Skip to main content

Ulcerative Colitis: Surgical Management

  • Chapter
  • First Online:
The ASCRS Textbook of Colon and Rectal Surgery

Abstract

Surgical management of ulcerative colitis may be required in patients with medically refractory disease, toxic colitis, dysplasia, or colorectal cancer. Restorative proctocolectomy with ileal pouch-anal anastomosis is the standard operation for ulcerative colitis. However, other options such as total proctocolectomy with end ileostomy, ileorectal anastomosis, and continent ileostomy remain. This chapter discusses the indications for surgery, surgical techniques, postoperative outcomes, and controversies surrounding surgery for ulcerative colitis.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 139.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

References

  1. Grone J, Lorenz EM, Seifarth C, Seeliger H, Kreis ME, Mueller MH. Timing of surgery in ulcerative colitis in the biologic therapy era-the patient’s perspective. Int J Color Dis. 2018;33(10):1429–35.

    Google Scholar 

  2. Eaden JA, Abrams KR, Mayberry JF. The risk of colorectal cancer in ulcerative colitis: a meta-analysis. Gut. 2001;48(4):526–35.

    CAS  PubMed  PubMed Central  Google Scholar 

  3. Yashiro M. Ulcerative colitis-associated colorectal cancer. World J Gastroenterol. 2014;20(44):16389–97.

    PubMed  PubMed Central  Google Scholar 

  4. Van Assche G, Dignass A, Bokemeyer B, et al. Second European evidence-based consensus on the diagnosis and management of ulcerative colitis part 3: special situations. J Crohns Colitis. 2013;7(1):1–33.

    PubMed  Google Scholar 

  5. Laine L, Kaltenbach T, Barkun A, McQuaid KR, Subramanian V, Soetikno R. SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. Gastrointest Endosc. 2015;81(3):489–501.e426.

    PubMed  Google Scholar 

  6. Thomas T, Abrams KA, Robinson RJ, Mayberry JF. Meta-analysis: cancer risk of low-grade dysplasia in chronic ulcerative colitis. Aliment Pharmacol Ther. 2007;25(6):657–68.

    CAS  PubMed  Google Scholar 

  7. Bernstein CN, Shanahan F, Weinstein WM. Are we telling patients the truth about surveillance colonoscopy in ulcerative colitis? Lancet. 1994;343(8889):71–4.

    CAS  PubMed  Google Scholar 

  8. Kiesslich R, Goetz M, Lammersdorf K, et al. Chromoscopy-guided endomicroscopy increases the diagnostic yield of intraepithelial neoplasia in ulcerative colitis. Gastroenterology. 2007;132(3):874–82.

    PubMed  Google Scholar 

  9. Dinesen LC, Walsh AJ, Protic MN, et al. The pattern and outcome of acute severe colitis. J Crohns Colitis. 2010;4(4):431–7.

    PubMed  Google Scholar 

  10. Dignass A, Eliakim R, Magro F, et al. Second European evidence-based consensus on the diagnosis and management of ulcerative colitis part 1: definitions and diagnosis. J Crohns Colitis. 2012;6(10):965–90.

    PubMed  Google Scholar 

  11. Jarnerot G, Rolny P, Sandberg-Gertzen H. Intensive intravenous treatment of ulcerative colitis. Gastroenterology. 1985;89(5):1005–13.

    CAS  PubMed  Google Scholar 

  12. Williams JG, Alam MF, Alrubaiy L, et al. Infliximab versus ciclosporin for steroid-resistant acute severe ulcerative colitis (CONSTRUCT): a mixed methods, open-label, pragmatic randomised trial. Lancet Gastroenterol Hepatol. 2016;1(1):15–24.

    PubMed  PubMed Central  Google Scholar 

  13. Bernardo S, Fernandes SR, Goncalves AR, et al. Predicting the course of disease in hospitalized patients with acute severe ulcerative colitis. Inflamm Bowel Dis. 2019;25(3):541–6.

