The impact of preoperative steroid use on short-term outcomes following surgery for inflammatory bowel disease

A Comparison of Clinical Outcomes of Colectomies for Pediatric and Adult Patients With Inflammatory Bowel Disease

Background: Crohn's disease (CD) and ulcerative colitis (UC) are prevalent in adult and pediatric populations, but their differences are not well studied using national data. We compared the clinical outcomes of these patients using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) databases.Methods: Colectomy cases for CD and UC, the 2 major forms of inflammatory bowel disease (IBD), were compared between adult and pediatric patients using the 2017-2019 ACS NSQIP databases. Various clinical factors were analyzed, with postoperative complications being the primary outcome of interest.Results: We identified 542 pediatric and 5174 adult CD patients and 360 pediatric and 1292 adult UC patients. Adults with CD or UC were more likely to be on steroids preoperatively (CD: 60.15% vs 24.54%; UC: 65.63% vs 51.39%). Children with IBD were more likely to have preoperative transfusions (CD: 1.48% vs .33%; UC: 8.33% vs .62%), systemic inflammatory response syndrome (CD: 3.51% vs .93%; UC: 12.78% vs 3.10%), or sepsis (CD: 1.85% vs .66%; UC: 1.39% vs .31%). Unplanned reoperations were more common among pediatric patients in both disease states compared to adults (CD: 6.27% vs 4.10%; UC: 11.11% vs 4.26%), with P-values for all factors described as ≤.02. Multivariate logistic regression found pediatric age to be associated with higher odds of needing a reoperation among UC patients but not CD patients.Conclusion: Pediatric patients were sicker at the time of surgery, and those with either disease were more likely to require a reoperation within 30 days.

Impact of Biologics and Small-Molecule Agents on Postoperative Complications in IBD: A Systematic Review

BACKGROUND

Patients with IBD may require colectomy for severe disease unresponsive or refractory to pharmacological therapy. The question of the impact of biologic use on postoperative complications is a topic of active investigation.

OBJECTIVE

A systematic literature review was performed to describe the current state of knowledge of the impact of perioperative biologic and tofacitinib use on postoperative complications in patients with IBD.

DATA SOURCES

PubMed and Cochrane databases were searched.

STUDY SELECTION

Studies between January 2000 and January 2023, in any language, were searched, followed by a snowball search identifying further studies in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Articles regarding pediatric or endoscopic management were excluded.

INTERVENTIONS

Preoperative or perioperative exposure to biologics in IBD was included.

MAIN OUTCOME MEASURES

Infectious and noninfectious complications, including anastomotic leaks, surgical site infections, urinary tract infections, pneumonia, sepsis, septic shock, postoperative length of stay, readmission, and reoperation, were the main outcomes measured.

RESULTS

A total of 28 studies were included for analysis in this review, including 7 meta-analyses or systematic reviews and 5 randomized studies. Snowball search identified 11 additional studies providing topical information. Overall, tumor necrosis factor inhibitors likely do not increase the risk of postoperative adverse outcomes, while data on other biologics and small-molecule agents are emerging.

LIMITATIONS

This is a qualitative review including all study types. The varied nature of study types precludes quantitative comparison.

CONCLUSIONS

Although steroids increase postoperative infectious and noninfectious complications, tumor necrosis factor inhibitors do not appear to increase postoperative infectious and noninfectious complications. There is a need for further perioperative data for other agents. See video from symposium .

Bariatric surgery in inflammatory bowel disease: a comparative analysis of 450,000 patients

BACKGROUND

Studies were conducted to investigate the outcomes of bariatric surgery (BS) among inflammatory bowel disease (IBD) patients.

OBJECTIVES

We aimed to analyze previous literature, comparing the outcomes of BS between IBD and non-IBD patients.

SETTING

Not applicable.

METHODS

PubMed, Scopus, and Web of Science were searched on 25/9/2023 for comparative studies on outcomes of BS in IBD patients. RevMan Software v5.4 was used to conduct the analysis.

RESULTS

Our analysis revealed an insignificant difference in the change of body mass index (BMI) at 1-year post-BS between IBD and non-IBD patients. IBD patients had a higher risk of acute renal failure, hemorrhage, and readmission following BS (RR: 2.16, 95% CI: 1.55-3, RR: 1.57, 95% CI: 1.22-2.04, RR: 1.56, 95% CI: 1.17-2.08, respectively). No significant difference was observed between both groups regarding wounds, leak/intra-abdominal infection, thromboembolic complications, and bowel obstruction. A higher incidence of postoperative complications was seen among IBD patients undergoing RYGB compared with SG (RR: 2.21, 95% CI: 1.43-3.41). There was a significant decline in steroid use following BS in IBD patients (RR: .67, 95% CI: .53-.84). Comparison between UC and Crohn's disease (CD) revealed insignificant differences in treatment escalation or de-escalation. Both IBD and non-IBD patients had similar lengths of hospitalization.

CONCLUSIONS

BS is equally effective in IBD and non-IBD patients in terms of weight loss at 1-year follow-up. Nevertheless, IBD patients are at a higher risk of postoperative complications, micronutrient deficiency, and readmission. Both UC and CD reported a decline in steroid use following surgery without a preferential advantage to a particular IBD sub-type.

Peri-Operative Optimization of Patients with Crohn's Disease

PURPOSE OF REVIEW

The management of patients with Crohn's disease (CD) undergoing surgery is complex and optimization of modifiable factors perioperatively can improve outcomes. This review focuses on the perioperative management of CD patients undergoing surgery, emphasizing the need for a multi-disciplinary approach.

RECENT FINDINGS

Research highlights the benefits of a comprehensive strategy, involving nutritional optimization, psychological assessment, and addressing septic complications before surgery. Despite many CD patients being on immune-suppressing medications, studies indicate that most of these medications are safe to use and should not delay surgery. However, a personalized approach for each case is needed. This review underscores the importance of multi-disciplinary team led peri-operative management of CD patients. We suggest that this can be done at a dedicated perioperative clinic for prehabilitation, with the potential to enhance outcomes for CD patients undergoing surgery.

Effects of Preoperative Glucocorticoid Use on Patients Undergoing Single-Level Lumbar Fusions: A Retrospective Propensity Score-Matched Registry Study

Objective Spinal fusions are gaining popularity as a means of treating spinal deformity and instability from a range of pathologies. The prevalence of glucocorticoid use has also increased in recent decades, and their systemic effects are well-documented. Although commonly used in the preoperative period, the effects of steroids on outcomes among patients undergoing spinal fusions are inadequately described. This study compares the odds of developing complications among patients who underwent single-level lumbar fusions with and without preoperative glucocorticoid use in hopes of establishing more evidence-based parameters for guiding preoperative steroid use. Methods The TriNetX multi-institutional electronic health record database was used to perform a retrospective, propensity score-matched analysis of clinical outcomes of two cohorts of patients who underwent posterior or posterolateral single-level lumbar fusions with and without interbody fusion, those who used glucocorticoids for at least one week within a year of fusion and those who did not. The outcomes of interest were examined within 30 days of the operation and included death, reoperation, deep or superficial surgical site infection (SSI), pneumonia, reintubation, ventilator dependence, tracheostomy, acute kidney injury (AKI), renal insufficiency, pulmonary embolism (PE) or deep venous thrombosis (DVT), urinary tract infection (UTI), emergency department (ED) visit, sepsis, and myocardial infarction (MI). Results The odds of developing pneumonia within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.67 (p≤0.001, 95% CI: 0.59-0.69). The odds of requiring a tracheostomy within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.39 (p≤0.001, 95% CI: 0.26-0.60). The odds of reoperation, deep and superficial SSI, and ED visits within 30 days of operation were significantly higher for the same glucocorticoid-receiving cohort, with odds ratios of 1.4 (p=0.003, 95% CI: 1.11-1.65), 1.86 (p≤0.001, 95% CI: 1.31-2.63), 2.28 (p≤0.001, 95% CI: 1.57-3.31), and 1.25 (p≤0.001, 95% CI: 1.17-1.33), respectively. After propensity score-matching, there was no significant difference between the odds of death, DVT, PE, MI, UTI, AKI, sepsis, reintubation, and ventilator dependence between the two cohorts. Conclusion In support of much of the current literature regarding preoperative glucocorticoid use and rates of complications, patients who underwent a single-level lumbar fusion and have used glucocorticoids for at least a week within a year of operation experienced significantly higher odds of reoperation, deep and superficial SSI, and ED visits. However, these patients using glucocorticoids were also found to have lower odds of developing pneumonia, renal insufficiency, and tracheostomy requirement than those who did not use steroids within a year of surgery.

Infliximab rescue therapy in a case of severe granulomatous colitis associated with rituximab use

Colitis occurs in about 4% of individuals treated with rituximab. Optimal management of rituximab-induced colitis, which does not improve with cessation of the drug and supportive care alone, is poorly defined due to limited evidence. Severe refractory disease can lead to colectomy. We present a case of suspected rituximab-induced colitis occurring in a woman in her 70s suffering from rheumatoid arthritis. The patient achieved full clinical, endoscopic and histological remission of colitis with infliximab therapy. The use of biological therapy to treat rituximab-induced colitis can be a potentially organ-saving rescue therapy; however, it must be balanced against the increased risks of immunosuppression in patients already exposed to rituximab. While more evidence is required to fully understand the efficacy and risks of antitumour necrosis factor therapy in this scenario, our case provides an example of the successful use of infliximab for rituximab-induced colitis, which likely helped the patient avoid a colectomy.

Early Discharge after Uncomplicated Elective Colectomy and Risk of Postdischarge Complication

BACKGROUND

This was a retrospective cohort study of adult patients undergoing uncomplicated elective colectomy using the NSQIP database from January 2012 to December 2019. A colectomy is deemed uncomplicated if there are no complications reported during the hospitalization. The objective of this study was to examine the association between discharge timing and postdischarge complications in patients who undergo uncomplicated elective colectomy.

STUDY DESIGN

Patients were stratified into an early discharge group if their length of postoperative hospitalization was ≤3 days for laparoscopic or robotic approaches, or ≤5 days for the open approach, and otherwise into delayed discharge groups. The association between early discharge and any postdischarge complication was examined using unadjusted logistic regression after propensity score matching between early and delayed discharge groups.

