Potentially avoidable surgery in inflammatory bowel disease: what proportion of patients come to resection without optimal preoperative therapy? A guidelines-based audit.

BACKGROUND: Recently, promulgated inflammatory bowel disease (IBD) guidelines seek to decrease the need for surgery by improving disease control. However, resection rates remain static. AIMS: We therefore sought to determine the proportion of patients coming to surgery where preoperative management was not optimal according to guidelines. METHODS: Case notes of all patients with resection surgery for IBD from January 2007 to March 2008 at a metropolitan teaching hospital were retrospectively reviewed. Judgement was made as to whether preoperative management was optimal or suboptimal depending on whether it met guidelines. RESULTS: A total of 22 subjects with IBD-related resections were identified (15 males and seven females). In total, 17 had Crohn's disease (CD) (11 males) and five ulcerative colitis (UC) (four males). There were 10 smokers (nine CD and one UC). The two most common indications for surgery were inflammatory mass/abscess (n= 8) and refractory to medical therapy (n= 7). While all patients with known IBD (20/22) had seen a gastroenterologist in the past, five known IBD patients had resections undertaken without preoperative gastroenterologist input. Overall preoperative management was judged as optimal in only (9/22) 41%. Of those whose therapy did not meet guidelines (n= 13), five had azathioprine at doses <2 mg/kg, one declined therapy and nine with CD were current smokers. CONCLUSIONS: Over 50% of IBD resection patients had suboptimal preoperative management, with sub-therapeutic thiopurine dosing and smoking in CD the main problems. Thus, there are significant gains to be made with better use of standard therapies, as it appears that ∼50% of resection surgery was 'potentially avoidable'.

A 13-nation population survey of upper gastrointestinal symptoms: prevalence of symptoms and socioeconomic factors.

BACKGROUND: Previous data collected in separate studies using various different survey instruments have suggested some variability in the prevalence of symptoms between nations. However, there is a lack of studies which assess and compare the prevalence of upper gastrointestinal symptoms contemporaneously in various countries using a uniform, standardised method. AIM: To determine the prevalence of upper gastrointestinal (UGI) symptoms in 13 European countries, and the association between socioeconomic factors and symptoms using a standardised method. METHODS: A representative age- and gender-stratified sample of 23,163 subjects (aged 18-69 years) was surveyed. RESULTS: The prevalence of UGI symptoms was 38%. UGI symptoms were most prevalent in Hungary [45%, 95% confidence interval (CI): 42.2-48.4] and lowest in the Netherlands (24%, 95% CI: 21.0-26.2). UGI symptoms were more prevalent in women (39%, 95% CI: 38.4-39.6) vs. men (37%, 95% CI: 36.4-37.6). Heartburn (24%, 95% CI: 23.4-24.6) and acidic reflux (14%, 95% CI: 13.6-14.4) were most common. With age, the prevalence of UGI symptoms decreased (e.g. 18-29 years: 43%, 95% CI: 41.4-44.3 vs. 50-69 years: 33%, 95% CI: 32.3-34.4); in contrast, the frequency of symptom episodes/year increased with age (e.g. 18-29 years: 11.3 episodes per years, 95% CI: 10.5-12.1 vs. 50-69 years: 21.8, 95% CI: 20.7-22.9). Socioeconomic status as measured by gross domestic product was inversely associated with symptoms and in total, socioeconomic factors, gender, body mass index, smoking habits and alcohol consumption explained 83% of the variance of UGI symptoms. CONCLUSIONS: There are marked differences in the country specific prevalence of upper gastrointestinal complaints. Socioeconomic factors are closely associated with the prevalence of upper gastrointestinal symptoms.