    PubMed  Google Scholar 

  14. Chang KH, Burke JP, Coffey JC. Infliximab versus cyclosporine as rescue therapy in acute severe steroid-refractory ulcerative colitis: a systematic review and meta-analysis. Int J Color Dis. 2013;28(3):287–93.

    Google Scholar 

  15. Le Baut G, Kirchgesner J, Amiot A, et al. A scoring system to determine patients’ risk of colectomy within 1 y after hospital admission for acute severe ulcerative colitis. Clin Gastroenterol Hepatol. 2020;10:S1542-3565(20)30029-X. https://doi.org/10.1016/j.cgh.2019.12.036. Epub ahead of print. PMID: 31927106.

  16. Teeuwen PH, Stommel MW, Bremers AJ, van der Wilt GJ, de Jong DJ, Bleichrodt RP. Colectomy in patients with acute colitis: a systematic review. J Gastrointest Surg. 2009;13(4):676–86.

    CAS  PubMed  Google Scholar 

  17. Carter FM, McLeod RS, Cohen Z. Subtotal colectomy for ulcerative colitis: complications related to the rectal remnant. Dis Colon Rectum. 1991;34(11):1005–9.

    CAS  PubMed  Google Scholar 

  18. Gu J, Stocchi L, Remzi F, Kiran RP. Intraperitoneal or subcutaneous: does location of the (colo)rectal stump influence outcomes after laparoscopic total abdominal colectomy for ulcerative colitis? Dis Colon Rectum. 2013;56(5):615–21.

    PubMed  Google Scholar 

  19. Bass EM, Del Pino A, Tan A, Pearl RK, Orsay CP, Abcarian H. Does preoperative stoma marking and education by the enterostomal therapist affect outcome? Dis Colon Rectum. 1997;40(4):440–2.

    CAS  PubMed  Google Scholar 

  20. Zaghiyan K, Melmed GY, Berel D, Ovsepyan G, Murrell Z, Fleshner P. A prospective, randomized, noninferiority trial of steroid dosing after major colorectal surgery. Ann Surg. 2014;259(1):32–7.

    PubMed  Google Scholar 

  21. Achilli P, Mazzola M, Bertoglio CL, et al. Preoperative immunonutrition in frail patients with colorectal cancer: an intervention to improve postoperative outcomes. Int J Color Dis. 2020;35(1):19–27.

    Google Scholar 

  22. Gillis C, Buhler K, Bresee L, et al. Effects of nutritional prehabilitation, with and without exercise, on outcomes of patients who undergo colorectal surgery: a systematic review and meta-analysis. Gastroenterology. 2018;155(2):391–410.e394.

    PubMed  Google Scholar 

  23. Carmichael JC, Keller DS, Baldini G, et al. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum. 2017;60(8):761–84.

    PubMed  Google Scholar 

  24. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J. 1978;2(6130):85–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. McKenna NP, Potter DD, Bews KA, Glasgow AE, Mathis KL, Habermann EB. Ileal-pouch anal anastomosis in pediatric NSQIP: does a laparoscopic approach reduce complications and length of stay? J Pediatr Surg. 2019;54(1):112–7.

    PubMed  Google Scholar 

  26. Gorgun E, Cengiz TB, Aytac E, et al. Does laparoscopic ileal pouch-anal anastomosis reduce infertility compared with open approach? Surgery. 2019;166(4):670–7.

    PubMed  Google Scholar 

  27. Yao L, Fleshner P, Zaghiyan K. Modified technique for laparoscopic total abdominal colectomy with stoma site specimen extraction - stage one of a three-stage ileal pouch anal anastomosis. Presented at Society of American Gastrointestinal and Endoscopic Surgeons Annual Meeting 1–4 April 2020, Cleveland: V201.2020.

