El-Hussuna, Alaa

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    Aalborg UniversitetSurgical Intervention in Patients with IBD: Be Prepared!How Pre-Operative Management Can Change the Post-Operative OutcomeEl-Hussuna, AlaaPublished in:EC Gastroenterology and Digestive systemCreative Commons LicenseCC BY 4.0Publication date:2019Document VersionPublisher's PDF, also known as Version of recordLink to publication from Aalborg UniversityCitation for published version (APA):El-Hussuna, A. (2019). Surgical Intervention in Patients with IBD: Be Prepared! How Pre-Operative ManagementCan Change the Post-Operative Outcome. EC Gastroenterology and Digestive system, 6(10), 891-895.https://www.ecronicon.com/ecgds/pdf/ECGDS-06-00450.pdfGeneral rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.            ? Users may download and print one copy of any publication from the public portal for the purpose of private study or research.            ? You may not further distribute the material or use it for any profit-making activity or commercial gain            ? You may freely distribute the URL identifying the publication in the public portal ?Take down policyIf you believe that this document breaches copyright please contact us at vbn@aub.aau.dk providing details, and we will remove access tothe work immediately and investigate your claim.Downloaded from vbn.aau.dk on: November 24, 2020CroniconO P E N  A C C E S S EC GASTROENTEROLOGY AND DIGESTIVE SYSTEM  Mini ReviewSurgical Intervention in Patients with IBD: Be Prepared!How Pre-Operative Management Can Change the Post-Operative OutcomeAlaa El-Hussuna*Department of Surgery, Aalborg University Hospital, Hobrovej, Aalborg, DenmarkCitation: Alaa El-Hussuna. “Surgical Intervention in Patients with IBD: Be Prepared!”. EC Gastroenterology and Digestive System 6.10 (2019): 891-895.*Corresponding Author: Alaa El-Hussuna, Department of Surgery, Aalborg University Hospital, Hobrovej, Aalborg, Denmark.Received: May 23, 2019; Published: September 11, 2019AbstractSurgical management of inflammatory bowel disease (IBD) still presents a challenge for surgeons. Pre-operative optimization (PO) is a bundle of measures to bring the patient in optimal condition to surgery and to reduce the risk of unfavorable post-operative outcome. PO in patients with IBD is often suboptimal, and the evidence supporting it is scanty calling for more attention. This mini-review shows the most important pre-operative measures that can optimize the patients with IBD. These measures are optimization of medical treatment, nutritional support, treatment of pre-operative sepsis, thrombosis prophylaxis, bowel preparation, pre-oper-ative antibiotics treatment, cessation of smoking and psychological support. This bundle is to be provided by a multi-disciplinary team, which includes gastroenterologist, surgeon, IBD nurse, dietitian, radiologist and other health care providers if needed.Keywords: Surgical Intervention; Inflammatory Bowel Disease (IBD), Crohn’s disease, operation, surgery, complicationsIntroductionSurgical management of inflammatory bowel disease (IBD) still presents a challenge for surgeons. The timing of operation depends on disease severity, disease presentation, medical treatment, patients’ perspectives, and pre-operative optimization (PO) [1]. PO is used to bring the patient in optimal condition to surgery and to reduce the risk of unfavorable post-operative outcome [2]. PO in patients with IBD is often suboptimal, and the evidence supporting it is scanty calling for more attention [3]. Keywords: Surgical Intervention; Inflam-matory Bowel Disease (IBD) Few studies attempted to provide evidence-based clear recommendations for PO of patients with IBD. There is a need for well-designed prospective studies to explore the effect of PO on post-operative outcome and length of stay in hospital. PO might also be a factor in reduction of health care costs. The PO typical regime can be summarised as followsCardinal factors in pre-operative optimization of patients with IBDPharmacological considerationsPre-operative medicationsThe impact of corticosteroids on surgical outcome was investigated in a meta-analysis of observational studies which showed an in-creased risk of all post-operative complications especially infectious complications. Gradual withdraw of steroids should be attempted, so that the patient is steroid free for 1 week prior to surgery Oxford evidence level IIb.Two reviews investigated the Immuno-modulators’ effect on post-operative complications and found no increase in the risk of post-operative complications [5,6]. No indication to withdraw immunomodulators prior to surgical intervention Oxford evidence level III.Citation: Alaa El-Hussuna. “Surgical Intervention in Patients with IBD: Be Prepared!”