Surgery of acute severe ulcerative colitis. Subtotal colectomy: when and how to do it?

Abstract

The aim of this review is to focus attention on the role of surgery in the management of acute ulcerative colitis (UC). UC is a chronic inflammatory disease of the mucosa of the large intestine. We have examined the data from the literature of the past 20 years and we have analyzed the role of emergency surgery. A medical literature search was conducted using Medline, Embase, Ovid Journals, and Science Direct. Acute severe colitis (ASC) occurs in 12–25% of patients affected by UC. Patients with ASC should be managed by a multidisciplinary team. Aggressive medical or surgical treatment is undertaken with the final aim of reducing mortality. Intravenous corticosteroids are the mainstay of therapy. Medical rescue therapy based on cyclosporine or infliximab should be considered if there is no response to corticosteroids after 3 days. In the event that there has been no response to medical rescue therapy after 4–7 days, the patient must undergo urgent colectomy surgery. Prolonged observation is counterproductive as over time it increases the risk of toxic megacolon and of perforation burdened with a very high mortality rate. The best possible treatment is represented by subtotal colectomy with ileostomy and preservation of a long rectal stump. Emergency colectomy is characterized by high morbidity and low mortality rates.