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2 May 2022

This is the second of a series of two articles reporting the European Crohn’s and Colitis Organisation [ECCO] evidence-based consensus on the management of adult patients with ulcerative colitis [UC]. The first article is focused on medical management, and the present article addresses medical treatment of acute severe ulcerative colitis [ASUC] and surgical management of medically refractory UC patients, including preoperative optimisation, surgical strategies, and technical issues. The article provides advice for a variety of common clinical and surgical conditions. Together, the articles represent an update of the evidence-based recommendations of the ECCO for UC.

Ulcerative colitis [UC] usually presents as a mild condition, but often leads to life-threatening and systemic complications that require urgent interventions.1–4 Acute severe ulcerative colitis [ASUC] and medically refractory UC represent the main indications for surgery in UC patients.5,6 The first-line treatment of ASUC consists of intravenous corticosteroid treatment.7,8 However, up to 30% of patients fail to respond to conservative treatments and require a colectomy.9 Refractory UC includes steroid dependency and immunomodulator- or biologic-refractory disease. Refractory UC is often accompanied by deteriorated patient condition and is a recognised risk factor of poor postoperative outcomes10–12; thus a staged procedure is often preferred, to improve patient status and minimise postoperative complications.13

Despite the increasing availability of new pharmacological treatments, multiple attempts at conservative management and consequent therapeutic failures may affect the condition of patients with ASUC and refractory UC and considerably influence postoperative outcomes.11,12 Accordingly, multidisciplinary [including gastroenterologists and surgeons] management of UC patients is of crucial importance to identify the best therapeutic pathway.

The European Crohn’s and Colitis Organisation [ECCO] aims to develop a practical guide for the medical and surgical management of adult patients with UC, based on an interdisciplinary, evidence-based approach. The present article is focused on the first-line treatment of adult ASUC patients and on the surgical management of refractory adult UC patients, including preoperative assessment and technical aspects. The following statements are complementary to the guidelines on medical treatment of adult UC patients, which are presented in a separate article.

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