IBD Drive Time: Perioperative Optimization of Patients With IBD

Host Dr Raymond Cross leads the discussion on perioperative optimization in patients with IBD with colorectal surgeon Karen Zaghiyan, MD, and dietitian Kelly Isaacson in this episode of IBD Drive Time.

Raymond Cross, MD, is director of the IBD Center at Mercy Medical Center in Baltimore, Maryland, and professor of medicine at the University of Maryland. Karen Zaghiyan, MD, is a colorectal surgeon with the Cedars‑Sinai Colorectal Surgery Center in Los Angeles, California. Kelly Issokson, MS, RD, is a registered dietitian and director of the Advanced Diet IBD Ed & Training Program at Cedars-Sinai.

TRANSCRIPT:

Any views and opinions expressed are those of the authors and/or participants and do not necessarily reflect the views, policies, or positions of the A IBD network or HMP Global its employees and affiliates.

Dr Cross:

Welcome everyone to IBD Drive Time. I'm Raymond Cross from Mercy Medical Center and I'm delighted to have Karen Zaghiyan and Kelly Isaacson from Cedar-Sinai here today to talk about perioperative optimization in patients with IBD. So Karen and Kelly, welcome to IBD Drive Time.

Ms Issokson:

Thank you. Great to be here.

Dr Zaghiyan:

Thank you. Thanks for having both of us.

Dr Cross:

And for those of you that do not know Karen or Kelly, Karen is a colorectal surgeon and Kelly is a dietician. So we're having a multidisciplinary round table including me as the gastroenterologist. So Karen, I'm going to ask you the first question. So let's think about a patient with, it's usually going to be stricturing disease, but sometimes we get patients with short isolated inflammatory disease or refractory inflammatory disease for surgery. So when you see a patient like that in the office, what are you looking at from a surgical perspective that tells you this patient is going to be at higher risk for complications? I think that'll help us focus on maybe modifiable risk factors.

Dr Zaghiyan:

Yeah, sure. I mean these are questions I think we don't always do a good job of asking and paying attention to as surgeons, but weight loss, I always ask if they've had recent weight loss; that is a good indicator that somebody may be malnourished and it's an easy answer that you can get right away right there in the office. If I have labs available, I'll look back and look at their albumin. If there's a prealbumin, I'll look at their prealbumin. Those were the main things. And then obviously steroids, less so important nowadays with PUCCINI kind of debunking the idea that anti-TNFs and presumably also the newer small molecules and things like that have an impact on surgical outcomes. So I care a lot less about that, but I'll find out if they're on steroids. Budesonide, honestly even too, but specifically prednisone, if they're on prednisone, those are the main things that I'll want to assess in office to determine the risk.

Dr Cross:

So what about, I wanted to ask you a couple of other factors. So obviously you don't like to see smoke, I mean you're not anti, you'll take care of smokers, but smoking is something also that obviously you want to try to modify. So that's going to be one thing. For patients that have profound anemia, that are iron deficient, I try to get them some iron infusions before surgery. Do you care about that as a surgeon?

Dr Zaghiyan:

I do. I think more and more we're kind of beginning to buy into that data historically and traditionally preop anemia, unless they're so anemic that we think it's going to affect their hemodynamics at the time of surgery has been less of a factor. But I do, I mean I think we have some more recent evidence and it is a factor. It's definitely something that we'll look at. And our IBD team here will help us get those patients iron counts and their hemoglobin a little bit better prior to surgery, too.

Dr Cross:

We talked about weight loss, but increasingly our IBD patients are normal body weights or overweight or obese. So in a patient who's coming in for sort of semielective, do you have any guidelines for the overweight obese patients and what you want to do with them?

Dr Zaghiyan:

You mean as far as for weight loss?

Dr Cross:

Yeah, if someone comes in with A BMI of 34 and they need an ileocolic, do you make any recommendations as far as weight loss in those patients? Do you defer the surgery at all or is that more like your pouch patients and hernia patients?

Dr Zaghiyan:

Definitely, yeah, it's definitely a lot more for our pouch patients. I try to get the patients below BMI of 35 for their pouches whenever we can. It's easier now with the GLP-1s to get patients there. Historically, we would send them even off to go get sleeve gastrectomies and bariatric surgery before doing pouches on them. The ileocolic resections less so. I do like using the robot for our obese patients. I mean sometimes, especially if they have inflammatory slash fistulizing Crohn's disease and things like that, the robot and doing things intracorporeally can be challenging and it doesn't always help, but the robot can be helpful and help us get over the surgical hump of pulling a specimen out of the abdominal wall. So it's less of an issue. And I think it just kind of depends on how urgently the patient needs their surgery. Right? With a UC patient, you do their colectomy and then now you have all the time in the world to get them ready for their pouch.

