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

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 1, 1995 and December 18, 2020.11 The complete search strategy is listed in Supplemental Digital Content https://links.lww.com/DCR/B558. Keyword combinations included “ulcerative colitis,” “indeterminate colitis,” “inflammatory bowel disease,” “Crohn’s disease,” “surgery,” “colectomy,” “proctocolectomy,” “ileostomy,” “laparoscopic,” “robotic,” “Kock pouch,” “mucosectomy,” “ileoproctostomy,” and “ileal pouch-anal anastomosis.” Directed searches using embedded references from primary articles were performed in selected circumstances. After removal of duplicate references, a total of 8661 unique journal titles were identified. A total of 1232 titles were selected for manuscript review with an emphasis placed on prospective trials, meta-analyses, systematic reviews, and practice guidelines.16,17 Peer-reviewed observational studies and retrospective studies were included when higher-quality evidence was insufficient. Of the 1232 full-text manuscripts reviewed, 296 references were included in the final manuscript (Fig. 1). The final source material used was evaluated for methodological quality, the evidence base was examined, and a treatment guideline was formulated. The final grade of recommendation was designated using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system (Table 1).18 When there was disagreement regarding the evidence base or treatment guideline, consensus from the committee chair, vice chair, and 2 assigned reviewers determined the outcome. Members of the ASCRS Clinical Practice Guidelines Committee worked in joint production of these guidelines from inception to final publication. Recommendations formulated by the subcommittee were reviewed by the entire Clinical Practice Guidelines Committee, selected members of the ASCRS Inflammatory Bowel Disease committee, and selected practicing gastroenterologists. Consideration was given to align recommendations with the 2020 ASCRS Clinical Practice Guidelines for the Surgical Management of Crohn’s Disease because there was significant overlap in the evidence base supporting these 2 guidelines.19 The final guideline was approved by the ASCRS Executive Council and peer reviewed by Diseases of the Colon & Rectum. In general, each ASCRS Clinical Practice Guideline is updated every 5 years. No funding was received for preparing this guideline and the authors have declared no competing interests related this material. This guideline conforms to the Appraisal of Guidelines Research and Evaluation (AGREE) checklist. TABLE 1. - The GRADE System: grading recommendations Description Benefit versus risk and burdens Methodologic quality of supporting evidence Implications 1A Strong evidence risk and burdens or vice or evidence from observational studies Strong can to most patients in most circumstances Strong evidence risk and burdens or vice with or or evidence from observational studies Strong can to most patients in most circumstances Strong or evidence risk and burdens or vice studies or Strong recommendation may when higher-quality evidence available evidence with and burdens or evidence from observational studies best may on circumstances or or evidence with and burdens with or or evidence from observational studies best may on circumstances or or or evidence in the of and and may be studies or other may be GRADE Grades of Recommendation, Assessment, Development, and from of recommendations and quality of evidence in clinical from an American of with search 1. A multidisciplinary including surgical should be used to optimal care in patients with UC of of Strong recommendation based on The for UC is to and achieve mucosal as the of inflammatory on the and of disease is to The of disease should be the as colitis as and colitis as Disease is to the and may be to the Clinical Colitis or the The American of guidelines using a and of the and that inflammatory including and disease When patients or have disease of may be and a disease for over and can treatment management of UC in with is beyond the scope of this guideline is reviewed in other In the can be to which patients should with of and which should surgical and these circumstances should including to and risk for a total abdominal colectomy including age at of disease with and for or and In patients with a UC to is as In general, these patients should be on a as because bowel on no in 2 should be and should be as to for patients these circumstances to disease and are for and Patients with UC in this are for of a clinical including and a in and a general in their used to disease and as a for mucosal there is in the to 5 of at a of 5 to or is considered as and have a of approximately 5 to in during this treatment is with colectomy for patients who do not or during this A review of versus these circumstances is beyond the scope of this In patients condition a of the and for colectomy may be to or in colectomy in to of patients to the and in of patients to 5 the who a colectomy at their have a risk of a In patients with a for or for may at and to at the the of using a can be a systematic review that and in and of patients with this In these