Complications and Management Approaches

[00:30]

Hello, I’m Dr. Jordan Axelrad, 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. Optimizing postoperative care is an important aspect of managing patients with inflammatory bowel disease (or IBD), which may help to enhance recovery and improve outcomes.

Today, we’ll explore the risk of surgery over time in patients with IBD, perioperative management approaches, and postoperative management and monitoring for ulcerative colitis (or UC) and Crohn’s disease (or CD). We’ll then review approaches to enhance patient recovery after IBD-related surgery.

[01:13]

Let’s start where many patients often find themselves—facing the risk of surgery. Despite the advancements in medical therapies for IBD, patients may still require surgical intervention as part of long-term disease management.^1,2 That’s why understanding the principles of perioperative management—before, during, and after surgery—is key to improving outcomes.

To illustrate the overall risk of surgery, let’s start by looking at a systematic review that included a meta-analysis of 44 population-based cohort studies in patients with incident ulcerative colitis and/or Crohn’s disease.³ This study estimated the risk of major abdominal surgery—defined as colectomy with or without an ileal pouch-anal anastomosis (or IPAA) in patients with ulcerative colitis, and intestinal resection in patients with Crohn’s disease—before and after the year 2000.

[02:16]

In the study demonstrated here, over 25% of patients diagnosed with Crohn’s disease still required surgery after the year 2000, within 10 years of diagnosis—down from nearly 50% before the year 2000.³ For ulcerative colitis, approximately 10% of patients required surgery within 10 years, compared to 15% before the year 2000. Such results support the observation that, even with therapies currently available, some patients may still need surgery.⁴

Given these long-term risks, perioperative management—an approach that refers to integrated care beginning when surgery is first considered and continuing through recovery—becomes essential.^4,5 

[03:00]

Because perioperative management of patients with IBD requires the consideration and optimization of numerous patient- and disease-oriented factors to reduce postoperative complications and enhance recovery, the American Gastroenterological Association (or AGA) and the European Crohn's and Colitis Organisation (or ECCO) have provided recommendations on the perioperative care required to optimize outcomes.^6-8

AGA and ECCO publications recommend limiting preoperative corticosteroid use due to the increased risk of infection and impaired wound healing.^4,8 AGA recommendations advised against delaying surgery in patients on biologic therapy, including anti-tumor necrosis factor (or anti-TNF) medications, due to the perception of increased infections, as delayed surgery may increase the risk of postoperative complications including mortality in severe cases.⁴ 

With these key recommendations in mind, let’s shift our focus to what happens after surgery—starting with postoperative management in Crohn’s disease.

[04:09]

While surgery may relieve certain IBD symptoms, it does not eliminate the possibility of postoperative recurrence.⁹ Let’s walk through some of the key strategies for postoperative management and monitoring in Crohn’s disease.

Surgery may be one of the ways to manage complications of Crohn’s disease—such as strictures, fistulas, and abscesses—but it’s not considered to be a cure.^4,9,10 And with nearly half of patients with Crohn’s disease needing surgery within 10 years of diagnosis, understanding aspects related to post-surgical complications and recurrence is important.¹¹

Major postoperative complications in Crohn’s disease include intra-abdominal sepsis, hemorrhage, anastomotic fistula, and intestinal obstruction.¹²

After surgery, timely identification of Crohn’s disease recurrence is key to guiding management decisions.¹³ Recurrence can occur quickly after surgery, with evidence for histologic recurrence appearing within one week of surgery and often progressing to endoscopically detected recurrence within 1 year of surgery.^14,15

[05:18]

One way to assess recurrence is through endoscopic evaluation, quantified using a scoring system known as the modified Rutgeerts score. Let’s now dive deeper into the Rutgeerts score.

The Rutgeerts score and modified Rutgeerts score for assessing postoperative recurrence range from i0 to i4.¹³ A score of i2 or greater reflects increasing severity of endoscopic lesions associated with recurrence and a greater likelihood of clinical symptoms and future requirement for repeat surgery.^6,14 Findings representing endoscopic recurrence range from more than 5 aphthous ulcers with normal mucosa in between, which is consistent with a score of i2, to diffuse inflammation with large ulcers, nodules, and/or strictures, which is consistent with a score of i4.¹⁴

[06:13]

Perioperative assessment of the risk for postoperative disease recurrence is critical to identify patients at higher risk for recurrence who may benefit from postoperative medical prophylaxis.^4,6 With that in mind, let’s take a look at published information from the AGA, which stratifies patients based on risk factors for recurrence.

Several factors can help determine a patient’s risk for postoperative recurrence.⁶ Higher risk patients are typically under 30 years old, are active smokers, and have had 2 or more prior surgeries for penetrating disease, with or without perianal disease.

