Introduction

Ulcerative colitis defined as a non-granulomatous idiopathic inflammatory disease which mainly affects the colon and rectum. The disease may arise at any age but most commonly affects the adults between the age group of 30–40 years^.1,2. The etiology of the disease is multifactorial, involving genetic predisposition, dysregulated immune responses, epithelial barrier defects and environmental factors. No sex predilection is seen in ulcerative colitis.^3,5 The peak age of onset of disease is between 30 to 40 years.^4,6 The environmental factors has also been found to play an important role in the etiopathogenesis of ulcerative colitis. Cigarette smoking is one of the major factor associated with ulcerative colitis, non-smokers have a milder disease course and active smokers are less likely to develop ulcerative colitis⁷ Appendectomy also confers a protective effect against ulcerative colitis, especially in young patients operated for acute appendicitis.^8. Classic findings in endoscopy in patients with ulcerative colitis include loss of normal vascular pattern, erythema, erosions, granularity, friability, ulcerations and bleeding ^9.The primary aim of medical management is to induce and maintain remission with the long-term goals of improving quality of life and prevent disability. Absolute indications for surgery include uncontrolled hemorrhage, perforation, and colorectal carcinoma or dysplastic lesions not amenable to endoscopic removal.¹⁰ Surgery is also indicated in refractory acute severe ulcerative colitis or medically refractory disease. The most commonly performed surgery for ulcerative colitis is restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). An important aspect of the surgery is the use of either sutures or staplers for anastomosis. Two types of ileal pouch-anal anastomosis (IPAA) have been described: a mucosectomy of the rectal stump followed by a hand-sewn ileal pouch-anal anastomosis.¹¹ The alternative technique is to retain the mucosa of the rectal stump and perform a stapled pouch-anal anastomosis.

1. Høivik ML, Moum B, Solberg IC, et al. Work disability in inflammatory bowel disease patients 10 years after disease onset: results from the IBSEN Study. 2013;62:368–75.
2. Torres J, Billioud V, Sachar DB, Peyrin-Biroulet L, Colombel J-F. Ulcerative colitis as a progressive disease: the forgotten evidence. Inflamm Bowel Dis. 2012;18:1356–63.
3. Bernstein CN, Wajda A, Svenson LW, et al. The epidemiology of inflammatory bowel disease in Canada: a population-based study. Am J Gastroenterol. 2006;101:1559–68.
4. Cosnes J, Gower-Rousseau C, Seksik P, Cortot A. Epidemiology and natural history of inflammatory bowel diseases. 2011;140:1785–94.
5. Loftus EV. Clinical epidemiology of inflammatory bowel disease: Incidence, prevalence, and environmental influences. 2004;126:1504–17.
6. Shapiro JM, Zoega H, Shah SA, et al. Incidence of Crohn’s disease and ulcerative colitis in Rhode Island: report from the Ocean State Crohn’s and Colitis Area Registry. Inflamm Bowel Dis. 2016;22:1456–61
7. Ananthakrishnan AN. Epidemiology and risk factors for IBD. Nat Rev Gastroenterol Hepatol. 2015;12:205–17.
8. Sahami S, Kooij IA, Meijer SL, Van den Brink GR, Buskens CJ, Te Velde AA. The link between the appendix and ulcerative colitis: clinical relevance and potential immunological mechanisms. Am J Gastroenterol. 2016;111:163–69.
9. Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. 2010;105:501–23.
10. Laine L, Kaltenbach T, Barkun A, et al. SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. 2015;148:639–51.e28.
11. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J. 1978;2:85–88.
12. Baumgart DC, Sandborn WJ. Inflammatory bowel disease: clinical aspects and established and evolving therapies. 2007;369:1641–57.
13. Dai N, Haidar O, Askari A, Segal JP. Colectomy rates in ulcerative colitis: A systematic review and meta-analysis. Digestive and Liver Disease. 2022 Sep 28
14. Wetwittayakhlang P, Gonczi L, Lakatos L, Kurti Z, Golovics P, Pandur T, David G, Erdelyi Z, Szita I, Lakatos PL. Long-term Colectomy Rates of Ulcerative Colitis over 40 Years of Different Therapeutic Eras–Results from a Western Hungarian Population-based Inception Cohort Between 1977 and 2020. Journal of Crohn's and Colitis. 2023 May 1;17(5):712-21.
15. Shah SC, Khalili H, Gower-Rousseau C, Olen O, Benchimol EI, Lynge E, Nielsen KR, Brassard P, Vutcovici M, Bitton A, Bernstein CN. Sex-based differences in incidence of inflammatory bowel diseases—pooled analysis of population-based studies from western countries. Gastroenterology. 2018 Oct 1;155(4):1079-89.
16. Gunisetty S, Tiwari SK, Bardia A, Phanibhushan M, Satti V, Habeeb MA, Khan AA. The epidemiology and prevalence of Ulcerative colitis in the South of India.
17. Almogy G, Sachar DB, Bodian CA, Greenstein AJ. Surgery for ulcerative colitis in elderly persons: changes in indications for surgery and outcome over time. Archives of surgery. 2001 Dec 1;136(12):1396-400.
18. Michelassi F, Lee J, Rubin M, Fichera A, Kasza K, Karrison T, Hurst RD. Long-term functional results after ileal pouch anal restorative proctocolectomy for ulcerative colitis: a prospective observational study. Annals of surgery. 2003 Sep 1;238(3):433-45.
19. McIntyre PB, Pemberton JH, Wolff BG, Beart RW, Dozois RR. Comparing functional results one year and ten years after ileal pouch-anal anastomosis for chronic ulcerative colitis. Diseases of the colon & rectum. 1994 Apr;37:303-7.
20. Lovegrove RE, Constantinides VA, Heriot AG, Athanasiou T, Darzi A, Remzi FH, Nicholls RJ, Fazio VW, Tekkis PP. A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients. Ann Surg 2006; 244: 18-26.
21. Hoda KM, Collins JF, Knigge KL, Deveney KE. Predictors of pouchitis after ileal pouch-anal anastomosis: a retrospective review. Diseases of the colon & rectum. 2008 May;51:554-60
22. Achkar JP, Al-Haddad M, Lashner B, et al. Differentiating risk factors for acute and chronic pouchitis. Clin Gastroenterol Hepatol 2005; 3:60.

Dr Aakanksha Soni

Department of Surgical Gastroenterology

SVP Hospital, Ahmedabad, Gujarat