The Impact of Multiple Biologic Failures on Surgical Outcomes: A Retrospective Cohort Study of Elective Subtotal Colectomy for Ulcerative Colitis

Background: Subtotal colectomy (STC) with end ileostomy (EI) is usually the first surgical stage for patients with ulcerative colitis (UC) who fail medical treatment, most often with biological agents. Is there a difference in surgical outcome after failure of one or two biologicals vs. three or four? Methods: A retrospective study of all patients who underwent STC with EI for UC (5-2018 to 1-2022). After excluding emergent cases, the elective cohort was divided into patients who failed 1–2 biologicals (group 1–2) vs. patients who failed 3–4 biologicals (group 3–4), and surgical outcomes were compared. Data collected included patients’ demographics, preoperative clinical manifestations, and operative and postoperative outcomes. Results: Ninety-eight patients underwent STC for UC, and of them, 53 were elective. Thirty patients failed 1–2 biologics (group 1–2), and 23 failed 3–4 biologics (group 3–4). The groups were similar in average age (37.6 ± 11 vs. 32.7 ± 10), BMI (26.7 ± 6 vs. 27.7 ± 7), number of years with UC (9.5 ± 9 vs. 9 ± 8), rate of steroid dependence (20 (67%) vs. 13 (57%)) but differed in sex; there were 25 (83%) males in group 1–2, and 8 (35%) in group 3–4 (p < 0.01). The operative approaches were similar, as was the operative time (217 ± 74 vs. 210 ± 79 min). The length of hospital stay was 3.2 ± 1 days for group 1–2 and 5 ± 6 days for group 3–4 (p = 0.14). Postoperative complications were seen in 10 patients (33%) vs. 7 patients (30%) (p = 0.82), and of them, two (7%) and two (9%) (p = 0.82) had Venous thromboembolism (VTE), respectively. Only 20 patients (67%) in group 1–2 and 16 patients (70%) in group 3–4 (p = 0.82) progressed to a second stage of an Ileoanal pouch (IPAA) at 11.1 ± 4 and 9.2 ± 2 months, respectively. The overall average follow-up time was 41.1 months. Conclusions: Ulcerative Colitis patients who fail 3–4 biological agents and choose to go to elective STC with EI have very similar surgical outcomes compared to patients who choose elective surgery after failing only 1–2 biological agents in the same time span of known disease. UC patients with severe colitis and poor quality of life who fail two lines of biological agents may be better off electing surgical treatment than failing more biologics and then going to surgery. On the other hand, patients who try 3–4 biologics may expect no worse surgical outcomes than after 1–2 biologics.