Keywords
acute severe ulcerative colitis; left-sided colitis; subtotal colectomy; total abdominal colectomy; emergency surgery; colorectal surgery; systematic review
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Plascevic J, Jose MM, Hussein I et al. Establishing the optimal surgical approach for the acute presentation of left-sided colitis: a systematic review [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:1142 (https://doi.org/10.12688/f1000research.171820.1)
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Systematic Review
Establishing the optimal surgical approach for the acute presentation of left-sided colitis: a systematic review
[version 1; peer review: awaiting peer review]
PUBLISHED 20 Oct 2025
OPEN PEER REVIEW
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Abstract
Corresponding author:
Alishah Haider
Competing interests:
No competing interests were disclosed.
Grant information:
The author(s) declared that no grants were involved in supporting this work.
Copyright:
© 2025 Plascevic J et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Plascevic J, Jose MM, Hussein I et al. Establishing the optimal surgical approach for the acute presentation of left-sided colitis: a systematic review [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:1142 (https://doi.org/10.12688/f1000research.171820.1)
First published: 20 Oct 2025, 14:1142 (https://doi.org/10.12688/f1000research.171820.1)
Latest published: 20 Oct 2025, 14:1142 (https://doi.org/10.12688/f1000research.171820.1)
Introduction
Inflammatory bowel disease (IBD) is a significant global health issue, affecting approximately 0.3% of the world’s population.1 In the UK, the estimated prevalence is around 1 in 123 individuals, or approximately half a million patients.2 Ulcerative Colitis (UC) is form of IBD which primarily affects the colon,3 it can be further classified by the disease extent: proctitis (E1), left-sided colitis (E2) or extensive colitis (E3), or by the disease severity: mild (S1), moderate (S2) or severe (S3), as per Montreal classification.4 Within the IBD cohort of patients, a complex group of patients are those with acute severe ulcerative colitis (ASUC). Initial treatment is medical and typically involves intravenous steroids and then may include rescue biological therapy.5,6 However, despite the improvements in the medical management available, up to 30% of ASUC patients require surgical management, often in the form of colectomy, whilst being unwell.7
Deciding on what is the optimal operation for such high-risk individuals is therefore important. In the emergency surgical management of ulcerative colitis, subtotal colectomy (STC) with end ileostomy and a retained rectal stump,8 remains the standard operative approach. The term total abdominal colectomy (TAC) is frequently used interchangeably with STC; however, it technically denotes a more extensive resection that includes additional distal colonic or upper rectal segments. Both procedures are designed to remove the acutely diseased colon while avoiding pelvic dissection and preserving the potential for future restorative proctocolectomy. Conceptually, a TAC will remove the proximal colon and divide the sigmoid colon, potentially including a creation of mucous fistula. In patients with pancolitis, this operation aims to reduce the extent of the inflammatory load whilst also diverting the faecal stream from the rectum. However, such procedures will leave disease in the distal sigmoid and thus the continued inflammation there in.9
One particularly challenging group of patients is when the disease is severe but isolated to the left side of the colon (E1-E2). Such disease is estimated to account for approximately 20-30% of all UC cases.10 Acute presentations, refractory to medical management present in this cohort and may necessitate surgical intervention. However, it remains unclear as to what operation would be the most appropriate in this context. Subtotal colectomy leaves the risk of the diseases portion in E1 behind, likewise TAC may risk removal of significant lengths of near normal colon and leave the majority of the disease process unresected. However, pelvic dissection may come with significant risks in the acute setting and prevent the potential for restoration of GI continuity in the future. Thus, it remains unclear whether TAC is the optimal approach for patients with left-sided colitis. Other surgical interventions, such as a proximal diverting colostomy, may be more straightforward and less physiologically invasive, but their use in this context is not well documented.
To clarify the optimal surgical approach for acute left sided colitis refractory to medical therapy, we conducted a systematic review of the literature. Eligible studies were those involving adult patients (≥18 years) with left-sided UC undergoing surgical management following failed medical therapy. We systematically searched major databases, including Ovid MEDLINE, EMBASE, Cochrane Library, Web of Science, and Scopus, for studies published between 2001 and November 2023.
