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Introduction:
The aim of our study was to compare outcomes of patients treated with elective vs. urgent surgery for active Ulcerative Colitis (UC) in the hopes of defining modifiable factors that could decrease complications.

Methods:
We performed a retrospective review of 179 UC patients undergoing surgery for failure of medical management. Patients treated urgently (while hospitalized) were compared to those treated electively with univariate (chi square, t test) and multivariable regression analyses.

Results:
Patients undergoing urgent (n=99) vs. elective (n=80) surgery were younger (28.3±1.6 vs. 32.6±1.6 years; p=0.05) with lower mean BMI (22.3±0.1 vs. 25.9±0.6 kg/m2; p=0.0001). Significantly more urgent patients were on steroids at the time of surgery (93.5% vs. 66.7%; p<0.0001). Use of anti-TNF drugs (21.3% vs. 26.3%; p=0.44) and other immunomodulators (42.5% vs. 43.4%; p=0.91) were equivalent between the two groups. Urgent patients reported more daily bowel movements at the time of surgery (11.7±0.7 vs. 9.0±0.8; p=0.01) and had an increased prevalence of severe disease on final pathology (87.5% vs. 73.7%; p=0.02) compared to patients treated electively.

During surgery, urgent and elective patients had similar degrees of hemodynamic stability (mean apgar scores 6.1±0.2 vs. 6.5±0.1; p=0.1). However, urgent cases had more than a 5-fold increase in the proportion of subtotal colectomies (5.1% vs. 29%; p<0.0001) and half as many laparoscopic procedures (8.8% vs. 18%; p=0.07). Postoperatively, patients treated urgently had more short-term complications (1.0±0.3 vs. 0.6±0.2; p=0.05), but no increase in anastamotic leaks [OR 1.7 (0.5, 6.5); p=0.26] or in-hospital length-of-stay (7.3±0.5 vs. 6.5±0.4 days; p=0.21) at their initial operation. Long-term complications, including pouchitis, fistula/abscess, ileus/SBO, stricture, and pouch failure were similar regardless of urgency status (p≥0.08). Multivariate regression analysis controlling for disease severity, steroid use, and infliximab use suggested that short-term complications were attributable to higher BMI in addition to urgent status (p≤0.05). Surgeon inexperience and use of immunomodulators other than infliximab were associated with increased odds of long-term fistula/abscess [OR 5.56 (1.1, 33); p=0.05) and pouch failure [OR 13.3 (1.75, 318); p=0.01], respectively.

Conclusion:
Although urgent surgery is associated with an increased number of short-term complications, it does not affect the risk of anastomotic leak, in-hospital length-of-stay, or long-term complications provided that the surgery is performed by an expert. Weaning from immunomodulators other than infliximab and early transfer to an institution with IBD expertise would likely decrease complications overall for patients undergoing both elective and urgent interventions for severe UC.