The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Ulcerative Colitis

Abstract

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines 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 and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not 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. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician considering all the circumstances presented by the individual patient. STATEMENT OF THE PROBLEM Ulcerative colitis (UC) is an idiopathic chronic inflammatory condition that affects the mucosa lining the colon and rectum that, for unknown reasons, continues to increase in incidence with nearly 3.1 million people affected in the United States alone.1 Patients most often present in 2 general age categories, between about ages 15 and 30 or 55 and 65, with rectal bleeding, urgency, and/or tenesmus from proctitis.2,3 The degree of symptomatology is variable over a patient's lifetime, and patients often exhibit a remitting and relapsing phenotype at various points during their course. Although patients can achieve mucosal healing by using an ever-expanding repertoire of immunoregulatory medications, approximately 15% to 20% of patients with UC still require colectomy for medically refractory disease and/or neoplasia of the colon or rectum.4–8 Regardless of the indication for surgical intervention, complete removal of all at-risk tissue (ie, the colon and the rectum) is considered curative for the intestinal manifestations of UC. Depending on the clinical scenario, operative strategies for patients with UC may include a total abdominal colectomy with end ileostomy or ileoproctostomy or total proctocolectomy with a permanent end ileostomy, a continent ileostomy, or construction of an IPAA, all of which are increasingly performed using minimally invasive techniques.7–10 This guideline focuses on the surgical management of medically refractory UC and UC-associated colorectal neoplasia, key technical aspects of operative intervention, postoperative considerations specific to patients with UC, and emerging concepts in UC that warrant further exploration and consideration. Because the optimal management of patients with UC involves a multidisciplinary team approach, including colorectal surgeons, gastroenterologists, radiologists, pathologists, nutritionists, and enterostomal therapists, these guidelines should be viewed in that context and represent only a portion of the treatment paradigm utilized when caring for patients with UC. METHODOLOGY This guideline was written as an update to the ASCRS Practice Parameters for the Surgical Treatment of Ulcerative Colitis published in 2014.11 Although bowel preparation, enhanced recovery pathways, ostomy care, and prevention of thromboembolic disease are relevant to the surgical management of patients with UC, these topics are addressed in other ASCRS clinical practice guidelines and are beyond the scope of this guideline.12–15 An organized search of MEDLINE, PubMed, EMBASE, Scopus, and the Cochrane Database of Collected Reviews limited to the English language was performed between January