Langenbeck's Archives of Surgery

, Volume 397, Issue 1, pp 11–17

Surgical management of ulcerative colitis

Review Article



Surgery is the only curative option in the treatment of ulcerative colitis. Despite advances in the medical management surgery is required in about a third of patients.

Surgical management

In the acute setting surgery is indicated when medical treatment fails to improve an episode of acute severe colitis. The intervention of choice is a staged colectomy with end ileostomy and preservation of the rectal stump in the first instance. Indications for elective surgery are failure of medical therapy and malignant transformation. The surgical options include conventional proctectomy with ileostomy or a Kock's continent ileostomy and colectomy with an ileorectal anastomosis. The current gold standard is restorative proctocolectomy with ileal pouch–anal anastomosis. Most frequently the technique includes a J pouch with a stapled anastomosis and temporary faecal diversion with a loop ileostomy. Laparoscopic pouch surgery is a feasible and safe option with an excellent cosmetic result.


Although the morbidity remains significant after surgery, the quality of life is good with a satisfactory long-term functional outcome.


Ulcerative colitis Treatment Surgery 


  1. 1.
    Grainge MJ, West J, Card TR (2010) Venous thrombembolism during active disease and remission in inflammatory bowel disease: a cohort study. Lancet 375:657–663PubMedCrossRefGoogle Scholar
  2. 2.
    Truelove SC, Witts LJ (1955) Cortisone in ulcerative colitis; final report on a therapeutic trial. Br Med J 2:1041–1048PubMedCrossRefGoogle Scholar
  3. 3.
    Lichtiger S, Present S, Kornbluth A, Gelernt I, Bauer J, Galler G, Michelassi F, Hanauer S (1994) Cyclosporine in severe ulcerative colitis refractory to steroid therapy. N Engl J Med 330:1841–1845PubMedCrossRefGoogle Scholar
  4. 4.
    Shibolet O, Regushevskaya E, Brezis M, Soares-Weiser K (2005) Cyclosporine A for induction of remission in severe ulcerative colitis. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD004277. doi:10.1002/14651858.CD004277.pub2
  5. 5.
    Jarnerot G, Hertervig E, Friis-Liby I et al (2005) Infliximab as rescue therapy in severe to moderately severe ulcerative colitis: a randomized, placebo-controlled study. Gastroenterology 40:476–481Google Scholar
  6. 6.
    Travis SP, Farrant JM, Ricketts C, Nolan DJ, Mortensen NM, Kettlewell MG, Jewell DP (1996) Predicting outcome in severe ulcerative colitis. Gut 38:905–910PubMedCrossRefGoogle Scholar
  7. 7.
    Travis SP, Stange EF, Lemann M et al (2008) European evidence-based consensus on the management of ulcerative colitis: current management. J Crohns Colitis 2:24–62PubMedCrossRefGoogle Scholar
  8. 8.
    Alves A, Panis Y, Bouhnik Y, Maylin V, Lavergne Slove A, Valleur P (2003) Subtotal colectomy for severe acute colitis: a 20-year experience of a tertiary care center with an aggressive and early surgical policy. J Am Coll Surg 197:379–385PubMedCrossRefGoogle Scholar
  9. 9.
    Hyman NH, Cataldo P, Osler T (2004) Urgent subtotal colectomy for severe inflammatory bowel disease. Dis Colon Rectum 48:70–73CrossRefGoogle Scholar
  10. 10.
    Dunker MS, Bemelman WA, Slors JF, van Hogezand RA, Ringers J, Gouma DJ (2000) Laparoscopic-assisted vs open colectomy for severe acute colitis in patients with inflammatory bowel disease (IOBD): a retrospective study in 42 patients. Surg Endosc 14(10):911–914PubMedCrossRefGoogle Scholar
  11. 11.
