[00:30]
Hello, I’m Dr. Benjamin Cohen, and welcome to IBDIQ, part of The IBD Project by Takeda, where we’re coming together to help enhance expertise in IBD care—right from the start. As a key part of managing patients with inflammatory bowel disease (or IBD), optimizing care around the time of surgery, known as the perioperative period, may help improve postoperative outcomes.
Our discussion today of perioperative care will focus on approaches to help reduce the risk of postoperative complications through actions taken before surgery. We will begin by discussing the burden of surgery in IBD and issues of timing and complications. Then, we will delve into the role of the multidisciplinary team in managing patients with IBD who may need surgery, identify potential risk factors associated with postoperative complications, and finally discuss approaches to optimize perioperative management to help reduce postoperative complications.
[01:23]
Despite advancements in medical therapies, including biologics and small molecule oral medications used in the treatment of moderate to severe forms of ulcerative colitis (or UC) and Crohn's disease (or CD), surgery remains an important intervention for select patients with refractory IBD or complications such as strictures, fistulas, and colorectal cancer.1,2
Let's take a look at a systematic review and meta-analysis of 44 population-based cohort studies spanning 17 countries across five continents—North America, Europe, Asia, Africa, and Australia. The review assessed the cumulative risk of major abdominal surgery in patients with UC and CD, as well as an analysis of cohorts in which the majority of patients were diagnosed with IBD after the year 2000 to estimate the contemporary risks of major abdominal surgery.3
[02:14]
Major abdominal surgery was defined in patients with UC as colectomy with or without an ileal pouch-anal anastomosis and in CD patients as intestinal resection as well as any repeat major abdominal surgeries in the CD patients with initial resection. 3
The contemporary 10-year risk assessment of major abdominal surgery in patients with IBD diagnosed after 2000 was estimated. Approximately 1 in 10 patients with UC and approximately 1 in 4 patients with CD will require major abdominal surgery within 10 years of their diagnosis.3,4 This highlights the role surgery plays in the treatment of IBD despite major advances in medical management.5,6
The clinical presentation of IBD can necessitate surgery across a spectrum of urgency.7-10 This ranges from planned procedures, which are referred to as elective, to those required when a patient's condition rapidly worsens or they face a life-threatening complication, which are categorized as urgent or emergent.8-11
[03:10]
Elective surgeries may be indicated in patients with UC for medically refractory disease or for associated dysplasia or cancer.9,10
In contrast, urgent or emergent surgery becomes necessary when a patient experiences rapid deterioration or a life-threatening complication.12 For UC, this could include critical complications such as colonic perforation, hemorrhage, toxic megacolon, or worsening acute severe colitis.12,13
Surgical management of ulcerative colitis may include a total colectomy, which involves removing the entire colon, or a total proctocolectomy, where both the colon and rectum are removed.14,15
Another surgical procedure in UC is a restorative proctocolectomy with ileal pouch-anal anastomosis, or IPAA. In this approach, the end of the small intestine—the ileum—is converted into a pouch and connected to the anal canal, creating what's commonly referred to as a J-Pouch.14,16,17
[04:03]
In CD, elective surgery may be considered for refractory disease, neoplasia and dysplasia, and complications like penetrating disease not controlled by medications.8,18-23 This often involves strictures or fistulas that are symptomatic despite medical therapy.24,25 Other elective surgery indications can include chronic intestinal obstruction, drainable abscesses, or perianal fistulas.12,20,26
Urgent or emergent procedures in CD may be required for acute, severe issues.21 These can include acute severe colitis, acute intestinal obstruction, free bowel perforation with peritonitis, or sepsis arising from the disease. Undrainable or complicated abscesses may also necessitate urgent surgery.
