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Advances in the Peri-Operative Management of IBD Patients

Advances in the Peri-Operative Management of IBD Patients

For the ACG 2019 Midwest Course, talk on perioperative management of IBD in Minneapolis on August 17, 2019

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Peter Higgins

August 17, 2019
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  1. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Peter D.R. Higgins, MD, PhD, MSc Director, IBD Program University of Michigan @ibddoctor https://speakerdeck.com/higgi13425/
  2. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Agenda • Preparing patients for IBD surgery • Patient factors - Psychological & Physical • Elective vs Emergent surgery • Medication factors • Surgical Options • Management after IBD surgery • Infections • Steroids & Narcotics • Mobility • Postop Monitoring • Stoma and J-Pouch Education
  3. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Preparing Patients for Surgery • Being psychologically prepared • Start at the first visit • When describing treatment options: • Surgery is one of our tools in IBD care • Surgery is always a reasonable option • Planned surgery has better outcomes than emergency surgery. • Delayed surgery for IBD has worse outcomes
  4. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Elective vs Emergency Surgery For UC 8.9 1.8 7.4 27.3 0.6 20.8 7.4 20.5 57.7 13.1 0 10 20 30 40 50 60 Length of Stay (days) Open Wound/ Wound Infection (%) Return to OR (%) Major Complication (%) 30 day Mortality (%) Elective Emergent > 20X Mortality Am J Surgery 2013; 205: 333-338 Data on 4,962 cases from NSQIP database, 2005-2010. Similar data in CD, Gastro 2015; 149: 928-937.
  5. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Risk factors for Poor Surgical Outcomes • Patient Factors • Sicker patients do worse • Timing of Surgery • Elective vs. Emergent • Surgical factors • Diversion vs. Immediate Anastomosis • Medication Factors • Pre-op and perioperative medications • Steroids, steroids, steroids. • TPN?
  6. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Patient Factors - Stamina • Major abdominal surgery can take 3-6+ hours • Major systemic stress • Like running 1-2 marathons. • Muscle matters • Psoas muscle size predictive of surgical outcomes • Pre-habilitation (pre-hab) RCTs underway • At minimum, build walking stamina – able to walk > 2 miles in a day preop. • Plan with patient and family to get out of bed and walk ASAP after surgery Annals of Surgery 2012; 256: 255-261
  7. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Patient Factors - Nutrition • Nutritional status – increased risk with • Weight loss > 10% • BMI < 18.5 • Albumin < 30 g/L – higher mortality and infection rates • Enteral supplementation and TPN both reduce risk (low quality data) • But enteral safer. TPN if obstructed/unable to meet > 60% of caloric needs • Exclusive enteral nutrition (EEN) associated with • improved albumin and CRP • Reduced surgical (32-> 8%) and infectious (20-> 3%) complications • Benefits increase when accompanied by steroid tapering. Nutrients 2017; 9: 562. JCC 2019; doi: 10.1093
  8. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Patient Factors - Habits • Smoking • More wound infections • More pulmonary complications • Strongly encourage to quit > 30 days prior to surgery • Alcohol • Increased cardiac and pulmonary complications • Increased wound and bleeding complications • Strongly encourage to quit > 30 days prior to surgery Int Anesthesiol Clin 2017; 55: 12-20.
  9. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Elective vs. Emergent Surgery in CD Meta-Analysis: Mortality increased 6-fold in Emergent Surgery for Crohn’s disease Gasstroenterology 2015; 149: 928-937.
  10. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Surgical Options: Stages, Diversion • No RCTs in 2 stage vs 3 stage surgery for UC • Urgent and emergent cases tend to be done in 3 stages • More steroid use, weight loss, low albumin - > 3 stage • 28% of UC restorative proctocolectomy nationally done in 3 stages • At time of J pouch surgery, 3 stage patients had less weight loss, use of steroids, better albumin (time to get healthy before J pouch). • Diverting stoma in CD recommended for • Hemodynamically unstable, edematous bowel • Perforation with abdominal contamination • Significant malnutrition or chronic steroid use.