Methods
Protocol and registration
This review has been created in line with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement. The protocol was developed and registered to PROSPERO prior to analysis (PROSPERO CRD42023473654).
Eligibility criteria
Studies were eligible if they included adults (≥18 years) with left-sided UC (E1–E2, as defined by the Montreal classification) refractory to medical therapy who underwent surgery. Eligible interventions included TAC or any alternative surgical procedure for left sided colitis. Comparators could include other surgical approaches or standard medical management. Primary outcomes were patient-centred outcomes such as quality of life and satisfaction with surgery. Secondary outcomes included short- and long-term surgical outcomes such as length of hospital stay, morbidity, mortality, recurrence, bowel function, and nutritional status. Exclusion criteria included studies that involved Chron’s disease, pharmacological management only, isolated proctitis, rectal cancer, non-human subjects, or non-English publications.
Information sources
A comprehensive search was conducted across Ovid MEDLINE, EMBASE, the Cochrane Library, Web of Science, and Scopus. The search covered studies published from 2001 (marking the first use of infliximab for steroid-refractory UC) to 1 November 2023. Only studies in English and involving human participants were included.
Search strategy
A comprehensive literature search was developed with the support of an expert in literature searching. It was conducted across the following databases: Ovid MEDLINE and EMBASE ( Figure 1), the Cochrane Library ( Figure 2), Web of Science ( Figure 3), and Scopus ( Figure 4). The publication period was limited from 2001 (marking the first pilot study of infliximab use for steroid-refractory ulcerative colitis11) to 1 November 2023, when the search was performed. Other restrictions included the English language and studies involving human participants.
Figure 1. Search strategy used in Ovid MEDLINE and EMBASE databases (search conducted 1 November 2023).
Figure 2. Search strategy used in The Cochrane Library (search conducted 1 November 2023).
Figure 3. Search strategy used in Web of Science (search conducted 1 November 2023).
Figure 4. Search strategy used in Scopus (search conducted 1 November 2023).
Key search terms covered disease characteristics (‘ulcerative colitis’, ‘left-sided colitis’, ‘colitis gravis’, ‘idiopathic proctocolitis’, ‘inflammatory bowel disease’), treatment methods (‘surgical management’, ‘surgical treatment’, ‘surgical intervention’, ‘colectomy’, ‘subtotal colectomy’, ‘loop colostomy’, ‘sigmoidectomy’), and patient outcomes (‘quality of life’, ‘postoperative complications’, ‘surgical outcome’, ‘recurrence’, ‘length of stay’, ‘hospital stay’). The search strategy was tailored to each database to optimise retrieval. Full search strategies are provided in Figures 1–4.
Selection process
Inclusion and exclusion criteria were developed using the PICO framework (Population, Intervention, Comparison, Outcomes) and aligned with PRISMA guidelines12 to guide the systematic selection of studies. Population (P): adult (>18 years old) patients diagnosed with left-sided colitis (as per Montreal classification4) caused by UC, refractory to medical treatment, who underwent surgical management. Intervention (I): standard surgical management of UC patients - TAC. Comparison (C): any other type of surgical management used for left-sided colitis. Primary outcomes (O): patient-focused outcomes (eg., quality of life, satisfaction with surgery). Secondary outcomes included short-term and long-term surgical outcomes (e.g., length of hospital stay (LOS), morbidity rates, mortality rates, recurrence rates, bowel function, nutritional status, etc). Patients who only had pharmacological interventions or had isolated proctitis or rectal cancer were set to be excluded from the study.
A narrative review of those papers that did not fulfil the PICO criteria, but had relevance to answering the key question was also undertaken. For example, if the paper involved surgical interventions on patients with left-sided colitis but in the elective setting (not emergency), we decided to mark such manuscripts and undertake a commentary on their findings.
Screening of the studies (title, abstract) was independently conducted by three independent reviewers (JP, IH, MJ) employing the software Rayyan.13 Duplicate records were subsequently removed. Discrepancies between the studies in the screening stage were discussed and adjudicated with a senior reviewer (GR). In the full-text screening, the process was repeated utilising the same principle where a senior reviewer was involved in resolving the discrepancies. The PRISMA flow chart is available as Figure 5.
