Surgical Management of Ulcerative Colitis (2026)

Amy L. Lightner, M.D., M.B.A.¹; Ira L. Leeds, M.D., M.B.A., Sc.M.²; Michael F. McGee, M.D.³; Aaron J. Dawes, M.D., Ph.D.⁴; Carrie Y. Peterson, M.D., M.S.⁵; Mukta K. Krane, M.D.⁶; Traci L. Hedrick, M.D., M.Sc.⁷; Wolfgang B. Gaertner, M.D., M.Sc., M.B.A.⁸

Diseases of the Colon & Rectum 2026; 69: 2012–2039

doi: 10.1097/DCR.0000000000004290

CLINICAL PRACTICE GUIDELINES PDF

Author Information

¹Department of Molecular and Cellular Biology, Immunology and Microbiology, The Scripps Research Institute, and Scripps Clinic, La Jolla, California

²Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut

³Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan

⁴Section of Colon and Rectal Surgery, Department of Surgery, Stanford Medicine Improving IBD Outcomes through Multidisciplinary Care (IBD-OMICs) Program, Stanford University School of Medicine, Stanford, California

⁵Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin

⁶ Section of Colon and Rectal Surgery, Department of Surgery, University of Washington Medicine, Seattle, Washington

⁷Division of General Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia

⁸Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s website (www.dcrjournal.com).

Funding/Support: None reported.

Financial Disclosure: Dr. Lightner is a consultant in Mirador Therapeutics. Dr. Leeds is a consultant in Intuitive Surgical. Dr. Dawes is a consultant for Intuitive Surgical and is associated with Behind the Knife. Dr. Peterson is a consultant and speaker for Applied Medical. Dr. Gaertner serves as a proctor and speaker for Intuitive Surgical; advisory board member for Coloplast; and advisory board member, consultant, and speaker for Becton Dickinson.

Correspondence: Wolfgang B. Gaertner, M.D., M.Sc., M.B.A., Division of Colon and Rectal Surgery, University of Minnesota, 420 Delaware St SE, MMC 450, Minneapolis, MN 55455. E-mail: gaert015@umn.edu

Prepared by the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. This Clinical Practice Guidelines Committee is charged with leading international efforts in defining quality care for conditions related to the colon, rectum, and anus by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, not prescriptive, and are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment.It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.

STATEMENT OF THE PROBLEM

Ulcerative colitis (UC) is an idiopathic chronic inflammatory condition that affects the mucosa lining the colon and rectum, which, for unknown reasons, continues to increase in incidence, with nearly 3.1 million people affected in the United States alone.[1][2] Patients most often present in 2 general age categories—ages 15 to 30 years and 55 to 65 years—with rectal bleeding, urgency, or tenesmus from proctitis.[3][4] The degree of symptomatology is variable during a patient’s lifetime, and patients often exhibit a remitting and relapsing phenotype at various points during their course. Although patients can achieve mucosal healing by use of an ever-expanding repertoire of immunoregulatory medications, approximately 15% to 20% of patients with UC still require colectomy for medically refractory disease or neoplasia of the colon or rectum.[5][6][7][8][9] Regardless of the indication for surgical intervention, complete removal of all at-risk tissue (ie, the colon and the rectum) is considered curative for the intestinal manifestations of UC. Depending on the clinical scenario, operative strategies for patients with UC may include a total abdominal colectomy with end ileostomy or ileoproctostomy or total proctocolectomy (TPC) with permanent end ileostomy, a continent ileostomy, or construction of an IPAA, all of which are increasingly performed using minimally invasive techniques.[6][8][10][11] This guideline focuses on the surgical management of medically refractory UC and UC-associated colorectal neoplasia, key technical aspects of operative intervention, postoperative considerations specific to patients with UC, and long-term outcomes that require consideration. Because the optimal management of patients with UC involves a multidisciplinary team approach, including colorectal surgeons, gastroenterologists, radiologists, pathologists, nutritionists, and enterostomal therapists, these guidelines should be viewed in that context and represent only a portion of the treatment paradigm used when caring for patients with UC.

METHODOLOGY

This guideline was written as an update to the ASCRS Practice Parameters for the Surgical Treatment of Ulcerative Colitis published in 2021.[12] Although bowel preparation, enhanced recovery pathways, ostomy care, and prevention of thromboembolic disease are relevant to the surgical management of patients with UC, these topics are addressed in other ASCRS CPG and are beyond the scope of this guideline. An organized search of MEDLINE, PubMed, Embase, and Scopus limited to the English language was performed from January 1, 2020, to December 29, 2025, as the present CPG was meant to be an update to the 2021 guidelines.[12] Keyword combinations included “ulcerative colitis,” “indeterminate colitis,” “inflammatory bowel disease,” “Crohn’s disease,” “surgery,” “colectomy,” “proctocolectomy,” “ileostomy,” “laparoscopic,” “robotic,” “Kock pouch,” “mucosectomy,” “ileoproctostomy,” and “ileal pouch-anal anastomosis.” Directed searches using embedded references from primary articles were performed in selected circumstances. After removal of duplicate references, a total of 2183 unique journal titles were identified. A total of 1037 titles were selected for article review with an emphasis on prospective and randomized controlled clinical trial data as shown in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram (Fig. 1).