RESULTS

Of the 113,940 patients included, 77,979, 15,877, and 20,084 patients underwent uncomplicated laparoscopic, robotic, and open colectomy, respectively. After propensity score matching, the odds of a postdischarge complication were lower for the early discharge group in laparoscopic (odds ratio 0.73, 95% CI 0.68 to 0.79) and robotic (odds ratio 0.63, 95% CI 0.52 to 0.76) approaches, and not different in the open approach (odds ratio 1.02, 95% CI 0.91 to 1.15). There were no clinically meaningful differences in the risk of return to the operating room for all surgical approaches.

CONCLUSIONS

Early discharge after uncomplicated colectomy appears to be safe and is associated with lower odds of postdischarge complications in minimally invasive approaches. Our findings suggest that surgical teams practice sound clinical judgments on selecting patients who benefit from early discharge.

Healthcare professionals' knowledge and attitudes towards surgical site infection and surveillance: A quasi-experimental study

AIM

SSI is one of the most prevalent healthcare-associated infections and is associated with extended hospital stays, increased need for reoperation and higher hospital readmission rates. Implementing systematic SSI surveillance can reduce these adverse outcomes. Implementing a surveillance system into a hospital is a complex intervention requiring that staff involved in a patient's perioperative journey have the knowledge of SSI prevention, the data required for surveillance, an understanding of how data informs quality improvement initiatives and their role in surveillance. The aim of this study was to evaluate the impact of a complex intervention on the knowledge and attitudes of healthcare professionals towards surgical site infection (SSI), SSI prevention and surveillance in a university hospital setting.

DESIGN

The study used a quasi-experimental pre-test-post-test design.

METHOD

The impact of a complex intervention was evaluated by measuring healthcare professionals' (n = 74) knowledge of and attitudes towards SSI and surveillance. Normalisation process theory (NPT) guided the study and the development of the intervention.

RESULTS

There was a statistically significant increase in scores on the knowledge of SSI and prevention from pre-intervention to post-test. The knowledge of risk factors scores at post-test was significantly higher than that at pre-intervention. Overall attitudes to SSI prevention and surveillance were good both pre-intervention and post-test but there was a significant change in the attitude of participants. The findings reveal an overall positive impact of the complex intervention on the knowledge and attitude of healthcare professionals relating to SSI, SSI prevention and surveillance; however, the extent of the change varied across items measured.

Risk and management of post-operative infectious complications in inflammatory bowel disease: A systematic review

BACKGROUND

Indications for surgery in inflammatory bowel disease (IBD) include treatment-refractory disease or severe complications such as obstruction, severe colitis, dysplasia, or neoplasia. Infectious complications following colorectal surgery in IBD are significant, particularly in high-risk patients.

AIM

To gather evidence on risk factors associated with increased post-operative infectious complications in IBD and explore management strategies to reduce morbidity and mortality.

METHODS

A systematic review adhering to PRISMA-P guidelines was conducted. MEDLINE (PubMed) and Cochrane Library databases were searched using specific keywords. Inclusion criteria encompassed studies involving patients with IBD undergoing abdominal surgery with infectious complications within 30 d postoperatively. Exclusion criteria included patients under 18 years and non-infectious complications. Selected papers were analyzed to identify factors contributing to post-operative infections. A narrative analysis was performed to provide evidence-based recommendations for management. The data were then extracted and assessed based on the Reference Citation Analysis (https://www.referencecitationanalysis.com/).

RESULTS

The initial database search yielded 1800 articles, with 330 articles undergoing full-text review. After excluding duplicates and irrelevant papers, 35 articles were included for analysis. Risk factors for post-operative complications in patients with IBD included hypoalbuminemia, malnutrition, preoperative abscess, and obesity. Perioperative blood transfusion was associated with increased infectious complications. Medications such as 5-aminosalicylates and immunomodulators did not increase post-operative complications. Corticosteroids were associated with an increased risk of complications. Ustekinumab and vedolizumab showed similar rates of infectious complications compared to other treatments. The impact of minimally invasive surgery on post-operative complications varied across studies.

CONCLUSION

In order to reduce post-operative infectious complications in patients with IBD, a comprehensive approach involving multiple disciplines is necessary.

Effects of the preoperative use and dosage of steroids on postoperative complications of gastric cancer surgery

PURPOSE

To investigate the effects of preoperative steroid administration, including dosage, on complications after gastrectomy for gastric cancer.

METHODS

We reviewed patients who underwent gastrectomy for gastric and esophagogastric junctional adenocarcinoma between 2013 and 2019 at the Department of Gastrointestinal Surgery, The University of Tokyo.

RESULTS

Among the total 764 patients eligible for inclusion in the study, 17 were on steroid medication preoperatively (SD group) and 747 were not (ND group). The hemoglobin, serum albumin levels, and respiratory functions were significantly lower in the SD group than in the ND group. The incidence of postoperative complications classified as Clavien-Dindo (C-D) ≥ 2 was significantly greater in the SD group than in the ND group (64.7% vs. 25.6%, p < 0.001). Intra-abdominal infection (35.2% vs. 9.6%, p < 0.001) and anastomotic leakage (11.8% vs. 2.1%, p < 0.001) occurred more frequently in the SD group than in the ND group. On multiple logistic regression analysis for C-D ≥ 3 postoperative complications, the odds ratio for oral steroid use ≥ 5 mg per day as prednisolone had the highest value, of 13.0 (95% confidence interval 2.46-76.2, p < 0.01).

CONCLUSION

Preoperative oral steroid use was identified as an independent risk factor for postoperative complications after gastrectomy for gastric cancer. Furthermore, the complication rate appears to increase as the oral steroid dosage is increased.

Postoperative Crohn's Disease

Although surgery rates in Crohn's disease are declining in the past twenty years, bowel resection remains an important and still commonly used therapeutic option in Crohn's disease. Preoperatively, patients clinical status must be optimized including preparation for perioperative recovery including with nutrition optimization and preparation for postoperative pharmacotherapy. Postoperatively a medical therapy is often required and in recent years it has often been a biological therapy. One randomized controlled study suggested that infliximab is more likely to prevent endoscopic recurrence than placebo. But other biologicals have been used as well. Ileocolonoscopy should be undertaken by 6 months after an ileal or ileocecal resection especially. Adjunctive imaging such as transabdominal ultrasound, capsule endoscopy or cross sectional imaging may be required. Biomarker measurement with fecal calprotectin especially, or C-reactive protein, serum ferritin, serum albumin and serum hemoglobin will also be helpful.

Risk of Postoperative Venous Thromboembolism After Benign Colorectal Surgery: Systematic Review and Meta-analysis

BACKGROUND

Venous thromboembolism is a well-established preventable complication after colectomy. Specific guidance on venous thromboembolism prevention after colectomy for benign disease is limited.

OBJECTIVE

This meta-analysis aimed to quantify the venous thromboembolism risk after benign colorectal resection and determine its variability.

DATA SOURCES

Following Preferred Reporting Items for Systematic Review and Meta-Analysis and Meta-analysis of Observational Studies in Epidemiology Guidelines (PROSPERO: CRD42021265438), Embase, MEDLINE, and 4 other registered medical literature databases were searched from the database inception to June 21, 2021.

STUDY SELECTION

Inclusion criteria: randomized controlled trials and large population-based database cohort studies reporting 30-day and 90-day venous thromboembolism rates after benign colorectal resection in patients aged ≥18 years. Exclusion criteria: patients undergoing colorectal cancer or completely endoscopic surgery.

MAIN OUTCOME MEASURES

Thirty- and 90-day venous thromboembolism incidence rates per 1000 person-years after benign colorectal surgery.

RESULTS

Seventeen studies were eligible for meta-analysis reporting on 250,170 patients. Pooled 30-day and 90-day venous thromboembolism incidence rates after benign colorectal resection were 284 (95% CI, 224-360) and 84 (95% CI, 33-218) per 1000 person-years. Stratified by admission type, 30-day venous thromboembolism incidence rates per 1000 person-years were 532 (95% CI, 447-664) for emergency resections and 213 (95% CI, 100-453) for elective colorectal resections. Thirty-day venous thromboembolism incidence rates per 1000 person-years after colectomy were 485 (95% CI, 411-573) for patients with ulcerative colitis, 228 (95% CI, 181-288) for patients with Crohn's disease, and 208 (95% CI, 152-288) for patients with diverticulitis.

LIMITATIONS

High degree of heterogeneity was observed within most meta-analyses attributable to large cohorts minimizing within-study variance.

CONCLUSIONS

Venous thromboembolism rates remain high up to 90 days after colectomy and vary by indication for surgery. Emergency resections compared to elective benign resections have higher rates of postoperative venous thromboembolism. Further studies reporting venous thromboembolism rates by type of benign disease need to stratify rates by admission type to more accurately define venous thromboembolism risk after colectomy.

REGISTRATION NO

CRD42021265438.

Biological therapy prior to repeat ileocolic resection in Crohn's disease can reduce the postoperative complication rate

BACKGROUND

The aim of this study was to assess the effect of preoperative biologic therapy on the surgical outcome of Crohn's disease (CD) patients undergoing repeat ileocolic resection.

METHODS

This was a retrospective analysis of all CD patients who underwent repeat ileocolic resection at Cleveland Clinic Florida between January 2011 and April 2021. Patients were divided into two groups: treatment biologic therapy prior to surgery and controls.

RESULTS

Sixty-five patients (31males, median age 54 [range 23-82] years) were included in the study. Twenty nine (44.6%) were treated with biologic therapy prior to repeat ileocolic resection. No demographic differences were found between the biologic therapy and control groups. In addition, no differences were found in mean time from index ileocolic resection (p = 0.9), indication for surgery (p = 0.11), and preoperative albumin (p = 0.69). The majority of patients (57; 87.7%) were operated on laparoscopically, and mean overall operation time was 225 (SD 49.27) min. Overall, the postoperative complication rate was 43.1% (28 patients) and median length of stay was 5 (range 2-21) days. Postoperative complications were more common in the control group, compared to the biologic therapy group (55.6 vs 27.5%; p = 0.04). Conversion rate (35.7 vs 20.7%; p = 0.24), operation time (223 vs 219 min; p = 0.75), length of stay (5.2 vs 5.9 days; p = 0.4), and readmission (16.6 vs 11.1%; p = 0.72) were similar between the two groups. Multivariate analysis of risk factors for postoperative complications showed that biologic treatment was correlated with a lower risk (HR -0.28, CI 95% -0.5596 to -0.01898, p = 0.03).

