Laparoscopic Versus Open Surgery for Acute Severe Colitis and Fulminant Colitis: A Systematic Review and Meta-Analysis

Subtotal colectomy is the gold standard for acute severe ulcerative colitis (ASUC) refractory to medical therapy. While laparoscopy is preferred for elective resections, its safety and efficacy in the emergency setting remain debated due to the technical challenges of manipulating friable, dilated bowel in critically ill patients. This systematic review and meta-analysis aimed to compare the perioperative outcomes of laparoscopic versus open subtotal colectomy for ASUC and fulminant colitis. A systematic search of electronic databases was conducted to identify comparative studies published until 2025. The primary outcome was overall postoperative morbidity. Secondary outcomes included hospital length of stay (LOS), operative time, and mortality. Meta-analysis was performed using a random-effects model. Heterogeneity was assessed using the I2 statistic, and robustness was evaluated via sensitivity analyses and meta-regression. Methodological quality was appraised using the Newcastle-Ottawa Scale. Fourteen studies, comprising 6,544 patients (4,357 laparoscopic and 2,187 open), were included. The laparoscopic approach was associated with a significant reduction in overall morbidity (odds ratio (OR) 0.49, 95% confidence interval (CI) 0.45-0.53; p < 0.0001) with no statistical heterogeneity (I2 = 0%). Hospital LOS was significantly shorter in the laparoscopic group (weighted mean difference -3.07 days, 95% CI -3.88 to -2.25; p < 0.0001). Subgroup analyses stratified by surgical era (pre-biologic vs. biologic) showed no difference in outcomes (p = 0.38), indicating sustained benefits over time. Sensitivity analysis confirmed that results were not driven by large registry data. Laparoscopic subtotal colectomy for ASUC is associated with significantly lower postoperative morbidity and shorter hospital stay compared to open surgery. These benefits are robust across different surgical eras and study designs. Laparoscopy should be considered the preferred approach for emergency colectomy in colitis when expertise is available.