Introduction

Up to one-third of acute colitis patients from Inflammatory Bowel Disease (IBD) will require colectomy having had an inadequate response to medical therapy.1 Timely operative intervention is important, as delay increases post-operative complications, including mortality.2, 3 IBD management has become more complex with the widespread use of rescue immunobiologics.4 As a result, it is not possible for IBD care to be managed by a single clinical specialty. However, there is a lack of evidence on whether a multi-disciplinary (MDT) approach for these patients can improve outcomes. We assess the impact of adopting an MDT bundle on early post-operative complication rates of subtotal colectomy in patients with acute colitis. The bundle consisted of a treatment algorithm for patients presenting with acute colitis, weekly IBD MDT meetings and the availability of colorectal surgeons with an interest in IBD.

Methods

This was a single-centre retrospective observational study. Adult (>16 years) patients were identified through clinical discharge codes. Notes of patients who underwent subtotal colectomies from 01/01/2006 to 31/12/2019 were analysed. Socio-demographics, diagnosis, complications (Clavien-Dindo classification I to V), medical and surgical management data were collected. The MDT care bundle was started on 1st April 2014. Data obtained were analysed using SPSS v26 (IBM, New York). A multivariable logistic regression analysis was modelled using all the parameters in the univariate assessment. The study was registered as an audit of clinical practice with the clinical effectiveness department of NHS Grampian.

Results

A total of 296 patients were included. Of these, 199 patients were in the pre-bundle group and 97 in the post-bundle group. There were no differences in sex (p=0.109), age (p=0.246), BMI (p=0.569), laparoscopic procedures (p=0.286) and rate of previous operations (p=0.632) between the groups. The number of patients who had biologic medications before their operation was significantly higher in the post-bundle group (n=38; 39%) when compared to the pre-bundle group (n=21; 11%; p<0.0001). Patients treated in the post-bundle group had significantly reduced overall complication rates (44.6% versus 33.7%, p=0.045. The rates of severe complications (Clavien Dindo III/IV/V) had also reduced significantly between the pre-bundle (n=36; 18%) and the post-bundle (n=9; 9.3%) (p=0.021) (Table 1). On multivariate analysis, increasing age [1.023 OR; 95% CI 1.004, 1.041] and procedure performed before MDT bundle [3.1 OR; 95% CI 1.689, 5.723] were independent predictors for post-operative complications (Table 2).

Table 1 Complication profile before and after the start of the IBD care bundle, by Clavien Dindo
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Table 2 Multivariable model for complication analysis results
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Discussion

This work demonstrates that the rates of complications after IBD colectomies in the North of Scotland have improved since 2014 following the introduction of an MDT care bundle. This was more than merely a weekly MDT discussion and allowed for a consistent timepoint of surgical referral to surgeons with an interest in IBD. Whilst we cannot apportion causality, this improvement is contemporaneous with the establishment of a formalised IBD MDT working process and the adoption of a care bundle in our tertiary centre. Despite the increased use of immunobiologics, not only has the overall rate of complications reduced, but the rate of severe complications has also decreased.

The literature on IBD MDT has previously concentrated on non-operative outcomes such as timing of diagnosis, flare-up detection rates, side effects of medical therapies and time to surgery as primary end points.5, 6 However, this study has found that an MDT care bundle can improve surgical outcomes in patients with IBD. We propose that, through optimal referral to the surgical team and early awareness of individuals who are starting rescue therapy to the IBD colorectal surgeon, patients who proceed to an operation do so in a more controlled and organised way and this leads to improved surgical outcomes.