Ulcerative colitis (UC) is a chronic, idiopathic, inflammatory bowel disease characterized by a relapsing and remitting course.1, 2, 3 In recent years, there has been a significant global rise in the number of individuals diagnosed with inflammatory bowel disease (IBD), particularly in developing countries.4, 5 In Brazil, studies have reported an increasing incidence and prevalence of UC between 2012 and 2020, sparking speculation about a proportional rise in surgical procedures required for UC management.6 Conversely, the availability of advanced therapies, including biologics and small molecules, has expanded within Brazil's Unified Public Healthcare System (SUS) since 2019. This expansion has substantially improved access to these therapies, potentially contributing to a reduction in colectomy rates.7

Surgical indications for UC occur in both emergency and elective settings. Emergencies include massive hemorrhage, toxic megacolon, or intestinal perforation, while elective procedures are typically indicated for refractory disease, colorectal carcinoma, or dysplastic lesions not amenable to endoscopic resection. The preferred surgical approach for UC is restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Other surgical options include subtotal colectomy with ileostomy, total proctocolectomy with permanent ileostomy, and total colectomy with ileorectal anastomosis.8, 9, 10, 11

Epidemiological studies worldwide have highlighted declining surgical indications for UC in recent decades, driven by therapeutic advancements. However, findings remain inconsistent: while some studies report stable surgical rates, others suggest that biologics have primarily reduced elective surgeries, with emergency procedures showing little change.12, 13, 14, 15, 16, 17, 18 Additionally, as treatment options expand, there may be delays in surgical evaluation, potentially worsening patients’ condition and increasing the risk of perioperative and postoperative complications.

Recent studies have provided valuable insights into colectomy trends and the impact of advanced therapies in UC management. Martins et al. reported a high burden of intestinal complications in Brazilian UC patients on conventional therapies, with 20% requiring surgical procedures.19 Dai et al., in a systematic review, described a modest reduction in colectomy rates during the biologic era, with a pooled relative risk of 0.71 at 5 years post-diagnosis.20 Kotze et al., in 2020, highlighted significant regional disparities in Latin America, where colectomy rates remained relevant despite limited access to advanced therapies.21 Wetwittayakhlang et al. in, in 2023 observed stable colectomy rates over 40 years in Hungary, despite increased use of biologics, with extensive colitis and continuous disease activity identified as predictors of surgery.17 Currently, there are limited data on surgical rates for UC in Brazil and Latin America.

This study aims to analyze the temporal trends in colectomy rates for UC within Brazil's public healthcare system over a 10-year period, evaluating surgical procedures, hospitalization rates, and regional disparities. By leveraging publicly available healthcare data, this research aims to provide a comprehensive analysis of colectomy rates for UC in Brazil, as well as regional disparities and the impact of advanced therapies within the public healthcare system.