P203 - Morbidity Associated With Delayed Surgical Referral in Ulcerative Colitis.

Purpose/Background: One third of patients with ulcerative colitis (UC) ultimately require surgical intervention. However, increasing reliance on medical therapy and the absence of formal referral guidelines contribute to delayed surgical consultation. Such delays may adversely affect both quality of life and operative outcomes. We aimed to characterize factors associated with preoperative morbidity in patients undergoing surgery for UC and to identify predictors of delayed referral.

Methods/Interventions: We retrospectively reviewed records of patients who underwent surgical treatment of UC at our high-volume multidisciplinary IBD center between 2018 and 2024. We compiled a pragmatic list of factors contributing to preoperative morbidity. We used the comprehensive complication index (CCI), a validated score from the Clavien-Dindo classification, to assess preoperative ulcerative colitis burden in each patient. We defined delayed referral as referral to a colon and rectal surgeon more than one year post-UC diagnosis and a preoperative CCI exceeding the mean CCI of the entire cohort. We performed univariable and multivariable analyses to identify patient and disease factors associated with delayed referral.

Results/Outcomes: A total of 211 patients were included (mean age 54, SD 16; 56% male). The mean pre-operative CCI score was 37 (SD 16), and 46% (n=98) of patients had delayed referral. Patients in the delayed versus non-delayed referral group exhibited significantly higher rates of steroid-dependence (43% vs. 27%, p=0.013) and steroid-refractory disease (44% vs. 22%, p=0.001). Delayed referral was associated with adverse clinical outcomes, including a higher frequency of urgent/emergent operative procedures (67% vs. 4%, p< 0.001), presentation with perforation (14% vs. 0%, p< 0.001), open laparotomy (17% vs. 7%, p=0.021) and experiencing moderate side effects from medical therapy (26% vs. 4%, p< 0.001). On multivariable logistic regression, adjusting for age and sex (ROC area under the curve 0.891), patients referred in a delayed manner were more likely to have anemia (Hgb < 12, OR 3.8, 95% CI 1.7-8.5), hypoalbuminemia (albumin < 3.5, OR 12.5, 95% CI 5.5-28.6), and metabolic side effects of steroids (OR 42.6, 95% CI 10.5-173.5), however, they were less likely to have disease refractory to two or more biologic medications (OR 0.44, 95% CI 0.20-0.98).

Conclusion/Discussion: Delayed surgical referral in ulcerative colitis correlates with adverse perioperative events, such as urgent procedures, perforations, open surgery, and ostomy formation. Identified objective markers of refractory UC (anemia, hypoalbuminemia, and metabolic steroid complications) provide a preliminary framework for multidisciplinary IBD teams to develop criteria for mitigating these adverse outcomes and ensuring timely surgical intervention.

Outcomes of Total Colectomy with lleorectal Anastomosis and Segmental Colectomy for UC, 2018-2024
Figure. Factors Associated with Delayed Referral. Table. Post-operative Outcomes