Risk factors and timing for colectomy in chronically active refractory ulcerative colitis: A systematic review

Background: In patients with chronic refractory ulcerative colitis (UC) the precise timing for indication to colectomy is unclear. Aims: We performed a systematic review of the literature on the risk factors for colectomy in patients with chronic refractory UC in the biologic era. Methods: PubMed Central/Medline and Embase were systemically searched for records published between January 2000 and December 2017. Current evidence was summarized and filtered by expert opinion. Results: 70 studies were included in the qualitative synthesis. Several factors were found to be associated with a higher or reduced risk for colectomy, including variables at baseline – such as progression from proctitis/left-sided to extensive colitis, extensive colitis at diagnosis, high baseline C Reactive Protein or erythrocyte sedimentation rate, male gender, and younger age at diagnosis – previous medical history, and factors arising during therapy with biologics, including the absence of clinical response after induction with infliximab or adalimumab, and the lack of mucosal healing during therapy with anti-TNFs. Conclusions: Two main points may help physicians to decide when the surgical option may be considered in patients with chronic refractory UC: (1) a first risk stratification can be obtained by analyzing factors at baseline and medical history, including the previous exposure to anti-TNFs; (2) during therapy with biologics, the early assessment (after 12–16 weeks of treatment) of clinical and endoscopic response is a strong predictor of the subsequent risk of colectomy.