But with a Crohn's patient, depending on how they're doing, that may not be the case. And the other thing I wanted to mention, and it's a little bit difficult, and maybe Kelly can weigh in on this too, but it's a little more difficult to determine, but sarcopenia, right? So sarcopenia is a factor that is something that can affect even obese patients and it's been shown to also independently be a risk factor for surgical outcomes. And you may not think of a patient who is obese sitting in front of you as malnourished, but I think it's also an important thing to try to figure out. And we refer all of our patients to our IBD prehab program, so it kind of makes our job easy as far as selection goes, Kelly and the team do that for us.

Dr Cross:

I would want to summarize real quickly, so for the listeners, we're going to come to Kelly to talk about nutrition and how we can optimize our patients from a nutritional perspective. But just for the listeners, so obviously we're going to talk about how to maybe screen for malnutrition, like what practical things, try to fix that, try to reduce steroid dose. So for me, I try to get people under 20 milligrams a day if possible. Sometimes that's not possible. Even smoking cessation for at least a week can sometimes improve outcomes, fix the things you can fix like bad iron deficiency, anemia, give a couple of doses of iron. Those are things that is a gastroenterologist and obviously don't wait too late to send your patient to the surgeon. So pick the optimal time, ideally when they're less ill for an operation.

So Kelly, quick question. Most people aren't doing nutritional screens in a community practice or even in some hospital practice, but what are some quick things a provider can do to screen for malnutrition? Karen mentioned weight loss, which I think the threshold there is around 10%, but what things can we do to screen for malnutrition?

Ms Issokson:

Well, we see an increase in postop complications with weight loss as little as 5%. So asking your patient about weight loss is very important and I would recommend using a validated screening tool. There's a couple that I really like. I'll talk about one, it's called the malnutrition screening tool and it just involves 2 questions. So asking your patient if they've lost weight recently without trying and asking them if they've been eating less recently due a decrease in appetite. And if they say yes to either of those questions, that's a red flag that you should send them over to a registered dietician for a more comprehensive evaluation of their nutrition status so that we can really get to the root cause of what's going on and how we can best intervene to optimize them for preparing them for surgery.

Dr Cross:

Yeah, I agree. We added just 2 simple questions to a quality of life form. Have you lost your appetite, have you lost weight? And I think those are 2 very simple things to ask and you can even do those in your previsit questionnaire so you don't even have to increase the time of your visit.

So in that patient that Karen and I were talking about, let's say a 15 centimeter stricture that is going to have an ileocolic resection. So what can we do from a diet perspective to improve that patient's outcome? And is that just before surgery or does that extend afterwards? So how do you approach this?

Ms Issokson:

Well, I think patients who are presenting for surgery usually present with a specific phenotype. So they typically have a prolonged disease course and they will have been living with some degree of inflammation, maybe complications to their disease. So you mentioned this patient has strictures. One thing that we've found to be really beneficial in helping to improve postop outcomes is a preop exclusive enteral nutrition. So is this an inflammatory stricture? Is this a fibrotic stricture? Nutrition formula when used solely to nourish an individual has been shown to decrease inflammation and really in our malnourished patients helps to decrease risk for complications equivalent to those going into surgery who are well-nourished. So we see really great benefits for preop exclusive enteral nutrition. So this is definitely something that I would talk about with this patient.

Now I understand that exclusive enteral nutrition is difficult for people to do so other things that we can consider would be just adding in a nutrition supplement throughout the day, maybe one or two or three times throughout the day between meals, talking about ways to modify the diet to help with nourishing a lot of times making sure patients are chewing well, maybe altering the texture of their foods instead of just flatly saying no fiber.

How can we incorporate those healthy fruits and vegetables that are rich in antioxidants that will help with recovering from surgery? How can we incorporate those foods into the diet in a way that won't increase that patient's risk for an obstruction? A couple of other things to consider: immunonutrition. This has been studied mostly in a severely malnourished patients and oncology populations, but immunonutrition has been shown to decrease risk for postop complications. And in our prehabilitation program we implement immunonutrition as part of a perioperative strategy and we see an early analysis that this helps to decrease postop length of stay. So immunonutrition is basically, it's pretty similar to your standard polymeric nutrition supplement shake, but there are specific components that are added to these formulas to help modulate the immune system and mitigate the inflammation associated with surgery and just active disease. And this can help support the patient perioperatively, help them to prepare for surgery and recover from surgery a lot easier.

Dr Cross:

And so these immunonutrition formulas, can they be purchased over the counter or are those through prescription?

