Last updated January 11, 2022

Surgical Treatment of Ulcerative Colitis

Recommendations

INDICATIONS FOR SURGERY

Acute Colitis

Patients with clinical evidence of actual or impending perforation should undergo urgent surgery. (1B)
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For patients with moderate to severe colitis, early surgical consultation should be obtained. (1C)
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Patients whose condition worsens on medical therapy or who do not make significant improvement after a period of 48 to 96 hours of appropriate medical therapy should be considered for either a second-line agent or surgery. (1B)
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A decision regarding the response to second-line or “rescue” therapy should be made within 5 to 7 days after initiation. (1C)
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Intractability

Surgery is indicated in chronic UC when medical therapy is ineffective. (1B)
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Cancer Risk and Surveillance

Patients with long-standing UC should undergo endoscopic surveillance. (1B)
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Endoscopic surveillance should involve 2 sets of 4-quadrant random biopsies at ~10-cm intervals throughout the colon and rectum, along with directed biopsies of suspicious lesions. (1C)
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Total proctocolectomy, with or without IPAA, is recommended for patients with carcinoma, non-adenomalike dysplasia-associated lesion or mass, or high-grade dysplasia. (1B)
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Total proctocolectomy, or surveillance endoscopy, is recommended for patients with UC and low-grade dysplasia. (1C)
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Patients with UC who develop a stricture, especially with long-standing disease, should typically undergo resection. (1B)
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SURGICAL OPTIONS

Emergency

The procedure of choice for emergency surgery in UC is total or subtotal abdominal colectomy with end ileostomy. (1B)
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Elective Surgery

Total proctocolectomy with ileostomy is an acceptable surgical option for patients with UC. (1B)
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Total proctocolectomy with IPAA is an appropriate operation for selected patients with UC. (1B)
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Patients with UC considering pelvic operations should be counseled regarding the potential negative effects on sexual function and fertility. (1B)
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Total proctocolectomy with IPAA may be offered to selected UC patients with concomitant colorectal cancer. (1C)
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Total proctocolectomy with IPAA may be offered to selected elderly patients with UC. (1C)
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Mucosectomy and double-stapled procedures are both acceptable techniques in most circumstances. (1B)
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Pouch configuration may be chosen based on individual surgeon preference. (2B)
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In carefully selected patients, a 1-stage IPAA can be considered. (1C)
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Continent ileostomy is an alternative for patients with UC who are not eligible for or have had a failed restorative proctocolectomy. (2B)
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Total abdominal colectomy with ileoproctostomy may be considered only in a highly selected group of patients with UC. (2B)
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POSTOPERATIVE CONSIDERATIONS

Routine surveillance of ileal pouches for dysplasia in the ileal mucosa is not warranted. (1C)
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Surveillance of the residual rectal cuff or the anal transition zone following restorative proctocolectomy may detect malignant degeneration. (1C)
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Pouchitis is common after IPAA and is managed with antibiotics in most circumstances. (1B)
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Recommendation Grading

Overview

Title

Surgical Treatment of Ulcerative Colitis

Authoring Organization

Publication Month/Year

January 1, 2014

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Emergency care, Hospital, Outpatient

Intended Users

Surgical technologist

Scope

Prevention, Management

Diseases/Conditions (MeSH)

D003093 - Colitis, Ulcerative, D015212 - Inflammatory Bowel Diseases

Keywords

inflammatory bowel disease, ulcerative colitis, ileal pouch-anal anastomosis, ileostomy, ileoproctostomy