Indications for surgery in UC can be either acute or elective. Acute indications encompass patients with acute severe fulminant colitis either refractory to medical therapy or with complications. Elective indications include (1) medically refractory disease, (2) intolerable side effects of medical therapy, and (3) patients who develop colon cancer or dysplasia [1]. The rate of surgery for UC reported in the literature is highly variable and depends on a variety of factors including whether studies are population or hospital based and the geographic location of the centers [6].

However, collective data indicates that the incidence of elective surgery in UC has declined, but the incidence of acute surgery has remained steady. It is estimated that approximately 50 % of surgeries for UC are performed for acute indications. Cumulatively, these data imply that biologics and immune modulators have resulted in improved control of chronic disease, but acute presentations still plague disease management and lead to early surgical intervention.

There are multiple surgical options for UC depending on whether surgery is acute or elective. The simplest procedures, typically performed for acute indications, are subtotal or total proctocolectomy with end ileostomy (“Brooke” ileostomy). In a subtotal colectomy with end ileostomy, the remaining distal colon is preserved in a Hartmann’s pouch. This leaves all operative possibilities after recovery from the acute insult. In contrast, a total proctocolectomy with end ileostomy is the definitive procedure that precludes reversal.

The restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most commonly performed elective surgical procedure for UC. In this surgery, the colon and rectum are removed, and the distal 20 cm of ileum is fashioned into a pouch and either stapled or hand-sewn to the proximal anal canal. A variety of pouch configurations (“S,” “W,” “K”) are possible, but the most common is the “J [1].” The ileal pouch is anastomosed to either the anal transition zone in close proximity to the dentate line or directly to the proximal anal canal. The former is a stapled anastomosis and is associated with less nocturnal incontinence [7, 11]. This is attributed to the preservation of the anal sensation and a lower likelihood of anal sphincter complex damage [7, 11]. However, it comes with the theoretically increased risk of “cuffitis” and a small risk of cancer because of a small band of preserved mucosa, the “anal transition zone.” In contrast, the hand-sewn IPAA anastomosis requires a mucosectomy, resulting in a lower incidence of cuffitis and theoretically no remaining risk of colon cancer. This surgery preserves intestinal continuity, improves quality of life, and significantly decreases the risk of colorectal cancer [2, 3, 13, 14].

The restorative proctocolectomy with IPAA is usually performed in 2 or 3 stages. The first stage involves colon and rectal resection with a diverting loop ileostomy and pouch creation. The loop ileostomy is then closed in the second stage, which is generally performed 8–12 weeks later. If a 3-stage procedure is performed, the first stage is usually a subtotal colectomy with loop ileostomy, and the second stage involves removal of the distal colon/rectum and formation of the “J” pouch. A single-stage procedure can be performed, but the majority of data indicate higher rates of anastomotic leaks and pelvic sepsis compared to multistage surgeries. In general, the optimal procedure depends on several disease and patient factors, including medication exposure, and is best considered on a case-by-case basis in consultation with an experienced surgeon in a high-volume center.