    Google Scholar 

  28. de Zeeuw S, Ahmed Ali U, van der Kolk MB, van Laarhoven KC. Ileal pouch anal anastomosis with close rectal dissection using automated vessel sealers for ulcerative colitis: a promising alternative. Dig Surg. 2011;28(5–6):345–51.

    PubMed  Google Scholar 

  29. Kaminski JP, Zaghiyan K, Fleshner P. Transanal mucosectomy revisited. Dis Colon Rectum. 2016;59(10):998–9.

    PubMed  Google Scholar 

  30. Salum M, Wexner SD, Nogueras JJ, et al. Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure? Tech Coloproctol. 2006;10(3):187–90; discussion 190-181.

    CAS  PubMed  Google Scholar 

  31. Chough I, Zaghiyan K, Ovsepyan G, Fleshner P. Practice changes in postoperative feeding after elective colorectal surgery: from prospective randomized study to everyday practice. Am Surg. 2018;84(10):1675–8.

    PubMed  Google Scholar 

  32. Lau C, Phillips E, Bresee C, Fleshner P. Early use of low residue diet is superior to clear liquid diet after elective colorectal surgery: a randomized controlled trial. Ann Surg. 2014;260(4):641–7; discussion 647–649.

    PubMed  Google Scholar 

  33. Daskivich TJ, Houman J, Lopez M, et al. Association of wearable activity monitors with assessment of daily ambulation and length of stay among patients undergoing major surgery. JAMA Netw Open. 2019;2(2):e187673.

    PubMed  PubMed Central  Google Scholar 

  34. Patel DN, Felder SI, Luu M, Daskivich TJ, Zaghiyan KN, Fleshner P. Early urinary catheter removal following pelvic colorectal surgery: a prospective, randomized, noninferiority trial. Dis Colon Rectum. 2018;61(10):1180–6.

    PubMed  Google Scholar 

  35. Karjalainen EK, Renkonen-Sinisalo L, Mustonen HK, Farkkila M, Lepisto AH. Restorative proctocolectomy in ulcerative colitis: effect of preoperative immunomodulatory therapy on postoperative complications and pouch failure. Scand J Surg. 2021;110(1):51–58.

    Google Scholar 

  36. Hainsworth PJ, Bartolo DC. Selective omission of loop ileostomy in restorative proctocolectomy. Int J Color Dis. 1998;13(3):119–23.

    CAS  Google Scholar 

  37. Widmar M, Munger JA, Mui A, et al. Diverted versus undiverted restorative proctocolectomy for chronic ulcerative colitis: an analysis of long-term outcomes after pouch leak short title: outcomes after pouch leak. Int J Color Dis. 2019;34(4):691–7.

    Google Scholar 

  38. Lavryk OA, Hull TL, Duraes LC, et al. Outcomes of ileal pouch-anal anastomosis without primary diverting loop ileostomy if postoperative sepsis develops. Tech Coloproctol. 2018;22(1):37–44.

    CAS  PubMed  Google Scholar 

  39. Markel TA, Lou DC, Pfefferkorn M, et al. Steroids and poor nutrition are associated with infectious wound complications in children undergoing first stage procedures for ulcerative colitis. Surgery. 2008;144(4):540–5; discussion 545–547.

    PubMed  Google Scholar 

  40. Okita Y, Araki T, Okugawa Y, et al. The prognostic nutritional index for postoperative infectious complication in patients with ulcerative colitis undergoing proctectomy with ileal pouch-anal anastomosis following subtotal colectomy. J Anus Rectum Colon. 2019;3(2):91–7.

    PubMed  PubMed Central  Google Scholar 

  41. Selvaggi F, Pellino G, Canonico S, Sciaudone G. Effect of preoperative biologic drugs on complications and function after restorative proctocolectomy with primary ileal pouch formation: systematic review and meta-analysis. Inflamm Bowel Dis. 2015;21(1):79–92.

