Perioperative Management of Ulcerative Colitis: A Systematic Review

Abstract

Background: Patients with ulcerative colitis may require colectomy for severe disease unresponsive or refractory to pharmacological therapy. Managing ulcerative colitis is complicated because there are many factors at play, including patient optimization and treatment, as the guidance varies on the ideal perioperative use of corticosteroids, immunomodulators, biologics, and small molecule agents.

Objective: A systematic literature review was performed to describe the current status of perioperative management of ulcerative colitis.

Data sources: PubMed and Cochrane databases were used.

Study selection: Studies published between January 2000 and January 2022, in any language, were included. Articles regarding pediatric or endoscopic management were excluded.

Interventions: Perioperative management of ulcerative colitis was included.

Main outcome measures: Successful management, including reducing surgical complication rates, was measured.

Results: A total of 121 studies were included in this review, including 23 meta-analyses or systematic reviews, 25 reviews, and 51 cohort studies.

Limitations: Qualitative review including all study types. The varied nature of study types precludes quantitative comparison.

Conclusion: Indications for colectomy in ulcerative colitis include severe disease unresponsive to medical treatment and colitis-associated neoplasia. Urgent colectomy has a higher mortality rate than elective colectomy. Corticosteroids are associated with postsurgical infectious complications and should be stopped or weaned before surgery. Biologics are not associated with adverse postoperative effects and do not necessarily need to be stopped preoperatively. Additionally, the clinician must assess individuals' comorbidities, nutrition status, and risk of venous thromboembolism. Nutritional imbalance should be corrected, ideally at the preoperative period. Postoperatively, corticosteroids can be tapered on the basis of the length of preoperative corticosteroid use.

FIGURE 1.

PRISMA flow diagram. PRISMA = preferred reporting items for systematic review and meta-analysis.

FIGURE 2.

Indications for colectomy. A, Acute severe UC. B, UC with stiff colon. C, UC-associated neoplasia. Flat lesion with high-grade dysplasia. UC = ulcerative colitis.