Clinical trajectories after preoperative traditional Chinese medicine in biologic-refractory surgery- intended acute severe ulcerative colitis: an exploratory retrospective case series

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Objective Acute severe ulcerative colitis (ASUC) is a life-threatening condition, and biologic-refractory patients may ultimately require surgery. The clinical role of individualised integrative management including traditional Chinese medicine (TCM) in surgery-intended ASUC remains uncertain. Methods This single-centre retrospective exploratory case series included 39 biologic-refractory, surgery-intended ASUC patients treated between January 2020 and June 2025. Eleven accepted adjunctive preoperative TCM and 28 did not. Five selected TCM-treated patients experienced remission after integrative management including TCM and surgery was cancelled; 6 underwent surgery and were compared descriptively with 28 non-TCM surgical patients. Baseline imbalance was summarised using absolute standardised mean differences (SMDs). Continuous postoperative outcomes were reported as Hodges-Lehmann location shifts with 95% confidence intervals (CIs), and binary outcomes as risk differences with Newcombe-Wilson 95% CIs. Clinically relevant postoperative outcomes were prioritised, whilst postoperative day (POD) 1 white blood cell count (WBC) and POD3 C-reactive protein (CRP) were retained as exploratory inflammatory markers. Results Important baseline imbalances were present in the surgical comparison cohort, including surgical scope, urinalysis, haemoglobin, haematocrit, albumin, platelet count, baseline WBC, and CRP. Thirty-day postoperative complications occurred in 10/28 (35.7%) non-TCM patients and 1/6 (16.7%) TCM surgical patients (risk difference -19.0 percentage points, 95% CI -42.0 to 23.4). The Hodges-Lehmann location shift was -4.00 days (95% CI -11.00 to 3.00) for length of stay, -3.17 mg/L (95% CI -6.15 to 0.48) for POD3 CRP, and -2.59 ×10 9 /L (95% CI -6.98 to 0.76) for POD1 WBC. No 95% CI excluded the null value. In the five selected remission cases, pre-treatment Mayo endoscopic subscore (MES) was 3 and post-treatment MES was 0 or 1; surgery was cancelled, four patients subsequently received infliximab maintenance therapy, and no subsequent surgery was recorded during 27–48 months of available follow-up. Conclusions This case series describes heterogeneous clinical trajectories after individualised integrative management including TCM in selected biologic-refractory, surgery-intended ASUC patients. The small non-randomised cohorts, major baseline imbalance, concomitant treatment, surgical heterogeneity, and imprecise effect estimates preclude efficacy or causal inference. The observations should be considered descriptive and hypothesis-generating.

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