Up-to-date surgery for ulcerative colitis in the era of biologics

ABSTRACT

Introduction: In recent decades, biologics have resulted in significantly improved medical management of ulcerative colitis (UC). Rates of surgery for UC are declining. However, there is still a controversial question of the relation of biologics to postoperative adverse outcomes and the most appropriate timing for operative intervention.

Areas covered: In this review, we explore the updated treatment algorithm of acute severe colitis, describe postoperative outcomes in patients exposed to biologics preoperatively, and discuss the primary indications for staging surgery in chronic refractory cases, largely with prolonged medical therapy.

Expert opinion: Delaying pouch construction to when patients are in better health is suggested as a safer strategy over the long term. The surgical management of UC patients in the biologic era needs to be individualized, and a case-based multidisciplinary decision is critical for improved outcomes and a reduction of morbidity and mortality.

KEYWORDS:

• Colitis
• ulcerative
• surgery
• monoclonal antibodies
• postoperative complications

Article highlights

• Since the era of corticosteorids, significant advances have been made in medical therapies available for ulcerative colitis, including many approved classes of biologics, and, more recently, small molecule inhibitors.

• The data regarding whether biologics increase postoperative complications in surgery for UC, largely focusing in IPAA, remain controversial.

• Anti-TNF therapy has been the most widely studied and may increase postoperative pouch complications. Thus, people moved more to a three-stage approach to IPAA.

• There are still limited data on vedolizumab and ustekinumab, and, more recently, small molecule inhibitors.

• In the future, a risk calculator would be helpful, and would likely include biologics, but biologics are one of many risk factors in surgery for UC.

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Declaration of interest

P Kotze has received speaking and consulting fees from Pfizer, Takeda, Abbvie, Janssen, UCB, and has conduced clinical research for Janssen. A Lightner has acted as a consultant for Takeda. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.