managed in the above institute over a period of five years were evaluated.  15 being medically treated, 15 had surgery and 15 were healthy normal people.  Of the medically managed cases, four were in exacerbation, two had continuous mild activity and nine were in remission.

 

The IBD questionnaire was a 32 item questionnaire.  It evaluates general activities of daily living and intestinal, social and emotional status.  Responses were graded on a seven point Likert scale with scores ranging from 32 to 224 with a higher score indicating a better QOL. 

 

Four "dimensional scores" cluster items under:  Bowel—loose stool, abdominal pain;  Systemic—fatigue, altered sleep;  Social function—need to cancel social events;  Emotional—anger, irritability.  Diagnostic tests were performed on all subjects.

 

Results

 

Demographics of the population:

·        Male: Female was 12:3

·        Mean age was 35.5

·        Mean disease duration was 34.6 months in medically treated patients

·        Mean disease duration was 73.3 months in surgically treated patients

·        Educational status was beyond matriculation in all patients except one

·        Family history of UC was noted in three patients

 

The inflammatory bowel disease quality of life score average was:

(A higher score reflects a better quality of life.)

 

·        85.5 (sd39) who do not respond to medical treatment (very poor)

·        168.6 in successfully medically-treated patients

·        133.6 (sd60) with ileal pouch anal anastomosis

·        206.6 (sd34) with ileostomies

·        284.4 in control group (normal population)

 

The QOL in UC is significantly impaired.  Medically controlled patients had a reasonably good quality of life, but the patients who did not respond to medical treatment had a very poor QOL.  The AOL improves considerably after surgery and is comparable to the group which was treated medically.  The QOL in patient with IL is better than that of patients undergoing an IAP.

 

A study by A. Martin et al. was aimed at studying the AOL in patients who underwent IAP with a "J" pouch for severe UC, and compare it to patients with UC of different severity who were under medical treatment.  In UC the scores were significantly higher than in the control group increasing with the severity of the disease.  Even patients in remission had higher scores than controls.  The patient who underwent surgery had a much better score than patients with severe disease.  They had values comparable to patients in remission or with mild disease activity.

 

The authors concluded that in patients with UC that even in remission, there is still a measurable impairment of the QOL which increases with the severity of the disease.  IAP may restore an acceptable quality of life in patients with moderate or severe UC.  These finding are corroborative with this study.

 

In this study, patients undergoing an IL had better scores than patients with IAP.  A similar study was performed by Jimmo and Hyman.  According to the authors, IAP formations are widely claimed to have replaced IL as the procedure of choice for UC largely based on the basis of a perceived improved QOL.   The aim of the study was to determine whether educated patients choosing IL have a similar QOL as IAP.

 

All the patients with UC referred to a single surgeon and deemed as an appropriate surgical candidate were educated and offered IAP or IL.  Age, gender and complications were recorded prospectively, and all the patients were questioned regarding functional outcome and level of satisfaction.  They were then asked to complete a modified IBDQ which was analyzed by categorical and overall scores. 

 

Fifty-five patients with IAP had significantly more short-term or long-term complications with pouchitis being frequent.  The authors concluded that patients with IAP can expect a good quality of life.  The best educated patients choosing an IL can achieve the same QOL without the higher complication rate associated with an IAP.

 

A similar study was performed by Herschel et al.  They proposed that preservation of function is the decisive advantage of the IAP but it is not equal to AOL.  AOL is a multi-dimensional concept which can only be assessed by standardized and validated questionnaires.  Pre-operatively, patients should be informed that preservation of function by restorative proctocolectomy is accompanied by increased post-operative morbidity (effects and complications of disease).

 

References

·        Surgery of the Anus, Rectum and Colon Goligher-Ulcerative colitis ED.2000;2(22):805-61

·        E Dan Irvine, Quality of Life Issues in Patients with Inflammatory Bowel Disease.  American Journal of Gastroenterology 1997; 12:12.

·        Guyatt GH, Mitchell A., Irvine E.K., Sinfer j., Williams n., Goodcare R., Tompkins L., A New Measure of Health Status for Clinical Trials in IBD.  Gastroenterology 1989; 96:804-10.

·        E. Jan Irvine, Brian Feagan, James Rochon, Andre Archambautt, Richard Fedorak, Aubrey Groli, Dougleas Kinnear, Fredic Saibil, John McDonald.  Quality of Life:  A Valid and Reliable Measure of Therapeutic Efficacy in Treatment of Inflammatory Bowel Disease.  Gastroenterology 1994; 106:287-96.

·        Farouk R., Pemberton H.P.  Surgical Options in Ulcerative Colitis.  Surgical Clinics of North American 1997; 77:85-93.

·        Jimmo B., Hyman H.N. Is Ileal Pouch Anal Anastomosis Really the Procedure of Choice for Patients with Ulcerative Colitis.  Disease of Colon and Rectum.  1998; 41 (1); 41-5.

·        Victor Faizo, Yehield Z.I.V., James Church, John Oakley, Ian C. Lavery.  Ilea Pouch Anal Anastomosis, Complications and Functions in 1005 Patients.  Annals of Surgery 1995; 22(2): 120-27.

·        Kohler L.W., Pemberton H.J., Ainsmeister A.R., Kelly K.A. Quality of Life After Proctocolectomy.  A Comparison of Brooke Ileostomy, Kock Pouch and Ileal Pouch and Anastomosis.  Gastroenterology 1991; 101 (3);  679-84.

·        Hulten I., Proctocolectomy and Ileostomy to Pouch Surgery for Ulcerative Colitis.  World Journal of Surgery  1998;  22(4): 335-41.

·        Thiriby R.C., Land J.C., Fenster L.F., Lonborg R., Effect of Surgery on Health Related QOL in Patients with IBD:  A Prospective Study.  Archives of Surgery 1998; 133(8): 26-32.

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