circumstances a of patients who to further and are at risk for care of these patients can their and including and the have not evaluated in UC regarding and their use these When the care of patients with UC, surgical should be considered to patient and as a relevant treatment when there an to the of This for the surgical of a patient’s clinical and and with the surgical for patients with UC who do not of of or because operative with considerations include of an enterostomal to ostomy care, the and Patients with medically refractory UC, or should total abdominal colectomy with end of Strong recommendation based on patients are at risk for colitis or colitis a form of colitis that may bleeding, a an and abdominal and these circumstances can include and a colon with an form of is with a colon and total or a with In in the of medically refractory UC, or clinical and of or (ie, or may be by In a retrospective of patients who have with colitis and colitis who a colon or during most often in the or of the that increase with between and surgical intervention, in the of colitis or should total abdominal colectomy with end A is these given the for a rectal a of can be as the rectal in the a of a rectal or the rectal a rectal A for an should be considered in patients with or of Strong recommendation based on Although the of for the treatment of and refractory UC to is with postoperative as of are with postoperative the of use that to risk is not this patients on should total abdominal colectomy and end ileostomy as their a total proctocolectomy with to the risk of and the of After a total abdominal with should be have because of the risk of and related to these and used as for of the of and used in with to with have not with postoperative to and systematic The to a proctocolectomy and in a should not be by The between and postoperative in the of UC studies no significant between the use of and postoperative the 2 to at the of of and with the relevant of patients with UC a risk of and in patients to In a retrospective review using from an of postoperative in the of to in the prospective to presented at Disease in not any between or their and postoperative a prospective of from patients with UC no between and with medications, the regarding to of or postoperative retrospective no significant in to a retrospective review including patients with UC and with Crohn’s disease of abdominal in patients to with patients to an approved for UC treatment in not with to postoperative in patients with UC. approved for UC treatment in not evaluated regarding postoperative the is that a to proctocolectomy and in the of may the risk of postoperative in patients with risk as in the the or a Patients with UC should at or is for optimal of Strong recommendation based on with patients with UC are at risk for colorectal for in patients with UC include age at the of of UC, of of disease a risk or of disease and disease a a of the age of and the of primary that the risk for in the of UC over a and risk of and 30 the of UC, a risk of and the risk of neoplasia, for patients with UC is by regarding the optimal for and Regardless of the of disease at patients should a of the of The for are determined by risk and by their risk for neoplasia, patients with should at the of and The Crohn’s and Colitis that the with or a of or that patients with or colitis or a of every 2 to and that patients a be performed when the disease is in the American Society for that patients with a of or in a or an as a have and that patients every to Of patients with UC who have a colectomy have a rectal in are at risk of neoplasia and should as for patients with UC, to American Society for and American is using with (ie, at with a total of or using with studies that was to for with or and in with with demonstrated during with these In the for of may be a to given the and related to and the limited technical expertise available in these reasons, or can be used for on and because most these circumstances is with with the to only or to may be based on risk on A prospective of patients with in from to patients with The of by was of only of the patients with were by Of by was with a of a colon with of and and this during for patients with these risk a of patients with from a in with and that was to in of In this with an of the Patients with or that is should Patients with not to in the mucosa a or colorectal should total proctocolectomy with or of Strong recommendation based on In patients with may be as for for or based on In general, these circumstances should be by a because of is addressed in the of and are based on the of the of the is by to the of the the The or and have with of or are by the as or or or and of are as or studies that to of colorectal in patients with UC is include and of as and to with that may be with the to a and the for The management of in patients with UC on the is or and a is with or in or that are to complete (ie, in the mucosa to the or in the colon, should be with when expertise is removal is over to for regarding the of this may require to a in including mucosal and Although the of mucosal and in the of UC only demonstrated in and the of these with to neoplasia or the for is these