CERTAINTY OF EVIDENCE

The final grade of recommendation and level of evidence for each statement were determined using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology system. The certainty of evidence reflects the extent of our confidence in the estimates of effect. Evidence from randomized controlled trials (RCTs) starts as high certainty, and evidence from observational studies start as low certainty. For each outcome, the evidence is graded as high, moderate, low, or very low (Table 1). The evidence can be rated down for risk of bias, inconsistency, indirectness, imprecision, and publication bias. The certainty of evidence originating from observational studies can be rated up when there is a large magnitude of effect or dose–response relationship. Per GRADE methodology, recommendations are labeled as “strong” or “conditional.” All statements with strength of GRADE recommendations are stated in Table 2 (Table 2). Table 3 (Table 3) summarizes the new, updated, and excluded recommended CPG compared with the 2021 guidelines. Recommendations formulated by the subcommittee were reviewed by the entire CPG Committee. The submission was then approved by the ASCRS Executive Council and peer-reviewed in Diseases of the Colon & Rectum. Each ASCRS Clinical Practice Guideline is generally updated approximately every 5 years. No funding was received for preparing this guideline, and the authors have declared no competing interests related to this material. This guideline conforms to the Appraisal of Guidelines for Research and Evaluation checklist.

INDICATIONS FOR SURGERY

1. A multidisciplinary approach, including early surgical consultation, typically guides care for patients with moderate-to-severe active UC. Strength of recommendation: strong based on low-quality evidence.

When patients with UC experience clinical deterioration or worsening endoscopic disease activity, escalation of medical therapy becomes necessary, and surgical intervention may be considered. The 2025 American College of Gastroenterology (ACG) guidelines for UC recommended an updated disease activity index that integrates clinical symptoms, modern UC-specific biomarkers, most notably fecal calprotectin, and endoscopic assessment of disease severity (Table 4).[2][13]

The management of hospitalized patients with UC requires an individualized assessment that incorporates patient-specific factors, including prior medical therapies, comorbidities, and preferences. Risk factors associated with worse surgical outcomes include younger age at diagnosis (younger than 40 years), extensive colitis, severe endoscopic disease, previous hospitalization for colitis, elevated inflammatory markers (C-reactive protein [CRP] or erythrocyte sedimentation rate [ESR]), anemia, and hypoalbuminemia.[14][14][15][16]

Initial multidisciplinary management during an acute UC flare includes intravenous corticosteroids, encouraging oral intake as tolerated, venous thromboembolism (VTE) prophylaxis, and repeat cross-sectional imaging such as CT or CT enterography as needed.[2][15][15][17] Avoidance of anticholinergic medications and narcotics should be encouraged. Lower endoscopic evaluation with either ileocolonoscopy or flexible sigmoidoscopy within 24 hours (up to 72 hours) is essential to assess disease activity and exclude CMV colitis infection via biopsy. Testing for Clostridium difficile infection should also be performed routinely.[2][18]

The goal of early multidisciplinary involvement of hospitalized patients with severe UC is 2-fold: 1) to promptly identify acute decompensation or indication requiring emergency surgical intervention (see next position statement); and 2) to recognize “medically refractory” disease where the benefit of surgery outweighs the risk of ongoing inpatient or outpatient medical therapy. Hospitalized patients should undergo vigilant, periodic clinical reassessment with multidisciplinary input. Several risk assessment indices help predict the likelihood of colectomy, guiding decision-making.[19][19][20][21] Common features of favorable response include decreased stool frequency, decreased hematochezia, a downward trend in serum CRP, and a general improvement in subjective symptomatology.[2][22] Transition to longer-term maintenance strategies after hospitalization is beyond the scope of this CPG; however, this guideline supports the treat-to-target principles established by the Selecting Therapeutic Targets in IBD initiative.[23][24]

If there is insufficient clinical improvement within 3 to 5 days of corticosteroid initiation, intravenous infliximab or intravenous cyclosporine should be considered as medical rescue therapy.[25][26] Both therapies typically demonstrate clinical response within 5–7 days.[27] Second-line rescue therapy with infliximab or cyclosporine can avoid colectomy in 60% to 80% of patients at 3 months and in greater than 60% of patients at 5 years, although long-term colectomy risk remains unevaluated.[25][28][29][30][31][32] The ACG guidelines recommend early surgical consultation by at least the time medical rescue therapy is being initiated.[2] Patients who fail to respond to rescue therapy have their disease classified as “medically refractory” and warrant consideration for proctocolectomy.