Ms Issokson:

So patients going through our program, that's something that we provide to them. They can be moderate in cost, they're more expensive than your standard nutrition shakes. They do have ?? and fish oil and some formulations have ribonucleic acids and glutamine, but they can be purchased over the counter. And I think that it's a good investment; if you can save yourself one day in the hospital, the cost is really minimal compared to what you're going to spend in the hospital, not going back to work or back to your life. So I think the cost is minimal compared to the benefits that people see.

Dr Cross:

And do you continue that for a period of time after surgery or basically once they resume their diet, they're back to the more Mediterranean style diet which we're recommending for most patients or do you to extend that for a period of time?

Ms Issokson:

So there's no standardized protocol for our patients. I think that there was a recently published meta-analysis, which is really a wonderful read, and what they summarized was that using the immunonutrition perioperatively, we see the most benefit with that. But in our program we use it both preoperatively and postoperatively. Some institutions just use it postop. I think patients will get the most benefit using it postopand a little bit preop, but there's different ways you can use it. I think the most important thing is that if they're able to consume it, it's a great thing to add in that's relatively low cost and easy to do and can really make a difference in postop healing and recovery.  

Dr Zaghiyan:

So it's actually available on Amazon and you can actually purchase it in bulk. So you can purchase it with, it's like 5 days before a surgery, 5 days after surgery. And it even comes with the carb load beverages that you drink right the day before in the morning of surgery. So you can buy it as a packaged item. And generally when we're doing the perioperative dosing, it's 5 days, right, Kelly? Before and after?

Ms Issokson:

Yeah, we do 2 shakes per day along with the usual diet for 5 days before surgery and then 5 days after surgery. And one thing that Dr. Zaghiyan mentioned was carbohydrate loading. We encourage our patients to drink carbohydrate rich clear liquid beverages in the day before their surgery and the morning of their surgery. This has been shown to help metabolically prepare patients for surgery. They go into surgery in a fed state instead of a fasted state. So this can help to preserve lean muscle mass and it can also help with postop glycemic control and reducing postop nausea vomiting. So that's a really important thing to incorporate into the perioperative nutrition strategy as well.

Dr Cross:

One of the simple things, and this was presented at a 2024 ECCO, a dietician did a wonderful presentation, I can't remember her name, but she quoted a study where they just gave people 2 enteral supplements a day for the 2 weeks leading into their surgery and they're a better outcome. So I've adopted that across the board for all of my patients. Simple, easy to do, but maybe if I tweak that with some immunonutrition for the 5 days before with some increased carbs, I'd be doing even a better job.

Ms Issokson:

It's really a simple strategy and a simple approach that can have significant improvements in outcomes. So the immunonutrition and carb loading are something that I think would be beneficial to add.

Dr Cross:

Karen mentioned sarcopenia, and I think you made a really good observation that we can see that at obese patients as well. I think typically we think of that when we see a frail patient and we just know that they're frail when we see them. We don't even have great criteria for who is a frail patient, but maybe I'll ask Karen, who's a frail patient and then this whole concept of prehabilitation, obviously it includes nutrition, but what are the other components of prehabilitation?

Dr Zaghiyan:

Yeah, it's part of the physical exam and especially I still try to see as much as possible my preop patients in person because you can judge a lot from seeing how somebody walks in to the office versus them just sitting via Zoom. So the questions, the things you can assess looking at them is you can kind of get a sense for their, I don't know, their muscle mass by assessing their skeletal muscle bulk I guess based on their extremities. You can see that in the obese patients, you can get a sense for it. If they have a big pot belly and then they have really thin skinny arms and extremities, you can get a sense that this person may be malnourished even if they are otherwise classified as obese. They have a high BMI. And then I always ask patients how much activity, what their day-to-day looks like, how much activity do they get?

In the older patients I'll find out if they go out for walks and you want to know if they get short of breath. These are general questions you ask that I've always asked just to assess their cardiac status and if I need to send them for cardiac workup, cetera. But now I'm a lot more in tune to it in our IBD patients as well because of trying to select out who I really need to make sure gets into our program. So those are the kinds of things you want to assess what their, you want to assess what their activity level is like. Is this somebody who normally plays tennis a few times a week and goes for a walk and is on their treadmill or is this somebody that's really just homebound and unable to do things; that'll get you a sense for their physical ability because that is a huge component of the prehab program in addition to just nutrition.