may complete with the of on the a can be placed to the to and should be of the mucosa the to for The recommendation to total proctocolectomy for patients with UC who have a is based on the risk of these In studies the incidence of or at the removal of a in patients with UC was to over of to In a of 30 patients with UC who of a that were to have with a of is patients are at a risk of with at the is to and at removal of the Treatment recommendations for patients with that is warrant a multidisciplinary because there is limited evidence to practice and the clinical are often patients with not to in the mucosa or inflammatory with the to total proctocolectomy is because of the risk of or Patients with UC with should and be in a multidisciplinary team and are to total patients total proctocolectomy these an with should be performed to for Patients with UC with rectal who should be that an in this may have is not an to regarding the management of colon and rectal is beyond the scope of these guidelines. Although total proctocolectomy is most often to all at-risk selected patients with an operative risk or may from a colectomy on the degree and of In a retrospective of patients with UC with a age of a colectomy colitis at and a total proctocolectomy colitis at over a of no patient colectomy In retrospective of patients with UC who colectomy or proctocolectomy of the patients colectomy at a of patients proctocolectomy for medically refractory of the colon and rectum is when a colectomy is performed in these selected Patients with not to or should treatment to achieve mucosal healing and be to an for using with with and to of Strong recommendation based on The to the between and because of the of mucosa that can When is on (ie, to of patients with UC have on A retrospective of patients with with mucosal for who in of patients and in of patients over a of In the of for American guidelines to mucosal healing by to using with Patients with who and do not achieve mucosal healing or who have mucosal healing warrant a multidisciplinary because there is limited evidence to practice and the clinical are often Patients with should be to an for using with with and to Patients to have or any should be considered for total of Strong recommendation based on When or patients with UC should a with by an Patients who in this and are to have no or warrant a multidisciplinary because there is limited evidence to practice and the clinical are often total proctocolectomy is the evidence supporting this is A of patients who have UC with in of patients and a of risk for included and The of from the patients with with with between and and that the incidence of neoplasia was and 1, and 15 years. The between the of and neoplasia was years. In this there was no based on or of was with an risk of to supporting the recommendation for colectomy these a of patients who have UC with for a of that neoplasia at the of in a retrospective review of patients with UC who an abdominal colectomy or total of the patients who a of was in only patients at the of and of the patients a of only patients were to have in their colectomy with the management recommendations for patients with are based on of that are Although in to of patients with a of patients who UC with on or in and patients at the of in a retrospective of patients with only patients over a of 15 Regardless of the of is at using with total proctocolectomy is In should that including and of UC, as as and patients who have UC with is to patients about the and of versus total proctocolectomy in the of should be performed of Strong recommendation based on rectal mucosa the is at risk for A with at the of not this because of at-risk rectal mucosa can a Although the risk of in the rectal or is should be based on a of neoplasia in the proctocolectomy the risk of and of Although are not is performed and every to 5 for patients who neoplasia at the of their every to should be is often performed using a scope an to the Treatment of neoplasia these circumstances a multidisciplinary because there is limited evidence to practice and the clinical are often patients with UC total proctocolectomy with IPAA, a or is for most of Strong recommendation based on The of in is by patient and and to are the most the of and the regarding in the of these medications, the of a versus have not in the nearly of are performed with a The abdominal colectomy and end ileostomy by and a increasingly utilized in is not with of or with the proctocolectomy with and ileostomy by ileostomy this not with the a retrospective of patients with medically refractory UC who a or over an an of the In this were by were as performed and not by operative or to or The authors that a was not with an risk of or of patients with a with a and no in postoperative including of or Of there were no in the to or between the 2 the other 2 studies postoperative with a In is to treatment in these and disease to the of and in to as the and Although the with the ever-expanding of used to these a should be considered to postoperative Regardless of the or for are when expertise is available to including of and and In of other minimally invasive the to to be and in studies and demonstrated and to