Many patients with UC never receive a surgical consultation despite evidence that multidisciplinary management improves outcomes.[33] “Intermediate responders”—patients with incomplete responses—require vigilant multidisciplinary oversight.[34][35][36] Chronic corticosteroid use (ie, “steroid-dependent” disease) is associated with increased morbidity and mortality and may itself constitute an indication for colectomy. Furthermore, patients cycling through a number of advanced IBD medical therapies face an increased risk for colectomy at 1 year.[37] A recent Markov model analysis similarly supports improved quality of life with colectomy compared to ongoing medical therapies in these cases.[38]

Throughout medical escalation, early and proactive surgical consultation should be pursued not only to optimize education and decision-making but also to position surgery as a valid treatment option rather than a failure of care. Observational studies suggest early multidisciplinary engagement improves outcomes.[39] Ongoing surgical evaluation allows dynamic, longitudinal coordination with the gastroenterology team. Once surgery is under consideration, consultation with an enterostomal therapist is recommended (see ASCRS Clinical Practice Guidelines for Ostomy Surgery).[40]

2. Patients with fulminant UC, toxic megacolon, colonicperforation, or refractory hemorrhage in the setting of UC should undergo emergent total abdominal colectomy with end ileostomy. Strength of recommendation: strong based on moderate-quality evidence.

Acute complications of UC can be life-threatening and often necessitate emergent surgical intervention. Nationally representative retrospective studies have shown that delaying surgery by more than 1 day is associated with a 5-fold increase in mortality and a 42% increased risk of complications.[41][42][43][44] Notably, surgical outcomes are generally not adversely impacted by prior medical rescue therapies and should not be deferred on the basis of recent medication exposures.[2][45] However, there are no RCTs directly comparing surgical intervention with medical therapy for specific urgent indications in UC.

Despite the absence of RCT data, consensus across involved specialties has identified several clear indications for emergency surgery in UC, including fulminant UC, toxic megacolon, perforation, and refractory hemorrhage. Although the term “fulminant” UC remains controversially defined, the ACG has incorporated it into its UC activity index. Fulminant UC is characterized by more than 10 bowel movements per day, continuous hematochezia requiring blood transfusions, continuous rectal urgency, ESR >30 mm/h, elevated CRP level, abnormal fecal calprotectin level, and severe endoscopic findings.[2] In contrast, “moderate–severe” UC is characterized by 6 or more bowel movements per day, intermittent rectal bleeding, intermittent rectal urgency, anemia without blood transfusions, and similar laboratory and endoscopic parameters. In hemodynamically stable patients without concern of pending perforation, selective use of medical rescue therapy may be appropriate.[2]

“Toxic megacolon” represents a distinct entity within the spectrum of fulminant colitis and is classically defined by Jalan’s criteria, including right-sided colonic dilation of >6 cm on radiographic imaging, fever, tachycardia, leukocytosis, anemia, and at least 1 of the following: dehydration, altered mental status, electrolyte derangements, or hypotension.[46] In modern practice, the presence of radiographic colonic dilation and clinical signs of severe inflammation strongly support the diagnosis. Ultimately, bedside surgical judgment remains central to determining the presence of toxic megacolon and the patient’s physiologic capacity to withstand continued medical management.

Colon perforation (free or with penetration of the retroperitoneum) is best diagnosed via CT of the abdomen and pelvis.[47] Classic physical signs of peritonitis may be absent, particularly in patients receiving immunosuppressive therapies.[48] Refractory hemorrhage, as opposed to compensated acute blood loss anemia, lacks a consensus definition in the literature and relies on surgical clinical judgment for timely intervention.

3. Patients with colorectal dysplasia in the setting of UC are best managed by a multidisciplinary team including gastroenterologists, pathologists, surgeons, and a provider experienced in advanced endoscopy. Strength of recommendation: strong based on low-quality evidence.

Patients with UC are at an increased risk of developing colorectal dysplasia and colorectal cancer (CRC), particularly with longer disease duration, extensive colonic involvement, and the presence of primary sclerosing cholangitis (PSC).[49] Dysplasia and neoplasia can develop in patients with UC from inflammatory or noninflammatory molecular pathways. The former is associated with a field effect that is discontinuous, multifocal, and sometimes pan-colonic, whereas the latter is limited to a local clonal expansion of sporadically mutated cells. Furthermore, a field defect in any chronically inflamed mucosa is at risk for synchronous or metachronous neoplasia. Historically, dysplasia was believed to progress in a stepwise manner from low-grade dysplasia (LGD) to high-grade dysplasia (HGD) and eventually to invasive carcinoma. Before the implementation of high-definition (HD) endoscopy, biologic therapies, and structured surveillance protocols, meta-analyses estimated the cumulative risk of CRC to be 2%, 8%, and 19% after 10, 20, and 30 years of disease duration, respectively.[50] However, more recent populationbased studies, including patients treated with modern therapies and undergoing routine, enhanced surveillance, have demonstrated significantly lower CRC rates, ranging from 1% to 5%.[51][52][53][54][55]

