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. 2025 Jan 14;40(1):12.
doi: 10.1007/s00384-024-04779-5.

The fate of the rectum in ulcerative colitis at index surgery and beyond-a contemporary cohort

Ian J B Stephens  1   2 , Brenda Murphy  1 , Niamh McCawley  1   2 , Deborah A McNamara  1   2 , John P Burke  3   4
Affiliations

The fate of the rectum in ulcerative colitis at index surgery and beyond-a contemporary cohort

Ian J B Stephens et al. Int J Colorectal Dis. .

Abstract

Purpose: Proctectomy is frequently deferred at index colectomy for ulcerative colitis due to acuity or immunosuppressive treatments. The retained rectum remains symptomatic in over 50% with associated cancer risk. Management options include index or delayed proctectomy with or without restoration of continuity or surveillance. Comparative studies of perioperative outcomes and reasons for retaining the rectum are lacking.

Methods: This 13-year retrospective cohort assesses the fate of the rectum in 168 ulcerative colitis patients by analysing index proctectomy, staged proctectomy and retained rectal remnant determinants and outcomes. The primary outcome was the fate of the rectum. Secondary analysis included perioperative morbidity, length of stay and decision-making determinants.

Results: Proctectomy was performed in 69% of patients, with 16.1% at index surgery. Restorative surgery rate was 44%. Index proctectomy patients were older (54 vs 37 years, p < 0.01), more co-morbid (59.3% vs 38.2%, p = 0.04) and likely to have elective surgery (81.5% vs 21.3%, p < 0.01) or neoplasia (33.3% vs 1.1%, p < 0.01). Outcomes after staged proctectomy were comparable, with age influencing restoration of continuity (33.5 vs 46 years, p < 0.01). Younger patients were indecisive on proctectomy, while those opting for endoscopic surveillance were older (median 65 years, p < 0.01), had more complications (64.3%, p = 0.23) and prolonged hospitalisation (median 15 days, p = 0.02) at colectomy.

Conclusions: Index proctocolectomy for ulcerative colitis is infrequently performed. Perioperative outcomes of restorative and non-restorative staged proctectomy are comparable. Perioperative experience at colectomy may influence patient decisions regarding future management of their rectum.

Keywords: Endoscopic surveillance; Ileal pouch-anal anastomosis; Proctectomy; Rectum; Ulcerative colitis.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The retrospective review was assessed and approved by the local audit department, registration number CA2023/224. Analysed data contained no personal identifiers. Formal consent was not required as the analysis was performed for service evaluation. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
A total of 183 patients underwent total abdominal colectomy between January 2010 and June 2023 for inflammatory bowel disease. Following the application of inclusion criteria, 168 ulcerative colitis patients were identified. n = total patient number per group, with subgroup numbers denoted in italics. Below these outcomes, follow-up attrition and surgical preferences of patients with their rectum still in situ are reported
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