CONCLUSIONS

Patients treated with biologic therapy for CD who underwent repeat ileocolic resection had fewer postoperative complications.

Early Anti-Tumor-Necrosis-Factor Therapy for Crohn's Disease-Related Abdominal Abscesses and Phlegmon in Children

BACKGROUND

Internally penetrating Crohn's Disease complications, including abscesses and phlegmon, represent a high-risk Crohn's Disease phenotype. Anti-tumor-necrosis-factor-α (Anti-TNF) therapies are effective in treating penetrating Crohn's Disease and early initiation has shown unique benefits. However, timing of anti-TNF initiation in the setting of internally penetrating Crohn's Disease complications is typically heterogenous due to concern over precipitating serious infections. Recent studies demonstrate such an association may not exist.

AIMS

We aimed to describe the multidisciplinary management of pediatric patients with internally penetrating Crohn's Disease complications, focusing on the utilization and timing of anti-TNF therapy relative to complication resolution and adverse events.

METHODS

We performed a single-center retrospective cohort study of pediatric patients with internally penetrating Crohn's Disease complications from 2007 to 2021. The safety and effectiveness of anti-TNF therapy initiation prior to complication resolution was assessed by comparing rates of infectious and Crohn's Disease-related adverse events between those who received anti-TNF therapy prior to complication resolution, versus those who did not.

RESULTS

Twenty-one patients with internally penetrating Crohn's Disease complications were identified. 7/21 received anti-TNF therapy prior to complication resolution. Infectious adverse events within 90 days of complication occurred in 0/7 patients initiating anti-TNF therapy prior to complication resolution and 10/14 patients who did not (p = 0.004). Crohn's Disease-related surgeries and hospitalizations within 1 year of complication occurred in 12/20 patients, with similar frequency between groups.

CONCLUSIONS

Initiating anti-TNF therapy prior to internally penetrating Crohn's Disease complication resolution may be a safe and effective strategy to improve clinical outcomes.

Timing of individualized surgical intervention in Crohn’s disease

Crohn’s disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract with an increasing incidence worldwide. Comprehensive therapy for CD focuses on symptom control and healing the intestinal mucosa to improve the quality of life and prevent complications. Surgical intervention plays a vital role in comprehensive therapy. However, deciding the optimal timing for surgical intervention has long been a focus of controversy. This review provides insights into the timing of surgery for CD and guides clinicians in daily treatment.

Perioperative Management of Ulcerative Colitis: A Systematic Review

BACKGROUND

Patients with ulcerative colitis may require colectomy for severe disease unresponsive or refractory to pharmacological therapy. Managing ulcerative colitis is complicated because there are many factors at play, including patient optimization and treatment, as the guidance varies on the ideal perioperative use of corticosteroids, immunomodulators, biologics, and small molecule agents.

OBJECTIVE

A systematic literature review was performed to describe the current status of perioperative management of ulcerative colitis.

DATA SOURCES

PubMed and Cochrane databases were used.

STUDY SELECTION

Studies published between January 2000 and January 2022, in any language, were included. Articles regarding pediatric or endoscopic management were excluded.

INTERVENTIONS

Perioperative management of ulcerative colitis was included.

MAIN OUTCOME MEASURES

Successful management, including reducing surgical complication rates, was measured.

RESULTS

A total of 121 studies were included in this review, including 23 meta-analyses or systematic reviews, 25 reviews, and 51 cohort studies.

LIMITATIONS

Qualitative review including all study types. The varied nature of study types precludes quantitative comparison.

CONCLUSION

Indications for colectomy in ulcerative colitis include severe disease unresponsive to medical treatment and colitis-associated neoplasia. Urgent colectomy has a higher mortality rate than elective colectomy. Corticosteroids are associated with postsurgical infectious complications and should be stopped or weaned before surgery. Biologics are not associated with adverse postoperative effects and do not necessarily need to be stopped preoperatively. Additionally, the clinician must assess individuals' comorbidities, nutrition status, and risk of venous thromboembolism. Nutritional imbalance should be corrected, ideally at the preoperative period. Postoperatively, corticosteroids can be tapered on the basis of the length of preoperative corticosteroid use.

Prehabilitation prior to intestinal resection in Crohn’s disease patients: An opinion review

Patients with Crohn’s disease (CD) are at a considerable risk for intestinal surgery. Approximately 25% of patients with CD will undergo an intestinal resection within 10 years of diagnosis. Postoperative complications after CD surgery have been reported in 20%-47% of the patients. Both general and CD-related risk factors are associated with postoperative complications, and comprise non-modifiable (e.g., age) and potentially modifiable risk factors (e.g., malnutrition). Prehabilitation focuses on the preoperative period with strategies designed to optimize modifiable risk factors concerning the physical and mental condition of the individual patient. The aim of prehabilitation is to enhance postoperative recovery and return to or even improve preoperative functional capacity. Preoperative improvement of nutritional status, physical fitness, cessation of smoking, psychological support, and critical revision of preoperative use of CD medication are important strategies. Studies of the effect on postoperative outcome in CD patients are scarce, and guidelines lack recommendations on tailored management. In this opinion review, we review the current evidence on the impact of screening and management of nutritional status, physical fitness, CD medication and laboratory values on the postoperative course following an intestinal resection in CD patients. In addition, we aim to provide guidance for individualized multimodal prehabilitation in clinical practice concerning these modifiable factors.

Therapeutic strategies in Crohn’s disease in an emergency surgical setting

Crohn’s disease (CD) remains a chronic, incurable disorder that presents unique challenges to the surgeon. Multiple factors must be considered to allow development of an appropriate treatment plan. Medical therapy often precedes or complements the surgical management. The indications for operative management of CD include acute and chronic disease complications and failed medical therapy. Elective surgery comes into play when patients are refractory to medical treatment if they have an obstructive phenotype. Toxic colitis, acute obstruction, perforation, acute abscess, or massive hemorrhage represent indications for emergency surgery. These patients are generally in critical conditions and present with intra-abdominal sepsis and a preoperative status of immunosuppression and malnutrition that exposes them to a higher risk of complications and mortality. A multidisciplinary team including surgeons, gastroenterologists, radiologists, nutritional support services, and enterostomal therapists are required for optimal patient care and decision making. Management of each emergency should be individualized based on patient age, disease type and duration, and patient goals of care. Moreover, the recurrent nature of disease mandates that we continue searching for innovative medical therapies and operative techniques that reduce the need to repeat surgical operations. In this review, we aimed to discuss the acute complications of CD and their treatment.

Diagnostic Accuracy of Magnetic Resonance Enterography for the Evaluation of Active and Fibrotic Inflammation in Crohn’s Disease

Background

Despite the success of standard magnetic resonance enterography (MRE) in detecting Crohn’s disease (CD), characterization of strictures and, thus, therapy guidance is still limited. The aim of the study was to determine diagnostic accuracy of MRE in detecting or ruling out active inflammation and identifying fibrotic lesions in patients with terminal ileal CD with histopathology as reference.

Methods

Sixty-seven consecutive patients (median age 32 years, range 19–79 years) with terminal ileal CD were retrospectively enrolled between January 2015 and October 2020. The median interval between MRE and surgery was 9 days (range 0–86 days). Sensitivity, specificity, positive and negative predictive value (PPV and NPV, respectively), and area under the curve (AUC) with 95% confidence intervals (CIs) were calculated for the MRE-based AIS (acute inflammation score) using the histopathology of surgical specimens as the reference standard.

Results

Sensitivity, specificity, PPV, and NPV for detecting or ruling out active inflammation were 100% (CI, 0.94–1.00; 0.44–1.00; 0.93–1.00; 0.31–1.00) using an AIS cut-off of >4.1. AUC was 1.00 (CI, 1.00–1.00; p < 0.01). In all patients with fibrotic changes only and no active inflammation, AIS was <4.1. Interobserver agreement was substantial (κ = 0.65, p < 0.01).

Conclusion

Our study has shown an excellent diagnostic performance of the MRE-based AIS for determining whether active inflammation is present or lesions are due to chronic changes in ileal CD using the histopathology of surgical specimens as reference. These findings indicate that the MRE-based AIS allows a better determination of the inflammatory stage of terminal ileal CD, which facilitates the decision to perform surgery.

Is it time to include older adults in inflammatory bowel disease trials? A call for action

The therapeutic management of older patients with inflammatory bowel disease (IBD) is challenging, particularly because of the absence of evidence-based guidelines for these patients, who seem to frequently be excluded from clinical trials. In this systematic review we investigated the exclusion of older patients with IBD from phase 3 studies registered on PubMed and ClinicalTrials.gov, by assessing the upper limit of age exclusion criteria and the percentage of patients older than 65 years included in the trials. Exclusion criteria other than age were also recorded, and comorbidities were analysed separately. Our review of 222 phase 3 studies shows that older patients are frequently excluded from IBD clinical trials because of their age, which was used as an exclusion criterion in 129 (58%) of the 222 assessed trials. Of the 32 trials that detailed the percentage of included patients who were 65 years or older, only 763 (5·4%) patients of the 14 124 patients included were older than 65 years. In addition to age, patients were also excluded because of comorbidities (mainly renal, hepatic, and cardiovascular, and used as an exclusion criterion in 76% of trials), a history of dysplasia (45% of trials), and previous treatment for IBD (19% of trials). We propose a three-step process that should enable the inclusion of all older patients in IBD clinical trials, regardless of their age, comorbidities, and frailty.

Functional panniculectomy vs cosmetic abdominoplasty: Multicenter analysis of risk factors and complications

BACKGROUND

Amidst the rising trend of bariatric surgical procedures being performed across the country and around the world, patients seeking functional panniculectomy after massive weight loss represent a different population than those seeking cosmetic abdominoplasty. The purpose of this study was to determine whether certain complications are more likely to occur in patients undergoing functional panniculectomy, as well as identify risk factors that are implicated in the occurrence of adverse events.