. EC Gastroenterology and Digestive System 6.10 (2019): 891-895.Surgical Intervention in Patients with IBD: Be Prepared!892There are 106 studies about the impact of anti-tumor necrosis factor-α agents (anti-TNF-α) on post-operative outcome with divergent conclusions [7]. It seems that the impact of anti-TNF-α is affected by an interplay of many factors; the most important of these factors are disease severity, nutritional status, concomitant steroid treatment, drug concentration in blood and the presence of anti-drug antibodies. Withdrawal of anti-TNF-α is not supported by current evidence Oxford evidence level III. Steroid stress doseThis, well entrenched practice, is based on two case reports from 1960s. No evidence to support administration of supra-physiological dose of steroid at the induction of anaesthesia in patients on regular steroid treatment [8]. The patient need only his/her regular steroid dose at the day of operation Oxford evidence level Ib.Nutritional supportAn abundance of studies described the effect of nutritional therapy on remission of IBD, but the evidence of nutrition as a PO factor is less studied [9,10]. There are two rationales for nutritional support prior to surgery. First, treatment of malnutrition is advised since it has been well established that malnutrition is an important risk factor for post-operative complications and mortality [11]. The second is to modify the underlying inflammatory process and reduce disease activity prior to surgery. Reviews conclude that nutritional support for malnourished CD patients (at least 10 - 14 days prior to surgery) is important and that parenteral nutrition should only be used for those who cannot tolerate enteral nutrition [12-14]. All IBD patients should be screened for malnutrition pre-operatively. There is no standard-ized test for malnutrition. The European Society for Parenteral and Enteral Nutrition recommend NRS-2002, which primarily considers four clinical parameters: BMI, weight loss, reduced dietary intake, and severe illness [15]. Malnutrition must be corrected prior to surgical intervention. Anaemia can be treated with ferric injections Oxford evidence level III. Thrombosis prophylaxisIt is well established that patients with IBD carry a high risk of venous thromboembolism (VTE) [16-18]. The mechanism of hyperco-agulability in IBD is multifactorial and consists of acquired factors such as inflammation, vitamin deficiencies, surgery, steroid therapy, and fluid depletion along with a pro-thrombotic condition and hypercoagulability state [17].All current guidelines recommend the use of anticoagulants to prevent VTE in all hospitalized IBD patients. However, data is regard-ing thrombosis prophylaxis in patients with IBD undergoing surgery is scanty. A recent systematic review [4] identified six retrospective studies investigating the incidence of post-operative VTE in patients with IBD [19].Patients with IBD, who are not at high risk of bleeding, should receive pre- and post-operative anticoagulants during their hospital stay in order to prevent VTE.The evidence supporting 4 - week thrombosis prophylaxis after discharge is scanty Oxford evidence level III.Treatment of pre-operative sepsisThe presence of intra-abdominal abscess at the time of surgery is risk factor for post-operative septic complications [11,20]. Treat-ments include antibiotics (Abs), percutaneous abscess drainage (PAD) and surgical drainage (SD). There is a significant increase in the use of PAD and decrease in SD. Ultra-sound or CT-guided drainage of abscess is recommended prior to surgery, preferably with antibacterial coverage. There is no clear recommendation in the literature about how many days/weeks surgical intervention should be performed after abscess drainage Oxford evidence level III.Prophylactic antibioticsCitation: Alaa El-Hussuna. “Surgical Intervention in Patients with IBD: Be Prepared!”