Despite the declining incidence of UC-associated CRC,[54] the risk remains elevated in certain high-risk subgroups, as mentioned earlier.[56] Notably, some studies suggest a paradoxical increase in the incidence of dysplasia and early cancers, likely reflecting improved detection through enhanced endoscopic visualization and heightened awareness.[57] In light of these risks, current guidelines from international societies recommend routine colonoscopic surveillance in patients with long-standing UC to detect dysplasia before malignant transformation occurs.[58][59] Surveillance colonoscopy should begin 8 to 10 years after symptom onset, with subsequent intervals (every 1–5 years) determined by individualized risk factors, including disease extent and severity, family history, and presence of PSC.[2] Patients with PSC should undergo colonoscopy, even if no abdominal or GI symptoms are present. Modern surveillance relies on HD white-light endoscopy or chromoendoscopy, either dye-based or virtual (eg, narrow-band imaging), to identify visible dysplasia. These advances have largely replaced the need for random biopsies, which were the mainstay of earlier surveillance strategies performed with standard-definition endoscopes. Current societal recommendations favor targeted biopsies of visible lesions using HD chromoendoscopy, and referral to an experienced endoscopist should be considered if these techniques are not available locally.[60]

Accurate diagnosis of UC-associated dysplasia is complex and requires expert pathology review. Interobserver variability among pathologists is well documented, particularly in distinguishing LGD from regenerative or reactive changes. Therefore, when feasible, biopsy specimens should be reviewed by at least 2 experienced GI pathologists with IBD expertise.[61][62][63][64][65][66] A multidisciplinary case review, including gastroenterologists, surgeons, advanced endoscopists, and pathologists, is recommended to inform diagnosis, surveillance strategy, and treatment planning.

3a. In patients with UC, visible low-grade colorectal dysplasia amenable to complete endoscopic excision may be endoscopically managed with subsequent close surveillance. Strength of recommendation: conditional based on moderate-quality evidence.

Before the widespread adoption of modern endoscopic surveillance and treatment paradigms, the detection of any UC-associated dysplasia was considered indicative of widespread, occult neoplasia. As such, colectomy was historically recommended for all dysplasia based on studies demonstrating high rates of synchronous and occult dysplasia and CRC. A large, single-institution study showed that invasive cancer was found at the time of proctocolectomy in 29% of patients with HGD and 3% with LGD identified on preoperative colonoscopy.[67] Another study found that 43% of colectomy specimens with any dysplasia at preoperative colonoscopy also contained invasive carcinoma; and preoperative dysplasia predicted synchronous cancer with a sensitivity and specificity of 81.2% and 79.5%.[68]

Improvements in modern endoscopic techniques have led to endoscopic surveillance and excision becoming the first-line management for UC-associated dysplasia. In a prospective trial, chromoendoscopy outperformed conventional white-light endoscopy for dysplasia detection,[69] and a meta-analysis demonstrated a 1.8-fold increase in dysplasia detection compared to white light, with an absolute risk increase of 6%.[58] Since the 2015 endorsement of chromoendoscopy by multiple gastroenterology societies, newer studies have evaluated additional advanced techniques.[68][69] HD white-light colonoscopy with segmental reinspection (double-pass per segment) has also been shown to be noninferior to chromoendoscopy for dysplasia detection in IBD.[70] In addition, a large meta-analysis suggested that virtual chromoendoscopy (eg, narrowband imaging) achieves similar detection rates to dye-based chromoendoscopy.[71] Although no advanced endoscopic method has proven to be superior for visualizing UC-associated dysplasia, surveillance is best performed by an experienced endoscopist skilled in advanced techniques such as virtual or dye-spray chromoendoscopy or double-pass HD white-light colonoscopy.

The endoscopic diagnosis of UC-associated neoplasia is challenging and requires a stepwise approach using multiple endoscopic modalities. The presence of HGD or higher, or a lesion that is invisible, without clear borders, nonliftable, or not able to be completely excised endoscopically (see part B below), is an indication for proctocolectomy. Even in the context of medically controlled UC and prior multidisciplinary discussion, the management of LGD remains controversial. Visible LGD lesions should typically be excised endoscopically using techniques such as cold snare, endoscopic mucosal resection, or endoscopic submucosal dissection (ESD) when technically feasible. Cold snare polypectomy is suitable for small (< 1 cm), clearly delineated, nonfibrotic lesions.[72][73] Safety profiles for advanced endoscopic excision techniques in patients with UC are similar to those in non-IBD patients.[74] A single comparative retrospective study including 204 UC-associated lesions versus 80 non-UC lesions showed no significant difference in recurrence or complications from a Paris class 0 to II adenoma-like mass, except for a higher recurrence rate in lesions with lateral spreading (14% vs 0%; p = 0.048) during a 4-year follow-up.[75] In a single study involving patients with colonic neoplasms, ESD was associated with higher en bloc excision rates than endoscopic mucosal resection (relative risk [RR] 6.84), an increased RR of perforation (RR 4.96), and additional surgery for incomplete excision and perforation (RR 2.16); however, the absolute risks of each were relatively low (5.7% and 9.9%, respectively).[76]

After complete endoscopic excision, current evidence supports early surveillance colonoscopy within 3 to 24 months, depending on disease- and lesion-specific characteristics, due to recurrence rates approaching 4.9% at a median follow-up of 33 months.[63][64][65][74] Two large Dutch cohort studies of more than 4000 patients using the Dutch National Pathology Registry and Nationwide Pathology Database reported cumulative incidences of metachronous advanced neoplasia (HGD or CRC) of 0.6% to 1.9% at 1 year and 8.5% to 12.4% at 5 years.[77][78] Older age (55 years or older) at diagnosis of dysplasia, male sex, and follow-up at an academic (vs nonacademic) medical center were independent risk factors for advanced neoplasia after diagnosis of LGD, and endoscopic resection versus surgical excision was an independent risk factor for metachronous lesions.[77][78] The median time to develop advanced neoplasia after LGD was 3.6 years. Although recurrent or metachronous low- and high-grade lesions may be considered for repeat endoscopic excision on an individualized basis, provided they remain amenable to complete removal and lack high-risk features for invasive cancer, strict endoscopic surveillance and early multidisciplinary discussions remain imperative to the management of patients with UC and dysplasia.