Dr Cross:

Yeah, I agree. I was a big proponent of telemedicine and I still am, but I think there is still good value to see people in the office and I think watching a patient transfer from the chair up to the exam table, you can learn a lot about their muscle strength and just, we've got away, again, from shaking hands and fist bumping and elbow bumps, but sometimes shaking a hand and getting an idea of someone's grip strength just can be just little clues about whether they're frail or not. So when people are really sick and they need surgery and there's not time, then you just get what you get. And I say that our colorectal surgeons are really heroes. They operate on super sick people without complaint and do a great job, but the patient you have a little more time and you feel like maybe there's, from a muscle strength perspective, they could use a little buffing, enhancing. So would other than nutrition, what other things can we do for them? This could be for you or Kelly.

Dr Zaghiyan:

Weight bearing exercise. I mean, again, I'll let Kelly, maybe she wants to comment on exactly what we do in the program, but if let's say somebody you don't have a program and let's say you just want to get patients fit for surgery, I get them to do 30 minutes of cardio where they feel like they're panting. So whatever that means for the patient, if that's a walk for the patient for 30 minutes every day, then that's what it is. If it's a more fit patient, you want them out and jogging and doing things where they get a little bit of cardio.

Now you can also get cardio with weight training. So again, it's limited by what the patient can do, but if you just pick up some 5-pound weights and do that or get those bands that you can do some squats with or something where you're doing a little bit of physical activity, I think for people that are not, they're not heavy exercisers, they don't know what to do, those are little things that anybody can kind of lift a 5-pound weight hopefully and just do whatever they can to try to get a little bit more muscle mass and help with that sarcopenia.

Dr Cross:

Kelly, the program that you guys are using is a little bit more formal, but I agree with the pragmatic stuff that Karen recommends if you don't have a physical therapist that you can utilize.

Ms Issokson:

Yeah, those are great tips. Our program uses a trimodal approach to help prepare patients for surgery. So we've already talked a little bit about the nutrition aspects. There's also a physical therapist team that we work with and they've created a handout, like a folder of exercises that they give to patients based on their initial assessment of their physical fitness. And that patient works on the exercises at home in the weeks leading up to surgery and then after surgery. And then we also have a social worker that we work with to address the mental health needs of our patients and their support services and their anxiety. Surgery is a big deal. It can have a profound impact on somebody's life and helping to mentally prepare for that is a really important aspect of just being ready for surgery and having a good outcome.

Dr Zaghiyan:

I really think giving patients something to do, giving them, because patients would always in the past come to us and say, doc, what can I do? What can I do to make sure I'm going to have a good outcome? We sit there and we tell them about their risk, and you might leak and this might happen and that might happen and this is what I'm going to do to assure that you don't have complications. But patients would always ask us, what can I do? People want to feel like they have control over what's going to happen to them and they want to be able to contribute. So I think it gives patients, it kind of lets them refocus their energy on things that they can do to improve their outcome, which does I think help with that anxiety component rather than just sitting and thinking, okay, I have a month to my surgery, and just not having things to kind of distract you and try to get you a little bit more buy-in to how you're going to recover.

Dr Cross:

I just want to remind our listeners that IBD Drive Time is sponsored by the AIBD Network and that we are on Spotify and Apple Podcasts. Also, there is an AIBD regional coming up in Dallas June 21st to June 22nd. So we hope to see you there.

And for the listeners that may be freaking out a little bit like, oh my gosh, you're asking me to do so many things, you want me to vaccinate? You want me to do shared decision making? We're not suggesting that every practice is going to have a prehabilitation program, but the things that we're talking about with enteral supplements, immunonutrition, carb loading, or things that you can implement, you can implement if you can't, don't have access to a social worker, a peer network where you can connect a patient with someone who's had surgery doing the exercises, getting them physically active before surgery. Those simple things, I mean, we can get to the basement floor to optimize our outcomes. So this is going to be incremental over time.

Karen, I wanted to give you a different scenario. So this is the sicker patient who has the intra-abdominal abscess with or without stricture who we're going to operate on. And for the sake of time, I'm going to tell you what my approach has been. Typically, I don't really try to salvage these patients medically. I try to reduce steroids, control sepsis, drain abscess, and then I've been a big proponent of short bowel rest 1 or 2 weeks with TPN to sort of decrease the amount of fluid in the cavity to decrease the chances they get a stoma. But I realize that's very controversial in every place does a little different. Some people give comfort feeds or liquids, which to me, bowel rest is bowel rest. You shouldn't be stimulating your gut. Some people do purely enteral nutrition, some people don't modify anything. So in that scenario, and it may be different case by case, how do you approach it?