Figure 5. PRISMA 2020 flow diagram illustrating the study selection process for inclusion in the systematic review.
Data extraction
Data extraction was planned to be conducted by three independent reviewers (JP, IH, MJ). In the event of discrepancies, a senior reviewer (GR) was to be involved in resolving disagreements through discussion. All studies were to be evaluated for eligibility prior to data extraction. Subsequently, data from eligible studies would have been extracted by two independent reviewers using a predefined Excel form. Extracted data would have included study population. If necessary, missing data would have been sought by contacting study investigators for unreported information or additional details.
Data items
Data were collected on study characteristics, patient demographics, disease extent, type of surgical procedure, comparator, and outcomes.
Primary outcomes comprised patient-centred measures such as quality-of-life post-surgery. Secondary outcomes comprised peri-surgical and long-term outcomes including morbidity, mortality, recurrence, and bowel function.
Risk of bias assessment
The planned assessment of selected studies was to employ the GRADE system (Grading of Recommendations Assessment, Development, and Evaluation),14 which would evaluate study limitations, inconsistency, indirectness, imprecision, and publication bias. Following the same principles for article screening, three reviewers would have applied these criteria to each study and outcome, with another reviewer resolving discrepancies.
Effect measures
For comparative studies, dichotomous data were to be summarised using odds ratios or risk differences, and continuous data using mean differences.
Due to the absence of eligible studies, quantitative synthesis was not performed.
Synthesis methods
A meta-analysis was planned if sufficient homogeneous data were available. In its absence eligible randomised controlled trials, a narrative synthesis was conducted to summarise available findings and highlight gaps in the literature.
Reporting bias assessment
Assessment of reporting bias, including publication bias and selective reporting, was planned using funnel plot analysis and protocol comparison where applicable. This was not performed because no eligible studies met inclusion criteria.
Certainty assessment
The overall certainty of evidence for each outcome was to be assessed using the GRADE framework. As no studies met inclusion criteria, this assessment was not undertaken.
Study registration
The study protocol was registered on the PROSPERO website15 prior to completing the review (CRD42023473654).
Results
Study selection
A total of 6,606 records were identified through database searching. After removing duplicates and screening titles and abstracts, 127 full-text articles were assessed for eligibility. No studies met the inclusion criteria for patients with acute left-sided ulcerative colitis undergoing surgery. Six studies examining surgical management of UC in related contexts (such as elective surgery or non-acute settings) were narratively reviewed. The study selection process is summarised in the PRISMA flow diagram ( Figure 5).
Study characteristics
Despite a systematic approach exploring as comprehensive a search as possible we were unable to identify any suitable papers that were eligible for inclusion. There were, however, six papers that did explore the surgical management of left-sided colitis in other settings, such as elective presentations or in patients without acute flares ( Table 1). We therefore continued to undertake a narrative review of this literature.
Table 1. Characteristics of the studies discussed in the review.
| Study | Country | Intervention | Outcomes | Exclusion reason |
|---|---|---|---|---|
| Zaharie et al. 201316 | Romania | Multiple | Outcome of surgical interventions in CD and UC patients | No comparison of interventions, not focused on acute presentations |
| Gu et al. 201317 | US | Laparoscopic TAC for UC:
| Postoperative outcomes of intraperitoneal compared to subcutaneous group | No subgroup assessment of left-sided colitis |
| Jain et al. 201718 | India | Colectomy in left-sided vs extensive colitis |
| No comparison of surgical interventions, colectomy was outcome |
| Carpenter et al. 202319 | US | TAC versus PC | 30-d postoperative outcomes | Elective surgeries included, no stratification of outcomes by disease extent |
| Frontali et al. 202020 | Europe/US | Segmental colectomy | Postoperative complications, long-term results, risk factors for postoperative colitis, re-operation for colitis on the remnant colon | Elective surgeries, no outcomes for medically refractory colitis |
| McKenna et al. 201921 | US | Semi-urgent1 TPC with IPAA, semi-urgent TAC, or elective TPC with IPAA | 30-d major morbidity and organ space infection | Elective surgeries included, no stratification of outcomes by disease extent |
Zaharie et al.16 is a retrospective single centre retrospective study that discussed the surgical management of 221 IBD patients. A total of 33 (14.93%) patients underwent surgical management, including 16 UC patients. Patients were grouped into those with (n = 3) or without (n = 13) proctectomy. The commonest indication for surgery was the failure of medical management (n = 7). Authors reported no complications or postoperative morbidity. While surgical management and postoperative outcomes were stratified by disease extent, the study did not compare outcomes for different surgical interventions or whether surgeries were performed for acute colitis, leading to its exclusion ( Table 1).
Gu et al.17 conducted a retrospective cohort study on 204 UC patients undergoing laparoscopic colectomy, comparing outcomes between intraperitoneal (n = 99) and subcutaneous (n = 105) placement of the rectal stump. Of these, 104 (55%) had TAC for limited left-sided colitis. Only one (0.5%) postoperative death occurred in the subcutaneous group, and there were no significant differences in reoperation rates or overall morbidity. Again, the study did not provide a specific subgroup analysis for left-sided colitis or focus on outcomes related to acute colitis presentations, limiting its relevance to our review ( Table 1).
Jain et al.18 retrospectively assessed colectomy rates in patients with left-sided colitis compared to extensive colitis following an index episode of ASUC in a single centre. Out of a cohort of 2,076 patients with UC, 241 (11.6%) experienced ASUC, with 34 (14.1%) requiring colectomy during the index admission. Among those with ASUC, 85 (35%) presented with left-sided colitis at the time of hospitalisation. Colectomy rates were similar for left-sided colitis (10 [11.9%]) and extensive colitis (24 [15.4%]). No significant differences occurred in long-term outcomes, including colectomy-free survival rate, mortality, readmission rates (due to repeat ASUC), the number of relapses per year or duration of remission between the two groups ( Table 2). This study assessed colectomy rates in patients with an acute UC and provided a comparison of long-term outcomes based on the disease extent. However, it did not compare different surgical interventions and focuses solely on colectomy as an outcome, thus falling outside the scope of our review ( Table 1).
Table 2. Patient outcomes across discussed studies.
| Study | Sample size (N) | Any complication N (%) | Reoperation N (%) | Mortality N (%) | Morbidity N (%) | Postoperative LOS (d [med, IQR]) |
|---|---|---|---|---|---|---|
| Zaharie et al.16 | 166 | NA | NA | NA | NA | NA |
| Gu et al.17 | 204 | NA | 9 (9) vs 6 (6) | 0 (0) vs 1 (1) | 37 (37) vs 44 (42) | 4 (2-30) vs 4 (2-32) |
| Jain et al.18 | 2076 | NA | NA | 2 (2.4) vs 6 (3.8) | NA | NA |
| Carpenter et al.19 | 18461 | 343 (37.2) vs 291 (31.5)* | 88 (9.5) vs 91 (9.9) | 55 (6) vs 44 (4.8) | NA | 7 (4-12) vs 7 (4-12) |
| Frontali et al.20 | 72 | NA | NA | NA | NA | NA |
| McKenna et al.21 | 3763 | NA | NA | 0 (0) vs 7 (<1)2 | 28 (28) vs 558 (20)2* | NA |
| NA | NA | 0 (0) vs 6 (1)3 | 28 (28) vs 175 (22)3 | NA |
Carpenter et al.19 utilized the American College of Surgeons – National Surgical Quality Improvement Program database to compare postoperative outcomes of partial colectomy (PC) and TAC in unmatched (n = 9,888) and matched (n = 1,856; 1:1) cohorts. Post-matching, patients undergoing TAC had higher overall 30-day post operative complications (41.9% versus 36.5%, P = 0.017) and serious complications (37.2% versus 31.5%, P = 0.011). Although TAC patients suffered from more postoperative VTE (6.4% versus 3.6%, P < 0.005), rates of most other individual outcomes were similar between the groups. When restricted to emergency settings, there was no significant difference in outcomes between TAC and PC ( Table 2). Despite reporting the comparison of outcomes between PC and TAC, this study was excluded as it did not stratify outcomes by disease extent and included elective surgeries ( Table 1).
Frontali et al.20 conducted a multicentred retrospective study reporting the outcomes associated with segmental colectomy in 72 UC patients without active colitis patients. Early (<30 d) postoperative complications occurred in 17 (24%) patients, including three (4%) postoperative deaths. No cases of ASUC were reported during that timeframe. Five patients (7%) experienced early UC flares within three months, all requiring reoperation. Late UC flares occurred in 29 (45%) patients, with 12 (41%) needing surgical intervention. Over a median follow-up of 40 months, 24 (35%) patients underwent re-operation, primarily for refractory colitis (n = 14) ( Table 2). Although disease extent was mentioned, postoperative outcomes were not stratified by the disease extent, the operations were mostly elective, and surgeries were not performed for refractory medical treatment, making this study irrelevant to our review ( Table 1).
McKenna et al.21 evaluated 3,763 UC patients for 30-day major morbidity following semiurgent total proctocolectomy (TPC) with IPAA (n = 101), semiurgent STC (n = 797), and elective TPC with IPAA (n = 2,865). Major morbidity was higher in semiurgent TPC with IPAA (28%) compared to elective TPC with IPAA (22%) (P = 0.04), with the largest differences seen in organ space infection (19% vs 8%, P < 0.01) and postoperative sepsis (16% vs 7%, P < 0.01) ( Table 2). No significant difference was observed in major morbidity between semiurgent TPC with IPAA and semiurgent STC (28% vs 22%, P = 0.19), though organ space infections were more frequent in the TPC group (19% vs 9%, P < 0.01). Although this study provides outcomes based on surgery type in semiurgent settings, it does not stratify results by disease extent, limiting its applicability to our focus on acute left-sided colitis ( Table 1).
Synthesis of results
No eligible studies addressed surgical management in acute left-sided colitis. The related studies reviewed provided indirect evidence, primarily from elective or non-acute settings. Collectively, they showed similar postoperative outcomes between different colectomy types, with no clear advantage of one surgical approach for left-sided disease.
Risk of bias in studies and reporting bias and certainty of evidence
As no studies met inclusion criteria, formal risk of bias assessment was not undertaken. Given the absence of eligible studies, assessment of reporting bias and grading of the certainty of evidence using GRADE could not be performed.
Discussion
To the best of our knowledge, this is the first exploration of the optimal surgical management of isolated left-sided colitis during an acute flare, primarily in patients with UC. Despite an extensive search undertaken in a systematic manner, our most striking finding is that there were no suitable papers to include to address this question. Acute flares of left-sided colitis remain a common problem and unfortunately cannot always be treated in a medical fashion. Which is the optimal operation for such patients thus remains unanswered.
There was a total of six papers which were identified as relevant but could not be included in a true systematic review. Most of these studies lacked outcomes stratified by the disease extent (ie, left-sided colitis) while others focused solely on colectomy as the primary outcome or evaluated outcomes in elective settings. It is also of note that most of these papers were retrospective and in single centres. Thus, each were of limited quality and offered limited value for the on-call colorectal surgeon when faced with this problem.
We also observe that there is a significant heterogeneity in approach of the operations performed in this cohort. Broadly speaking, the comparison occurred across surgical interventions (TAC versus TPC- IPPA), timing (urgent versus elective), or postoperative outcomes (segmental colectomy, colectomy following index hospitalisation for ASC). Future work would benefit significantly from a homogenisation of definitions in this field.
Frontali et al.20 evaluated the outcomes of segmental colectomy (SC) in patients without active colitis. Although early postoperative recurrence occurred at a relatively low rate (7%), 45% of patients developed recurrent colitis in the residual colon, and 35% required reoperation. Similar results were reported by Yilmaz et al., 22 who observed early postoperative colitis in 9.1% of cases and late recurrence in 14.5%. Collectively, these findings suggest that SC should be avoided in the setting of acute colitis flares, given the high risk of recurrence and the frequent need for subsequent surgery. SC may have a limited role in carefully selected patients—such as older individuals with significant comorbidities and quiescent disease—where the risks of extensive surgery are prohibitive. However, segmental colectomy and other limited resections in the acute setting are not supported by evidence and are associated with unfavourable outcomes due to residual disease, recurrent inflammation, and delayed definitive management. Likewise, urgent ileal pouch–anal anastomosis (IPAA) appears suboptimal for patients presenting with low disease burden acute colitis flares,21 as this could mean resecting segments of otherwise healthy colon.
When disease activity is primarily confined to the sigmoid colon and rectum, total abdominal colectomy (TAC) results in resection of predominantly normal right and transverse colonic segments. Consequently, this approach may confer limited benefit in terms of disease control, as only a small proportion of affected bowel is removed. The observed improvement in such cases is likely attributable to diversion of the faecal stream through the creation of an ileostomy. Rescue diverting loop ileostomy (RDLI) has also been employed in other severe colitis during pregnancy associated with acute ulcerative pancolitis.23,24 The therapeutic effect of RDLI is thought to derive from interruption of the inflammatory cycle of mucosal injury characteristic of severe colitis. Faecal diversion may relieve intraluminal pressure, reduce bacterial translocation, and protect the inflamed mucosa, thereby promoting mucosal healing and clinical stabilisation.
Russell et al. assessed 33 IBD patients who underwent RDLI.25 More than 90% patients avoided urgent or emergent colectomy. Furthermore, >80% had reduced steroid dependence or bridge to medical rescue therapy, these patients showed improved enteral intake and nutritional status and were able to undergo a definitive laparoscopic procedure or ileostomy reversal with colon salvage. The use of RDLI was supported by The American Society of Colon and Rectal Surgeons. In 2021 guidelines for surgical management of UC, they suggested a consideration of RDLI in the setting of acute, severe UC to potentially avoid an emergent TAC.26 Future trials could assess TAC versus RDLI. It is nevertheless of note that there are few papers specifically concentrating on the management of acute left-sided colitis patients requiring an operation.
This study has several strengths. It was undertaken in a comprehensive manner utilising standard systematic review approaches. That there are no studies which met the inclusion criteria underscores the gaps in the current literature, rather than reflecting limitations in our methodology. This review highlights a clinically significant problem in a large cohort of UC patients. Our weaknesses are in the lack of published literature available for analysis. Given the lack of specific, robust data, it may be beneficial to develop a registry or multicentred collaboration to systematically assess how surgeons assess and manage acute left-sided colitis across the colorectal community.
Conclusion
Colorectal surgeons frequently encounter the complex challenge of managing acute colitis with disease confined to the left side of the colon. In such cases, total abdominal colectomy (TAC) remains the standard emergency operation; however, this procedure involves extensive resection of macroscopically normal bowel and represents a substantial physiological burden for acutely unwell patients. Despite its widespread use, the evidence supporting TAC as the optimal approach for left-sided colitis is limited, and its applicability to this specific disease distribution remains uncertain.
Alternative surgical strategies, including more limited resections or faecal diversion procedures, have been described in select clinical contexts, but these approaches lack robust evidence in the setting of acute ulcerative colitis. Well-designed, multicentre prospective studies or registry-based analyses are therefore needed to clarify the relative safety and efficacy of different surgical options in patients with left-sided disease. Such data are essential to inform evidence-based decision-making, optimise patient outcomes, and reduce the morbidity associated with emergency colectomy in this challenging cohort.
Author contributions
Josip Plascevic and Mefin Mathew Jose contributed equally to this work and share first co-authorship.
Reporting guidelines
Zenodo: PRISMA 2020 checklist for “Optimal emergency surgical strategy for acute left-sided colitis: a systematic review.” DOI: https://doi.org/10.5281/zenodo.17290364.27
License: Creative Commons Attribution 4.0 International (CC BY 4.0).
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Plascevic J, Jose MM, Hussein I et al. Establishing the optimal surgical approach for the acute presentation of left-sided colitis: a systematic review [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:1142 (https://doi.org/10.12688/f1000research.171820.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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