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.
Ulcerative colitis (UC) usually presents as a mild state, but it often leads to life-threatening and systemic complications that require urgent intervention
.
Acute severe ulcerative colitis (ASUC) and drug-refractory UC are the main indications for surgery in UC patients
.
Up to 30% of UC patients do not respond to conservative treatment and require colectomy
.
In October 2021, the European Crohn's Disease and Colitis Organization (ECCO) issued guidelines for surgical treatment of UC, focusing on the first-line treatment of adult patients with ASUC and the surgical treatment of patients with refractory UC
.
Medical treatment of ASUC 1.
For adult ASCU patients, intravenous corticosteroids are recommended as the initial standard treatment because it can induce clinical remission and reduce mortality [EL3]
.
2.
Infliximab or cyclosporine can be used for adult corticosteroid refractory ASUC
.
When choosing between the two, the experience of the center and the maintenance treatment plan after cyclosporine treatment should be considered [EL3]
.
3.
At present, there is not enough evidence to determine the best regimen of infliximab salvage treatment for patients with corticosteroid refractory ASUC [EL4]
.
4.
Calcineurin inhibitors (cyclosporine or tacrolimus) third-line rescue treatment of corticosteroid-refractory ASUC may delay the need for colectomy, but it is related to the high incidence of adverse events and should only be used Special treatment center application [EL2a]
.
Drug and surgical treatment of refractory moderate to severe UC 1.
Despite the risk of early or late complications, reconstructive surgery can be performed for refractory and corticosteroid-dependent patients and can improve the quality of life [EL2b]
.
For some patients, colorectal resection with terminal ileostomy is an option, and has a lower incidence and a comparable quality of life [EL3a]
.
Preoperative optimization of refractory moderate to severe UC 1.
Although the evidence is limited, it is recommended to correct the disorder and nutritional imbalance before surgery [EL5]
.
There is no evidence to support routine enteral or parenteral nutrition to improve the surgical outcome of UC patients [EL5]
.
When iron deficiency anemia is present, iron supplementation is recommended [EL1]
.
2.
Patients treated with >20mg prednisolone >6 weeks have an increased risk of early complications and specific complications of storage bags
.
Steroids should be discontinued before restorative rectal resection or proctocolectomy, and if this is not feasible, surgery should be postponed [EL4]
.
Preoperative use of mercaptopurine or cyclosporine does not increase the risk of postoperative complications [EL3]
.
Patients using biological agents may have an increased risk of early and late bag-specific complications; in this case, a phase 3 or phase 2 modified strategy that delays the construction of the bag can be considered [EL4]
.
Patients receiving biologics treatment should avoid single-segment restorative rectocolectomy [EL5]
.
3.
Considering the higher risk of venous thromboembolism (VTE) during the onset of UC, it is recommended that adult patients with active UC receive preventive anticoagulation during hospitalization [EL4]
.
Surgical treatment of refractory moderate-severe UC 1.
For drug-refractory UC, after total rectal resection, choose ileal bag anal anastomosis (IPAA)
.
For some patients, permanent terminal ileostomy is also a reasonable option
.
Decisions should be shared with patients, and surgical options should be made according to patient preferences [EL3]
.
2.
For patients with drug-refractory UC, compared with stage 3 or stage 2 IPAA, modified stage 2 IPAA has fewer septic or non-septic complications and shorter hospital stay [EL3]
.
Surgical techniques for refractory moderate-to-severe UC 1.
IPAA can use a stapler or manual suture technique, and the functional outcome of the two methods is equivalent
.
Therefore, the type of anastomosis should be determined by the surgeon [EL2]
.
2.
Laparoscopic surgery is the first choice for patients with refractory UC, because it has low intraoperative and postoperative morbidity, faster recovery, fewer adhesions and incisional hernias, shorter hospital stays, and can improve the fertility of female patients.
The cut is more beautiful and other advantages [EL2]
.
3.
Although it is associated with increased risk of rectal dysplasia, cancer, dysplasia, and cancer recurrence, UC patients with the least affected rectum may choose ileo-rectal anastomosis (IRA) [EL4]
.
Reference source: Raine T, Bonovas S, et al.
ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment.
J Crohns Colitis.
2021 Oct 12:jjab178.
doi: 10.
1093/ecco-jcc/jjab178.
