Appendicectomy After Biologic Failure in Ulcerative Colitis: Reconsidering the Appendix as a Therapeutic Target

ABSTRACT Management of ulcerative colitis (UC) after biologic failure remains challenging, with decreasing efficacy of sequential therapies and growing concerns regarding long‐term immunosuppression. Appendicectomy has been proposed as a potential disease‐modifying intervention, but its role relative to further medical escalation remains unclear. The COSTA study is a multicentre, prospective, patient‐preference cohort study comparing laparoscopic appendicectomy as an adjunct to ongoing advanced therapy with switching to Janus kinase (JAK) inhibitor monotherapy in biologic‐exposed patients with active UC. The primary endpoint was clinical remission at 12 months without therapy failure. At 12 months, remission without therapy failure was achieved more frequently in patients undergoing appendicectomy than in those receiving JAK inhibitors (32.8% vs. 12.2%), representing a clinically meaningful absolute difference of 20.6 percentage points. Clinical response and endoscopic outcomes were also consistently higher following appendicectomy. Safety profiles were comparable, with a low rate of minor postoperative complications. These findings suggest that appendicectomy, when used as an adjunct to ongoing therapy, may offer a clinically relevant benefit compared with switching to JAK inhibitor monotherapy. Although methodological limitations warrant cautious interpretation, appendicectomy represents a low‐risk therapeutic option that may be considered in selected patients. Further randomised studies are needed to define its role within treatment algorithms.