Practice Parameters for the Surgical Treatment of Ulcerative Colitis

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The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.STATEMENT OF THE PROBLEMUlcerative colitis (UC) is characterized by a chronic inflammatory condition that affects the rectum and extends proximally into the colon for varying distances. Although many patients are treated effectively by a wide variety of medications, approximately 15% to 30% of patients will require or elect operative intervention. Surgical indications vary from acute colitis to malignancy and often have a dramatic impact on morbidity, mortality, and quality of life.1,2 Failure to respond to medical therapy (ie, intractability) remains the most common surgical indication for UC. Whether it is secondary to an inability to control symptoms, poor quality of life, risks/side effects of chronic medical therapy (especially long-term corticosteroids), noncompliance, or growth failure, patients may opt for surgery in the elective or semielective setting.3 Complete removal of all the potential disease-bearing tissue is theoretically curative in UC. Operative options include an abdominal colectomy or total proctocolectomy with either a permanent end ileostomy or surgical construction of a “new” rectum through an IPAA that restores GI continuity.4,5 All these procedures may be performed by using open or minimally invasive techniques.6,7 Although various treatment options are available for UC, this parameter will focus on the surgical management for the patient with UC.METHODOLOGYThese guidelines are built on the last set of the American Society of Colon and Rectal Surgeons Practice Parameters for treatment of UC published in 2005.8 An organized search of Medline, PubMed, and the Cochrane Database of Collected Reviews was performed through July 2013. Key-word combinations included inflammatory bowel disease, ulcerative colitis, ileal pouch-anal anastomosis, ileostomy, proctocolectomy, colorectal neoplasm, surgery, colectomy, ileoproctostomy, immunomodulator, infliximab, steroids, and related articles. Directed searches of the embedded references from the primary articles also were accomplished. The final grade of recommendation was performed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system (Table 1).9INDICATIONS FOR SURGERYAcute ColitisPatients with clinical evidence of actual or impending perforation should undergo urgent surgery. Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B.The diagnosis of severe colitis is based on the criteria of Truelove and Witts10 and is defined as colitis with more than 6 bloody stools per day, fever (temperature, >37.

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