3b. Any type of dysplasia in patients with UC that is not amenable to endoscopic excision, is persistently invisible, or is multifocal or metachronous should typically be considered for TPC with or without IPAA. Strengthof recommendation: strong based on low-quality evidence.

Despite demonstrated success in endoscopic management of UC-related dysplasia, several situations merit strong consideration of surgery to reduce the elevated risk of cancer development. Patients with either LGD or HGD that cannot be completely excised endoscopically should be strongly considered for proctocolectomy.[67][68] Surgery should also be considered in the presence of additional high-risk features that are associated with progression to invasive cancer, such as multifocal lesions, lesions larger than 10 mm, nonpolypoid (ie, flat) morphology, PSC, recurrent dysplasia, uncontrolled mucosal inflammation, strictures or pseudopolyposis that cause suboptimal visualization, family history of CRC, a history of smoking, and previous piecemeal endoscopic excision.[57][79][80] Patients with multiple risk factors should be strongly considered for proctocolectomy, as increasing numbers of risk factors incrementally increase the risk of future CRC development.[57] An internet-based decision-making tool derived from meta-analyzed risk factors for UC-related cancer development can guide patients and health care providers through shared decision-making (https://uc-care.uk).[79] Shared decision-making with the patient and their advocates is required because substantial discrepancies between the patient and the physician regarding cancer risk tolerance may exist.[81][82][83]

Patients with “invisible” dysplasia may have many different forms of presentation, including those detected at the time of random biopsies, biopsies for disease activity, follow-up biopsies in areas previously affected by colitis, biopsies in broad areas of hyperplastic polyps, or biopsies surrounding a polypectomy site. These patients should typically first undergo HD white-light colonoscopy with segmental reinspection or high-quality chromoendoscopy.[84] Although flat or persistent invisible dysplasia is less common given the general decrease in random biopsies in patients with chronic UC, it has been typically associated with increased cancer risk and generally warrants surgical consultation. Invisible LGD has been identified as increasing the risk of future CRC development by 2 to 3 times.[79][85] However, clinical equipoise exists regarding the optimal management of unifocal invisible LGD due to conflicting data.[86] A Dutch endoscopic surveillance study showed only 1 of 26 patients with invisible LGD undergoing adequate endoscopic surveillance progressed to cancer during a median follow-up of 4.7 years; however, the risk of invisible LGD progressing to either HGD or cancer was nearly double compared to visible LGD lesions (2.3 vs 0.97 cases per 100 patient-years).[87] Alternatively, the CRC incidence for unifocal LGD was 4.3 per 100 patient-years in a UK multicenter study.[79] An older systematic review that included studies before the advent of modern endoscopic techniques showed that 22% of patients (18/81) with invisible LGD who underwent proctocolectomy had an occult invasive cancer at the time of surgery.[88] Occult CRC risks for invisible HGD are even historically higher, with older pre-chromoendoscopy studies showing the risk of occult CRC to be 42% to 67%.[89][90][91][92] As such, the management of persistently invisible dysplasia should be individualized through shared decision-making.

Dysplasia in the setting of PSC merits special consideration due to the high risk of accelerated dysplasia and cancer development. Nearly one-third of patients with PSC and IBD (138 patients with UC and 35 patients with Crohn’s disease) from a single-institution registry developed dysplasia, which is often associated with nonconventional dysplastic features, invisible endoscopic/gross appearance, proximal lesions, and multifocality.[93] Given the high likelihood of synchronous cancer, any dysplasia in patients with PSC typically warrants strong consideration of proctocolectomy.

Although endoscopic excision techniques are safe and appear effective in treating visible, unifocal dysplasia in UC patients with acceptable risks of recurrence and cancer development, rigorous long-term prospective data comparing endoscopic excision and proctocolectomy are lacking. Concerns regarding pragmatic difficulties in ensuring timely and adequate follow-up within endoscopic dysplasia surveillance programs have been raised, with 2 large European studies showing poor endoscopic surveillance (< 46% and 54%) in patients with UC who underwent endoscopic excision of UC-associated dysplasia.[94] A single-institution retrospective root cause analysis showed that 64% (27/42) of patients with IBD who developed IBD-associated cancer were not under surveillance despite eligibility.[95] Although the cause of noncompliance is likely multifactorial, 1 survey of 545 practicing IBD physicians in Japan suggested that many physicians were nonadherent to established surveillance guidelines.[96] Although many patients with UC-associated dysplasia can be effectively managed in endoscopic surveillance programs, relatively high rates of noncompliance suggest that unreliable or noncompliant patients may benefit from proctocolectomy.