  11. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Medication Factors – Steroids 2.56 3.12 9.16 3.69 1.68 0 1 2 3 4 5 6 7 8 9 10 CS <20 mg CS 20-40 mg CS > 40 mg Corticosteroids Thiopurines Odds Ratio for Infectious Complications of Surgery, adjusted for CD, age, surgery duration Aberra, Lewis, Lichtenstein, et al. Gastroenterology 2003; 125: 320-327.
  12. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    TNF: PUCCINI Study of Post-op Infections 37 Time in days from Surgery 0 4 - 30 30 Screen/Baseline Discharge Day Phone F/U Medical record review for infections and non- infectious outcomes Anti-TNF Level @ Baseline 17 centers, 955 patients with complete data Enrolled 2014-2017 Observational cohort study – Does anti-TNF exposure increase infections After controlling for confounders?
  13. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    PUCCINI Primary analysis (unadjusted): Frequency of any infection and surgical site infection by TNFi exposure 20.0% 19.7% 19.4% 19.6% 0 5 10 15 20 25 30 35 40 45 50 TNFi use within 12 weeks of surgery Detectable TNFi level % with Any Infection Exposure Definition Frequency of Any Infection TNFi unexposed TNFi exposed 12.4% 10.3% 11.5% 12.1% 0 5 10 15 20 25 30 35 40 45 50 TNFi use within 12 weeks of surgery Detectable TNFi level % with Surgical Site Infection Exposure Definition Frequency of Surgical Site Infection TNFi unexposed TNFi exposed P=0.513 P=0.692 P=0.985 P=0.801
  14. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    PUCCINI Predictors of any postoperative infection by detectable TNFi level in multivariable analysis Exposure Definition Detectable TNFi level at time of surgery (n=491) Predictor aOR Post-Op Infection 95% CI p-value Detectable TNFi level at time of surgery 1.112 0.672-1.834 0.677 Genitourinary fistula repair 5.229 1.156-25.020 0.031 Pre-Op total parenteral nutrition 2.842 1.112-6.947 0.024 Comorbidity score 1.136 1.042-1.238 0.004 Variables not significant (p≥0.05) in stepwise selection model: age, disease type, disease duration, gender, pre-op steroids, pre-op non-abdominal infection, enterocutaneous fistula repair, internal fistula repair, other fistula repair, ureteral stent Variables not chosen in stepwise selection: ASA status, BMI, creatinine, hospital transfer, primary ileocolic resection, revision of ileocolic resection, pre-op methotrexate, pre-op thiopurine, pre-op ustekinumab, pre-op vedolizumab, incidental appendectomy, pre-op fever, pre-op length of stay, prior abdominal surgery, hospital admission within 30 days pre-op, active smoking, stoma formed, surgical incision type, surgical blood loss, surgical timing, surgical time
  15. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    PUCCINI Predictors of surgical site infection by detectable TNFi level in multivariable analysis Exposure Definition Detectable TNFi level at time of surgery (n=463) Predictor aOR Post-Op Infection 95% CI p-value Detectable TNFi level at time of surgery 1.554 0.832-2.907 0.165 Ulcerative colitis/Indeterminate colitis 0.463 0.217-0.925 0.036 Pre-Op Thiopurine 0.427 0.180-0.910 0.038 Urgent/Emergent Surgery 5.763 1.118-24.337 0.021 Comorbid score 1.190 1.074-1.318 0.001 Age 1.025 1.006-1.045 0.011 Variables not significant (p≥0.05) in stepwise selection model: gender, pre-op steroids, semi-urgent surgery Variables not chosen in stepwise selection: BMI, creatinine, disease duration, hospital transfer, primary ileocolic resection, revision of ileocolic resection, pre-op methotrexate, pre-op ustekinumab, pre-op vedolizumab, pre-op fever, pre-op length of stay, prior abdominal surgery, hospital admission within 30 days pre-op, active smoking, stoma formed, surgical bowel prep, surgical approach, ureteral stent
  16. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Optimization Before Surgery • Treat Abscesses (Antibiotics / drainage) • Improve iron status / reduce anemia • Build Patient Walking Stamina • Optimize medications • Minimize inflammation • Minimize corticosteroids • Plan when to stop medications • And when to restart medications in CD