METHODS

Retrospective cohort study was conducted of patients undergoing cosmetic abdominoplasty and functional panniculectomy in North America between 2015 and 2019 using the National Surgical Quality Improvement Program database sponsored by the American College of Surgeons. Comorbidities and postoperative complications between these two cohorts were analyzed with appropriate statistics.

RESULTS

During the study interval, 11,137 patients underwent excision of excessive infraumbilical abdominal skin, including 57.4% (n = 6397) patients undergoing functional panniculectomy and 42.6% (n = 4740) patients undergoing cosmetic abdominoplasty. Patients undergoing functional panniculectomy were significantly more likely to have comorbidities than those undergoing cosmetic abdominoplasty (p < .001). Overall adverse events (p < .001), medical complications (p = .047), surgical complications (p < .001), related readmission (p < .001), and related reoperation (p < .001) were significantly higher in patients undergoing functional panniculectomy. Surgical complications significantly higher in functional panniculectomy included superficial incisional infection (p < .001), deep incisional infection (p < .001), organ/space infection (p < .001), dehiscence (p = .003), and bleeding requiring transfusion (p = .003).

CONCLUSIONS

Patients undergoing functional panniculectomy are significantly more likely to have comorbidities and experience postoperative wound infection, dehiscence, sepsis, bleeding, related readmission, and related reoperation.

Increasing Prevalence of Frailty and Its Association with Readmission and Mortality Among Hospitalized Patients with IBD

BACKGROUND

Although age is often used as a clinical risk stratification tool, recent data have suggested that adverse outcomes are driven by frailty rather than chronological age.

AIMS

In this nationwide cohort study, we assessed the prevalence of frailty, and factors associated with 30-day readmission and mortality among hospitalized IBD patients.

METHODS

Using the Nationwide Readmission Database, we examined all patients with IBD hospitalized from 2010 to 2014. Based on index admission, we defined IBD and frailty using previously validated ICD codes. We used univariable and multivariable regression to assess risk factors associated with all-cause 30-day readmission and 30-day readmission mortality.

RESULTS

From 2010 to 2014, 1,405,529 IBD index admissions were identified, with 152,974 (10.9%) categorized as frail. Over this time period, the prevalence of frailty increased each year from 10.20% (27,594) in 2010 to 11.45% (33,507) in 2014. On multivariable analysis, frailty was an independent predictor of readmission (aRR 1.16, 95% CI: 1.14-1.17), as well as readmission mortality (aRR 1.12, 95% CI 1.02-1.23) after adjusting for relevant clinical factors. Frailty also remained associated with readmission after stratification by IBD subtype, admission characteristics (surgical vs. non-surgical), age (patients ≥ 60 years old), and when excluding malnutrition, weight loss, and fecal incontinence as frailty indicators. Conversely, we found older age to be associated with a lower risk of readmission.

CONCLUSIONS

Frailty, independent of age, comorbidities, and severity of admission, is associated with a higher risk of readmission and mortality among IBD patients, and is increasing in prevalence. Given frailty is a potentially modifiable risk factor, future studies prospectively assessing frailty within the IBD patient population are needed.

Venous and arterial thromboembolism in patients with inflammatory bowel diseases

The risk of thromboembolism (TE) is increased in patients with inflammatory bowel disease (IBD), mainly due to an increased risk of venous TE (VTE). The risk of arterial TE (ATE) is less pronounced, but an increased risk of cardiovascular diseases needs to be addressed in IBD patients. IBD predisposes to arterial and venous thrombosis through similar prothrombotic mechanisms, including triggering activation of coagulation, in part mediated by impairment of the intestinal barrier and released bacterial components. VTE in IBD has clinical specificities, i.e., an earlier first episode in life, high rates during both active and remission stages, higher recurrence rates, and poor prognosis. The increased likelihood of VTE in IBD patients may be related to surgery, the use of medications such as corticosteroids or tofacitinib, whereas infliximab is antithrombotic. Long-term complications of VTE can include post-thrombotic syndrome and high recurrence rate during post-hospital discharge. A global clot lysis assay may be useful in identifying patients with IBD who are at risk for TE. Many VTEs occur in IBD outpatients; therefore, outpatient prophylaxis in high-risk patients is recommended. It is crucial to continue focusing on prevention and adequate treatment of VTE in patients with IBD.

Impact of Biological Agents on Postsurgical Complications in Inflammatory Bowel Disease: A Multicentre Study of Geteccu

Background: The impact of biologics on the risk of postoperative complications (PC) in inflammatory bowel disease (IBD) is still an ongoing debate. This lack of evidence is more relevant for ustekinumab and vedolizumab. Aims: To evaluate the impact of biologics on the risk of PC. Methods: A retrospective study was performed in 37 centres. Patients treated with biologics within 12 weeks before surgery were considered “exposed”. The impact of the exposure on the risk of 30-day PC and the risk of infections was assessed by logistic regression and propensity score-matched analysis. Results: A total of 1535 surgeries were performed on 1370 patients. Of them, 711 surgeries were conducted in the exposed cohort (584 anti-TNF, 58 vedolizumab and 69 ustekinumab). In the multivariate analysis, male gender (OR: 1.5; 95% CI: 1.2–2.0), urgent surgery (OR: 1.6; 95% CI: 1.2–2.2), laparotomy approach (OR: 1.5; 95% CI: 1.1–1.9) and severe anaemia (OR: 1.8; 95% CI: 1.3–2.6) had higher risk of PC, while academic hospitals had significantly lower risk. Exposure to biologics (either anti-TNF, vedolizumab or ustekinumab) did not increase the risk of PC (OR: 1.2; 95% CI: 0.97–1.58), although it could be a risk factor for postoperative infections (OR 1.5; 95% CI: 1.03–2.27). Conclusions: Preoperative administration of biologics does not seem to be a risk factor for overall PC, although it may be so for postoperative infections.

Postoperative outcomes after preoperative ustekinumab exposure in patients with Crohn's disease: a systematic review and meta-analysis

Background

Recent studies have reported conflicting data on the risk of postoperative complications in patients with Crohn’s disease (CD) exposed to ustekinumab (UST) preoperatively. We performed a systematic review and meta-analysis to better assess and quantify the risk of postoperative complications in this population undergoing major abdomino-pelvic surgery.

Methods

We conducted a comprehensive search of multiple electronic databases and conference proceedings (earliest inception through October 2020) to identify studies that reported the postoperative outcomes in CD patients with preoperative UST exposure. We estimated and compared the pooled rates of postoperative complications, including intra-abdominal sepsis, surgical site infection, any infection, any adverse event, readmission, and reoperation.

Results

A total of 5 studies were included in the analysis. The last dose of the drug was at most 16 weeks prior to abdomino-pelvic surgery. A total of 172 CD patients (61% female; median age 35 years) were included. The pooled rate of any complication and any infectious complications was 23.5% (95% confidence interval [CI] 16-33.1) and 20.2% (95%CI 10.3-35), respectively. There was no difference in rates of intra-abdominal sepsis between the UST group (7.2%, 95%CI 3-16.4) and the anti-tumor necrosis factor (TNF) group (11.9%, 95%CI 5.9-22.5; P = 0.4). The rates of readmission and reoperation in the UST group were 17.4% (95%CI 7.9-34) and 14.6% (95%CI 9-22.7), respectively.

Conclusions

The postoperative complication rate in patients with preoperative UST exposure may be similar to that for anti-TNF medication. Preoperative exposure to UST does influence postoperative complication risk. Future prospective studies are needed to validate these findings.

Preoperative Neutrophil-to-Lymphocyte Ratio Is Correlated with Severe Postoperative Complications After Emergency Surgery for Ulcerative Colitis

Introduction

The incidence of postoperative severe complications is reported to be high in patients undergoing emergency surgery for severe ulcerative colitis (UC). It has also been reported that the preoperative inflammatory status is associated with the frequency of postoperative complications. The neutrophil-to-lymphocyte ratio (NLR) is a simple and useful parameter for determining the inflammatory status.

Methods

In the present study, we retrospectively investigated the correlation between the NLR and the incidence of severe postoperative complications in patients undergoing emergency surgery for severe UC. A total of 105 UC patients who underwent emergency or semi-emergency surgery were enrolled. Various clinical factors and NLR values were evaluated to identify the risk factors for severe complications. Postoperative complications were stratified by their severity according to the Clavien-Dindo Classification (CD). A postoperative complication of CD IIIb or higher was defined as severe postoperative complications. The incidence of severe complications was 16.2%.

Results

A multivariate analysis revealed the ASA score, toxic megacolon, and NLR to be independent risk factors for severe postoperative complications.

Conclusions

The results of this retrospective study suggest that the NLR is an independent risk factor for severe postoperative complications in patients undergoing emergency surgery for UC.

Defining the Economic Burden of Perioperative Venous Thromboembolism in Inflammatory Bowel Disease in the United States

BACKGROUND

Patients with IBD are at increased risk of venous thromboembolism.

OBJECTIVE

This study aims to define the economic burden associated with inpatient venous thromboembolism after surgery for IBD that presently remains undefined.

DESIGN

This study is a retrospective, cross-sectional analysis using the National Inpatient Sample from 2004 to 2014.

SETTING

Participating hospitals across the United States were sampled.

PATIENTS

The International Classification of Diseases, 9th Revision codes were used to identify patients with a primary diagnosis of IBD.

INTERVENTIONS

Major abdominopelvic bowel surgery was performed.

MAIN OUTCOME MEASURES

The primary outcome measured was the occurrence of inpatient venous thromboembolism. Univariate and multivariable patient- and hospital-level logistic regression models were used to compare patient characteristics, hospital characteristics, and outcomes between venous thromboembolism and non-venous thromboembolism cohorts. Total average direct costs were then compared between cohorts, and the resulting difference was extrapolated to the national population.

RESULTS

Of 26,080 patients included, inpatient venous thromboembolism was identified in 581 (2.2%). On multivariable analysis, diagnosis of ulcerative colitis, transfer status, length of preoperative hospitalization, and insurance status were independently associated with inpatient venous thromboembolism. Patients with venous thromboembolism were observed to be associated with an increased median length of stay (17.6 vs 6.7 days; p < 0.001) and higher inpatient mortality (5.0% vs 1.1%; OR 4.7, SE 3.2-7.0; p < 0.001). After adjusting for clinically relevant covariates, the additional cost associated with each inpatient venous thromboembolism was $31,551 (95% CI, $29,136-$33,965).

