IBD: Avoiding Postoperative Infections and Complications

Multidisciplinary care, managing risk factors and thoughtful use of medication are key to preventing postoperative infections and complications in patients with inflammatory bowel disease (IBD).

These are some of the key takeaways in a presentation on biologic management in the perioperative period made by Benjamin Cohen, MD, MAS, clinical director for inflammatory bowel diseases at Cleveland Clinic’s Department of Gastroenterology, Hepatology and Nutrition. He spoke at the Advances in Inflammatory Bowel Diseases annual meeting in December.

Dr. Cohen notes that while some risk factors are unavoidable — including emergent surgery, older age and frailty — others can be managed prior to surgery to reduce the patient’s risk of complications. These include malnutrition, anemia, smoking, venous thromboembolism and using corticosteroids. The patient’s care team, including surgeon, gastroenterologist, nutritionist and pharmacist, should work together to address all possible risk factors.

“A multidisciplinary approach is critical to all IBD care, but it really lends itself well to perioperative care,” Dr. Cohen notes. “When you have multiple team members involved, it gives the patient more opportunities to ask questions and get their problems addressed. It also allows each provider to focus on one area and really manage that aspect of the disease.”

Research shows biologic use is safe

While some past studies have raised concerns about the use of TNF inhibitors prior to surgery, newer research shows that these medications are not associated with higher risk of postoperative complications, Dr. Cohen says. He notes that older research involved retrospective studies that attributed increased risk to biologic medications when actually it may have been due to more severe disease or comorbidities.

A 2022 prospective study on which Dr. Cohen was lead author, “Prospective Cohort Study to Investigate the Safety of Preoperative Tumor Necrosis Factor Inhibitor Exposure in Patients With Inflammatory Bowel Disease Undergoing Intraabdominal Surgery,” involved almost 1,000 patients, of whom 382 had TNF inhibitor exposure prior to surgery.

The research group measured drug levels in the blood to assess exposure, and also looked at whether patients had received any medication within 12 weeks of surgery. “By both assessments of exposure, there was no associated risk of postoperative infections or complications related to the TNF inhibitors,” he says.

At the same time, the study confirmed that use of systemic corticosteroids before surgery does increase risk, he added.

Coordinate medication and surgery

A key takeaway should be that there is no need to delay surgery — and risk further progression of disease — on account of TNF inhibitor use, notes Dr. Cohen. “If surgery is being done because the patient is no longer seeing any benefit from the biologic, there’s also no reason to continue use,” he explains.

A bigger concern is steroid use, which, he points out, is a significant risk factor for complications. Surgeons should coordinate closely with the patient’s gastroenterologist to create a plan to wean the patient off steroids or decrease use as much as possible prior to surgery. Providers should also be careful about the decision to use steroids in the first place.

“I would tend to avoid steroid use as much as possible if I think there’s a high probability of surgery,” Dr. Cohen says. “Or at least I would have clear goals in terms of when I’m going to expect a response to steroids versus moving on to surgery, so that I can taper them off preoperatively quickly.”

He noted that budesonide, a steroid that has first-pass metabolism in the liver, does not have the same risk as systemic corticosteroids like prednisone.

Five questions for patient management

Dr. Cohen suggests using five questions to guide treatment decisions:

1. Does the patient have risk factors for surgical complications? If so, time surgery around risk factor optimization and manage medical therapies to minimize additional risk.
2. Is the patient seeing any clinical benefit from IBD therapies? If so, make a plan for medication management to reduce or avoid the need for steroids.
3. Does the patient require any postoperative prophylaxis? Providers should consider individual patient risk factors.
4. If postoperative prophylaxis is needed, is the plan for the patient to continue on the medications they are already taking?
5. If the patient is on a TNF inhibitor and plans to continue after surgery, is there a risk of immunogenicity? If so, surgery should be timed so the patient can receive their next dose two to four weeks postoperatively, reducing the chance of developing antibodies.

More research needed

Dr. Cohen says that more research is needed, especially in the area of managing advanced medications around non-IBD surgeries.

He noted that guidelines for other disease states may be different, and that it’s important for providers to coordinate and thoughtfully manage each patient’s medication plan.

“The last thing you want is for a patient to withhold their IBD medications and unnecessarily wind up on steroids, which is going to be the biggest risk factor for complications in those non-IBD surgeries as well,” Dr. Cohen says.