3c. Patients with active mucosal inflammation and endoscopic biopsies that are indefinite or uncertain fordysplasia should typically first be treated medically, targeting mucosal healing, before reassessing for underlying dysplasia, and, when feasible, be referred to an experienced multidisciplinary team. Strength of recommendation: conditional based on low-quality evidence.

Active inflammation in UC can result in regenerative epithelial changes that mimic dysplasia, making it difficult to reliably distinguish between true neoplasia and inflammation induced atypia.[97],[98] In this context, lesions are often classified as “indefinite for dysplasia.” The accuracy of dysplasia diagnosis is significantly compromised in the presence of active colitis, and reevaluation should be deferred until mucosal healing is achieved.[63][98] This recommendation represents a departure from prior guidelines that recommended a fixed rescoping interval of 3 to 6 months; instead, this update emphasizes mucosal healing, not time, as the critical threshold for reassessment.

After the resolution of inflammation, a high quality surveillance examination using chromoendoscopy or another advanced imaging technique should be performed by clinicians experienced in IBD-related dysplasia detection.[63][98] Persistent indefinite dysplasia after mucosal healing, particularly when not attributable to technical or inflammatory artifacts, should prompt careful multidisciplinary discussion. Nearly 15% of these patients have been found to have invisible LGD or HGD on subsequent endoscopic evaluations.[99] In cases where dysplasia remains unconfirmed yet suspicious, or if the lesion is unresectable or located in high-risk areas, surgical consultation should be considered because of the potential for occult neoplasia.[97]

3d. Patients with colorectal adenocarcinoma in the setting of UC should typically be considered for TPC with or without IPAA, depending on cancer stage, disease activity, and operative risks. Strength of recommendation: strong based on moderate-quality evidence.

The incidence of CRC is approximately 3-fold higher in patients with IBD compared to the general population.[52][100][101] Furthermore, IBD-associated CRC carries a worse prognosis than sporadic CRC. In a Scandinavian population-based cohort, mortality from UC-associated CRC was 44% higher than in matched patients with sporadic CRC.[102] Similarly, in a national English study, patients with IBD-related CRC had a 2-year shorter stage-specific survival[103] than those with non-IBD CRC. A metaanalysis of 25 studies involving more than 8000 patients with IBD-associated CRC found this subgroup more likely to present with poor differentiation, mucinous or signet ring histology, synchronous and right-sided tumors, male predominance, and reduced rates of R0 (microscopically negative) resection.[104]

The 2022 ASCRS Clinical Practice Guidelines for the Management of Colon Cancer guidelines support resection with or without neoadjuvant therapy for curative treatment of nonmetastatic CRC.[105] Although nonoperative management strategies (eg, watch-and-wait) are increasingly adopted in rectal cancer for clinical complete responders, these approaches have not been validated in IBD populations, which exhibit higher rates of metachronous neoplasia and are generally excluded from clinical trials.[103] Thus, nonoperative strategies are not recommended for UC-associated colorectal adenocarcinoma at this time.

Surgical decision-making should consider tumor location, extent and activity of colitis, the presence and distribution of synchronous or prior dysplasia, rectal involvement, patient age, comorbidities, and anorectal function. In addition, shared decision-making must address the implications of the chosen operation, including long-term bowel surveillance, ongoing need for medical therapy, risk of future operations, and functional outcomes. A more detailed discussion of surgical options—such as segmental colectomy, total colectomy with ileorectal anastomosis (IRA), or TPC—is provided in a later section of this guideline.

Patients with isolated rectal adenocarcinoma in the setting of UC require individualized planning. If restorative proctocolectomy with IPAA is under consideration, the impact of neoadjuvant and adjuvant therapies on pouch function must be weighed. Data suggest that pelvic radiation for IBD-related rectal cancer, whether administered pre- or postoperatively, typically impairs pouch outcomes. Post-IPAA pelvic radiation is typically contraindicated given the high risk of postradiation enteritis and that it has not shown conclusive results on cancer-specific outcomes.[106][107] Preemptive fecal diversion may be selectively appropriate when patients requiring rectal cancer treatment have difficulty tolerating cytotoxic or immunologic therapies.[108][109][110]

PREOPERATIVE CONSIDERATIONS

TECHNICAL CONSIDERATIONS IN THE SURGICAL MANAGEMENT OF UC

8. Total abdominal colectomy with end ileostomy is typically the preferred operation for patients with UC undergoing emergent or urgent surgery. Strength of recommendation: strong based on moderate-quality evidence.