Dr Zaghiyan:

Yeah, it's different case by case. I think you just give what the patient will tolerate. So obviously at the beginning they're admitted, right? You want to drain the abscess, get them the antibiotics, bowel rests, but then at some point we'll challenge them and truly and see what they can tolerate. I think EEN exclusive enteral nutrition is a really great way to get nutrition into these patients without putting them on solid food that they may not be able to tolerate and may not eat a lot of and be able to get those calories in. I'm not a huge fan of TPN personally, unless you really can't use the gut. So if they're not tolerating feeding, if they're getting bloated, pain descended, some marker is getting worse that you're concerned about, you can't feed them, sure you can TPN them, but ideally, I like feeding the gut. And then like you said, you can't salvage these patients medically. So generally, traditionally we've been taught 6 weeks to surgery, but we bring these patients to or kind of a lot quicker, more like in the 2-, week mark in order to just kind of get them rolling with their lives.

Dr Cross:

You and I are completely aligned in timing because I think the worst thing is to prolong these patients out long term, they just seem to get sicker and sicker and just doesn't make sense. We'd argue a little bit about TPN versus enteral, but we'd come to some common ground, I'm sure. Last quick question, maybe more for Karen. We know that patients are at high risk for DVT/PE in the hospital, but studies are consistently emerging showing that that risk really persists at least for another 30 days after surgery. So at Cedars, are you routinely putting people on extended prophylaxis out of the hospital?

Dr Zaghiyan:

We actually don't, and the reason we don't is several. So one, those initial studies, maybe 5, 6, 7 years ago, it became a huge thing and every center, it kind of went into our guidelines, extended prophylaxis. When you look at the absolute risk reduction in those patients, it's small even in some of the higher rate VTE studies, the absolute risk is like four to 5%, and then with extended prophylaxis, you're reducing it to 2%. The newer studies are actually showing that the absolute rate of symptomatic VTE is probably more like 1 1/2, 2%, and then maybe with extended prophylaxis, you're reducing it to below 1%, which you're treating a lot of patients to be able to get that absolute risk reduction. And what does it mean? I think also anecdotally, we just don't see PEs, for example, all that much; we see below the knee DBTs. We're not seeing those patients the way that we used to, I think because presumably with our minimally invasive surgeries, et cetera.

We also at our institution did a study a long time ago, maybe 10 years ago, where we were trying to assess the role of preoperative versus postoperative heparin, and we scanned every patient, 400 patients who came in to have surgery. We did a full lower extremity duplex on them, and 4% of our patients actually walked in with a DVT. So what I'll do now is selectively that patient that's been hospitalized and now you're operating on them or somebody that's super frail or the operation is really extensive, and those patients I’ll actually scan them and make sure they're not going into surgery with a known preoperative DVT. And then in the people that we think they're going to a nursing home or they're just extremely sick and debilitated, I think it makes sense to give extended prophylaxis to those patients, but I think it's a little bit overkill to make every patient do it.

Dr Cross:

Yeah, we don't do that either. And I think I agree, the absolute risk benefit is low and there will be some people that have bleeding, and there's also a burden of trying to get that approved for your patients, and our staffs are already super overwhelmed as it is.

Sorry, the last questions are both of you. I'll start with Kelly. This is the best question in the podcast, so give us a fun fact. So Kelly, tell me something about you that I may not know and then Karen, likewise.

Ms Issokson:

Okay, so my husband and I live the quintessential LA life. We live on a palm tree-lined street in LA in a Spanish bungalow that was built in 1925. We bought it a few years ago, and I've always hated the porch. It was painted and the paint was flaking. And so I decided to tile my porch with some Saltillo tile, and I learned as I went. It was relatively easy in some stages and hard in other stages. I kind of broke down toward the end and roped in my husband who saved the day. But I think that I love just doing work around my house, and it's just so rewarding, and I'm really proud of our Saltillo tile porch now. It's beautiful. If you ever want to visit, we can marvel at my work.

Dr Cross:

You can hang out with David Rubin. He remodeled his closets during the pandemic. That was his fun fact that I remember. All right, Karen, that's a big one to follow.

Dr Zaghiyan:

Don't have, maybe it might not be unknown to people and it's not as cool as Kelly's, but I've grown a huge social media obsession. I'm a TikToker and an insta influencer, a micro influencer. So follow me on my socials. It started out as just trying to educate people about gut health and colorectal stuff that we do, but now it's taken over my life a little bit.

Dr Cross:

So we'll connect you with Aline Charabaty.

Dr Zaghiyan:

Yeah, exactly. I'll be seeing her this weekend at Scrubs and Heels.

Dr Cross:

Great. Alright, Kelly, Karen, this has been great. Thank you very much. Hopefully we'll have you back soon.

Dr Zaghiyan:

Thank you. Thanks for having us.

Ms Issokson:

Yeah, great to be here.