.
Ulcerative colitis (UC) usually presents as a mild state, but it often leads to life-threatening and systemic complications that require urgent intervention
.
Acute severe ulcerative colitis (ASUC) and drug-refractory UC are the main indications for surgery in UC patients
.
Up to 30% of UC patients do not respond to conservative treatment and require colectomy
.
In October 2021, the European Crohn's Disease and Colitis Organization (ECCO) issued guidelines for surgical treatment of UC, focusing on the first-line treatment of adult patients with ASUC and the surgical treatment of patients with refractory UC
.
Medical treatment of ASUC 1.
For adult ASCU patients, intravenous corticosteroids are recommended as the initial standard treatment because it can induce clinical remission and reduce mortality [EL3]
.
2.
Infliximab or cyclosporine can be used for adult corticosteroid refractory ASUC
.
When choosing between the two, the experience of the center and the maintenance treatment plan after cyclosporine treatment should be considered [EL3]
.
3.
At present, there is not enough evidence to determine the best regimen of infliximab salvage treatment for patients with corticosteroid refractory ASUC [EL4]
.
4.
Calcineurin inhibitors (cyclosporine or tacrolimus) third-line rescue treatment of corticosteroid-refractory ASUC may delay the need for colectomy, but it is related to the high incidence of adverse events and should only be used Special treatment center application [EL2a]
.
Drug and surgical treatment of refractory moderate to severe UC 1.
Despite the risk of early or late complications, reconstructive surgery can be performed for refractory and corticosteroid-dependent patients and can improve the quality of life [EL2b]
.
For some patients, colorectal resection with terminal ileostomy is an option, and has a lower incidence and a comparable quality of life [EL3a]
.
Preoperative optimization of refractory moderate to severe UC 1.
Although the evidence is limited, it is recommended to correct the disorder and nutritional imbalance before surgery [EL5]
.
There is no evidence to support routine enteral or parenteral nutrition to improve the surgical outcome of UC patients [EL5]
.
When iron deficiency anemia is present, iron supplementation is recommended [EL1]
.
2.
Patients treated with >20mg prednisolone >6 weeks have an increased risk of early complications and specific complications of storage bags
.
Steroids should be discontinued before restorative rectal resection or proctocolectomy, and if this is not feasible, surgery should be postponed [EL4]
.
Preoperative use of mercaptopurine or cyclosporine does not increase the risk of postoperative complications [EL3]
.
Patients using biological agents may have an increased risk of early and late bag-specific complications; in this case, a phase 3 or phase 2 modified strategy that delays the construction of the bag can be considered [EL4]
.
Patients receiving biologics treatment should avoid single-segment restorative rectocolectomy [EL5]
.
3.
Considering the higher risk of venous thromboembolism (VTE) during the onset of UC, it is recommended that adult patients with active UC receive preventive anticoagulation during hospitalization [EL4]
.
Surgical treatment of refractory moderate-severe UC 1.
For drug-refractory UC, after total rectal resection, choose ileal bag anal anastomosis (IPAA)
.
For some patients, permanent terminal ileostomy is also a reasonable option
.
Decisions should be shared with patients, and surgical options should be made according to patient preferences [EL3]
.
2.
For patients with drug-refractory UC, compared with stage 3 or stage 2 IPAA, modified stage 2 IPAA has fewer septic or non-septic complications and shorter hospital stay [EL3]
.
Surgical techniques for refractory moderate-to-severe UC 1.
IPAA can use a stapler or manual suture technique, and the functional outcome of the two methods is equivalent
.
Therefore, the type of anastomosis should be determined by the surgeon [EL2]
.
2.
Laparoscopic surgery is the first choice for patients with refractory UC, because it has low intraoperative and postoperative morbidity, faster recovery, fewer adhesions and incisional hernias, shorter hospital stays, and can improve the fertility of female patients.
The cut is more beautiful and other advantages [EL2]
.
3.
Although it is associated with increased risk of rectal dysplasia, cancer, dysplasia, and cancer recurrence, UC patients with the least affected rectum may choose ileo-rectal anastomosis (IRA) [EL4]
.
Reference source: Raine T, Bonovas S, et al.
ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment.
J Crohns Colitis.
2021 Oct 12:jjab178.
doi: 10.
1093/ecco-jcc/jjab178.