Lower risk patients are generally over 50 years old, do not smoke, and are undergoing their first surgery for a short segment of fibrostenotic disease, with a disease duration of more than 10 years.⁶

[07:09]

AGA guidelines suggest early pharmacologic prophylaxis preferred over monitoring alone with endoscopic activity-guided treatment in post-surgical Crohn’s disease remission.⁶ The strength of this recommendation is conditional based on very low quality of evidence. Patients—especially those at lower risk of recurrence—who value avoiding adverse events more than preventing early recurrence may reasonably choose endoscopy-guided treatment instead of prophylaxis.

According to guidelines from the American College of Gastroenterology (or ACG), postoperative prophylaxis to help prevent recurrence of Crohn’s disease may include imidazole antibiotics, and anti-TNF medications or select anti-integrin therapy in patients with high-risk Crohn’s disease.^16,17 Recommendations for imidazole antibiotics and select anti-integrin therapy are conditional, while anti-TNFs carry a strong recommendation. Antibiotics with or without immunomodulators could be another potential prophylactic option in patients with lower risk.¹⁶

[08:19]

According to ACG guidelines, treatment for postoperative recurrence of Crohn’s disease depends on recurrence risk.¹⁶ Low-risk patients may not require treatment, while moderate-risk patients may receive thiopurines with or without an imidazole antibiotic. High-risk patients are treated with anti-TNF therapy, with or without an immunomodulator.

Recommendations published by the AGA on postoperative management of Crohn’s disease indicate that in patients with prior intolerance to anti-TNF monotherapy, anti-integrin or anti-IL-12/23 therapy may be considered for postoperative management.⁴

[09:01]

ECCO guidelines recommend that the pharmacologic prophylaxis with biologic and/or immunomodulator therapy may be initiated within 2 to 4 weeks of surgery, based on a thorough risk-benefit assessment.⁸

Recommendations published by the AGA suggest a colonoscopy evaluation for low-risk patients, who are initially not on medications, at 6 months after surgery.⁴ For high-risk patients on pharmacologic prophylaxis, post-surgical colonoscopy is recommended at 6 to 12 months.

While ileocolonoscopy remains the standard approach for assessing endoscopic disease activity and to measure Rutgeerts score postoperatively, AGA guidelines also recognize a complementary short-term role for fecal calprotectin and/or C-reactive protein monitoring as non-invasive options.^18,19

[09:57]

Low fecal calprotectin levels after surgery—specifically under 50 µg/g—may indicate endoscopic remission and that routine ileocolonoscopy may be unnecessary, particularly if patients are asymptomatic after surgically induced remission within the past 12 months, have low risk for recurrence, or have 1 or more risk factors for recurrence but are receiving prophylactic treatment.¹⁹ This recommendation by the AGA is conditional and based on low to moderate certainty of evidence.

While low fecal calprotectin levels may help identify patients who can delay routine postoperative colonoscopy, it remains the current standard for assessing recurrence.^16,19 In a randomized postoperative Crohn’s endoscopic recurrence (or POCER) clinical trial of 174 consecutive patients with Crohn’s disease undergoing intestinal resection of all macroscopic disease, with an endoscopically accessible anastomosis, the results indicated a continued role for endoscopic monitoring—even in patients who are considered low risk.²⁰

[11:09]

For patients with residual disease after intestinal resection, ECCO recommends resuming therapy after surgery when it is clinically safe to reduce the risk of flare.⁸

Now that we’ve covered postoperative considerations for Crohn’s disease, let’s turn to postoperative management and monitoring for ulcerative colitis.

For medically refractory ulcerative colitis and ulcerative colitis-related dysplasia, restorative proctocolectomy with IPAA remains the current standard surgical approach.^4,21 This procedure offers patients the ability to live without a stoma and preserved bowel continuity for an anal route of defecation.²² IPAA should typically be performed in stages, which may reduce the risk of infectious complications, particularly in the setting of recent corticosteroid and/or biologic therapy.⁴

[12:05]

In the short term, patients with ulcerative colitis who undergo IPAA may experience complications such as wound infection, pelvic abscesses, anastomotic stricture, bowel obstruction, pouch leak, or hemorrhage.²³

In the long term, patients with ulcerative colitis may experience complications such as pouchitis, bowel obstruction, pouch dysfunction, pouch fistulae, sexual dysfunction, and reduced fecundity—which refers to the biological capacity to reproduce.²³

One of the most frequent long-term complications following IPAA is the inflammation of the ileal pouch, also known as pouchitis.^24,25 To better understand its impact, a retrospective study analyzed US insurance claims from 2007 to 2016, evaluating pouchitis incidence and outcomes in 594 adult patients with ulcerative colitis who underwent IPAA.²⁶

[13:10]

In this study, nearly half of patients—around 48%—developed pouchitis within just 2 years of IPAA for ulcerative colitis.²⁶ This highlights how common and early pouchitis can occur, reinforcing the need for close monitoring of symptoms following the surgery. Pouchitis is much more common in IBD than in patients who undergo IPAA for non-IBD indications.²⁷

When pouchitis occurs, the patient may experience varied symptoms—often including lower abdominal cramping, increased stool frequency, urgency, and pelvic discomfort.⁷