LIMITATIONS

Our study is limited by the administrative nature of the National Inpatient Sample database, which limits our ability to evaluate the impact of clinical covariates (eg, use of venous thromboembolism chemoprophylaxis, steroid use, and nutrition status).

CONCLUSION

Inpatient venous thromboembolism in abdominopelvic surgery for IBD is an infrequent, yet costly, morbid complication. Given the magnitude of patient morbidity and economic burden, venous thromboembolism prevention should be a national quality improvement and research priority. See Video Abstract at http://links.lww.com/DCR/B544.

DEFINICIN IMPACTO ECONMICO DE LA TROMBOEMBOLIA VENOSA PERIOPERATORIA EN LA ENFERMEDAD INFLAMATORIA INTESTINAL EN LOS ESTADOS UNIDOS

ANTECEDENTES:Pacientes con enfermedad inflamatoria intestinal (EII) tienen un mayor riesgo de tromboembolismo venoso (TEV).OBJETIVO:Definir el impacto económico de TEV hospitalaria después de la cirugía por EII, que en la actualidad permanece indefinida.DISEÑO:Un análisis transversal retrospectivo utilizando la Muestra Nacional de Pacientes Internos (NIS) de 2004 a 2014.ENTORNO CLINICO:Hospitales participantes muestreados en los Estados Unidos.PACIENTES:Se utilizaron los códigos de la 9ª edición de la Clasificación Internacional de Enfermedades (ICD-9) para identificar a los pacientes con diagnóstico primario de EII.INTERVENCIONES:Cirugía mayor abdominopélvica intestinal.PRINCIPALES MEDIDAS DE VALORACION:Incidencia de TEV en pacientes hospitalizados, utilizando modelos de regresión logística univariado y multivariable a nivel de pacientes y hospitales para comparar las características de los pacientes, las características del hospital y los resultados entre las cohortes de TEV y no TEV. Se compararon los costos directos promedio totales entre cohortes y la diferencia resultante extrapolando a la población nacional.RESULTADOS:De 26080 pacientes incluidos, se identificó TEV hospitalario en 581 (2,2%). En análisis multivariable, el diagnóstico de colitis ulcerosa, el estado de transferencia (entre centros hospitalarios), la duración de la hospitalización preoperatoria y el nivel de seguro medico se asociaron de forma independiente con la TEV hospitalaria. Se observó que los pacientes con TEV se asociaron con un aumento de la duración media de la estancia (17,6 versus a 6,7 días; p <0,001) y una mayor mortalidad hospitalaria (5,0% versus a 1,1%; OR 4,7, SE 3,2 -7,0; p <0,001). Después de ajustar las covariables clínicamente relevantes, el costo adicional asociado con cada TEV para pacientes hospitalizados fue de $ 31,551 USD (95% C.I. $ 29,136 - $ 33,965).LIMITACIONES:Estudio limitado por la naturaleza administrativa de la base de datos del NIS, que limita nuestra capacidad para evaluar el impacto de las covariables clínicas (por ejemplo, el uso de quimioprofilaxis de TEV, el uso de esteroides y el estado nutricional).CONCLUSIÓN:TEV hospitalaria en la cirugía abdominopélvica para la EII es una complicación mórbida infrecuente, pero costosa. Debido a la magnitud de la morbilidad el impacto económico, la prevención del TEV debería ser una prioridad de investigación y para mejoría de calidad a nivel nacional. Consulte Video Resumen en http://links.lww.com/DCR/B544.

Adverse effects of chronic steroid use following thyroidectomy

BACKGROUND

Prior to thyroid surgery, a subset of patients chronically uses steroids to manage medical conditions such as Grave's disease, auto-immune conditions, or organ transplantation. Existing literature describes adverse effects of prolonged steroid use on surgical outcomes, however there remains a paucity of data investigating the specific effects of steroid use on postoperative outcomes after thyroidectomy. This study aims to identify complication risks steroid users are predisposed to after thyroidectomy.

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program Database (ACS-NSQIP) was queried to identify and isolate all patients who had undergone thyroidectomy procedures by Current Procedure Terminology codes from 2005 through 2018. Univariate analysis was performed to compare steroid uses and non-steroid users. Coarsened exact matching was utilized to homogenize the two cohorts based on demographics and preoperative comorbidities.

RESULTS

A total of 153,595 thyroidectomies were initially included. After Coarsened exact matching, 116,861 patients were categorized as non-steroid users, and 2,965 as steroid users. The steroid cohort demonstrated significantly higher rates of any complication (P < 0.001) as well as overall surgical, cardiopulmonary, and renal complications. Individual complications such as superficial surgical site infections (P = 0.013), pulmonary embolism (P = 0.016), deep vein thrombosis (P = 0.011), progressive renal insufficiency (P = 0.006), and unplanned readmission (P = 0.026) were also increased.

CONCLUSIONS

Patients with chronic steroid use undergoing thyroidectomy are at an increased risk for surgical, cardiopulmonary, and renal complications. Further research on preoperative steroid management is necessary for optimizing outcomes in this population.

Are immunosuppressive conditions and preoperative corticosteroid treatment risk factors in inguinal hernia repair?

INTRODUCTION

Immunosuppressive conditions and/or preoperative corticosteroid treatment have a negative influence on wound healing and can, therefore, lead to higher rates of surgical site infections (SSIs) and seromas. For inguinal hernia, no such studies have been carried out to date.

METHODS

In an analysis of data from the Herniamed Registry, 2312 of 142,488 (1.6%) patients with primary unilateral inguinal hernia repair had an anamnestic history of an immunosuppressive condition and/or preoperative corticosteroid treatment. Using propensity score matching, 2297 (99.4%) pairs with comparative patient characteristics were formed. These were then compared using the following primary outcome criteria: intra- and postoperative complications, complication-related reoperations, recurrence at one-year follow-up, pain on exertion, pain at rest, and chronic pain requiring treatment at one-year follow-up. Of the 2297 matched pairs with primary unilateral inguinal hernia repair, 82.76% were male patients. 1010 (44.0%) were operated in laparo-endoscopic techniques (TEP, TAPP), 1225 (53.3%) in open techniques (Bassini, Shouldice, Lichtenstein, Plug, TIP, Gilbert, Desarda), and 62 (2.7%) in other techniques.

RESULTS

The matched pair analysis results did not identify any disadvantage in terms of the outcome criteria for patients with an anamnestic history of immunosuppressive condition and/or preoperative corticosteroid treatment (yes vs no). In particular, no disadvantage was noted in the rate of surgical site infections (0.65% vs 0.70%; ns) or seromas (1.22% vs 1.57%; ns). The overall rates of postoperative complications were 3.40% vs 4.31% (p = ns) (plus 0.22% concordant events in five matched pairs).

CONCLUSION

In primary unilateral inguinal hernia surgery, an immunosuppressive condition and/or preoperative corticosteroid treatment does not appear to have a negative influence on wound complications.

Trends and Outcomes of Hip Fracture Hospitalization Among Medicare Beneficiaries with Inflammatory Bowel Disease, 2000-2017

BACKGROUND

Patients with inflammatory bowel disease (IBD) have a higher risk of hip fracture, but lower likelihood of having arthroplasties than non-IBD patients in Nationwide Inpatient Sample. Little is known about hip fracture-associated hospitalization outcomes.

AIMS

We assessed the trends in hip fracture hospitalization rates from 2000 to 2017 and estimated 30-day readmission, 30-day mortality, and length of stay in 2016 and 2017.

METHODS

We estimated trends of age-adjusted hospitalization rates using a piecewise linear regression. Medicare beneficiaries aged ≥ 66 years with Crohn's disease (CD, n = 2014) or ulcerative colitis (UC, n = 2971) hospitalized for hip fracture were identified. We performed propensity score matching to create 1:3 matched samples on age, race/ethnicity, sex, and chronic conditions and compared hospitalization outcomes between matched samples.

RESULTS

In 2017, the age-adjusted hospitalization rates (per 100) were 1.15 [95% CI = (1.07-1.24)] for CD, 0.86 [95% CI = (0.82-0.89)] for UC, and 0.59 [95% CI = (0.59-0.59)] for no IBD. The hospitalization rates for CD and UC decreased from 2000 to 2012 and then increased from 2012 to 2017. Compared to matched cohorts, CD patients had longer hospital stays (5.55 days vs. 5.30 days, p = 0.01); UC patients were more likely to have 30-day readmissions (17.27% vs. 13.71%, p < 0.001), longer hospital stays (5.59 days vs. 5.40 days, p = 0.02), and less likely to have 30-day mortality (3.77% vs. 5.15%, p = 0.003).

CONCLUSIONS

Prevention of hip fracture is important for older adults with IBD, especially CD. Strategies that improve quality of inpatient care for IBD patients hospitalized for hip fracture should be considered.

The impact of chronic steroid use on early postoperative complications in shoulder surgery

OBJECTIVES

Chronic steroid use has been associated with poor healing and worse long-term outcomes in patients undergoing orthopedic surgery, but the specific risk profile and short-term complications related to chronic steroids in patients undergoing outpatient shoulder surgery are inadequately defined. The purpose of this study is to characterize the effects of chronic steroids on 30-day post-operative complications following arthroscopic and open shoulder surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent arthroscopic and open rotator cuff repair, shoulder stabilization, and associated procedures from 2011 to 2018. Patients on chronic steroids were compared with patients not on chronic steroids. Demographic data and 30-day postoperative complications were analyzed. Multivariable logistic regression was used to isolate the effects of chronic steroid use on postoperative complications.

RESULTS

We identified 99,970 patients who underwent shoulder surgery during this period, of which 1.7% (1,662 patients) were on chronic steroids. Patients on chronic steroids were older (58.3 ± 0.30vs52.1 ± 0.05 years, p < 0.01), had higher average BMI (30.6 vs 30.1, p = 0.02), and were more likely to be female (54.9%vs38.0%, p < 0.01) and white (76.2%vs73.1%, p < 0.01). Patients on steroids had a higher American Society of Anesthesiologists class, and higher rates of diabetes, CHF, COPD, hypertension, bleeding disorders, and functionally dependency (all P < 0.01). Patients on chronic steroids were less likely to smoke (P < 0.01). Multivariable logistic regression revealed that chronic steroid use was an independent risk factor for major (OR 2.20[1.51-3.21], p < 0.001), minor (OR 2.32[1.13-3.2], p < 0.001), and infectious complications (OR 1.90[1.13-3.2], p = 0.01).

