When Is Surgery Indicated in Ulcerative Colitis?

Background: Surgery continues to play an important role in ulcerative colitis (UC) therapy, with the operation rate for severe UC (SUC) cases varying between 25 and 30% in western countries. The indication and timing for surgery are not clearly defined, and there are some differences between the West and the East. By analyzing present data from different levels, the evidence on the clinical decision-making of surgery could be provided. Methods: Firstly, we searched Medline and PubMed for literature reviews about surgical management for UC and directly searched the references embedded in these primary articles; secondly, we performed a computer-assisted Chinese literature search for relevant studies of UC from 1985 to 2009 using the databases of CBM (the Chinese Medical Disc Library) and VIP. Finally, the data about surgical indication for UC and the quality of life of postoperative patients in recent 14 years from West China Hospital were analyzed retrospectively. Results: From the literature review, the indications for surgery could be categorized into absolute and relative. For the former, massive hemorrhage, perforation and malignancy are beyond controversy. For the latter, the indications are not well defined and include failure of medical therapy, resistance to steroids or immunosuppressants, and some complications. The timing of operation and assessment criteria for surgery in Western countries are well defined and documented (i.e. Oxford index and Sweden index). From our Chinese literature search, we learned that in 24 years only 37 clinical studies have been conducted, with the operation rate between 2.0 and 8.0% for overall UC and 17.1-18.6% for SUC. Out of all cases with indication for surgery, 179(55.6%) were SUC with serious complications or not responding to maximal medical therapy, 112 (34.8%) were chronic relapsing or continuous disease refractory to medical therapy and 31(9.6%) were prophylaxis/cancer. SUC patients received intravenous steroids for 12.95 +/- 6.5 days on average. In West China Hospital, 29 (7.0%) UC cases underwent surgery between 1996 and 2008, which account for 17.9% of SUC. The preoperative i.v. steroids lasted for 22.6 +/- 13.9 days. Out of patients with indication for surgery, 23 (79.3%) with acute SUC, 2(6.9%) with chronic continuous colitis and 4 (13.8%) with cancer risk were operated on. The majority of patients had an acceptable postoperative outcome and a significantly improved quality of life. Conclusion: Surgery is not a consequence of failure of medical therapy, but offers a cure for UC. The timing for surgery is crucial, and Western experience should always be referred to. The indications for surgery in China are comparatively conservative, and the timing for surgery is rather late, which is being acknowledged by some experts right now. Copyright (C) 2011 S. Karger AG, Basel