Ulcerative Colitis Clinical Practice Guidelines (ASCRS, 2021)

Guidelines on the surgical management of ulcerative colitis (UC) were published in July 2021 by the American Society of Colon and Rectal Surgeons in the journal Diseases of the Colon & Rectum.^[1] Strong recommendations are outlined below unless noted otherwise.

Medically Refractory UC

For inpatients with moderate-to-severe UC undergoing escalation of medical therapy, a multidisciplinary team and early surgical consultation should guide optimal care.

Total abdominal colectomy with end ileostomy is typically recommended for patients with severe medically refractory UC, fulminant colitis, toxic megacolon, or colonic perforation.

Consider a staged approach for an ileal pouch-anal anastomosis (IPAA) in patients being treated with high-dose corticosteroids or monoclonal antibodies.

UC-Associated Colorectal Neoplasia

Endoscopic surveillance at regular intervals is recommended for patients with UC—with chromoendoscopy or high-definition white-light endoscopy typically recommended for optimal surveillance.

Endoscopic surveillance is also recommended in the setting of completely endoscopically excised visible polypoid or nonpolypoid dysplasia. For patients with visible dysplasia not amenable to endoscopic excision, invisible dysplasia in the flat mucosa surrounding a visible dysplastic lesion, or colorectal adenocarcinoma, total proctocolectomy with or without IPAA is typically recommended.

For patients with visible indefinite dysplasia not amenable to endoscopic excision or invisible indefinite dysplasia, medical treatment is typically recommended to achieve mucosal healing; referral to an experienced endoscopist is recommended for repeat colonoscopy using high-definition colonoscopy with chromoendoscopy with targeted and repeat random biopsies within 3 to 12 months.

For patients with invisible dysplasia, referral to an experienced endoscopist is typically recommended for repeat endoscopy using high-definition colonoscopy with chromoendoscopy with targeted and repeat random biopsies within 3 to 6 months. Consider total proctocolectomy when the presence of invisible multifocal, low-grade dysplasia or any invisible high-grade dysplasia is confirmed.

Perform endoscopic surveillance after IPAA.

Technical and Postoperative Considerations

For most patients with UC undergoing restorative total proctocolectomy with IPAA, a two-stage, three-stage, or modified two-stage approach is preferred.

For patients with UC undergoing elective surgery, acceptable options include total proctocolectomy with IPAA, end ileostomy, or continent ileostomy.

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

Counsel patients with UC undergoing proctectomy about potential effects on fertility, pregnancy, sexual function, and urinary function.

Pouchitis is common after IPAA performed in the setting of UC and is classified according to its responsiveness to antibiotics.

Potential Areas for Future Investigation

Appendectomy may reduce the need for proctocolectomy associated with medically refractory disease (weak recommendation).

In the setting of worsening, acute, severe UC, a "rescue"s diverting loop ileostomy can be considered to potentially avoid an emergent total abdominal colectomy (weak recommendation).

Consider extended postoperative venous thromboembolism prophylaxis in patients with UC exposed to tofacitinib (weak recommendation).

For more information, please go to Ulcerative Colitis, Ulcerative Colitis Imaging, and Surgical Treatment of Ulcerative Colitis.

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