Total abdominal colectomy with end ileostomy remains the preferred operative procedure for patients with UC undergoing emergent or urgent surgery. This approach is associated with the lowest morbidity and mortality, as up to 16% of patients with toxic colitis, many without colon dilation, may have occult perforations. Colon perforations most commonly involve the cecum and transverse colon and can occur in the absence of imaging findings.[48][167] Immunosuppressive therapy, which can mask typical signs of peritonitis in these patients, frequently complicates this clinical scenario, leading to delays in diagnosis and surgical intervention.[48]

In the emergent setting, pelvic dissection and proctectomy should be strongly avoided. Performing an IPAA in the setting of systemic inflammation or immunosuppression has been associated with increased postoperative morbidity, particularly organ space infections.[168] Management strategies for the severely inflamed rectosigmoid stump include positioning it in the subcutaneous tissue of an abdominal incision, formation of a mucus fistula, and transanal decompression with a rectal tube or drain to mitigate the risk of stump dehiscence,[169] with no conclusive evidence favoring one technique over another.

In select, very high-risk patients who are pregnant or present with significant comorbidities, including profound malnutrition or immunosuppression, fecal diversion alone with a loop ileostomy or colostomy (when appropriate) has been previously described in small series[166][167] and may be considered to reduce surgical morbidity, although these approaches have not been associated with long-term colon preservation or decreased complications.

9. Restorative and nonrestorative surgical options should be discussed with patients before elective surgery. Strength of recommendation: strong based on low-quality evidence.

Before elective surgery for UC, patients should be counseled on both restorative and nonrestorative surgical options to ensure informed decision-making regarding the operative risks and anticipated anorectal, genitourinary, and sexual functional outcomes. The most common restorative procedure is IPAA, which offers the potential to maintain intestinal continuity while avoiding a permanent stoma. Overall, IPAA is associated with a postoperative morbidity rate of approximately 25% and a mortality rate of less than 0.5%.[12] The risk of pouch failure is relatively low (approximately 9%–15% at more than 10-year follow-up), and chronic pouchitis affects approximately 13% to 19% of patients.[170][171]

In older patients, the decision to proceed with IPAA requires careful consideration. Although increasing age has been associated with increased potential postoperative morbidity, longer operative times, and prolonged hospital stays, the long-term outcomes of IPAA in select elderly patients remain favorable.[172] Older patients also report high satisfaction and good functional results; however, some studies suggest there may be transient differences in function postoperatively, particularly in nocturnal frequency.[173][173][174][175] Data from the International Pouch Registry revealed that patients older than 65 years had higher complication rates and longer hospital stays after IPAA, although minimally invasive approaches appeared to mitigate these risks.[176]

There is also controversy regarding the appropriate extent of mesorectal dissection during proctectomy for IPAA. A close rectal dissection, leaving some mesorectal tissue behind, is thought to minimize the dead-space in the pelvis and decrease the risk of sexual dysfunction in men compared to total mesorectal excision (TME), although there is no quality evidence showing differences in sexual function after IPAA.[163][177] Although some hypothesize that residual mesorectum is thought to contain inflammatory cells that may contribute to higher rates of fibrosis and pouch failure, a European study comparing close rectal dissection to TME did not find differences in pouch failure rates at a median follow-up of 7 years when comparing these 2 techniques.[178][179] Interestingly, an RCT of 60 patients who had close mesorectal dissection versus TME showed a higher rate of early severe complications in the TME group (19% vs 7%, p = 0.027), though anastomotic leak rates were not significantly different between the 2 groups.[180] Additional data are necessary before definitive recommendations can be provided.

Regarding pouch configuration, both J- and S-pouches provide acceptable functional outcomes, though J-pouches are technically easier to construct and generally associated with fewer evacuation issues. When additional length is required, S-pouches may be used selectively, potentially providing an additional 2 to 4 cm of caudad reach.[181] This often necessitates lengthening maneuvers, including division of the ileocolic artery and creation of a mesenteric window, provided that vascular integrity to the remaining small bowel is preserved.[181][182]

Stapled anastomosis is generally preferred over handsewn techniques, as it is associated with improved bowel function and quality of life.[183][183][184][185][186][187][188][189] Although mucosectomy and handsewn anastomosis may theoretically reduce the risk of neoplasia, cancer risk is not eliminated, endoscopic surveillance is still indicated at regular intervals, and anorectal function has been reported to be worse compared to stapled anastomosis.[190] A small single-center study showed no difference in oncologic outcomes among patients with dysplasia or carcinoma, whereas a systematic review and meta-analysis found that mucosectomy reduced but did not abolish the risk of cancer (anal transition zone [ATZ] dysplasia 7.2% in handsewn vs 18% in stapled; p = 0.08).[190][191][192] Mucosectomy with handsewn IPAA may be considered in patients with rectal cancer or HGD near the dentate line, or when a stapled technique is not oncologically acceptable.

For patients who are not candidates for restorative procedures or prefer to avoid a pelvic anastomosis, nonrestorative options such as TPC with end ileostomy remain viable, and studies have shown equivalent assessments in quality of life.[193] Other alternatives include continent ileostomy (Kock pouch), IRA (if rectal-sparing disease), and, in rare cases, segmental colectomy, although the latter 2 are typically avoided in UC due to the risk of disease persistence or recurrence.[194][194][195][196][197][198][199][200] If completion proctectomy is delayed after colectomy, regular endoscopic evaluation of the retained rectal stump every 1 to 2 years should be performed to ensure that no progression to dysplasia occurs.[201][202][203]

10. A staged surgical approach should typically be considered in patients with UC exposed to corticosteroidsor advanced medical therapies. Strength of recommendation: strong based on moderate-quality evidence.

