Surgical Management of Ulcerative Colitis

Guideline Citation

Holubar SD, Lightner AL, Poylin V, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Ulcerative Colitis. Dis Colon Rectum. 2021;64(7):783-804.[1]

Statement of the Problem

Ulcerative colitis (UC) is an idiopathic chronic inflammatory condition that affects the mucosa lining the colon and rectum that, for unknown reasons, continues to increase in incidence with nearly 3.1 million people affected in the United States alone.[2] Patients most often present in 2 general age categories, between about ages 15 and 30 or 55 and 65, with rectal bleeding, urgency, and/or tenesmus from proctitis.[3],[4] The degree of symptomatology is variable over 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 using an ever-expanding repertoire of immunoregulatory medications, approximately 15% to 20% of patients with UC still require colectomy for medically refractory disease and/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 with a permanent end ileostomy, a continent ileostomy, or construction of an IPAA, all of which are increasingly performed using minimally invasive techniques.[8],[9],[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 emerging concepts in UC that warrant further exploration and 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 utilized when caring for patients with UC.

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Full Text PDF

Ulcerative Colitis Guideline (Full Text PDF)

References

  1. Holubar SD, Lightner AL, Poylin V, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Ulcerative Colitis. Dis Colon Rectum. 2021;64(7):783-804.  [PMID:33853087]
  2. Rubin DT, Ananthakrishnan AN, Siegel CA, et al. ACG Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol. 2019;114(3):384-413.  [PMID:30840605]
  3. Hou JK, Kramer JR, Richardson P, et al. The incidence and prevalence of inflammatory bowel disease among U.S. veterans: a national cohort study. Inflamm Bowel Dis. 2013;19(5):1059-64.  [PMID:23448789]
  4. Loftus CG, Loftus EV, Harmsen WS, et al. Update on the incidence and prevalence of Crohn's disease and ulcerative colitis in Olmsted County, Minnesota, 1940-2000. Inflamm Bowel Dis. 2007;13(3):254-61.  [PMID:17206702]
  5. Holubar SD, Pendlimari R, Loftus EV, et al. Drivers of cost after surgical and medical therapy for chronic ulcerative colitis: a nested case-cohort study in Olmsted County, Minnesota. Dis Colon Rectum. 2012;55(12):1258-65.  [PMID:23135584]
  6. Sands BE. Fulminant colitis. J Gastrointest Surg. 2008;12(12):2157-9.  [PMID:18766416]
  7. Cima RR. Timing and indications for colectomy in chronic ulcerative colitis: Surgical consideration. Dig Dis. 2010;28(3):501-7.  [PMID:20926879]
  8. Holubar SD, Larson DW, Dozois EJ, et al. Minimally invasive subtotal colectomy and ileal pouch-anal anastomosis for fulminant ulcerative colitis: a reasonable approach? Dis Colon Rectum. 2009;52(2):187-92.  [PMID:19279410]
  9. Holubar SD, Privitera A, Cima RR, et al. Minimally invasive total proctocolectomy with Brooke ileostomy for ulcerative colitis. Inflamm Bowel Dis. 2009;15(9):1337-42.  [PMID:19266572]
  10. Goligher JC, Hoffman DC, de Dombal FT. Surgical treatment of severe attacks of ulcerative colitis, with special reference to the advantages of early operation. Br Med J. 1970;4(5737):703-6.  [PMID:5491253]
  11. Hultén L. Proctocolectomy and ileostomy to pouch surgery for ulcerative colitis. World J Surg. 1998;22(4):335-41.  [PMID:9523513]
Last updated: December 21, 2021