Subtotal colectomy with Deloyers colo-anal anastomosis for refractory ulcerative colitis: A case report

Abstract

BACKGROUND

Ulcerative colitis (UC) is a chronic inflammatory bowel disease often requiring advanced therapies, with up to 40% of patients experiencing non-response to anti-tumor necrosis factor agents. Tofacitinib offers rapid symptom improvement, but its long-term high-dose use and role in post-operative management are poorly documented. Subtotal colectomy with colo-anal anastomosis using Deloyers procedure is an uncommon alternative to standard proctocolectomy with ileal pouch-anal anastomosis.

CASE SUMMARY

We report the management of a patient with refractory extensive UC using prolonged high-dose tofacitinib followed by function-preserving subtotal colectomy. A 47-year-old male with extensive UC, refractory to 5-aminosalicylic acid and azathioprine, presented with severe disease activity. After primary non-response to infliximab, tofacitinib 10 mg twice daily was initiated, escalated to 10 mg thrice daily with a 5-aminosalicylic acid enema due to partial response. After four months, clinical remission was achieved, but endoscopy revealed a striking differential healing pattern, with endoscopic healing in the right colon (Mayo Endoscopic Score 0-1) but persistent severe inflammation distally (Mayo Endoscopic Score 3). Subtotal colectomy with Deloyers procedure was performed, followed by tofacitinib 10 mg twice daily post-operatively. At six-month follow-up, the patient was asymptomatic with only mild endoscopic erythema and histologic diversion colitis but no active UC.

CONCLUSION

This case highlights the novel use of prolonged high-dose tofacitinib, achieving differential mucosal healing, and function-preserving subtotal colectomy with post-operative tofacitinib to manage refractory UC. It underscores the importance of addressing clinical-endoscopic discordance and suggests a tailored medical-surgical approach for complex UC.

Keywords: Ulcerative colitis; Tofacitinib; Function-preserving subtotal colectomy; Clinical-endoscopic discordance; Differential healing; Case report

Core Tip: We report a rare case of refractory ulcerative colitis displaying “differential healing” following prolonged high-dose tofacitinib (10 mg thrice daily) rescue therapy. While the distal colon remained severely inflamed despite clinical remission (clinical-endoscopic discordance), the proximal colon achieved complete mucosal healing. This unique segmental response facilitated a function-preserving subtotal colectomy with Deloyers colo-anal anastomosis, avoiding a permanent stoma or ileal pouch. This case highlights a novel medical-surgical strategy leveraging differential healing to preserve colonic function and quality of life in complex scenarios.