Perioperative use of immunosuppressive medications in patients with Crohn's disease in the new "biological era"

Abstract

Crohn’s disease (CD) is characterized by transmural inflammation of the gastrointestinal tract leading to inflammatory, stricturing and/or and fistulizing disease. Once a patient develops medically refractory disease, mechanical obstruction, fistulizing disease or perforation, surgery is indicated. Unfortunately, surgery is not curative in most cases, underscoring the importance of bowel preservation and adequate perioperative medical management. As many of the medications used to treat CD are immunosuppressive, the concern for postoperative infectious complications and anastomotic healing are particularly concerning; these concerns have to be balanced with preventing and treating residual or recurrent disease. We herein review the available literature and make recommendations regarding the preoperative, perioperative and postoperative administration of immunosuppressive medications in the current era of biological therapy for CD. Standardized algorithms for perioperative medical management would greatly assist future research for optimizing surgical outcomes and preventing disease recurrence in the future.

Enteral nutrition is associated with a decreased risk of surgical intervention in Crohn’s disease patients with spontaneous intra-abdominal abscess

“…In addition, bowel resection for CD can be complicated by anastomotic septic complications and new fistula formation, which may hinder the recovery process. The advantage of surgical over nonsurgical management in reducing abscess recurrence rates and complications is controversial (9)(10)(11)(12)(13)(14)(15). As the concept of "bowel-sparing" is of paramount importance in the management of CD, factors involved in the need for surgery should be further studied.…”

Letter: when to withhold anti‐TNF agents prior to abdominal surgery in patients with Crohn's disease—the jury might still be out

“…5 Our study is the first meta-analysis to try to adjust for these confounding factors. 6 Although this showed a significant association with increased risk of post-operative complications in CD patients with pre-operative exposure to anti-TNF agents, as Gates et al 1 mentioned, some issues remained unsettled. Further studies with measurement of drug levels are required to answer this question in depth.…”

Impact of Modern Drug Therapy on Surgery: Crohn's Disease

“…Hence, the European Crohn's and Colitis Organisation (ECCO) and the German guidelines all recommend slow weaning of steroids in case of 20 mg of prednisolone or equivalent if taken over a period of 6 weeks prior to elective surgery [8,9]. Other authors recommend slow tapering already after a period of 3 weeks of previous administration and a prednisolone equivalent of 20 mg [5]. …”

“…Due to pragmatic reasons, we generally discontinue the treatment at least 4 weeks prior to elective surgery, which is also the recommendation from other high-volume centers [5]. …”

“…This in turn may result in surgeons adopting other treatment strategies in order to prevent or minimize morbidity in this setting. Furthermore, as virtually all of the patients now are on at least one of these drugs before being scheduled for surgery, the treating surgeon should be aware of the possible negative impact such drugs may have on postoperative outcome [5]. The most important aspects that need to be considered are summarized in table 2.…”