    Marceau C, Alves A, Ouaissi M, Bouhnik Y, Valleur P, Panis Y (2007) Laparoscopic subtotal colectomy for acute or severe colitis complicating inflammatory bowel disease: a case-matched study in 88 patients. Surgery 141(5):640–644PubMedCrossRefGoogle Scholar
  12. 12.
    Telem DA, Vine AJ, Swain G (2010) Laparoscopic subtotal colectomy for medically refractory ulcerative colitis: the time has come. Surg Endosc 24:1616–1620PubMedCrossRefGoogle Scholar
  13. 13.
    Cahill RA, Lindsey I, Jones O, Guy R, Mortensen N, Cunningham C (2010) Single-port laparoscopic total colectomy for medically uncontrolled colitis. Dis Colon Rectum 53:1143–1147PubMedCrossRefGoogle Scholar
  14. 14.
    Eaden JA, Abrams KR, Mayberry JF (2001) The risk of colorectal cancer in ulcerative colitis: a meta-analysis. Gut 48:526–535PubMedCrossRefGoogle Scholar
  15. 15.
    Biancone L, Michetti P, Travis S et al (2008) European evidence-based consensus on the management of ulcerative colitis: special situations. J Crohns Colitis 2:63–92PubMedCrossRefGoogle Scholar
  16. 16.
    Jayaram H, Satsangi J, Chapman RWG (2001) Increased colorectal neoplasia in chronic ulcerative colitis complicated by primary sclerosing cholangitis: fact or fiction? Gut 48:430–434PubMedCrossRefGoogle Scholar
  17. 17.
    Farraye FA, Odze RO, Eaden J (2010) AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology 138:738–745PubMedCrossRefGoogle Scholar
  18. 18.
    Castillo E, Thomassie LM, Whitlow CB (2005) Continent ileostomy: current experience. Dis Colon Rectum 48:1263–1268PubMedCrossRefGoogle Scholar
  19. 19.
    Da Luz A, Kiran RP, Lavery I (2010) Clinical outcome of ileorectal anastomosis for ulcerative colitis. Br J Surg 97:65–69Google Scholar
  20. 20.
    Gorfine SR, Harris MT, Bub DS, Bauer J (2004) Restorative proctocolectomy for ulcerative colitis complicated by colorectal cancer. Dis Colon Rectum 47:1377–1385PubMedCrossRefGoogle Scholar
  21. 21.
    Hahnloser D, Pemberton JH, Wolff BG (2004) The effect of ageing on function and quality of life in ileal pouch patients. Ann Surg 240(4):615–623PubMedGoogle Scholar
  22. 22.
    Wibmer AG, Kroesen AJ, Groene J (2010) Predictors of permanent ileostomy after restorative proctocolectomy. Br J Surg 97:1561–1566PubMedCrossRefGoogle Scholar
  23. 23.
    Burns EM, Bottle A, Aylin P (2011) Volume analysis of outcome following restorative proctocolectomy. Br J Surg 98:408–417PubMedCrossRefGoogle Scholar
  24. 24.
    Lovegrove RE, Constantinides VA, Heriot AG, Athanasiou T, Darzi A, Remzi FH, Nicholls RJ, Fazio VW, Tekkis P (2006) A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy. Ann Surg 244:18–26PubMedCrossRefGoogle Scholar
  25. 25.
    Weston-Petrides G, Lovegrove RE, Tilney HS (2008) Comparison of outcomes after restorative proctocolectomy with or without defunctioning ileostomy. Arch Surg 143(4):406–412PubMedCrossRefGoogle Scholar
  26. 26.
    Tilney HS, Lovegrove RF, Heriot AG, Purkayastha S, Constantinides V, Nicholls RJ, Tekkis PP (2007) Comparison of short-term outcomes of laparoscopic vs open approaches to ileal pouch surgery. Int J Colorectal Dis 22:531–542PubMedCrossRefGoogle Scholar
  27. 27.
    Ahmed Ali U, Keus F, Heikens JT, Berdah SV, Gooszen HG, van Laarhoven CJHM (2009) Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial polyposis (review). Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD006267. doi:10.1002/14651858.CD006267.pub2
  28. 28.
    El-Gazzaz GS, Kiran RP, Remzi FH, Hull TL, Geisler DP (2009) Outcomes for case-matched laparoscopically assisted versus open restorative proctocolectomy. Br J Surg 96:522–526PubMedCrossRefGoogle Scholar
  29. 29.