  17. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Abscess Treatment Before Surgery • Antibiotics • Drainage 70% success (Percutaneous > Surgical preferred) Abdominal wall abscesses are harder to drain percutaneously • EEN reduces recurrence in the short term
  18. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Optimizing medications before surgery • Minimize inflammation with steroid sparing medications • Minimize steroids to promote wound healing • Reduce the length of resection with “Neoadjuvant” therapy to “debulk” the length of inflammation
  19. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    When to stop medications before surgery • Steroids • Stop as soon as possible without worsening inflammation • Often taper as low as possible, then operate • Use IV equivalent of final steroid dose (not stress dose) • Taper rapidly after surgery (over 1-2 weeks) • Methotrexate, thiopurines, tofacitinib • Stop ~ 2 days before surgery • Antibody medications • Operate at midpoint between doses • If wound not infected • Restart shortly (1-2 weeks) after surgery for Crohn’s disease
  20. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    After Surgery • Infection • Debilitation and mobility • Narcotics lead to immobility, ileus • Steroid dosing and tapering
  21. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Infections • Lines, drains, and catheters out ASAP • Press and assess wound daily
  22. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Mobility •Reduces risk of VTE •Reduces ileus •Reduces Length of Stay
  23. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Narcotics at Discharge • Minimize outpatient prescriptions • 6% become new persistent opioid users • Use short-acting narcotics • OPEN Network Prescribing Recommendations: JAMA Surg. 2017;152(6):e170504 https://www.opioidprescribing.info/ Procedure Number of 5 mg Oxycodone Tablets at Discharge Colectomy 15 SB resection 20 Open cholecystectomy 15 Ostomy creation 15
  24. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    The Stress-Dose Steroid Tradition • Evidence-free standard of care • 100 mg hydrocortisone IV tid • No difference in RCT of HDS vs low dose through surgery • Use the IV hydrocortisone equivalent of pre-op prednisone dose, with rapid taper. Zaghiyan, Melmed, Fleshner, et al. Ann Surg. 2014; 259: 32-37. 5% 4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% High Dose Steroids Low Dose Steroids Postural Hypotension on POD 1
  25. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Bundled In-hospital Postoperative Care: ERAS (Enhanced Recovery After Surgery) Principles • Fasting only 2h prior to surgery • Carbohydrate-loading drinks prior • Minimal incision size • Fluid homeostasis – do not flood the patient • Start drinking, eating again on day of surgery • Early mobilization – up and walking on day 1 • Early removal of (or no use of) drains, catheters, tubes • Minimize narcotics • UM IBD Postop protocol: http://www.med.umich.edu/ibd/docs/IBD_PostOp.pdf JAMA Surg. 2017;152(3):292-298. underscore
  26. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Who is at High Risk for CD Recurrence? • Postoperative Crohn’s disease • Smokers • Previous penetrating disease • 2nd (or more) intestinal resection • Early post-operative therapy for high risk patients • Close monitoring for recurrence in both low and high risk
  27. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    PREVENT study of Post-op Infliximab in CD • Randomized 297 postop CD participants to IFX vs PBO for 76 weeks • Evaluated clinical recurrence and endoscopic recurrence 51% 22% 0% 50% 100% Endoscopically Mild in PREVENT Rutgeerts i0 or i1 Placebo Infliximab 87% 80% 0% 50% 100% Clinical Remission in PREVENT Placebo Infliximab p = 0.10 p = < 0.001 Gastro 2016; 150: 1568-1578
  28. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    POCER study of Postoperative Strategy in CD • Started therapy shortly after surgery in high-risk CD patients • Smokers, prior resection, penetrating complications • Randomized to active monitoring vs. symptom driven care • Sequential step up to thiopurines, adalimumab • Monitored all patients closely • FCP q 3 months • Scope at 6 months • Can detect endoscopic recurrence with high sensitivity with FCP >100 q 3 months (NPV 91%) • Stepped up therapy for endoscopic recurrence in the first 18 months 22% 8% 0% 20% 40% Endoscopic Remission (i0) in POCER Symptom Driven Care Active Monitoring / Step Up Lancet, 2015; 385: 1406-1417. Gastro 2015; 148: 938-947
