From colon-sparing techniques to pelvic ileal pouch: history and evolution of surgery for ulcerative colitis

Background: Since the first decription of ulcerative colitis(UC) by Sir Wilkins from the London Guy’s Hospital in 1859, medical and surgical management have gradually evolved. Aims of this review are to describe the milestones and pioneers of surgery for UC, taking the readers on a journey through the steps that led to the development of restorative proctocolectomy with ileal pelvic pouch. Methods: This is an historical, narrative review. We reviewed scientific literature and historical archives, seeking for documentation of surgery of UC. Information were integrated with our personal experience, taking into accout patients’ perspective. Results: Different surgical approaches have been attempted over time, grounding on different concepts. As long as pathophysiology of UC has become clearer, surgeons have profoundly modified their attitudes toward this disease. Early approaches aimed at preserving organs, with “damage-control” surgery. Advances in knowledge and surgical skills led surgeons to demolitive treatments, which proved to be very effective, but with poor quality of life in most patients, especially in young, due to permanent stoma—even if continent ileostomy ameliorated patient satisfaction. On the other hand, straight ileoanal anastomosis, despite preserving trans-anal defaecation, resulted in inacceptably high bowel frequency. Restorative proctocolectomy was the turning point. By combining the concepts of disease removal, continence, and physiological evacuation, it has become the surgical treatment of choice in most UC patients. Conclusion: Choice and timing of treatment of UC need to be individualized. Besides surgical knowledge and techniques, the patient’s perspective must be examined closely. Restorative proctocolectomy is the mainstay.