CONCLUSIONS

Preoperative chronic steroid use is independently associated with increased odds of major, minor, and infectious complications after open and arthroscopic rotator cuff repair, shoulder stabilization, and associated procedures. Patients on chronic steroids should be counseled about their increased risk for these complications, and both preoperative risk stratification and optimization should be employed to minimize perioperative risk.

A scoring system to predict a prolonged length of stay after surgery for Crohn's disease

AIM

Many factors influence the postoperative length of stay (LOS) in Crohn's disease (CD). This study aims to identify the factors associated with a prolonged LOS after ileocolic resection (ICR) for CD and to develop a scoring system to predict the postoperative LOS in CD.

METHOD

Patient data were collected from St Marks Hospital, London, UK, and the Humanitas Clinical and Research Center Milan, Italy, for all patients who underwent an ICR for CD from 2005 to 2017. Logistic regression was used for multivariate analysis. The scoring system was developed from the logistic regression model. The performance of the scoring system was evaluated using the area under the receiver operating characteristic curve (AUROC).

RESULTS

A total of 628 surgeries were included in the analysis. Eighty eight surgeries were excluded due to missing data. The remaining 543 were divided into two cohorts for the development (n = 418) and validation (n = 125) of the scoring system. The regression model was statistically significant (p < 0.0001). The statistically significant independent variables included the time since diagnosis, American Society of Anesthesiologists (ASA) grade, perioperative use of steroids, surgical access, strictureplasty and platelet count. The AUROCs for the development and validation cohorts were 0.732 and 0.7, respectively (p < 0.0001). The cut-off score suggested by Youden's index was 50, with a sensitivity of 65.6% and a specificity of 73.3%.

CONCLUSION

The time since diagnosis, ASA grade, steroid use, surgical access, strictureplasty and platelet count were associated with a prolonged LOS and were used to develop a scoring system. The calculator is available online at https://rebrand.ly/Crohnscal.

Venous Thromboembolism in Pediatric Inflammatory Bowel Disease: A Case-Control Study

OBJECTIVES

Inflammatory bowel disease (IBD) is associated with increased risk of venous thromboembolism (VTE). Despite this recognized risk, there are limited data and no anticoagulation guidelines for hospitalized pediatric IBD patients. The objectives of this study were to characterize pediatric IBD patients with VTE and determine risk factors.

METHODS

This was a nested case-control study comparing hospitalized children with IBD diagnosed with VTE to those without VTE over a decade at a large referral center. Standard descriptive statistics were used to describe the VTE group. Multivariable conditional logistic regression was used to assess risk factors.

RESULTS

Twenty-three cases were identified. Central venous catheter (CVC) presence (odds ratio [OR] 77.9; 95% confidence interval [CI]: 6.9--880.6; P < 0.001) and steroid use (OR 12.7; 95% CI: 1.3--126.4; P = 0.012) were independent risk factors. Median age at VTE was 17 years (interquartile range [IQR] 13.5--18.2), and in 48%, VTE was the indication for admission. Median duration of anticoagulation was 3.8 months (IQR 2.3--7.6), and there were no major bleeding events for patients on anticoagulation. There were no patients with known sequelae from VTE, though 22% had severe VTE that required interventions.

CONCLUSIONS

Pediatric patients with IBD are at risk for VTE, although the absolute risk remains relatively low. The safety and efficacy of pharmacologic thromboprophylaxis needs to be further evaluated in this population with attention to risk factors, such as steroid use and presence of CVC.

The reduced risk of septic shock/sepsis with laparoscopic surgery among ulcerative colitis patients with preoperative chronic steroid use

BACKGROUND

Preoperative steroid use has been associated with worse surgical outcomes. The purpose of this study was to determine whether laparoscopic surgery reduces the risk of septic shock/sepsis among ulcerative colitis patients with preoperative chronic steroid use.

METHODS

Patients with ulcerative colitis undergoing a total abdominal colectomy were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2005-2019). Patients were stratified based on preoperative chronic steroid use and operative approach (open versus laparoscopic). The primary outcome was septic shock/sepsis. Multivariable regression models were used to assess the association between laparoscopic surgery and rates of septic shock/sepsis among steroid users and non-steroid users in both the elective and emergent settings.

RESULTS

Among 8,644 patients undergoing a total abdominal colectomy, 67.1% were steroid users and 32.9% were non-steroid users. Compared with an open approach, elective laparoscopic surgery was associated with lower rates of septic shock/sepsis, albeit with higher readmission rates for both steroid users (15.1% [laparoscopic] vs 12.0% [open], P = .005) and non-steroid users (12.6% [laparoscopic] vs 9.4% [open], P = .019). On adjusted analysis, ulcerative colitis patients with chronic steroid use undergoing an elective laparoscopic total abdominal colectomy demonstrated a reduced risk of septic shock/sepsis compared to open surgery (odds ratio 0.61, 95% confidence interval 0.49-0.76, P < .001). Similar findings were seen among chronic steroid users undergoing emergent laparoscopic procedures (odds ratio 0.54, 95% confidence interval 0.31-0.95, P = .031).

CONCLUSION

Laparoscopic surgery was associated with a reduced risk of septic shock/sepsis among ulcerative colitis patients with preoperative chronic steroid use, suggesting that minimally invasive surgery may be a promising option among this unique patient population.

Comparison of outcome after right colectomy with an enhanced recovery programme in patients with inflammatory bowel disease and patients operated on for other conditions: a monocentric retrospective study

PURPOSE

Enhanced recovery programmes (ERPs) after surgery reduce postoperative complications and hospital stay. Patients with inflammatory bowel disease (IBD) often present risk factors for postoperative complications. This accounts for reluctance to include them in ERPs. We compared outcome after right colectomy with an ERP in IBD and non-IBD patients.

METHODS

In our GRACE colorectal surgery database comprising 508 patients, we analysed patients scheduled for right colectomy (n = 160). Adherence to the protocol, postoperative complications and length of hospital stay of IBD patients (n = 45) were compared with those of non-IBD patients (n = 115). Data (mean ± SD, median [IQR], count (%)) were compared by Student's t, Mann-Whitney U and chi-square tests when appropriate; p < 0.05 taken as statistically significant.

RESULTS

IBD patients were significantly younger (38.9 ± 13.8 vs. 58.9 ± 18.5 years, p < 0.001) and had lower BMI (23.0 ± 5.0 vs. 25.1 ± 5.0 kg m^-2, p < 0.01). Adherence to ERP was similar in the two groups. Resumption of eating on the day of the operation was less well tolerated (73.3% vs. 85.2%, p < 0.05) and postoperative pain (p < 0.001) was greater in IBD patients. The incidence of postoperative complications (13.3% vs. 17.3%) and the length of hospital stay (3 [3-4.5] vs. 3 [2-5] days) were comparable in IBD and non-IBD patients, respectively.

CONCLUSION

The management of IBD patients in an ERP is not only feasible but also indicated. These patients benefit as much from ERP as non-IBD patients.

Postoperative mortality in inflammatory bowel disease patients

Introduction Since the 1960s, mortality in Crohn's disease and Ulcerative Colitis patients had a significant decrease due to advances in medical and surgical therapy. An important proportion of these patients are submitted to surgical procedures during their disease course, with postoperative mortality between 4 and 10%.

Methods 157 inflammatory bowel disease patients submitted to surgical therapy were retrospectively identified and allocated in 2 groups (Crohn's and colitis). Deaths were individually discriminated in detail.

Results 281 surgical procedures were performed. In the colitis group, 43 operations were performed in 24 patients; in the abdominal Crohn's subgroup, 127 procedures in 90 patients and in the perineal Crohn's subgroup, 115 in 64 patients, respectively. Nine postoperative deaths were observed (3 in the colitis and 6 in the Crohn's groups). Overall postoperative mortality was 5.7% (4.5% for Crohn's; 6.6% in abdominal Crohn's and 12.5% for Colitis). Most of deaths were related to emergency procedures and previous use of corticosteroids. The cause of death in all patients was sepsis.

Conclusions Overall postoperative mortality in inflammatory bowel disease was 5.7%, and it was attributed to the severity of the cases referred.

Surgical Resection for Crohn's and Cancer: A Comparison of Disease-Specific Risk Factors and Outcomes

BACKGROUND AND OBJECTIVES

The goal of this study was to compare disease-specific risk factors and 30-day outcomes between patients with Crohn's disease (CD) and colon cancer (CC) undergoing right-sided surgical resection.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP®) was interrogated to extract all patients ≥18 years undergoing elective right-sided resection for CD versus CC. Independent risk factors for surgical complications were identified through multivariable logistic regression for both groups. In a second step, surgical and medical 30-day morbidity was compared after risk adjustment.

RESULTS

The cohort consisted of 17,516 patients, of which 2,899 (16.6%) underwent surgery for CD versus 14,617 (83.4%) for CC. Independent risk factors for surgical complications in patients with CD were male gender, African American race, ASA score (III or IV), active smoking, prolonged surgery, and preoperative anemia. Independent risk factors for surgical complications in the cancer group were age ≥70 years, male gender, ASA score (III or IV), respiratory and cardiovascular comorbidities, and preoperative hypoalbuminemia (<3.5 g/dL). After risk adjustment, surgical complications (OR 1.25, p = 0.002), sepsis (OR 1.64, p = 0.012), and unplanned readmissions (OR 1.39, p = 0.004) were more common in patients with CD. Thirty-day mortality was higher in cancer patients (1.1 vs. 0.1%, p < 0.0001).

CONCLUSIONS

Patients with Crohn's disease were more prone to surgical complications and postoperative sepsis compared to the cancer group undergoing the same procedure. Careful evaluation and correction of disease-specific modifiable risk factors of patients with CD and CC, respectively, are important.

Epidemiology and Risk Factors of Portal Venous System Thrombosis in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with inflammatory bowel disease (IBD) may be at risk of developing portal venous system thrombosis (PVST) with worse outcomes. This study aims to explore the prevalence, incidence, and risk factors of PVST among patients with IBD.

