Properly preparing your patients with inflammatory bowel disease (IBD) for surgical procedures is critical for ensuring a successful procedure and outcomes.
This was a topic of discussion today at the Advances in Inflammatory Bowel Disease Regionals 2020 meeting in Los Angeles. After her session, we caught up with speaker Karen N. Zaghiyan, MD, who is a colorectal surgeon and the director of the Colorectal Cancer Program and Samuel Oschin Comprehensive Cancer Program at Cedars Sinai Medical Center in Los Angeles, California.
Gastro Con: How can a gastroenterologist help prepare a patient with IBD for surgery?
Karen Zaghiyan: Prehabilitation for IBD surgery generally centers around medication and nutritional optimization. Gastroenterologists can help prepare our patients with IBD for surgery by helping reduce corticosteroid dosing to the lowest necessary dose. For patients with little inflammation, such as in the case of stricturing Crohn disease, steroids can be tapered. Preoperative nutritional support is also important, especially for patients with recent weight loss or hypoalbuminemia. Enteral support is always preferred over parental nutrition.
Gastro Con: Does bowel preparation for surgery matter? How do the gastroenterologist and surgeon work together to make sure a patient is adequately prepared?
KZ: A combination of oral antibiotic and mechanical bowel preparation is the optimal method to prepare patients and minimize infectious complications. Patients who need preoperative colonoscopy for disease localization can sometimes undergo a single preparation if the procedures can be staggered a day apart. Working together, gastroenterologists and surgeons can minimize the need for multiple bowel preparations over a short period of time.
Gastro Con: How do the gastroenterologist and surgeon work together to ensure optimal outcomes after surgery?
KZ: I cannot stress the importance of early surgical referral enough. Patients who have ample time to consider and process the concept of surgery fare better and feel more in control of their fate when surgery is inevitable. While the need for surgery is often considered a failure by our gastroenterology colleagues, it is important for surgeons and gastroenterologists to work together to assure that a surgical referral is not considered a failure but rather a tool to assist in treating complex IBD.
Gastro Con: Can you speak about a challenging experience you encountered where it was difficult to prepare the patient for surgery? What did you do to overcome the challenge?
KZ: One of the greatest challenges in preparing IBD patients for surgery is in severely malnourished and cachectic patients. In these patients, hospital admission can help expedite the workup while nutritional optimization is achieved.
Recently I had a patient who had severe malnutrition, steroid dependence, and long segment terminal ileal inflammation with a ileovesical fistula and pelvic abscess who was admitted to facilitate the preparation process. By admitting the patient, draining the abscess, tapering steroids, and starting aggressive enteral nutritional support, while obtaining necessary imaging and endoscopic workup, we were able to plan and execute a safe surgical plan for this patient.