in 2 proctocolectomy with IPAA, end ileostomy, or continent ileostomy are for patients with UC surgery. of Strong recommendation based on proctocolectomy with the most performed operative for patients with UC and is with an an and a quality of that that of the When a minimally invasive should be considered because of the of and and often a because of of construction and are with with an with a an construction may be when is for a In of a is over a with because the bowel and with this Although have an may not be for all significant bowel and should be considered to selected patients may because age not postoperative or and should be considered when these patients regarding Of and patients with may and bowel and of because the with in the of is with operative and in for a is not with including of bowel and can and a to for and an end may be a strategy in these proctocolectomy with an end ileostomy, an to is considered a and curative with to This may be the operative strategy in patients with to a to or limited to conditions who may be at risk of or A continent ileostomy is a for selected patients in an is or or in who a permanent ileostomy over a is in most these have of and of operative or In a of patients continent ileostomy with a of postoperative and retrospective of patients and continent ileostomy of and In this at a of patients on and and a of In of for patients who have UC with a may be a in is to patients regarding of because these can be by of and and and with primary regarding is beyond the scope of these guidelines. abdominal colectomy with may be considered in selected patients who have UC with rectal of recommendation based on abdominal colectomy with an or is with and with and a which may in selected patients for this should have a and Patients should be regarding the for to that at and to and of these patients for medically refractory In of the rectum is because and in the rectum in to and and to to and of patients at and years. of UC or a of colorectal neoplasia or the risk for neoplasia in this patients with who develop medically refractory or rectal neoplasia, from an to in to primary with of and for primary and Patients with UC should be regarding on and of Strong recommendation based on with or are to be related to postoperative related to the that may that total abdominal colectomy with an and no is not with this of of patients with UC of to to to 20% in The use of a minimally invasive may in this because that a minimally invasive to is with of and to with Regardless of the variable or there are no significant in the in between patients with UC or and patients to a retrospective review of patients with UC in the patients with a in with all other patients with is not with an of or including of or for an Although during the of this to be with to of the of the of to with a studies by colorectal that may When patients who have a a is to surgical expertise available to In of other studies IPAA, no significant on to achieve or an in quality of because of health with of have a risk of not to their IPAA, in only of In studies with and affected of IPAA, that these are The use of in an to and not an regarding postoperative not to be affected in the postoperative of urgency, and may increase over in is performed in the of UC and is to to of Strong recommendation based on is a of the mucosa of the with and in the in to of patients with UC and is in patients to and in patients with colitis or the of should be by with of mucosa of the and with a and are with a of The most form of is that to and or other are for to these is and is as or may be with a or with an for Crohn’s disease or other inflammatory disorders of the and to for management and treatment not when in a and have limited in retrospective and may be considered these Patients who have medically refractory may require intestinal or to their may the for proctocolectomy related to medically refractory of recommendation based on The that may be in patients with medically refractory UC evaluated in a In a prospective of 30 patients with medically refractory UC who were for who patients a clinical and 5 patients at In this the degree of was with clinical and In of patients with medically refractory UC who a patients a clinical 5 patients and patients a colectomy or of A ileostomy can be considered in the of UC to an total abdominal of recommendation based on In the and studies regarding a ileostomy and a colectomy to or colitis in of to a retrospective in the of that a ileostomy for medically refractory colitis was a to colectomy in patients who were or This of patients with demonstrated that a ileostomy not increase the of colon in patients with UC and Crohn’s was to an colectomy to an postoperative should be considered in patients with UC to of recommendation based on was approved in by the and for the treatment of to UC the and 2 which demonstrated that patients and of with a to the most in the clinical were and and of patients a the and a in of and from related to in patients with Although a retrospective in the of UC not a of thromboembolic patients with UC are at risk of postoperative patients with UC to may from postoperative

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