METHODS

PubMed, Embase, and Cochrane Library databases were searched. All the eligible studies were divided according to the history of colorectal surgery. Only the prevalence of PVST in patients with IBD was pooled if the history of colorectal surgery was unclear. The incidence of PVST in patients with IBD after colorectal surgery was pooled if the history of colorectal surgery was clear. Prevalence, incidence, and risk factors of PVST were pooled by only a random-effects model. Subgroup analyses were performed in patients undergoing imaging examinations. Odds ratios (ORs) with 95% CIs were calculated.

RESULTS

A total of 36 studies with 143,659 patients with IBD were included. Among the studies where the history of colorectal surgery was unclear, the prevalence of PVST was 0.99, 1.45, and 0.40% in ulcerative colitis (UC), Crohn's disease (CD), and unclassified IBD, respectively. Among the studies where all the patients underwent colorectal surgery, the incidence of PVST was 6.95, 2.55, and 3.95% in UC, CD, and unclassified IBD after colorectal surgery, respectively. Both the prevalence and incidence of PVST became higher in patients with IBD undergoing imaging examinations. Preoperative corticosteroids therapy (OR = 3.112, 95% CI: 1.017-9.525; p = 0.047) and urgent surgery (OR = 1.799, 95% CI: 1.079-2.998; p = 0.024) are significant risk factors of PVST in patients with IBD after colorectal surgery. The mortality of patients with IBD with PVST after colorectal surgery was 4.31% (34/789).

CONCLUSION

PVST is not rare, but potentially lethal in patients with IBD after colorectal surgery. More severe IBD, indicated by preoperative corticosteroids and urgent surgery, is associated with a higher risk of PVST after colorectal surgery. Therefore, screening for PVST by imaging examinations and antithrombotic prophylaxis in high-risk patients should be actively considered.

SYSTEMATIC REVIEW REGISTRATION

Registered on PROSPERO, Identifier: CRD42020159579.

Glasgow prognostic score is a predictive index for postoperative infectious complications after total proctocolectomy in ulcerative colitis patients

BACKGROUND AND AIM

Glasgow prognostic score is a systemic inflammatory-based score. The aim of this study was to determine whether the Glasgow prognostic score was a useful predictor of short-term outcomes in patients who undergo total proctocolectomy for ulcerative colitis.

METHODS

eighty ulcerative colitis patients who underwent a total proctocolectomy with ileal pouch-anal anastomosis or permanent end ileostomy from June 2014 to March 2020 were retrospectively analyzed. Patients were divided into a lower Glasgow prognostic score group and a higher Glasgow prognostic score group.

RESULTS

postoperative infectious complication occurred more frequently in the higher Glasgow prognostic score group (8.3 % vs 29.5 %, p = 0.018). According to the univariate and multivariate analysis, only a higher Glasgow prognostic score was associated with an increased risk of postoperative infectious complication (OR: 5.478, 95 % CI: 1.236-24.279).

CONCLUSION

Glasgow prognostic score is a simple and useful indicator of postoperative infectious complications.

Risk of Postoperative Infectious Complications From Medical Therapies in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

To assess the impact of inflammatory bowel disease (IBD) medications on postoperative infection risk within 30 days of surgery.

METHODS

We searched multiple electronic databases and reference lists of articles dating up to August 2018 for prospective and retrospective studies comparing postoperative infection risk in patients treated with an IBD medication perioperatively with the risk in patients who were not taking that medication. Outcomes were overall infectious complications and intra-abdominal infections within 30 days of surgery.

RESULTS

Sixty-three studies were included. Overall infectious complications were increased in patients who received anti-tumor necrosis factor (TNF) agents (odds ratio [OR] 1.26; 95% confidence interval [CI], 1.07-1.50) and corticosteroids (OR 1.34; 95% CI, 1.25-1.44) and decreased in those who received 5-aminosalicylic acid (OR 0.63; 95% CI, 0.46-0.87). No difference was observed in those treated with immunomodulators (OR 1.08; 95% CI, 0.94-1.25) or anti-integrin agents (OR 1.06; 95% CI, 0.67-1.69). Both corticosteroids and anti-TNF agents were associated with increased intra-abdominal infection risk (OR 1.63; 95% CI, 1.33-2.00 and OR 1.46; 95% CI, 1.08-1.97, respectively), whereas no impact was observed with 5-aminosalicylates, immunomodulators, or anti-integrin therapy. Twenty-two studies had low risk of bias while the remaining studies had very high risk.

CONCLUSIONS

Corticosteroids and anti-TNF agents were associated with increased overall postoperative infection risk as well as intra-abdominal infection in IBD patients, whereas no increased risk was observed for immunomodulators or anti-integrin therapy. Although these results may result from residual confounding rather than from a true biological effect, prospective studies that control for potential confounding factors are required to generate higher-quality evidence.

Risk of postoperative infectious complications from medical therapies in inflammatory bowel disease

BACKGROUND

Medications used to treat inflammatory bowel disease (IBD) have significantly improved patient outcomes and delayed time to surgery. However, some of these therapies are recognized to increase the general risk of infection and have an unclear impact on postoperative infection risk.

OBJECTIVES

To assess the impact of perioperative IBD medications on the risk of postoperative infections within 30 days of surgery.

SEARCH METHODS

We searched the Cochrane IBD Group's Specialized Register (29 October 2019), MEDLINE (January 1966 to October 2019), Embase (January 1985 to October 2019), the Cochrane Library, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform from inception up to October 2019, and reference lists of articles.

SELECTION CRITERIA

Randomized controlled trials, quasi-randomized controlled trials, non-randomized controlled trials, prospective cohort studies, retrospective cohort studies, case-control studies and cross-sectional studies comparing participants treated with an IBD medication preoperatively or within 30 days postoperatively to those who were not taking that medication (either another active medication, placebo, or no treatment). We included published study reports and abstracts.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts and extracted data. The primary outcome was postoperative infection within 30 days of surgery. Secondary outcomes included incisional infections and wound dehiscence, intra-abdominal infectious complications and extra-abdominal infections. Three review authors assessed risks of bias using the Newcastle-Ottawa Scale. We contacted authors for additional information when data were missing. For the primary and secondary outcomes, we calculated odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) using the generic inverse variance method. When applicable, we analyzed adjusted and unadjusted data separately. We evaluated the certainty of the evidence using GRADE.

MAIN RESULTS

We included 68 observational cohort studies (total number of participants unknown because some studies did not report the number of participants). Of these, 48 studies reported including participants with Crohn's disease, 36 reported including participants with ulcerative colitis and five reported including participants with indeterminate colitis. All 42 studies that reported urgency of surgery included elective surgeries, with 31 (74%) of those also including emergency surgeries. Twenty-four studies had low risk of bias while the rest had very high risk. Based on pooling of adjusted data, we calculated ORs for postoperative total infection rates in participants who received corticosteroids (OR 1.70, 95% CI 1.38 to 2.09; low-certainty evidence), immunomodulators (OR 1.29, 95% CI 0.95 to 1.76; low-certainty evidence), anti-TNF agents (OR 1.60, 95% CI 1.20 to 2.13; very low-certainty evidence) and anti-integrin agents (OR 1.04, 95% CI 0.79 to 1.36; low-certainty evidence). We pooled unadjusted data to assess postoperative total infection rates for the use of aminosalicylates (5-ASA) (OR 0.76, 95% CI 0.51 to 1.14; very low-certainty evidence). One secondary outcome examined was wound-related complications in participants using: corticosteroids (OR 1.41, 95% CI 0.72 to 2.74; very low-certainty evidence), immunomodulators (OR 1.35, 95% CI 0.96 to 1.89; very low-certainty evidence), anti-TNF agents (OR 1.18, 95% CI 0.83 to 1.68; very low-certainty evidence) and anti-integrin agents (OR 1.64, 95% CI 0.77 to 3.50; very low-certainty evidence) compared to controls. Another secondary outcome examined the odds of postoperative intra-abdominal infections in participants using: corticosteroids (OR 1.53, 95% CI 1.28 to 1.84; very low-certainty evidence), 5-ASA (OR 0.77, 95% CI 0.45 to 1.33; very low-certainty evidence), immunomodulators (OR 0.86, 95% CI 0.66 to 1.12; very low-certainty evidence), anti-TNF agents (OR 1.38, 95% CI 1.04 to 1.82; very low-certainty evidence) and anti-integrin agents (OR 0.40, 95% CI 0.14 to 1.20; very low-certainty evidence) compared to controls. Lastly we checked the odds for extra-abdominal infections in participants using: corticosteroids (OR 1.23, 95% CI 0.97 to 1.55; very low-certainty evidence), immunomodulators (OR 1.17, 95% CI 0.80 to 1.71; very low-certainty evidence), anti-TNF agents (OR 1.34, 95% CI 0.96 to 1.87; very low-certainty evidence) and anti-integrin agents (OR 1.15, 95% CI 0.43 to 3.08; very low-certainty evidence) compared to controls.

AUTHORS' CONCLUSIONS

The evidence for corticosteroids, 5-ASA, immunomodulators, anti-TNF medications and anti-integrin medications was of low or very low certainty. The impact of these medications on postoperative infectious complications is uncertain and we can draw no firm conclusions about their safety in the perioperative period. Decisions on preoperative IBD medications should be tailored to each person's unique circumstances. Future studies should focus on controlling for potential confounding factors to generate higher-quality evidence.

A baseline assessment of enhanced recovery protocol implementation at pediatric surgery practices performing inflammatory bowel disease operations

BACKGROUND

Enhanced recovery protocols (ERPs) have been used to improve patient outcomes and resource utilization after surgery. These evidence-based interventions include patient education, standardized anesthesia protocols, and limited fasting, but their use among pediatric populations is lagging. We aimed to determine baseline recovery practices within pediatric surgery departments participating in an ERP implementation trial for elective inflammatory bowel disease (IBD) operations.

METHODS

To measure baseline ERP adherence, we administered a survey to a staff surgeon in each of the 18 participating sites. The survey assessed demographics of each department and utilization of 21 recovery elements during patient encounter phases. Mixed-methods analysis was used to evaluate predictors and barriers to ERP element implementation.

