Nutrition, Disease Localization Are Part of Preparing Patients With IBD for Surgery

Preparing a patient with inflammatory bowel disease (IBD) for surgery to improve their symptoms requires several steps and involves cooperation between the patient and the gastroenterologist, explained Joel Goldberg, MD, at the virtual 2020 Advances in Inflammatory Bowel Disease regional meeting.

Joel Goldberg, MD, MPH, is an assistant professor of surgery at Harvard Medical School and practices at Brigham and Women’s Hospital and the Dana Farber Cancer Institute in Boston, Massachusetts.

Even with the many therapeutic tools available to control IBD symptoms and help patients attain and maintain remission, some patients have complications that require surgical intervention. Bleeding, infection, perforation, fistulas, and perianal disease are not uncommon among patients with severe IBD, and those who fail medical management have a 70% to 90% lifetime risk of requiring surgery, Goldberg explained. Surgery in such cases can enhance quality of life, improve gastric function, and reduce pain.

Appropriate preparation for surgery can reduce the risk of postoperative complications such as anastomotic leak, deep venous thrombosis (DVT) or pulmonary embolus (PE), wound infection, and abscess, as well as help preserve the maximum possible bowel length, Goldberg said.

Initial steps include localizing the disease through colonoscopy and other diagnostic procedures. Patients with complications of IBD often have nutritional deficiencies that should be corrected before surgery through total parenteral nutrition. Goldberg cited research showing that patients with malnutrition who were taking biologics had a 27% rate of postoperative complications vs the 8% rate of complication among patients on biologics who were not malnourished. Anemia should be treated with intravenous iron before surgery.

Goldberg also recommended that patients taking steroids should be weaned off these medications before surgery, due to the higher risk of sepsis, intra-abdominal infections, and DVT or PE, citing research showing that any steroid use within one month prior to surgery increased complications.

There is also a trend toward increased infectious complications in patients with IBD who take biologics prior to surgery, Goldberg pointed out. However, these patients did not have additional risk of anastomotic complications. Patients with Crohn disease are advised to stop taking biologics for 4 weeks before surgery and start these therapies again 4 weeks after. For patients with ulcerative colitis, the 3-stage ileal pouch-anal anastomosis (IPAA) vs 2-stage IPAA is recommended if other immunosuppressive agents are used.

—Rebecca Mashaw

Reference:

Goldberg J. Preparing your patients for surgery: a surgeon’s perspective. Talk presented at: Advances in Inflammatory Bowel Disease 2020 regional meeting; June 27, 2020; virtual.