Surgical Management of Ulcerative Colitis

- Executive summary

These guidelines offer evidence-based recommendations on the targeted levels of clinical practice guidelines and provide healthcare professionals with practice guidance on the surgical management of ulcerative colitis disease and its complications.

·       We advise diagnosing UC through the correlation of clinical, biochemical, endoscopic, and histopathologic aspects, (Conditional recommendation).

·       We advise clinically diagnosing UC by the presence of chronic diarrhea with mucus and blood, straining and rectal tenesmus, nocturnal stools, weight loss, fever, and abdominal pain, (Conditional recommendation).

·       We advise performing a complete blood count, acute-phase reactants (erythrocyte sedimentation rate, C-reactive protein), liver function tests, and stool tests as the initial laboratory approach in patients suspected of presenting with UC, (Conditional recommendation).

·       We advise performing fecal calprotectin and fecal lactoferrin levels to assess mucosal cicatrization or endoscopy to assess remission. (Conditional recommendation).

·       We advise performing plain abdominal x-ray to rule out toxic megacolon and a chest x-ray to rule out colon perforation in patients with severe UC, (Conditional recommendation).

·       We advise using the Truelove and Witts index and the Mayo score for evaluating the grade of UC activity, (Conditional recommendation).

·       We advise performing colonoscopy with ileocecal valve intubation as the diagnostic method of choice for evaluating the extension and grade of disease activity, (Conditional recommendation).

·       We advise performing at least two biopsies to be taken per segment at the level of the terminal ileum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum, including normal zones of the mucosa, to microscopically make the diagnosis and determine disease extension, (Conditional recommendation).

·        We advise diagnosing dysplasia through the Vienna classification by at least two pathologists, (Conditional recommendation).

·       We advise performing surgery for patients with confirmed diagnosis (through clinical, radiologic, and laboratory parameters) who do not improve with intravenous steroids within the first 72 hours, (Conditional recommendation).

·       Surgery is recommended to corticosteroid-dependent patients, as well as immunomodulator refractory patients (Strong recommendation).

·       We recommend a multidisciplinary approach to guide optimal care in hospitalized patients with moderate-to-severe UC before surgical intervention, (Strong recommendation).

·       We advise a shared decision-making approach to tailor procedure selection to the patient’s preference, (Conditional recommendation). 

·       We advise weaning steroids before restorative proctocolectomy, (Conditional recommendation).

·       We advise against performing single-stage restorative proctocolectomy in patients receiving biologics, (Conditional recommendation).    

·       We advise prophylactic anticoagulation therapy in adult patients with active UC during hospitalization, considering the high risk of venous thromboembolism during UC flares, (Conditional recommendation).    

·       We advise correction of nutrition imbalances preoperatively, (Good practice statement).

·       We advise performing appendectomy to decrease the need for proctocolectomy related to medically refractory disease, (Conditional recommendation).

·       Patients with UC undergoing proctectomy should be counseled regarding possible effects on fertility, pregnancy, sexual function, and urinary function, (Strong recommendation).

·       Total proctocolectomy (with IPAA, end ileostomy, or continent ileostomy) is recommended for patients with UC undergoing elective surgery, (Strong recommendation).    

·       For patients with UC undergoing restorative total proctocolectomy with IPAA, 2-stages, modified 2-stages, and 3-stages all are accepted approaches, (Strong recommendation).

·       IPAA is not recommended in case of fecal incontinence, intermediate colitis or low rectal cancer on top of ulcerative colitis, (Good practice statement).

·       We advise performing a staged approach for an IPAA in patients being treated with high-dose corticosteroids or monoclonal antibodies, (Conditional recommendation).

·       Total abdominal colectomy with ileorectal anastomosis may be considered in selected patients who have UC with relative rectal sparing, (Conditional recommendation).

·       We advise performing a “rescue” diverting loop ileostomy in the setting of worsening, acute, severe UC to potentially avoid an emergent total abdominal colectomy, (Conditional recommendation).    

·       We advise performing reconstructive surgery to refractory and corticosteroid-dependent patients as it improves the quality of life despite the risk of early and late complications, (Conditional recommendation).    

·       We advise performing laparoscopic surgery to patients with medically refractory UC, as it is associated with lower intra- and postoperative morbidity, faster recovery, fewer adhesions and incisional hernias, shorter hospital length of stay, improved female fertility, and better cosmoses, (Conditional recommendation).    

·       For patients with severe medically refractory UC, fulminant colitis, toxic megacolon, or colonic perforation, we advise performing total abdominal colectomy with end ileostomy, (Conditional recommendation).

·       Endoscopic surveillance is recommended for patients with visible polypoid or non-polypoid dysplasia that is completely excised endoscopically, (Strong recommendation).

·        Total proctocolectomy with or without IPAA is recommended for patients with visible dysplasia not amenable to endoscopic excision, invisible dysplasia in the flat mucosa surrounding a visible dysplastic lesion, or colorectal adenocarcinoma, (Strong recommendation).    

·       Total proctocolectomy is recommended for patients confirmed to have invisible multifocal, low-grade dysplasia or any invisible high-grade dysplasia, (Strong recommendation).

·        We advise performing restorative proctocolectomy in patients with carcinoma or multifocal high-grade or low-grade dysplasia, (Conditional recommendation).

·       We advise extended postoperative venous thromboembolism prophylaxis in patients with UC exposed to tofacitinib, (Conditional recommendation).

·       We advise against surveillance or follow-up of the ileo-anal pouch in the asymptomatic patient, unless there are risk factors, such as a history of neoplasia or primary sclerosing cholangitis, (Conditional recommendation).

·       We advise prescribing 500 mg of ciprofloxacin twice a day or 15-20 mg/kg/day of metronidazole for 2 weeks as the first-line treatment in patients with acute pouchitis, (Conditional recommendation).