A staged surgical approach for IPAA should be considered for patients with UC who have received corticosteroids or advanced biologic therapies before elective surgery. Immunosuppressive medications, including steroids, anti-TNF agents, integrin inhibitors, and JAK inhibitors, may impair wound healing, increase infectious risk, and impact overall surgical outcomes. High-dose corticosteroids (>20 mg/d prednisone equivalents) are particularly associated with elevated rates of infectious complications, anastomotic leaks, and pelvic sepsis.[12][204][205][206] The relationship between biologic therapies and surgical outcomes is more nuanced. Although many retrospective studies and systematic reviews report no consistent association between preoperative anti-TNF exposure and postoperative complications, some data suggest increased risk of anastomotic leak and pelvic sepsis when IPAA is performed shortly after such therapies.[12][207][208] The largest prospective studies, including the PUCCINI trial, have not demonstrated a clear link when such therapies are administered within 30 days of surgery, but conflicting findings from large insurance databases and single-center studies contribute to ongoing controversy.[127][128][129][130] For newer biologics such as vedolizumab and ustekinumab, most studies suggest they are not significantly associated with increased postoperative morbidity, but some have reported higher rates of postoperative ileus or surgical site infections.[132][133][134][135][136][137] Similarly, early data on JAK inhibitors such as tofacitinib raise concern for VTE.[138][139][140][141]

Due to concerns of surgical risk, a 3-stage procedure, beginning with total abdominal colectomy and end ileostomy, followed by completion proctectomy with IPAA, and finally loop ileostomy reversal, may be preferred in patients with recent or ongoing exposure to some of these agents, especially if comorbid conditions are present. This strategy defers proctectomy and pouch creation until after immunosuppressive agents have been weaned, thereby reducing perioperative risk at the time of IPAA and potentially decreasing the chance of pouch failure. Whether to plan for a protective ileostomy at the time of IPAA or not (known as modified 2-stage) is controversial, and forgoing a protective ileostomy may be appropriate in selected patients and experienced centers.[209][210][211][212][213][214][215][216]

In contrast, patients who are medically optimized, on minimal or no immunosuppression therapy, and undergoing surgery for noninflammatory indications, such as neoplasia, may be appropriate candidates for a classic 2-stage operation (TPC with IPAA and protective ileostomy) or, less commonly, a 1-stage restorative operation (TPC and immediate IPAA without protective ileostomy). These strategies have shown similar clinical outcomes in select patients compared to a 3-stage approach when performed at experienced centers.[217] These patients should have well-controlled disease, good nutritional status, and low surgical risk. Technical considerations for IPAA, including pouch configuration, anastomotic technique, and pelvic dissection, remain consistent regardless of operative staging. In all cases, the goal of staging is to mitigate overall risk for complications and optimize long-term functional outcomes.

Although some patients or providers may consider delaying surgery to allow for drug washout (particularly in the case of advanced therapies), there are no data to support this approach, especially when first performing a subtotal colectomy. The potential benefit of delaying surgery must be weighed against the risks of disease progression, medication failure, and the need for emergent operative intervention. Therefore, staging remains a critical tool for improving surgical outcomes and minimizing perioperative risk in medically complex patients with UC.

11. A minimally invasive surgical approach is typically preferred in patients with UC when feasible and safe. Strength of recommendation: strong based on moderate-quality evidence.

A minimally invasive surgical approach should be considered the preferred technique in patients with UC when technically feasible and clinically appropriate. Laparoscopic and robotic approaches have demonstrated clear advantages over open surgery in both emergent and elective settings, including reduced postoperative pain, shorter length of hospital stay, faster return of bowel function, decreased surgical site infection rates, improved cosmetic outcomes, and improved fertility preservation in reproductive-age women.[160][162][218][219][220][221][222][223][224][225][226][227][228][229][230][231][232][233][234][235][236] Several studies from pouch referral centers have shown that laparoscopic IPAA is associated with lower rates of infertility compared to open procedures.[160][162][220]

When performing restorative proctocolectomy with IPAA, minimally invasive techniques have become increasingly standard, with minimally invasive IPAA associated with comparable functional outcomes and lower short-term morbidity than open surgery.[205][224][237][238][239][240][241][242][243][244][245][246] The choice of approach should be tailored to surgeon expertise, patient anatomy, and disease severity. In select patients, transanal TME may offer an alternative approach for deep pelvic dissection, particularly in men with a narrow pelvis or patients with obesity.[247][248][249][250][251][252][253][254][255][256][257] However, concerns about urethral injury, complex orientation, and long-term functional outcomes require careful consideration regarding learning curve and should be considered when using this approach.[253][258][259]

Overall, minimally invasive techniques for UC surgery align with the goals of enhanced recovery, reduced morbidity, and fertility preservation and should be prioritized when safe and feasible.

POSTOPERATIVE CONSIDERATIONS

References