According to AGA guidelines, pouchitis treatment should be based on clinical characteristics such as disease chronicity, refractoriness, and responsiveness to antibiotic treatment.²⁸

[14:05]

Based on AGA guidelines, antibiotics are recommended for patients with intermittent symptoms of pouchitis, or chronic antibiotic-dependent pouchitis, in which symptoms recur soon after stopping antibiotics.⁷

For patients with recurrent antibiotic-responsive pouchitis—that is, recurrent episodes of pouchitis after IPAA that respond to antibiotics—AGA guidelines recommend probiotics to prevent pouchitis recurrences.⁷

Select advanced immunosuppressive therapies approved for ulcerative colitis may be considered in patients with chronic antibiotic-dependent pouchitis—that is, recurrent episodes of pouchitis that respond to antibiotics but relapse shortly after stopping antibiotics.⁷ 

[14:56]

Select advanced immunosuppressive therapies may also be considered in patients with antibiotic-refractory pouchitis—recurrent pouchitis after IPAA with an inadequate response to antibiotics.

Corticosteroids may also be used for patients with chronic antibiotic-refractory pouchitis, generally for a short duration, compared to steroid-sparing therapies that are typical for long-term use.⁷ These treatment recommendations by the AGA are conditional based on very low certainty of evidence.

When it comes to procedures to evaluate pouchitis, the AGA recommends pouchoscopy—an endoscopic examination of the ileo-anal pouch—for patients with atypical symptoms of pouchitis or suspected of having either chronic antibiotic-dependent or antibiotic-refractory disease.⁷

A potential concern with IPAA is the development of dysplasia in the ileal pouch and residual rectal cuff, which may be related to chronic inflammation.^29,30

[16:04]

The American Society for Gastrointestinal Endoscopy (or ASGE) IBD endoscopy consensus panel recommends surveillance pouchoscopy based on risk level for dysplasia.³¹ For high-risk patients—such as those with a history of colitis-associated dysplasia before colectomy—annual surveillance is advised. For moderate-risk patients, including those with primary sclerosing cholangitis, chronic pouchitis, or a family history of colorectal cancer, surveillance is recommended every 1 to 3 years. And for average-risk patients, every 3 years may be appropriate.

The objectives of surgical treatment in IBD have evolved—from reducing fatality and disease burden to now also focusing on improving quality of life.^32,33 While surgery can be a major life event associated with psychological implications, patients often experience improvements in quality of life after surgery.^34,35

[17:07]

Patients may report relief post-surgery, including improvements in both physical and psychological well-being. Other improvements may include satisfaction with their outcomes after colectomy and willingness to undergo the surgery again.^36-38

Now that we have looked at how surgery can impact QoL in patients with IBD, let us discuss how recovery after surgery could be optimized. Enhanced recovery after surgery (or ERAS), are consensus-based care pathways that may help guide and improve surgical outcomes and accelerate recovery for patients with IBD.^4,8,39

During and after surgery, ERAS-guided management approaches may include multimodal pain management to minimize opioid use; intraoperative fluids; early feeding and mobilization to support faster recovery; early catheter removal; and prophylaxis for venous thromboembolism (or VTE).^4,8,39

[18:07]

Preoperative counseling may also be included as a part of the ERAS pathways as it may lead to better compliance with the ERAS elements and a positive impact on recovery with faster discharge times, and lower complications in patients recovering from surgery.^40-42

Studies show that when ERAS pathways are implemented, they may reduce postoperative hospital stay and improvement in some of the surgical outcomes in patients with IBD.^41-43 To support this, let us take a look at a systematic review and meta-analysis of 8 studies conducted between the year 2000-2019 that included a total of 1939 patients with IBD undergoing surgery based in Italy, the US, China, the UK and France. The objective of this meta-analysis was to assess the effect of ERAS protocols on surgical outcomes of patients with IBD.⁴³

[19:05]

The analysis showed that implementation of ERAS pathway in IBD surgical management may have contributed to improvement in surgical outcomes such as reduced time to first bowel movement by 1 day, reduced risk of anastomotic fistula by 64%, and reduced postoperative length of hospital stay by 2 days.⁴³

Based on what we’ve discussed regarding postoperative management in patients with ulcerative colitis and Crohn’s disease, let’s take a moment to review some of the key points we have covered today.

In summary, perioperative risk stratification in Crohn’s disease may help guide postoperative management.^4,6,8,16 Patients at high risk of recurrence may benefit from pharmacologic prophylaxis and colonoscopy every 6 to 12 months may support earlier identification of recurrence.^4,6,13 For ulcerative colitis, post-surgical management of IPAA may involve different approaches for pouchitis based on clinical status.^7,28 

[20:08]

Guidelines recommend pouchoscopy to evaluate suspected chronic antibiotic-refractory pouchitis and for dysplasia surveillance.^7,31 And finally, ERAS protocols may support improved immediate postoperative recovery.^4,39

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.