In CD, surgical interventions may involve bowel resection with or without anastomosis, which refers to reconnecting the intestines after a damaged or diseased portion has been removed.27-29 Other procedures may include strictureplasty, which entails widening of a narrowed section of the intestine without removing it in order to preserve bowel length,30,31 and diversion procedures such as ostomy, which involves the creation of a stoma and rerouting the fecal stream away from diseased segments.30,32,33 Exam under anesthesia, or EUA, may also allow for thorough evaluation and treatment of perianal disease.34
[05:22]
Even with advances in IBD management, patients with complicated disease may still face acute complications that require emergency surgical care.12,35,36
Timely decision-making regarding surgical intervention is an important consideration for optimizing outcomes in patients with UC and CD.7,9,37
Delaying surgery in patients with CD in need of surgical management may lead to increased preoperative malnutrition, increased exposure to preoperative steroids, septic complications, more extensive bowel resections, and the need for a stoma.6,38,39
Timely decisions are also important for patients with acute severe ulcerative colitis (or ASUC), as shown in a retrospective analysis of the US National Inpatient Sample between 2002 and 2014 that included 2,650 patients with UC who underwent non-elective total colectomy.40-44
[06:14]
In that study, delaying the surgery by more than 24 hours after hospital admission was associated with increased postoperative complications such as renal dysfunction, gastrointestinal symptoms, and venous thromboembolic events, as well as extended length of hospital stay.44
To navigate these complex decisions and optimize perioperative management, a multidisciplinary, patient-focused strategy is essential.45,46 A multidisciplinary approach may help reduce complications and inform the timing of appropriate surgical intervention.
This multidisciplinary IBD care team may include a gastroenterologist, a colorectal surgeon and a range of specialists essential for comprehensive care such as radiologists, IBD nurses, dietitians, histopathologists, psychologists, pharmacists, and research coordinators.47 Collaboration among these disciplines helps ensure that many aspects of the patient's health are considered.46,48
[07:11]
Early involvement of a wound care nurse may also benefit patients with UC or CD who may require an ostomy, which involves creating a temporary or permanent opening for waste to exit the body into an external pouch.49-53
In addition to the multidisciplinary IBD team, patient-centered communication and decision-making about surgery as a treatment option may help reduce misconceptions about surgery in patients with severe IBD and improve patient satisfaction with a shared decision-making process.54
Preoperative planning by the multidisciplinary IBD team may involve risk assessments in several areas of concern. These may include assessment for malnutrition, which, if present, may warrant intervention with oral nutritional supplementation (or ONS), exclusive enteral nutrition (or EEN), or total parenteral nutrition (or TPN). Assessment of current medical therapy, which may include chronic corticosteroid use and other immunosuppressant therapies, may call for pausing therapy or reducing the dosage. Risk assessment of the planned operation may lead to adjustments in the surgical strategy.55-57
[08:16]
In patients with UC and CD, a preoperative comprehensive assessment may involve assessing disease severity and current activity, potential IBD-related complications (including nutritional deficiencies, anemia, venous thromboembolic [or VTE] risk, and chronic pain), and IBD-specific medication use, in addition to reviewing comorbidities and surgical history,56,58,59 This comprehensive assessment will also incorporate evaluating key imaging findings based on methods such as computed tomography enterography and magnetic resonance enterography.43,60
Early postoperative complications in IBD surgery may include abdominal wound infections, anastomotic leakage, and pelvic sepsis.61 Identifying risk factors for postoperative complications may help guide management decisions in patients with UC and CD.61-63
[09:05]
Patient-specific risk factors for postoperative complications in IBD—including older age, large and persisting number of emergent IBD-related surgeries, and racial and ethnic disparities—have been linked to a greater risk of postoperative complications.64-67
Additional disease-related risk factors for postoperative complications in IBD include hypoalbuminemia in both UC and CD, prolonged time of 5 years or more between diagnosis and elective intestinal resection in CD, and prolonged time from surgical indication to when the surgery is performed in UC and CD.58,61,68,69
Publications by the American Gastroenterology Association (or AGA) and guidelines by the American College of Gastroenterology (or ACG) highlight the importance of addressing modifiable risk factors to help improve surgical outcomes.70,71
Modifiable risk factors for poor outcomes of surgery in patients with UC and/or CD may include malnutrition, anemia, corticosteroid use, and smoking.45,70,72-74
[10:04]
Preoperative approaches to improve postoperative outcomes may include providing oral or enteral support for malnutrition and intravenous (or IV) iron supplementation for anemia or following protocols to taper or discontinue corticosteroid use if possible and encourage smoking cessation.73 Let’s take a closer look at each of these preoperative strategies now.