    PubMed  Google Scholar 

  42. Ferrante M, D’Hoore A, Vermeire S, et al. Corticosteroids but not infliximab increase short-term postoperative infectious complications in patients with ulcerative colitis. Inflamm Bowel Dis. 2009;15(7):1062–70.

    CAS  PubMed  Google Scholar 

  43. Ferrante M, de Buck van Overstraeten A, Schils N, et al. Perioperative use of vedolizumab is not associated with postoperative infectious complications in patients with ulcerative colitis undergoing colectomy. J Crohns Colitis. 2017;11(11):1353–61.

    PubMed  Google Scholar 

  44. Zittan E, Milgrom R, Ma GW, et al. Preoperative anti-tumor necrosis factor therapy in patients with ulcerative colitis is not associated with an increased risk of infectious and noninfectious complications after ileal pouch-anal anastomosis. Inflamm Bowel Dis. 2016;22(10):2442–7.

    PubMed  Google Scholar 

  45. Cohen BL, Fleshner P, Kane SV, Herfarth HH, Palekar N, Farraye FA, JAL, Katz J, Cohen RD, Gerich ME, Cross RK, PDH, Tinsley A, Glover SC, Siegel CA, Bohl JL, HI, Raymond S, Huang R, Suarez-Farinas M, Sands BE. 415a – Anti-tumor necrosis factor therapy is not associated with post-operative infection: results from prospective Cohort of ulcerative colitis and Crohn’s disease patients undergoing surgery to identify risk factors for postoperative infection I (Puccini). Gastroenterology. 2019;156:S-80.

    Google Scholar 

  46. Novello M, Stocchi L, Holubar S, et al. Surgical outcomes of patients treated with ustekinumab vs. vedolizumab in inflammatory bowel disease: a matched case analysis. Int J Color Dis. 2019;34(3):451–7.

    Google Scholar 

  47. Lightner AL, McKenna NP, Alsughayer A, et al. Biologics and 30-day postoperative complications after abdominal operations for Crohn’s disease: are there differences in the safety profiles? Dis Colon Rectum. 2019;62(11):1352–62.

    PubMed  Google Scholar 

  48. Poh KS, Qureshi S, Hong YK, et al. Multivariate prediction of intraoperative abandonment of ileal pouch anal anastomosis. Dis Colon Rectum. 2020;63(5):639–45.

    PubMed  Google Scholar 

  49. McKenna NP, Mathis KL, Khasawneh MA, et al. Obese patients undergoing ileal pouch-anal anastomosis: short-and long-term surgical outcomes. Inflamm Bowel Dis. 2017;23(12):2142–6.

    PubMed  Google Scholar 

  50. Sahami S, Bartels SA, D’Hoore A, et al. A multicentre evaluation of risk factors for anastomotic leakage after restorative proctocolectomy with ileal pouch-anal anastomosis for inflammatory bowel disease. J Crohns Colitis. 2016;10(7):773–8.

    PubMed  Google Scholar 

  51. Swenson BR, Hollenbeak CS, Poritz LS, Koltun WA. Modified two-stage ileal pouch-anal anastomosis: equivalent outcomes with less resource utilization. Dis Colon Rectum. 2005;48(2):256–61.

    PubMed  Google Scholar 

  52. Zittan E, Wong-Chong N, Ma GW, McLeod RS, Silverberg MS, Cohen Z. Modified two-stage ileal pouch-anal anastomosis results in lower rate of anastomotic leak compared with traditional two-stage surgery for ulcerative colitis. J Crohns Colitis. 2016;10(7):766–72.

    PubMed  Google Scholar 

  53. Utsunomiya J, Iwama T, Imajo M, et al. Total colectomy, mucosal proctectomy, and ileoanal anastomosis. Dis Colon Rectum. 1980;23(7):459–66.

    CAS  PubMed  Google Scholar 

  54. Lovegrove RE, Heriot AG, Constantinides V, et al. Meta-analysis of short-term and long-term outcomes of J, W and S ileal reservoirs for restorative proctocolectomy. Color Dis. 2007;9(4):310–20.

