Question

Surgical management of ulcerative colitis:
Discuss the indications of surgery in patients with ulcerative colitis in the era of biologics.

Hint:

Surgery for ulcerative colitis is generally considered when medical therapy fails, complications arise, or when there is an increased risk of colorectal cancer. The availability of biologics has delayed the need for surgery in many cases.

Answer 1

Ulcerative colitis (UC) is a chronic inflammatory bowel disease that affects the colon. Surgical management of UC is often required when medical therapy, including biologics, fails to control the disease or when complications arise.
Step 1: Indications for Surgery in UC:
1. Failure of Medical Therapy: Surgery is considered in patients with UC who fail to respond to conventional medical treatments, including corticosteroids, immunosuppressants, and biologic therapies (e.g., TNF inhibitors, integrin inhibitors, or JAK inhibitors). In such cases, surgery may be the only option to control disease symptoms.
2. Toxic Megacolon: This is a life-threatening complication of UC that may occur despite medical treatment. It requires emergency surgery to remove the colon, as the condition is associated with high mortality.
3. Severe Bleeding: In patients with UC, significant rectal bleeding may occur, and if this becomes refractory to medical treatment, surgical intervention may be required to control bleeding.
4. Colorectal Cancer or Dysplasia: Long-term UC increases the risk of colorectal cancer. Patients with high-grade dysplasia or early-stage cancer may require surgery to prevent the development of more advanced malignancy.
5. Perforation: In cases of bowel perforation, surgery is required as it poses a significant risk of peritonitis and sepsis.
Step 2: Surgery in the Era of Biologics:
Biologics have revolutionized the treatment of UC by reducing inflammation and inducing remission in many patients. However, despite the effectiveness of biologics, some patients may still require surgery, especially if they develop complications or fail to achieve long-term remission. Surgery remains the ultimate option for curative treatment in UC, particularly in cases of refractory disease or complications.