Urgent subtotal colectomy for ulcerative colitis: a Modified Delphi e-consensus on behalf of the Italian Society of Colorectal Surgery (SICCR)

Abstract

Acute severe ulcerative colitis (ASUC) affects up to 25% of patients with ulcerative colitis, with 20–40% ultimately requiring urgent subtotal colectomy. Despite established guidelines on the medical management of ASUC, current recommendations from guidelines do not address the procedural and technical aspects of the operation itself. Significant variability in surgical practice has been documented even among high-volume Italian inflammatory bowel disease (IBD) centers. A national e-consensus was conducted using a modified Delphi method. Fifteen expert colorectal surgeons members of Italian Society of Colorectal Surgery (SICCR) from 15 high volume IBD surgical Units (13 Italian, 2 international) evaluated 14 statements across four procedural domains. Each statement was rated on a 4-point ordinal scale (1 = full agreement; 4 = disagreement). Statements achieving > 75% full agreement or ≥ 80% combined full agreement + agreement were classified as appropriate. Uncertain statements were revised and resubmitted for a second voting round. In the first round, 8 of 14 statements achieved consensus; 6 were classified as uncertain and revised for resubmission. All six revised statements achieved consensus in the second round. The final document comprises 11 consensus statements addressing: management of the rectal stump and drainage (5 statements), role of the greater omentum (1 statement), laparoscopic versus open surgical approach (3 statements), and management of the mesocolon (2 statements). This e-consensus provides the first structured, evidence-graded procedural guidance for urgent subtotal colectomy in acute severe ulcerative colitis (ASUC), covering technical aspects not addressed by current international guidelines. These recommendations aim to reduce practice variability and support standardized surgical decision-making across IBD centers.