Indications, modalities, and outcomes of surgery for ulcerative colitis in 2024

•Aside from absolute emergencies for which surgical intervention is obviously required, the overwhelming majority of indications for surgery necessitates multidisciplinary discussion in a center specialized in inflammatory bowel disease, the reason being that multiple medical options may be proposed, even in non-elective situations.•In cases of refractory colitis, the choice between a new line of medical treatment and a surgical procedure is singularly complex. It is necessary to weigh chronic symptoms of the disease, which may be experienced as a burden, against the risks of complications and sequalae, subsequent to the operation.•The appearance of dysplastic lesions should be considered as a turning point in the evolution of monitored ulcerative colitis (UC). Detection of dysplastic lesions necessitates: (1) chromoendoscopy surveillance with staged biopsies of all visible lesions in the colonic framework, (2) anatomopathological verification, and (3) multidisciplinary discussion aimed at deciding on surgical or endoscopic management, which remains reserved for only a limited number of selected patients.•With regard to UC, total proctocolectomy with ileo-anal anastomosis (TCP-IAA) is the surgical treatment of reference insofar as it enables patients to be cured of the disease, while limiting functional digestive sequelae. It can be carried in one, in two modified, or in three phases. Treatment of ulcerative colitis (UC) has been revolutionized by the arrival of biotherapies and technical progress in interventional endoscopy and surgery. (Sub)total emergency colectomy is required in the event of complicated severe acute colitis: colectasis, perforation, hemorrhage, organ failure. Corticosteroid therapy is the reference treatment for uncomplicated severe acute colitis, while infliximab and ciclosporin are 2nd-line treatments. At each step, before and after each line of treatment failure, surgery should be considered as an option. In cases refractory to medical treatment, the choice between surgery and change in medication must weigh the chronic symptoms associated with the disease against the risks of postoperative complications and functional sequelae inherent to surgery. Detection of dysplastic lesions necessitates chromoendoscopic imaging with multiple biopsies and anatomopathological verification. Endoscopic treatment of these lesions remains reserved for selected patients. These different indications call for multidisciplinary medical-surgical discussi