    Lefevre JH, Bretagnol F, Ouaissi M, Taleb P, Alves A, Panis Y (2009) Total laparoscopoic ileal pouch-anal anastomosis: prospective series of 82 patients. Surg Endosc 23:166–173PubMedCrossRefGoogle Scholar
  30. 30.
    Indar AA, Efron JE, Young-Fadok T (2009) Laparoscopic ileal pouch–anal anastomosis reduces abdominal and pelvic adhesions. Surg Endosc 23:174–177PubMedCrossRefGoogle Scholar
  31. 31.
    Heuschen UA, Hinz U, Allemeyer EH, Autschbach F, Stern J, Lucas M, Herfarth C, Heuschen G (2002) Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis. Ann Surg 235(2):207–216PubMedCrossRefGoogle Scholar
  32. 32.
    Meagher AP, Farouk R, Dozois RR, Kelly KA, Pemberton JH (1998) J ileal pouch–anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg 85:800–803PubMedCrossRefGoogle Scholar
  33. 33.
    Gionchetti P, Rizzello F, Helwig U, Venturi A, Lammers KM, Brigidi P, Vitali B, Poggioli G, Miglioli M, Campieri M (2003) Prophylaxis of pouchitis onset with probiotic therapy: a double-blind placebo-controlled trial. Gastroenterology 124:1202–1209PubMedCrossRefGoogle Scholar
  34. 34.
    Mimura T, Rizzello F, Helwig U, Poggioli G, Schreiber S, Talbot IC, Nicholls RJ, Gionchetti P, Campieri M, Kamm MA et al (2004) Once daily high dose therapy (VSL3) for maintaining remission in recurrent or refractory pouchitis. Gut 53:108–114PubMedCrossRefGoogle Scholar
  35. 35.
    Olsen KO, Joelsson M, Laurberg S, Oresland T (1999) Fertility after ileal pouch–anal anastomosis in women with ulcerative colitis. Br J Surg 86:493–495PubMedCrossRefGoogle Scholar
  36. 36.
    Ording Olsen KO, Juul S, Berndtsson I, Oresland T, Laurberg S (2002) Ulcerative colitis: female fecundity before diagnosis, during disease, and after surgery compared with a population sample. Gastroenterology 122:15–19PubMedCrossRefGoogle Scholar
  37. 37.
    Waljee A, Waljee J, Morris AM (2006) Three-fold increased risk of infertility: a meta-analysis of infertility after ileal pouch anal anastomosis in ulcerative colitis. Gut 55:1575–1580PubMedCrossRefGoogle Scholar
  38. 38.
    Lepistoe A, Sarna S, Tiitinen A, Jaervinen HJ (2007) Female fertility and childbirth after ileal pouch–anal anastomosis for ulcerative colitis. Br J Surg 94:478–482CrossRefGoogle Scholar
  39. 39.
    Hahnloser D, Pemberton JH, Wolff BG (2007) Results at up to 20 years after ileal pouch–anal anastomosis for chronic ulcerative colitis. Br J Surg 94:333–340PubMedCrossRefGoogle Scholar
  40. 40.
    Scarpa M, van Koperen PJ, Ubbink DT (2007) Systematic review of dysplasia after restorative proctocolectomy for ulcerative colitis. Br J Surg 94:534–545PubMedCrossRefGoogle Scholar
  41. 41.
    Tulchinsky H, Hawley PR, Nicholls J (2003) Long-term failure after restorative proctocolectomy for ulcerative colitis. Ann Surg 238:229–234PubMedGoogle Scholar
  42. 42.
    Prudhomme M, Dehni N, Dozois RR, Parc R, Tiret E (2006) Causes and outcomes of pouch excision after restorative proctocolectomy. Br J Surg 93:82–86PubMedCrossRefGoogle Scholar
  43. 43.
    Karoui M, Cohen R, Nicholls J (2004) Results of surgical removal of the pouch after failed restorative proctocolectomy. Dis Colon Rectum 47:869–875PubMedCrossRefGoogle Scholar
  44. 44.
    Dehni N, Remacle G, Dozois RR, Banchini F, Tiret E, Parc R (2005) Salvage reoperation for complications after ileal pouch–anal anastomosis. Br J Surg 92:748–753PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  1. 1.Department of Digestive SurgeryHôpital Saint-Antoine AP-HP, University Paris VI (Pierre et Marie Curie)Paris Cedex 12France

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