    CAS  Google Scholar 

  55. Simillis C, Afxentiou T, Pellino G, et al. A systematic review and meta-analysis comparing adverse events and functional outcomes of different pouch designs after restorative proctocolectomy. Color Dis. 2018;20(8):664–75.

    CAS  Google Scholar 

  56. Larson DW, Cima RR, Dozois EJ, et al. Safety, feasibility, and short-term outcomes of laparoscopic ileal-pouch-anal anastomosis: a single institutional case-matched experience. Ann Surg. 2006;243(5):667–70; discussion 670-662.

    PubMed  PubMed Central  Google Scholar 

  57. Reilly WT, Pemberton JH, Wolff BG, et al. Randomized prospective trial comparing ileal pouch-anal anastomosis performed by excising the anal mucosa to ileal pouch-anal anastomosis performed by preserving the anal mucosa. Ann Surg. 1997;225(6):666–76; discussion 676-667.

    CAS  PubMed  PubMed Central  Google Scholar 

  58. Hallgren TA, Fasth SB, Oresland TO, Hulten LA. Ileal pouch anal function after endoanal mucosectomy and handsewn ileoanal anastomosis compared with stapled anastomosis without mucosectomy. Eur J Surg. 1995;161(12):915–21.

    CAS  PubMed  Google Scholar 

  59. Schluender SJ, Mei L, Yang H, Fleshner PR. Can a meta-analysis answer the question: is mucosectomy and handsewn or double-stapled anastomosis better in ileal pouch-anal anastomosis? Am Surg. 2006;72(10):912–6.

    PubMed  Google Scholar 

  60. Kirat HT, Remzi FH, Kiran RP, Fazio VW. Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3,109 patients. Surgery. 2009;146(4):723–9; discussion 729–730.

    PubMed  Google Scholar 

  61. Kariv R, Remzi FH, Lian L, et al. Preoperative colorectal neoplasia increases risk for pouch neoplasia in patients with restorative proctocolectomy. Gastroenterology. 2010;139(3):806–12, 812.e801–802.

    PubMed  Google Scholar 

  62. Lightner AL, Pemberton JH, Dozois EJ, et al. The surgical management of inflammatory bowel disease. Curr Probl Surg. 2017;54(4):172–250.

    PubMed  Google Scholar 

  63. Lee S, Ahn B. The relationship between the number of intersections of staple lines and anastomotic leakage after the use of a double stapling technique in laparoscopic colorectal surgery. Surg Laparosc Endosc Percutan Tech. 2017;27(4):273–81.

    CAS  PubMed  PubMed Central  Google Scholar 

  64. de Buck van Overstraeten A, Mark-Christensen A, Wasmann KA, et al. Transanal versus transabdominal minimally invasive (completion) proctectomy with ileal pouch-anal anastomosis in ulcerative colitis: a comparative study. Ann Surg. 2017;266(5):878–83.

    Google Scholar 

  65. Zaghiyan K, Warusavitarne J, Spinelli A, Chandrasinghe P, Di Candido F, Fleshner P. Technical variations and feasibility of transanal ileal pouch-anal anastomosis for ulcerative colitis and inflammatory bowel disease unclassified across continents. Tech Coloproctol. 2018;22(11):867–73.

    CAS  PubMed  Google Scholar 

  66. Chandrasinghe P, Carvello M, Wasmann K, et al. Transanal ileal pouch-anal anastomosis for ulcerative colitis has comparable long-term functional outcomes to transabdominal approach: a multicentre comparative study. J Crohns Colitis. 2020;14(6):726–33.

    PubMed  Google Scholar 

  67. Andersson P, Norblad R, Soderholm JD, Myrelid P. Ileorectal anastomosis in comparison with ileal pouch anal anastomosis in reconstructive surgery for ulcerative colitis – a single institution experience. J Crohns Colitis. 2014;8(7):582–9.