. EC Gastroenterology and Digestive System 6.10 (2019): 891-895.Surgical Intervention in Patients with IBD: Be Prepared!893Administration of AB prophylaxis prior to surgery is nowadays embedded into surgical practice with significant effect on the rate of surgical site infections (SSIs) [20]. Timing of administration is debated and evidence is lacking in IBD [20]. The effect of AB therapy for a longer period other than the routine perioperative administration is still unclear [21-23]. Zerbib., et al. described 78 patients with CD who underwent PO including over 2 weeks of intravenous AB, withdrawal from steroids and immunosuppressive therapy, abscess drainage, and nutritional support [24]. The study showed low rates of morbidity (18%) and no mortality in treated patients. Oral AB 24 hour prior to open surgery might be considered complementary to IV perioperative AB. However, this short interval can cause microbes resistant. Longer peri-operative AB treatment is not supported by evidence Oxford evidence level III.Bowel preparationAlthough bowel preparation (MBP) prior to surgery is discussed extensively in the literature, there is little data about this pre-opera-tive measure specifically in patients with IBD. Literature on the subject refers to IBD as part of a larger group of diseases treated surgically. Two large studies compared patients that received mechanical bowel preparation with or without oral ABs with patients who did not receive bowel preparation [23,25], showed that MBP with oral ABs prior to surgery could reduce the rate of surgical site infections, length of stay at hospital, and readmission rate. A recent study by Iesalnieks., et al. concluded that pre-operative MPB should be strongly consi-dered before colorectal surgery in patients with CD, especially in patients undergoing ileocolic resections for penetrating disease [26]. Combined ABs and mechanical bowel preparation prior to IBD surgery is recommended Oxford evidence level III.Smoking cessationSmoking has a significant effect on the course of IBD. There is a fair amount of data about the effect of smoking and smoking cessation on the clinical course of IBD. However, only a few studies addressed the effect of smoking cessation on the surgical outcomes [27-29]. All patients with IBD should be advised to stop smoking prior to elective surgery Oxford evidence level III.Other considerationsIn addition to the above-mentioned interventions, treatment of co-morbidities, psychological support, multi-disciplinary approach to manage patients with IBD in high volume hospital might also have an impact on post-operative outcome and must always be addressed. Pre-operative optimization may reduce the unfavourable post-operative outcome [30].A bundle of measurements to optimize patients with IBD is mandatory to improve post-operative outcome. Among the most important elements in this bundle are withdrawal of steroids, nutritional support [31], prophylaxis against thromboembolism, prophylactic antibi-otic, combined mechanical and oral antibiotic for bowel preparation. ConclusionBibliography1. Alos R and Hinojosa J. “Timing of surgery in Crohn’s disease: a key issue in the management”. World Journal of Gastroenterology 14.36 (2008): 5532-5539.2. Martindale RG and Deveney CW. “Preoperative risk reduction: strategies to optimize outcomes”. Surgical Clinics of North America 93.5 (2013): 1041-1055. 3. Gapasin J., et al. “Potentially avoidable surgery in inflammatory bowel disease: what proportion of patients come to resection without optimal preoperative therapy? A guidelines-based audit”. Internal Medicine Journal 42.5 (2012): e84-e88. Citation: Alaa El-Hussuna. “Surgical Intervention in Patients with IBD: Be Prepared!”. EC Gastroenterology and Digestive System 6.10 (2019): 891-895.Surgical Intervention in Patients with IBD: Be Prepared!8944. Zangenberg MS., et al. “Preoperative optimization of patients with inflammatory bowel disease undergoing gastrointestinal surgery: a systematic review”. International Journal of Colorectal Disease 32.12 (2017): 1663-1676.5. Ahmed Ali U., et al. “Impact of preoperative immunosuppressive agents on postoperative outcomes in Crohn’s disease”. Diseases of the Colon and Rectum 57.5 (2014): 663-674. 6. Subramanian V., et al. “Systematic review of postoperative complications in patients with inflammatory bowel disease treated with immunomodulators”. British Journal of Surgery 93.7 (2006): 793-799. 7. El-Hussuna A., et al. “Biological treatment and the potential risk of adverse postoperative outcome in patients with inflammatory bowel disease: An open source expert panel review of the current literature and future perspectives” (2019)8. Khazen BF and El-Hussuna A. “The use of a perioperative supra-physiological dose of glucocorticoid is not supported by evidence - a systematic review”. Danish Medical Journal 65.6 (2018): A5488. 9. Borrelli O., et al. “Polymeric diet alone versus corticosteroids in the treatment of active pediatric Crohn’s disease:a randomized con-trolled open-label trial”. Clinical Gastroenterology and Hepatology 4.6 (2006): 744-753. 10. Yamamoto T., et al. “Impacts of long-term enteral nutrition on clinical and endoscopic disease activities and mucosal cytokines during remission in patients with Crohn’s disease: a prospective study”. Inflammatory Bowel Diseases 13.12 (2007): 1493-1501. 