Practitioners Debate Risk of Post-Operative Complications in IBD From Medical Treatment

In a session at Digestive Disease Week 2013, held May 18-21, 2013, in Orlando, Fla., a group of surgeons and one gastroenterologist discussed not only common short- and long-term post-operative complications in patients with inflammatory bowel disease (IBD) and how to manage them, but also at what point to operate and when the referral should occur.

With patients’ perceptions, Feza H. Remzi, MD, chairman of the Department of Colorectal Surgery at the Cleveland Clinic, in Ohio, said “it’s tough to overcome that we are evil waiting at the door, and we need to change this perception.” Still, Remzi offered one solution in the form of “an early discussion of surgical options and outcomes with patients to clearly define goals of continued medical treatment and to clearly define criteria for referral to surgery.”

During the session, Remzi discussed how medical treatment, such as the use of a biologic agent, can increase post-operative complications. He began his talk by expressing frustration at the fact that while surgery is often considered a failure of medical therapy, it’s a part of the life-long treatment of patients with IBD.

“When I see a patient with immunosuppression, that impacts the surgical effect,” he said. “It puts the surgeon in a difficult situation.”

Remzi indicated that biologic agents form an important part of treatment and may be critical to longevity. However, he expressed concerns about surgical risks with the drugs and explained that a Cleveland Clinic study found the use of infliximab three months before an ileocoloic resection in patients with Crohn’s disease was associated with greater rates of post-op sepsis, intraabdominal abscess formation, and 30-day postoperative readmission, while another study showed a significantly increased risk of sepsis with the use of infliximab preoperatively.

“The risks of both infliximab and surgery should be presented to patients,” Remzi said. “Patients who come to us are in a sicker state.”

Waiting too long to provide a referral for surgery often results in patients arriving at a more severe disease state, such as malnourishment and severe weight loss, which affects surgical outcomes, he said.

Geert R D'Haens, MD, PhD, of the Department of Gastroenterology at the Academic Medical Centre, in Amsterdam, agreed that patients with IBD have co-morbidities that include a poor nutritional state, but he suggested that the IBD surgical population has changed. Though fewer patients need surgery, the surgeries are more complicated.

Regarding Remzi’s point on surgical risks, D’Haens countered that “medical treatment does not lead to increased post-operative complications in inflammatory bowel disease.” D’Haens encouraged the use of biologics with therapeutic drug monitoring and an optimized schedule of administration, and he urged health care professionals not to avoid hopeless cases. He added that avoiding long-term steroid exposure should be a goal, since it increases the risk of infections — particularly if the patient is on a high dose or has had a long duration of treatment.

While D’Haens supports the use of biologics, he said the inappropriate use of an anti-tumor necrosis factor (anti-TNF), such as infliximab, is common and leads to poor candidates at the time of surgery. But he noted if it’s used correctly, it can help bring the best possible candidate to the surgeon if a procedure is needed.

“Immunomodulation is not associated with increased risk of surgical complications,” D’Haens said. “Anti-TNF may be associated with more infectious post-op complications, but outcomes are similar.”