*2.2.1 Acute severe ulcerative colitis, not responding to medical therapy*

Acute UC is considered severe when the patient has at least 10 stools per day, tachycardia, fever, anemia, and increased erythrocyte sedimentation rate (ERS)/C reactive protein (CRP). The severity of ulcerative colitis classification by Truelove and Witts distinguishes acute severe ulcerative colitis from fulminant ulcerative colitis [7]. All authors do not recognize this division, but it makes it possible to infer the probability of failure with corticosteroid therapy and the need for a total colectomy (**Table 1**).

Acute severe UC, not responding to medical therapy, is one of the few cases that require emergent colectomy in UC. As shown in the management of flowchart in ASUC situations (**Figure 2**), about 30% of cases do not respond to corticosteroid therapy, and 50% of the ASUC will require surgery during the following year [8].

According to Saha et al., the policy of early colectomy, within 7 days, in patients with ASUC who fail to respond to intensive steroid-based therapy improves perioperative outcomes with significantly low inhospital mortality and morbidity [9].


### **Table 1.**

*Ulcerative colitis severity classification. Adapted from Truelove and Witts criteria.*

**Figure 2.**

*Management of flowchart in acute severe ulcerative colitis.*

On the other hand, when complications occur in severe ASUC, such as severe bleeding, toxic megacolon, and perforation, emergency surgery is mandatory. In these particular situations, the timing of colectomy is of utmost importance to reduce the postoperative complication rates.

#### *2.2.2 Complications of acute severe ulcerative colitis*

Severe bleeding, toxic megacolon, and perforation are the main complications of ASUC (**Figures 3** and **4**).

They are rare, but their presence increases surgery morbidity and mortality. If the UC surgery is urgent or emergent, the decision to perform surgery should be made in a multidisciplinary team, including the gastroenterologist and colorectal surgeon. In those cases, surgery is usually performed in three-step. Total colectomy, the first step, is made in an emergency room. The other steps electively, after confirmed diagnosis in the resected specimen.

#### *2.2.3 Chronic refractory UC*

Elective RPC for UC is indicated in chronic refractory UC (**Figure 5**) and also in the presence of high-grade dysplasia (HGD) or colorectal malignancies.

The introduction of biologic therapy has added further complexity to medical management decisions, surgery, and the relative timing of these choices. Appropriate medical management of UC may induce and maintain remission and may prevent surgery. However, medical management also carries risks of adverse effects, and recent data suggest that delay of surgery during ineffective medical therapy can increase the chances of adverse surgical outcomes. To make individualized, timely treatment decisions, early collaboration between gastroenterologists and surgeons is essential, and more data on predictors of treatment response and

*Restorative Proctocolectomy: When to Propose and When to Avoid DOI: http://dx.doi.org/10.5772/intechopen.98987*

#### **Figure 3.**

*Severe bleeding in acute severe ulcerative colitis not a responder to corticosteroids and infliximab. Surgery was performed in the emergency room.*

#### **Figure 4.**

*X-ray and surgical specimen of toxic megacolon reports. There are more frequent in extensive ulcerative colitis than in ulcerative proctosigmoiditis. Surgical mortality is 1–8% that rises to 40% in colon perforation with peritonitis.*

**Figure 5.** *Endoscopic images of chronic refractory ulceratice colitis.*

positive outcomes are needed. Early identification of patients who would benefit from biologic therapy or surgery is challenging, and the definition of chronic refractory ulcerative colitis (CRUC) difficult. In CRUC (**Figure 4**), several therapeutic

options have already been tried, such as infliximab, adalimumab, cyclosporine, azathioprine with 6-mercaptopurine, tacrolimus, or fecal transplantation, without success. When the therapeutic side effects are unbearable, or despite treatment, the patient has no quality of life, and RPC with IPAA may be the best solution.