11. Alves A., et al. “Risk factors for intra-abdominal septic complications after a first ileocecal resection for Crohn’s disease: a multivariate analysis in 161 consecutive patients”. Diseases of the Colon and Rectum 50.3 (2007): 331-336.12. Efron JE and Young-Fadok TM. “Preoperative optimization of Crohn’s disease”. Clinics in Colon and Rectal Surgery 20.4 (2007): 303-308. 13. Sharma A and Chinn BT. “Preoperative optimization of Crohn disease”. Clinics in Colon and Rectal Surgery 26.2 (2013): 75-79. 14. Spinelli A., et al. “Review article:optimal preparation for surgery in Crohn’s disease”. Alimentary Pharmacology and Therapeutics 40.9 (2014): 1009-1022. 15. Kondrup J., et al. “ESPEN guidelines for nutrition screening 2002”. Clinical Nutrition (Edinburgh, Scotland) 22.4 (2003): 415-421.16. Murthy SK and Nguyen GC. “Venous thromboembolism in inflammatory bowel disease: an epidemiological review”. The American Journal of Gastroenterology 106.4 (2011): 713-718. 17. Twig G., et al. “Systemic thromboembolism in inflammatory bowel disease: mechanisms and clinical applications”. Annals of the New York Academy of Sciences 1051 (2005): 166-173. 18. Yuhara H., et al. “Meta-analysis: the risk of venous thromboembolismin patients with inflammatory bowel disease”. Alimentary Phar-macology and Therapeutics 37.10 (2013): 953-962. 19. Papa A., et al. “Prevention and treatment of venous thromboembolism in patients with IBD: a trail still climbing”. Inflammatory Bowel Diseases 21.5 (2015): 1204-1213. 20. Morar PS., et al. “Determining predictors for intra-abdominal septic complications following ileocolonic resection for Crohn’s dis-ease-considerations in preoperative and peri-operative optimisation techniques to improve outcome”. Journal of Crohn’s and Colitis 9.6 (2015): 483-491. 21. Oshima T., et al. “Preoperative oral antibiotics and intravenous antimicrobial prophylaxis reduce the incidence of surgical site infec-tions in patients with ulcerative colitis undergoing IPAA”. Diseases of the Colon and Rectum 56.10 (2013): 1149-1155. Citation: Alaa El-Hussuna. “Surgical Intervention in Patients with IBD: Be Prepared!”. EC Gastroenterology and Digestive System 6.10 (2019): 891-895.Surgical Intervention in Patients with IBD: Be Prepared!89522. Remzi FH., et al. “Restorative proctocolectomy: an example of how surgery evolves in response to paradigm shifts in care”. Colorectal Disease 19.11 (2017): 1003-1012.23. Morris MS., et al. “Oral antibiotic bowel preparation significantly reduces surgical site infection rates and readmission rates in elec-tive colorectal surgery”. Annals of Surgery 261.6 (2015): 1034-1040. 24. Zerbib P., et al. “Pre-operative management is associated with low rate of post-operative morbidity in penetrating Crohn’s disease”. Alimentary Pharmacology and Therapeutics 32.3 (2010): 459-465. 25. Zhu QD., et al. “Efficacy of mechanical bowel preparation with polyethylene glycol in prevention of postoperative complications in elective colorectal surgery: a meta-analysis”. International Journal of Colorectal Disease 25.2 (2010): 267-275. 26. Iesalnieks I., et al. “Mechanical Bowel Preparation (MBP) Prior to Elective Colorectal Resections in Crohn’s Disease Patients”. Inflam-matory Bowel Diseases 24.4 (2018): 908-915. 27. JoyceMR., et al. “Impact of smoking on disease phenotype and postoperative outcomes for Crohn’s disease patients undergoing sur-gery”. Langenbeck’s Archives of Surgery 398.1 (2013): 39-45. 28. Reese GE., et al. “The effect of smoking after surgery for Crohn’s disease: a meta-analysis of observational studies”. International Jour-nal of Colorectal Disease 23.12 (2008): 1213-1221. 29. Sharma A., et al. “Tobacco smoking and postoperative outcomes after colorectal surgery”. Annals of Surgery 258.2 (2013): 296-300. 30. El-Hussuna A., et al. “The effect of pre-operative optimization on post-operative outcome in Crohn’s disease resections”. International Journal of Colorectal Disease 32.1 (2017): 49-56. 31. Cangelosi MJ., et al. “A clinical and economic evaluation of enteral nutrition”. Current Medical Research and Opinion 27.2 (2011): 413-22. Volume 6 Issue 10 October 2019©All rights reserved by Alaa El-Hussuna.

Surgical Intervention in Patients with IBD: Be Prepared!:How Pre-Operative Management Can Change the Post-Operative Outcome

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Surgical Intervention in Patients with IBD: Be Prepared!:How Pre-Operative Management Can Change the Post-Operative Outcome

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