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Perioperative Care of Patients with Inflammatory Bowel Disease: Focus on Nutritional Support 时间:2018-09-24 10:03   来源:未知   作者:admin   点击: 次 Abstract:Patients with inflammatory bowel disease (IBD) commonly require surgery despite the availability of an increasingly large repertoire of powerful immunosuppressive medications for the treatment of IBD. Optimizing patients’ care preoperatively is crucial to obtaining good surgical outcomes. This review discusses preoperative assessment and management principles including assessing disease location and activity with cross-sectional or endoscopic imaging, addressing modifiable risk factors (i.e., stopping smoking, weaning steroids, and correcting anemia), and properly managing medications. The major focus of our literature review is the evaluation for malnutrition, a common finding that affects up to 70% of patients with IBD and a well-known, independent risk factor for adverse postoperative outcomes. Our review confirms that whenever feasible, oral or enteral nutrition (EN) is the preferred method of nutritional support; parenteral nutrition (PN) should be reserved for nutritionally deficient IBD patients unable to tolerate EN. In selected patients, recent data demonstrated that the use of preoperative PN resulted in improved nutritional status, fewer postoperative complications, and reduced disease severity. Our review highlights the need for well-designed, prospective trials investigating perioperative nutritional support in patients with IBD. Future studies should perform modern nutritional assessment, standardize for diet, and include patients with UC since this subset of patients is underrepresented in existing studies. In addition, relevant outcome of interest specific to Crohn’s disease (CD) patients such as length of small bowel resected, number of anastomoses, and need for an ostomy should be included as these patients may require repeated small bowel resections.
1. Introduction
  Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), is characterized by chronic relapsing gastrointestinal (GI) inflammation. Though the underlying cause of IBD remains unknown, important insights into the pathogenesis have been gained through studies of immune mechanisms, genetics, and the microbiome [1]. In addition, an explosion of new therapeutics has revolutionized our approach to treatment. While new therapies have helped decrease hospital admission rates, incidence rates for surgery remain high. Indeed, the risk of surgery in patients with Crohn’s disease is approximately 50% at a 10-year disease duration [2], while 40% of patients with ulcerative colitis requiring inpatient care will ultimately require proctocolectomy [3]. Postoperative endoscopic recurrence of CD is near 90% at one year. In ulcerative colitis, a disease that has historically been considered curative with surgery, significant rates of postoperative transition to CD, difficult to control pouchitis, and systemic inflammatory manifestations remind us that the disease has an immunologic basis that persists even after proctocolectomy [3].
  An explanation for the persistently high surgical rates in CD even in the era of aggressive use of potent anti-inflammatory medications eludes the field. The answer can likely be found in the molecular mechanisms that underlie the progression from inflammation to fibrosis causing end organ dysfunction and structural damage such as strictures that often require surgery. Pathogenically, it seems that inflammatory mechanisms trigger fibrotic pathways that march on despite our potent therapeutics. In certain patients, aggressive disease appears to predispose patients to multiple surgeries such that 35% of patients requiring one resection will require a second resection within 10 years [2].
  Identifying patients destined to have aggressive IBD can help clinicians tailor therapy and set a strategy for monitoring disease progression. Discussing these risks with patients can help improve patient understanding of their disease and improve their adherence to medication and testing regimens. Understanding the consequences can help patients modify risk factors such as smoking in patients with CD. Predictors of aggressive CD are shown in Table 1 [4–7].