RESULTS

The assessment revealed an average of 6.3 ERP elements being practiced at each site. The most commonly practiced elements were using minimally invasive techniques (100%), avoiding intraabdominal drains (89%), and ileus prophylaxis (72%). The preoperative phase had the most elements with no adherence including patient education, optimizing medical comorbidities, and avoiding prolonged fasting. There was no association with number of elements utilized and total number of surgeons in the department, annual IBD surgery volume, and hospital size. Lack of buy-in from colleagues, electronic medical record adaptation, and resources for data collection and analysis were identified barriers.

CONCLUSIONS

Higher intervention utilization for IBD surgery was associated with elements surgeons directly control such as use of laparoscopy and avoiding drains. Elements requiring system-level changes had lower use. The study characterizes the scope of ERP utilization and the need for effective tools to improve adoption.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Mixed-methods survey.

Steroids and Postoperative Complications in IBD

Corticosteroids are frequently used in the management of Inflammatory Bowel Disease. Although they can be very useful, their potential adverse effects have to be kept in mind. One of the situations in which these drugs should be avoided, if possible, is the perioperative setting. If a patient reaches surgery while on steroids, surgical complications will be more likely to occur, both infectious and non-infectious. Attention should be paid to this fact, within a multidisciplinary approach, that also takes into account other factors, such as nutrition.

Preoperative Opioid Prescription Is Associated With Major Complications in Patients With Crohn's Disease Undergoing Elective Ileocolic Resection

BACKGROUND

Opioid use has grown exponentially over the last decade. The effect of preoperative opioid prescription in patients with Crohn's disease undergoing surgery is unknown.

OBJECTIVE

The purpose of this study was to identify whether preoperative opioid prescription is associated with adverse postoperative outcomes in Crohn's disease.

DESIGN

This is a single-institution retrospective observational study.

SETTINGS

This study was performed at an academic tertiary care center. Details of preoperative opioid prescription were collected from the Kentucky All-Schedule Prescription Electronic Reporting database and the electronic databases of bordering states.

PATIENTS

Consecutive patients undergoing ileocolic resection for Crohn's disease from 2014 to 2018 were included.

MAIN OUTCOME MEASURES

The outcomes examined were major complications (Clavien-Dindo ≥3a), length of stay, and 30-day hospital readmission.

RESULTS

Fifty one of 118 patients were prescribed opioids within 6 months preoperatively (range, 0-33,760 morphine milligram equivalents). Patients with preoperative opioid prescription compared with no preoperative opioid prescription required more daily opioids during hospital admission (p = 0.024). Nineteen patients had a major postoperative complication (preoperative opioid prescription: 26% (13/51) vs no preoperative opioid prescription: 9% (6/67)). On multivariable analysis, preoperative opioid prescription (OR = 2.994 (95% CI, 1.024-8.751); p = 0.045) was a significant risk factor for a major complication. Preoperative opioid prescription was associated with increased length of stay (p < 0.001) and was a risk factor for readmission (OR = 2.978 (95% CI, 1.075-8.246); p = 0.036). Twenty-four patients were readmitted. Using a cutoff for higher opioid prescription of 300 morphine milligram equivalents within 6 months preoperation (eg, 60 tablets of hydrocodone/acetaminophen 5/325), preoperative opioid prescription remained a risk factor for major postoperative complications (OR = 3.148 (95% CI, 1.110-8.928); p = 0.031).

LIMITATIONS

This was a retrospective study and could not assess nonprescribed opioid use.

CONCLUSIONS

Preoperative opioid prescription was a significant risk factor for adverse outcomes in patients with Crohn's disease undergoing elective ileocolic resection. See Video Abstract at http://links.lww.com/DCR/B113. LA PRESCRIPCIÓN PREOPERATORIA DE OPIOIDES SE ASOCIA CON COMPLICACIONES MAYORES EN PACIENTES CON ENFERMEDAD DE CROHN SOMETIDOS A RESECCIÓN ILEOCÓLICA ELECTIVA: El uso de opioides ha crecido exponencialmente en la última década. Se desconoce el efecto de la prescripción preoperatoria de opioides en pacientes con enfermedad de Crohn sometidos a cirugía.Identificar si la prescripción preoperatoria de opioides está asociada con resultados postoperatorios adversos en la enfermedad de Crohn.Este es un estudio observacional retrospectivo de una sola institución.Este estudio se realizó en un centro académico de atención terciaria. Los detalles de la prescripción preoperatoria de opiáceos se recopilaron de la base de datos de "Kentucky All-Schedule Prescription Electronic Reporting" y de las bases de datos electrónicas de los estados fronterizos.Pacientes consecutivos sometidos a resección ileocólica por enfermedad de Crohn entre 2014-2018.Los resultados examinados fueron complicaciones mayores (Clavien-Dindo ≥3a), duración de la estancia y el reingreso hospitalario de 30 días.A cincuenta y uno de 118 pacientes se le recetaron opioides dentro de los 6 meses preoperatorios (rango, 0 a 33,760 equivalentes de miligramos de morfina). Los pacientes con prescripción preoperatoria de opioides en comparación con ninguna prescripción preoperatoria de opioides requirieron más opioides diarios durante el ingreso hospitalario (p = 0,024). Diecinueve pacientes tuvieron una complicación postoperatoria importante (prescripción preoperatoria de opioides: 26% [13/51] frente a ninguna prescripción preoperatoria de opioides: 9% [6/67]). En el análisis multivariable, la prescripción de opioides preoperatorios (OR = 2.994, IC 95%: 1.024-8.751, p = 0.045) fueron factores de riesgo significativos para una complicación mayor. La prescripción preoperatoria de opioides se asoció con un aumento de la duración de la estadía (p <0.001) y fue un factor de riesgo para el reingreso (OR = 2.978, IC 95%: 1.075-8.246, p = 0.036). Veinticuatro pacientes fueron readmitidos. Utilizando un límite para una mayor prescripción de opioides de 300 miligramos equivalentes de morfina dentro de los 6 meses previos a la operación (p. Ej., 60 tabletas de hidrocodona / acetaminofén 5/325), la prescripción preoperatoria de opioides siguió siendo un factor de riesgo para complicaciones postoperatorias mayores (OR = 3.148 IC 95%: 1.110-8.928, p = 0.031).Este fue un estudio retrospectivo y no pudo evaluar el uso de opioides no prescritos.La prescripción preoperatoria de opioides fue un factor de riesgo significativo para los resultados adversos en pacientes con enfermedad de Crohn sometidos a resección ileocólica electiva. Consulte Video Resumen en http://links.lww.com/DCR/B113.

Extended thromboprophylaxis following colorectal surgery in patients with inflammatory bowel disease: a comprehensive systematic clinical review

AIM

Patients with inflammatory bowel disease (IBD) are at increased risk of postoperative venous thromboembolism (VTE) following major abdominal surgery. The pathogenesis is multifactorial and not fully understood. A combination of pathophysiology, patient and surgical risk factors increase the risk of postoperative VTE in these patients. Despite being at increased risk, IBD patients are not regularly prescribed extended pharmacological thromboprophylaxis following colorectal surgery. Currently, there is a paucity of evidence-based guidelines. Thus, the aim of this review is to evaluate the role of extended pharmacological thromboprophylaxis in IBD patients undergoing colorectal surgery.

METHOD

A search of Ovid Medline, EMBASE and PubMed databases was performed. A qualitative analysis was performed using 10 clinical questions developed by colorectal surgeons and a thrombosis haematologist. The Newcastle-Ottawa Scale was utilized to assess the quality of evidence.

RESULTS

A total of 1229 studies were identified, 38 of which met the final inclusion criteria (37 retrospective, one case-control). Rates of postoperative VTE ranged between 0.6% and 8.9%. Patient-specific risk factors for postoperative VTE included ulcerative colitis, increased age and obesity. Surgery-specific risk factors for postoperative VTE included open surgery, emergent surgery and ileostomy creation. Patients with IBD were more frequently at increased risk in the included studies for postoperative VTE than patients with colorectal cancer. The risk of bias assessment demonstrated low risk of bias in patient selection and comparability, with variable risk of bias in reported outcomes.

CONCLUSION

There is a lack of evidence regarding the use of extended pharmacological thromboprophylaxis in patients with IBD following colorectal surgery. As these patients are at heightened risk of postoperative VTE, future study and consideration of the use of extended pharmacological thromboprophylaxis is warranted.

Reducing Perioperative Risks of Surgery in Crohn's Disease

BACKGROUND

Approximately one-third of all patients suffering from Crohn's disease (CD) undergo surgery within the first 10 years after diagnosis and another 20% will have a second operation in the 10 years after their first operation. Surgery will remain an essential part of managing CD and therefore it is crucial to prevent perioperative complications by optimizing perioperative management.

METHODS

We reviewed the current literature on managing immunomodulating therapy, nutritional support, and thromboembolic prophylaxis in the perioperative situation.

RESULTS

CD patients with serious nutritional deficits (weight loss >10% in the last 3-6 months, body mass index <18.5 kg/m2, or albumin levels <30 g/L) benefit from intensive enteral or parenteral nutritional support, thereby reducing the risk of surgical-site infections and post-operative septic complications. Immunosuppressive therapy with prednisolone doses >20 mg should be avoided. The risk of therapy with anti-TNFα agents, vedolizumab, and ustekinumab for surgical complications has not been fully established. Analysis of currently available data suggests that an interval of 4-8 weeks is prudent to avoid complications and reduce risk by performing protective ostomy in the emergency setting. Finally, due to the high risk of venous thromboembolism, prophylactic therapy with heparin is recommended.

CONCLUSION

As most cases of CD-related surgery are performed in a non-emergency setting, careful planning and risk management can reduce the rate of surgical complications, increase quality of life, and also reduce costs.

Surgery and paediatric inflammatory bowel disease

The incidence of paediatric Crohn's disease (CD) and ulcerative colitis (UC) is increasing. Surgical intervention is required during childhood in approximately 25% of children diagnosed with CD, and for 10% of those diagnosed with UC. Although there is evidence that the rate of surgical intervention undertaken in children is decreasing since the introduction of biologic therapy, this may only represent a delay rather than true reversal of the risk of surgery. Surgery for CD is not curative and limited resection is the key principle thus preserving bowel length. For UC, subtotal colectomy is relatively curative; ileo-anal pouch anastomosis can be performed to restore bowel continuity.