    Google Scholar 

  68. Borjesson L, Lundstam U, Oresland T, Brevinge H, Hulten L. The place for colectomy and ileorectal anastomosis: a valid surgical option for ulcerative colitis? Tech Coloproctol. 2006;10(3):237–41; discussion 241.

    CAS  PubMed  Google Scholar 

  69. Pastore RL, Wolff BG, Hodge D. Total abdominal colectomy and ileorectal anastomosis for inflammatory bowel disease. Dis Colon Rectum. 1997;40(12):1455–64.

    CAS  PubMed  Google Scholar 

  70. Leijonmarck CE, Lofberg R, Ost A, Hellers G. Long-term results of ileorectal anastomosis in ulcerative colitis in Stockholm County. Dis Colon Rectum. 1990;33(3):195–200.

    CAS  PubMed  Google Scholar 

  71. Uzzan M, Kirchgesner J, Oubaya N, et al. Risk of rectal neoplasia after colectomy and ileorectal anastomosis for ulcerative colitis. J Crohns Colitis. 2017;11(8):930–5.

    PubMed  Google Scholar 

  72. Uzzan M, Cosnes J, Amiot A, et al. Long-term follow-up after Ileorectal anastomosis for ulcerative colitis: a GETAID/GETAID Chirurgie multicenter retrospective cohort of 343 patients. Ann Surg. 2017;266(6):1029–34.

    PubMed  Google Scholar 

  73. Grundfest SF, Fazio V, Weiss RA, et al. The risk of cancer following colectomy and ileorectal anastomosis for extensive mucosal ulcerative colitis. Ann Surg. 1981;193(1):9–14.

    CAS  PubMed  PubMed Central  Google Scholar 

  74. Derikx L, Nissen LHC, Smits LJT, Shen B, Hoentjen F. Risk of neoplasia after colectomy in patients with inflammatory bowel disease: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2016;14(6):798–806.e720.

    PubMed  Google Scholar 

  75. Kock NG, Darle N, Hultén L, Kewenter J, Myrvold H, Philipson B. Ileostomy. Curr Probl Surg. 1977;14(8):1–52.

    CAS  PubMed  Google Scholar 

  76. Litle VR, Barbour S, Schrock TR, Welton ML. The continent ileostomy: long-term durability and patient satisfaction. J Gastrointest Surg. 1999;3(6):625–32.

    CAS  PubMed  Google Scholar 

  77. Lepistö AH, Järvinen HJ. Durability of Kock continent ileostomy. Dis Colon Rectum. 2003;46(7):925–8.

    PubMed  Google Scholar 

  78. Fazio VW, Church JM. Complications and function of the continent ileostomy at the Cleveland Clinic. World J Surg. 1988;12(2):148–54.

    CAS  PubMed  Google Scholar 

  79. Beck DE. Clinical aspects of continent ileostomies. Clin Colon Rectal Surg. 2004;17:57–63.

    PubMed  PubMed Central  Google Scholar 

  80. Nessar G, Fazio VW, Tekkis P, et al. Long-term outcome and quality of life after continent ileostomy. Dis Colon Rectum. 2006;49(3):336–44.

    PubMed  Google Scholar 

  81. Mullen P, Behrens D, Chalmers T, et al. Barnett continent intestinal reservoir. Multicenter experience with an alternative to the Brooke ileostomy. Dis Colon Rectum. 1995;38(6):573–82.

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2022 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Zaghiyan, K.N., Fleshner, P.R. (2022). Ulcerative Colitis: Surgical Management. In: Steele, S.R., Hull, T.L., Hyman, N., Maykel, J.A., Read, T.E., Whitlow, C.B. (eds) The ASCRS Textbook of Colon and Rectal Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-66049-9_49

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-66049-9_49

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-66048-2

  • Online ISBN: 978-3-030-66049-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics