Abstract: Ulcerative colitis (UC) is one of the inflammatory bowel disease (IBD), a chronic inflammatory disease that occurs in the mucosa of the colon and rectum.UC currently focuses on medical treatment, while surgical treatment is also an important tool in the treatment of UC. Total colorectal resection and ileal pouch-anal anastomosis (IPAA) is the preferred surgical procedure for UC patients. Mastering the strategies and technical points of this procedure can help to improve the success rate, reduce the complication rate, improve the patient’s prognosis and improve the patient’s quality of life. Ulcerative colitis (UC) is a chronic inflammatory disease that occurs in the mucosa of the colon and rectum, and most patients with UC can be effectively managed with medical therapy, but 15% to 30% of UC patients still require surgical treatment. Studies have shown that up to 10% of patients require elective or emergency surgery within the first year of diagnosis. Choosing the right timing for surgery is critical for patients with UC. The National Inpatient Repository compares data related to the timing of surgery for patients with UC, counting deaths after surgery performed at ≤3 d of hospitalization, >3 to 6 d, >6 to 11 d, and >11 d. It was found that the morbidity and mortality rate gradually increased with delay in surgery. Delaying surgery may lead to deterioration of physiological reserve and further aggravation of the patient’s malnutrition; inappropriately delaying surgery, on the contrary, deprives the patient of the best time for surgical treatment and reduces the patient’s benefit. In 2006, the Chinese Inflammatory Bowel Disease Collaborative Group conducted a retrospective study of 3100 cases of UC patients in 23 hospitals in 11 regions, and found that patients with UC in China were mainly mild (35.4%) and moderate (42.9%), mostly treated with internal medicine, and the rate of surgery was only 3%. Deng Weiping et al. included 312 cases of inpatients with UC in Peking Union Medical College Hospital from August 1998 to September 2009, and their analysis found that the surgery rate of inpatients with UC was 10.9% and the surgery mortality rate was 5.9%; among them, the surgery rate of patients with severe UC was 23.9%, which was higher than other domestic reports of 3.0% to 17.9% and close to the 30% reported abroad. UC patients with high disease severity, extensive lesions, and hormone resistance are more likely to require surgical treatment. Not surprisingly, the current rate of surgery for domestic UC patients is low. It is generally believed that surgery can cure UC, reduce medical costs, most postoperative complications can be avoided, and postoperative quality of life can be significantly improved. Therefore, China should pay attention to the surgical treatment of UC. The surgical treatment of UC has a variety of surgical methods, including total colorectal resection, ileal pouch-anal anastomosis (IPAA) has now become the preferred surgical method for UC. IPAA procedure is modified from the direct ileo-anal anastomosis and controlled ileostomy adopted in the 1840s. To address the patient’s postoperative defecation dysfunction such as frequency and urgency, Valiente and Bacon first described IPAA in experimental animals in 1955. they constructed the pouch in three different ways in dogs: one with the bottom of the pouch facing the cephalic side, one with the bottom of the pouch facing the caudal side, and one with three bowel tabs. The greatest difficulty encountered in performing the procedure was obtaining sufficient length of ileum, which was not long enough to put tension on the anastomosis, leading to the occurrence of anastomotic leakage. Although 5 of the 7 animals died postoperatively (3 from anastomotic leak, 1 from hypokalemia, and 1 from peritonitis), the 2 that survived had promising results. In these 2 animals, a satisfactory storage pouch was successfully constructed, with complete preservation of sphincter function, a reduction in the number of bowel movements as well as a change in stool character from pasty to formed, and little perineal irritation. This procedure was not performed in UC patients because of the rather high mortality rate in animals at that time. 1969-1978 Controlled ileostomy (continuous ileostomy) was the main surgical procedure for UC, but it was complicated, had a high complication rate, and had the potential for loosening of the pouch. 1978 Parks at St. Mark’s Hospital, London, UK first reported the application of IPAA with an S-shaped storage bag in a patient and achieved satisfactory results. Since then, IPAA has rapidly replaced controlled ileostomy and has been widely used, mainly because it is safe and effective, with a low complication rate and morbidity and mortality rate of 19%-27% and 0.2%-0.4%, respectively. In addition, IPAA uses the terminal ileum to make a storage pouch and anastomoses with the anal canal, which preserves the function of the anal sphincter and maintains the continuity of the digestive tract, avoids permanent stoma, improves the patient’s quality of life, and is basically close to that of a normal person. A, UC surgery indications and timing drug treatment is ineffective in persistent UC, hormone dependence or intolerance and in colitis based on the occurrence of mucosal atypical hyperplasia or malignant patients are indications for surgery. The 2015 European Crohn’s and Colitis Organisation (ECCO) consensus highlights Two time points, day 3 and day 7: the main treatment for severe UC is usually intravenous administration of methylprednisolone 60 mg/d or hydrocortisone 100 mg four times a day; determination of the effectiveness of intravenous hormones is usually best assessed objectively around 3 d after use, at which point the option of surgery should be discussed for patients with poor hormonal results, and for patients who have not used azathioprine If the patient is not willing to undergo surgery, second-line drug therapy, including infliximab and cyclosporine, can be used; after 7 d of treatment with the above drug regimen, if the clinical situation is still not in remission, surgical resection of the colon is recommended; further prolongation of drug therapy not only does not benefit the patient, but adds to the inevitable complications of surgery. The consensus also emphasizes that the surgeon should be asked to discuss any clinical need to adjust the drug regimen throughout the course of treatment. Suspected Crohn’s disease, poor anal sphincter function, or resected anal sphincter are contraindications to IPAA; while obesity, emergency surgery, steroid use, and patients with suspected colitis are relative contraindications to IPAA [10]. Patients with psychological problems, emotional instability, poor motivation and compliance have difficulties in adapting to the psychological stress associated with storage bags and should be carefully evaluated preoperatively. Regarding the suitability of IPAA in elderly UC patients, the 2014 guidelines for the surgical treatment of ulcerative colitis developed by the American Association of Colorectal Surgeons Task Force on Standards concluded that total colectomy combined with IPAA is indicated for elderly UC patients and that physiologic age cannot be used as a mere exclusion criterion, but more consideration needs to be given to potential comorbidities as well as the patient’s mental status and anal sphincter function. II. Surgical strategy 2.1 Difference between emergency surgery and elective surgery Depending on the patient’s different disease conditions, surgical options can be divided into emergency surgery and elective surgery. The main purpose of emergency surgery is to stop the continued deterioration of the disease and save lives; the purpose of elective surgery is to completely remove the diseased bowel segment with the aim of curing the disease. Emergency surgery is commonly used for patients with toxic megacolon, intestinal perforation, fulminant UC and acute hemorrhage; elective surgery is used for most UC patients. Patients with emergency surgery are critically ill, in poor general condition, and cannot tolerate a wider range of surgery; patients with elective surgery are less ill, in good general condition, and can tolerate surgery. Emergency surgery is mostly performed in three stages, while elective surgery is mostly performed in two stages. 2.2 Perioperative drug use For patients with UC who require surgical treatment, one of the more important concerns of surgeons is the preoperative medication of the patient. Several studies have shown that glucocorticoid use can increase the incidence of postoperative complications in patients with UC. A study including 8260 patients with CD and 7235 patients with UC showed that although preoperative hormone use did not increase mortality in UC patients (1.7% vs. 2%), postoperative infectious complications (intra-abdominal infections, abscesses, and infectious shock) were significantly higher (19.4% vs. 15.6%), in addition to incisional dehiscence (2.4% vs. 1.1%), intraoperative In addition, the incidence of incisional dehiscence (2.4% vs. 1.1%), intraoperative blood transfusion (9.8% vs. 6%), reoperation after bowel surgery (9.1% vs. 6.9%), and deep vein thrombosis (5.4% vs. 2%) were all increased to varying degrees; relative to CD, preoperative hormone application also increased the incidence of postoperative pulmonary embolism in UC patients (1.5% vs. 0.4%). Studies have shown that preoperative application of methylprednisolone ≥20 mg/d or other glucocorticoids equivalent to this dose for >2 months in adults is a risk factor for surgical complications, and its duration and dose are positively associated with postoperative infection, anastomotic leak, venous thrombosis, and reoperation rates; the incidence of major postoperative complications increases 5-fold when prednisolone <20 mg daily, while 60 mg daily the risk is increased to 18-fold or higher. Therefore, if other medications can be used to control the disease, preoperative glucocorticoid dosage should be minimized or glucocorticoid treatment should be discontinued for at least 3 months before surgery, which can effectively avoid numerous surgical complications caused by glucocorticoids. It is important to note that the gradual reduction or discontinuation of glucocorticoids should not delay the timing of surgical treatment, thus affecting the outcome of treatment. 5-ASA agents such as salazosulfapyridine and mesalazine can be discontinued 1 d before elective surgery and resumption of drug therapy can be started 3 d after surgery. The preoperative application of purine immunosuppressants and cyclosporine does not increase the incidence of surgical complications, and purine immunosuppressants are generally discontinued 4 weeks before surgery. In patients with complications such as infection, it is recommended that cyclosporine be discontinued 1 week prior to surgery and that reapplication of cyclosporine be required beyond 1 week postoperatively or until the surgical incision has completely healed to maintain remission, but discontinuation may lead to recurrence or exacerbation of disease. in a study by Afzali et al, 15 of these patients who used methotrexate alone or in combination with methotrexate compared with those who did not found no increase in postoperative complications. Although there is no clear evidence that methotrexate increases postoperative complications, it is recommended that it be discontinued 1 week prior to surgery. The use of biologic anti-tumor necrosis factor alpha (anti-TNF-alpha) agents is increasing, with infliximab (IFX) being more commonly used in clinical practice. Zittan et al. included 758 UC patients (196 preoperatively on IFX and 562 not on IFX) and found that preoperative use of IFX did not significantly increase the incidence of complications in patients after IPAA: incisional infection (14.8% vs. 14.1%), pelvic abscess (19.9% vs. 17.1%), anastomotic leak ( 13.2% vs. 11.7%), deep vein thrombosis (5.1% vs. 4.1%) and intestinal obstruction (21.4% vs. 16.4%). Several other studies also compare support that preoperative use of IFX does not have an effect on early or late postoperative complications. In addition, some studies have suggested that preoperative IFX application increases the incidence of postoperative complications. anti-TNF-α was first demonstrated to have an adverse effect on postoperative complications in a study by Selvasekar et al. They found that IFX was the only risk factor associated with postoperative infection complications in 301 UC patients (47 with IFX) undergoing stage II IPAA, and that In a retrospective study of 523 patients with IPAA, Mor et al. found a 13.8-fold increase in postoperative infectious complications in those with preoperative IFX, thus advocating the use of a three-stage procedure. One study found an increased rate of serious infections as well as morbidity and mortality in patients over 65 years of age treated with IFX.In September 2015, the Crohn's and Colitis Foundation of America (CCFA) released an opinion letter on anti-TNF-α antibody therapy before and after intestinal surgery for inflammatory bowel disease stating that in patients with chronic UC, anti-TNF-α therapy may increase postoperative complications, especially for stage II IPAA and is an absolute contraindication to stage I IPAA, while performing subtotal colectomy (or stage III IPAA) is safe and feasible. in a recent Meta-analysis, Selvaggi et al. included 7 studies, 162 with preoperative biologics and 468 as controls, all patients undergoing IPAA for the first time. Their analysis found that preoperative use of IFX increased early reservoir bag-related complications (OR=4.12; 95% CI, 2.37 to 7.15; P<0.001) and post-stoma closure-related complications (OR=2.27; 95% CI, 1.27 to 4.05; P=0.005) in UC patients undergoing IPAA for the first time; in addition, they also studied 777 In an analysis of 777 UC patients who used preoperative biologics (2939 in the control group) but were not considered for surgical procedures, they found that preoperative use of biologics did not increase postoperative complications (OR=1.19; 95% CI, 1.00 to 1.42; I2=46%).In 2014, the guidelines for the surgical treatment of ulcerative colitis developed by the American Association of Colorectal Surgeons Task Force on Specifications stated , the effect of preoperative application of IFX on postoperative complications is inconclusive and limited to observational studies, which have not been uniform in their selection of populations and also lack a uniform definition of complications. Therefore, larger, multicenter studies with uniform surgical approaches and definitions of complications are needed to confirm this. 2.3 Three-stage surgery Three-stage surgery is mostly used in patients who require emergency surgery or who are at high surgical risk. A three-stage procedure is performed by first performing a subtotal colectomy and terminal ileostomy in one stage, followed by a residual colorectal resection and IPAA with an ileostomy in the second stage, and finally a stoma return in the third stage. The three-stage strategy provides clinical time to improve the patient's nutritional status, adjust preoperative anemia, and avoid systemic inflammatory reactions. The management of the rectal stump after subtotal colectomy remains somewhat controversial. One approach is to close the rectal stump intraperitoneally, that is, to transect the intestinal canal at the level of the upper rectum in the peritoneal cavity and perform Hartmann closure. Another approach is to place the rectosigmoid stump outside the peritoneum, i.e., to transect the intestinal canal at the level of the distal mid-sigmoid colon and then drag the remaining rectosigmoid colon out and place it outside the peritoneum, bringing the distal intestinal segment as a separate stoma from the surface of the abdominal wall, the so-called mucous fistula. This practice reduces the incidence of pelvic abscess complications, which has been reported in the literature to be 0-4%, and facilitates pelvic freeing during second-stage surgery. gu et al. performed a retrospective analysis of this issue of rectal stump management, which included 99 patients with intraperitoneal and 105 patients with extraperitoneal placement, and found that the overall postoperative complication rate, the incidence of pelvic abscesses, and the length of hospital stay and stump The differences in overall postoperative complication rates, pelvic abscess rates, as well as length of hospital stay and stump leak rates were not statistically significant, with extraperitoneal placement having a relatively high incidence of stump leak but less severe symptoms and intraperitoneal placement having the advantage of shorter operative time, less intraoperative bleeding and faster bowel recovery function. A variety of stump-related complications may occur in the residual rectum, such as rectal stump leakage, stump bleeding, pelvic infection, incisional infection, and cancer. Stump leakage can lead to pelvic infections, which can usually be treated by CT-guided percutaneous puncture and drainage or antibiotics. Pellino et al. treated the infectious complications of rectal stump by rectal irrigation and demonstrated that this method is well tolerated by patients and can avoid secondary stoma and improve the quality of life, especially for elderly people who need complete recovery before total rectal resection. The risk of deterioration of the residual rectum is 0-25%, especially in patients with a long course, extensive lesions, and abnormal growths found in the resected colon. For patients with high risk of cancer, strict follow-up monitoring is essential for early detection and timely management. Two patients in the author's unit presented with residual rectal bleeding, one improved after interventional embolization, and the other had recurrent hemorrhage after endoscopic hemostasis and was given surgical resection to complete the storage pouch anal anastomosis. 2.4 Second-stage surgery Elective IPAA is usually performed in two stages. First, total colorectal resection, construction of a storage pouch and a diverting ileostomy are performed in phase I, followed by stoma return in phase II. Compared to a three-stage procedure, the second stage avoids an additional surgery, has a shorter hospital stay, uses fewer anesthetic drugs, and returns the stoma earlier. A recent study of modified second-stage IPAA (IPAA with subtotal colectomy and ileostomy followed by rectal resection and non-transferable stoma) showed a significant reduction in the incidence of anastomotic leakage with modified second-stage surgery compared to conventional second-stage surgery. 2.5 Phase I surgery Currently, it is thought that patients with UC who meet certain criteria for IPAA can undergo IPAA without prophylactic stoma and proceed directly to phase I. Some studies have shown a higher incidence of postoperative bowel obstruction after closure of a diverting stoma and a higher rate of rehospitalization within 30 d in patients with IPAA compared to other colorectal procedures. It has also been suggested that in patients who meet certain criteria, performing IPAA without a diverting stoma does not increase the rate of pouch failure and does not affect quality of life. One study found that prophylactic stoma could be avoided at the time of IPAA in patients without intraoperative complications or technical difficulties and without risk of anastomotic leak such as anemia (hemoglobin <135 mg/L), malnutrition (albumin <35 mg/L), and a history of long-term hormone use (prednisone ≥20 mg for more than 3 months); furthermore, in terms of total patient costs including IPAA, stoma reimbursement, and In addition, the total patient costs, including IPAA, stoma reimbursement, and complication management, were 25% higher in the stoma group than in the no-stoma group. In general, patients who underwent a phase I IPAA were generally younger, healthier, not obese, did not have anemia or hypoproteinemia, did not use or use low doses of immunosuppressants, and had a smooth procedure with low intraoperative blood loss, good blood supply to the reservoir bag, and a tension-free and intact anastomosis.