Ulcerative colitis (UC) is a chronic inflammatory bowel disease affecting the large intestine. It causes inflammation and ulcers in the digestive tract lining. While medical treatments, including anti-inflammatory drugs and immunosuppressants, are the initial approach, they are not always effective. When medical management is insufficient, surgical intervention becomes a viable option.
Prevalence of Surgery for Ulcerative Colitis
Approximately 20% to 30% of people with ulcerative colitis will require at least one bowel surgery. A meta-analysis indicated that the overall 1-, 5-, and 10-year cumulative risks of colectomy after diagnosis were 4.0%, 8.8%, and 13.3%, respectively. These rates have declined due to more effective medical treatments, including biological therapies.
Despite these improvements, many patients still require surgery. The likelihood of needing surgery increases with the disease’s duration and extent. For instance, individuals with pancolitis, involving inflammation throughout the entire colon, face a higher risk of colectomy compared to those with less extensive disease. Most colectomies are performed within the first 10 years of disease onset.
Key Reasons for Surgical Intervention
Surgical intervention for ulcerative colitis becomes a consideration when medical therapies no longer provide adequate disease control. A primary reason is refractory disease, where patients do not respond to multiple medical treatments, including immunosuppressants and biologics. This persistent inflammation impacts quality of life, causing chronic symptoms like severe diarrhea, abdominal pain, and weight loss.
Surgery also addresses severe complications. These can be life-threatening and include toxic megacolon, a rapid colon dilation with a high perforation risk. Other urgent indications are severe, uncontrollable bleeding or a colon wall perforation, which requires immediate surgical repair.
Another reason for surgery is the risk of developing colorectal cancer. Long-standing, extensive ulcerative colitis increases the risk of dysplasia, abnormal cell changes that can precede cancer. In such cases, prophylactic surgery may be recommended to remove the diseased colon and eliminate this risk.
Common Surgical Procedures for Ulcerative Colitis
The most common surgical approach for ulcerative colitis is a total proctocolectomy, which involves removing the entire large intestine. This procedure eliminates the inflammation. Following a total proctocolectomy, two main reconstructive options manage waste elimination.
One common procedure is an ileal pouch-anal anastomosis (IPAA), also known as J-pouch surgery. Here, the surgeon constructs an internal pouch from the end of the small intestine (ileum) and connects it to the anus. This allows the patient to pass stool through the rectum, maintaining bowel control without an external appliance. The IPAA procedure is often performed in multiple stages, allowing for healing between operations.
Alternatively, some patients may undergo a total proctocolectomy with a permanent ileostomy. In this scenario, the end of the small intestine is brought through an opening in the abdominal wall, creating a stoma. Waste then empties into an external pouch worn on the abdomen. This option is chosen when an IPAA is not feasible due to factors such as poor sphincter function, advanced age, or if a patient cannot undergo multiple surgeries.