Perioperative Care of Patients with Inflammatory Bowel Disease: Focus on Nutritional Support

Abstract

Patients with inflammatory bowel disease (IBD) commonly require surgery despite the availability of an increasingly large repertoire of powerful immunosuppressive medications for the treatment of IBD. Optimizing patients' care preoperatively is crucial to obtaining good surgical outcomes. This review discusses preoperative assessment and management principles including assessing disease location and activity with cross-sectional or endoscopic imaging, addressing modifiable risk factors (i.e., stopping smoking, weaning steroids, and correcting anemia), and properly managing medications. The major focus of our literature review is the evaluation for malnutrition, a common finding that affects up to 70% of patients with IBD and a well-known, independent risk factor for adverse postoperative outcomes. Our review confirms that whenever feasible, oral or enteral nutrition (EN) is the preferred method of nutritional support; parenteral nutrition (PN) should be reserved for nutritionally deficient IBD patients unable to tolerate EN. In selected patients, recent data demonstrated that the use of preoperative PN resulted in improved nutritional status, fewer postoperative complications, and reduced disease severity. Our review highlights the need for well-designed, prospective trials investigating perioperative nutritional support in patients with IBD. Future studies should perform modern nutritional assessment, standardize for diet, and include patients with UC since this subset of patients is underrepresented in existing studies. In addition, relevant outcome of interest specific to Crohn's disease (CD) patients such as length of small bowel resected, number of anastomoses, and need for an ostomy should be included as these patients may require repeated small bowel resections.

Enteral Nutrition in Adult Crohn’s Disease: Toward a Paradigm Shift

“…Furthermore, sarcopenia, a loss in lean muscle mass and strength, has been shown in subgroup analyses to be a predictor of surgical complications [164,165]. Data are limited but it is estimated that up to 85% of patients awaiting surgery are malnourished [166]. ESPEN, accordingly, recommends that patients with CD undergoing surgery are screened for malnutrition, as with for general surgery [34,167].…”

Does preoperative enteral nutrition reduce the incidence of surgical complications in patients with Crohn’s disease? A case‐matched study

“…Patients with Crohn’s disease (CD) may become malnourished if the disease cannot be controlled medically . Enteral nutrition (EN) is well established as safe and effective in this situation .…”

Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management

“…There are no sufficient data to define the role of parenteral nutrition in the perioperative phase and it should be used only if enteral nutrition is contraindicated (EL3). [Agreement: "Agree" 72.2%, "Partially agree 16.7%, "Neutral" 5.6%, "Disagree" 5.6%, round I] An extensive review on nutritional support in IBD patients has been recently published [57]. It has been demonstrated that preoperative exclusive enteral nutrition in patients with fistulizing CD is associated with a significantly decreased risk of intra-abdominal septic complications and may result in an accelerated recovery and ability to return to work sooner [58].…”