Poor nutritional status is associated with increased in-hospital mortality, longer length of stay, higher costs, and increased infection rates.43
The ECCO topical review recommends that optimization of nutritional status should be considered before surgery for IBD, whenever possible. This may involve oral, enteral and/or parenteral options in malnourished patients, based on individual clinical scenarios.73
Preoperative anemia is another patient-specific risk factor that is associated with a poor outcome of surgery, including overall postoperative morbidity, intra-abdominal septic complications, and prolonged hospital stay.73
[11:04]
The ECCO topical review recommends preoperative screening for anemia and administering IV iron supplementation for relatively faster correction of iron deficiency compared to oral supplements.73
Perioperative use of corticosteroids—particularly at high doses over extended durations—may increase the risk of postoperative complications.73
The ECCO topical review recommends corticosteroid withdrawal before surgery whenever possible. If withdrawal is not possible, consider progressively tapering steroid use to the lowest dose.73 If high-dose steroid use is unavoidable in patients with CD, consider a staged procedure with a temporary stoma.75
Cigarette smoking can worsen disease activity and accelerate disease recurrence in CD, which may lead to an increased rate of surgical intervention as well as certain surgical complications.71,76 The ACG guidelines recommend smoking cessation counseling for patients with CD, as stopping may reduce intestinal inflammation and decrease the need for steroids and immunomodulator therapy.71 Smoking cessation has been shown to reduce certain surgical complications.76,77
[12:12]
The ECCO topical review recommends adapting enhanced recovery pathways, which are evidence-based protocols that may improve immediate postoperative recovery.73 These pathways typically include components such as preoperative counseling, cessation of smoking, optimization of the treatment of prior comorbidities, and adherence to appropriate fasting protocols.
According to the ECCO topical review, biologic and immunomodulator therapy can be continued during the perioperative period.57
Now, let’s take a look at the PUCCINI study—Prospective Cohort of Ulcerative Colitis and Crohn’s Disease Patients Undergoing Surgery to Identify Risk Factors for Post-Operative INfection I— study. This multicenter observational prospective study evaluated whether preoperative exposure to anti-tumor necrosis factor (or anti-TNF) medications is an independent risk factor for postoperative infectious complications within 30 days of intra-abdominal surgery.76
[13:08]
In the primary analysis, anti-TNF exposure was defined as patient-reported use of anti-TNF therapy within 12 weeks before surgery, whereas patients with anti-TNF exposure more than 12 weeks prior to surgery or with no prior anti-TNF use were considered unexposed.
The primary outcome was the occurrence of any infection—either surgical site infection (or SSI) or non-SSI—within 30 days of surgery.76 SSIs were defined by the Centers for Disease Control and Prevention criteria and classified as superficial, deep incisional, or organ/space infections. Non-SSIs were classified as sepsis, bacteremia, pneumonia, urinary tract infection, unexplained fever over 101.5 °F, or any other postoperative infection. One of the secondary outcomes focused specifically on SSIs.
The study enrolled 947 adult patients with IBD, 640 patients with CD and 307 with UC, undergoing intra-abdominal surgery for IBD between 2014 and 2017.76
[14:17]
This study showed that postoperative infections of any kind observed within 30 days of surgery occurred in 20.2% of patients with IBD who were unexposed to anti-TNF therapy and 18.1% of patients who received anti-TNF therapy within 12 weeks of surgery.76 Detectable anti-TNF drug levels were not an independent risk factor for post-operative infections.
Similarly, surgical site infections observed within 30 days of surgery occurred in 12.6% of patients with IBD who were unexposed to anti-TNF medications within 12 weeks of surgery, and 12% of patients who received anti-TNF therapy within 12 weeks of surgery.76 Anti-TNF drug levels were not independently associated with the development of SSIs.
Ultimately, it is important to consult the most recent guidelines or recommendations when making management decisions for patients during this period.
[15:11]
In summary, even with advances in IBD treatment, patients with complicated disease may still face acute complications that require emergency surgical care.12 Elective surgery in patients with IBD may have fewer post-operative complications compared to delayed or emergent surgeries.78,79 Patient-centered communication and decision-making about treatment options may reduce misconceptions about surgery and improve patient satisfaction.54 Optimizing modifiable risk factors—malnutrition, anemia, smoking, and corticosteroid use—may lead to better surgical outcomes.73 According to the ECCO topical review, biologic and immunomodulator therapy can be continued during the perioperative period. Adhering to current guidelines and recommendations is crucial for optimizing preoperative care and may help improve outcomes.73,75
[16:03]
Thank you for your interest and for spending some time with IBDIQ today to help adapt to the evolving care needs of all patients with IBD.
