Timing and indications for colectomy in chronic ulcerative colitis: Surgical consideration

Total proctocolectomy (TPC) cures a patient of the intestinal manifestation of chronic ulcerative colitis. The timing of surgery during the illness will influence the choice of operation, the frequency of post-operative complications, and the long-term functional outcomes. Surgery is divided into emergency, urgent, and elective procedures. Emergency cases are performed for complications of fulminant colitis: hemorrhage, perforation, toxic megacolon or sepsis. A subtotal colectomy (STC) with a Brooke ileostomy (BI) is the procedure of choice. STC removes the bulk of the disease, allows the patient's health to be restored, medication to be withdrawn, and permits a future restorative operation. Urgent operations occur in hospitalized patients with continued symptoms after seven days of maximal medical therapy. Once again the preferred operation is a STC-BI. Indications for elective colectomy include: persistent symptoms despite maximal medical therapy, medication side-effects, persistent chronic disease state, dysplasia/malignancy. Elective surgical options include TPC-BI, TPC with ileal-pouch anal anastomosis (IPAA), or STC-BI. The choice of operation is based upon patient preference and preoperative physiologic and functional status. Factors associated with increased post-operative complications are weight loss >10%, multiple preoperative blood transfusions, albumin <3.0 gm/dl, and degree of immuno-suppression. In high-risk patients, STC-BI should be performed. IPAA can be performed later after the patient's health is restored. In conclusion, numerous factors affect the timing and choice of operation in patients with CUC. Avoiding complications in IPAA patients is essential as they negatively impact the long-term function and durability of the IPAA.