  29. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Post-operative Care in UC? • UC – off immunosuppressive therapy • Keep rectal stump drained • Consider rectal stump treatment w/ suppository mesalamine if bleeding daily • Ileostomy • Educate on signs of dehydration • Educate on signs of obstruction • J pouch • Educate on signs of pouchitis • Surveill with scope q 2 years (probably overkill) • Annually if dysplasia in the resected colon
  30. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    How to Monitor CD? What I Do • High risk: • Prior resection, penetrating complication, smoking: start with biologic • Strongly consider combo for anti-TNFs or prior anti-biologic antibody • FCP q 3 months • Monitoring • Scope as soon as FCP >100 (very sensitive for endo recurrence) • Or scope at 12 m if FCP stays <100 • Stepping up • Step up for ≧i2b (5 or more ileal ulcers, not including anastomotic ulcers) • Discuss options with patient for i0 with histologic inflammation, or i1.
  31. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Stoma Education Checklist BEFORE Discharge • Knowledge • I have an ileostomy / colostomy / ileal conduit • A healthy stoma should look like: • My stoma is not healthy if: • Normal stoma output is: • If I have too little output I should: • If I have too much output I should: • Signs of dehydration are: • To prevent dehydration I should: • If the skin around my stoma is irritated, I will: • Phone # to call surgery / stoma office: ______________ http://www.med.umich.edu/1libr/WoundAndOstomy/StomaTeachingChecklist.pdf
  32. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Stoma Education: Skills BEFORE Discharge • Skills • I can open and close my pouch • I can empty my pouch without spillage • I can measure my own intake volume and output volume • I can perform a pouch change on my own • My stoma supplies include: ______________ • Stoma supply company: ___________ • Number to call to obtain more supplies: _____________ http://www.med.umich.edu/1libr/WoundAndOstomy/StomaTeachingChecklist.pdf @VeganOstomy
  33. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Take Home Message • Prepare patients for surgery psychologically, by reducing steroids, controlling inflammation, and improving nutrition & strength • Elective surgery >>> emergent surgery. Don’t wait. • Risk-stratify post-op patients with Crohn's disease with • Medical history • Fecal calprotectin monitoring to determine when to • Start therapy early post-op in high-risk patients, and • To scope to confirm biologic remission in low-risk patients • Avoid stress-dose steroids, and taper patients off steroids quickly • UC patients do not need immunosuppressive therapy after colectomy
  34. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Thank You https://speakerdeck.com/higgi13425/
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  36. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

  37. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    Upload slides to Website by June 20 • Make no changes • https://www.conferenceharvester.com/harvester2/home.asp?EventK ey=NFITUQMJ • Talk follows • SV Kane on Rx of CD • David Rubin on Rx of UC • Then Q & A until 2:30 PM
  38. ACG Midwest Regional Postgraduate Course August 17-18, 2019 Minneapolis, MN

    20 minutes • 1:55 PM – 2:15 PM • Assess strategies to optimize peri-operative management of IBD patients. • MOC statements • I will risk-stratify post-op patients with Crohn's disease with medical history and fecal calprotectin monitoring to determine when to start therapy early postop, and when to check for recurrent inflammation. • I will help patients prepare for surgery by (1) insisting that it is a reasonable option throughout their disease course, and (2) using prehab and minimizing steroids before surgery. • I will taper patients off of steroids after surgery, and watch for signs of adrenal insufficiency, and will not put ulcerative colitis patients on systemic IBD therapy in the colectomy postop period.