"Prehabilitation” for Older Patients Helps Reduce Complications of IBD Surgery

In this podcast, Dr Adam Faye explains the association between various patient-level demographic, nutritional and clinical factors and risk for complications among older patients who underwent intestinal resection for inflammatory bowel disease.

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Adam Faye, MD, MS, is an assistant professor of medicine and population health at the Inflammatory Bowel Disease Center at NYU Langone Health.

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TRANSCRIPT:

Any views and opinions expressed are those of the authors and/or participants, and do not necessarily reflect the views, policy, or position of the Gastroenterology Learning Network or HMP Global, its employees, and affiliates.

GLN:

Welcome to this podcast from the Gastroenterology Learning Network. I'm your host, Priyam Vora, and today, we are talking with Dr. Adam Faye. Dr. Faye is an Assistant Professor of Medicine and Population Health at the Inflammatory Bowel Disease Center at NYU Langone Health. We are going to discuss his research on preoperative factors that contribute to the risk of an adverse surgical outcome among patients with IBD. Thank you for joining us today.

Dr. Adam Faye:

Of course. Thanks for having me.

GLN:

I understand that there are some postoperative factors to watch out for among adults with IBD, but not much is known about the preoperative factors. Is this what prompted your research?

Dr. Adam Faye:

Yeah, absolutely. I think there's a couple of key things that prompted this research. I do a lot of research, particularly also, on the older adult or the aging inflammatory bowel disease patient population. And when you actually look at some of the prior data, you can see, overall, anyone or adults going for a surgery who have inflammatory bowel disease are at a higher risk of an adverse 30 day surgical outcome.

So that includes death or mortality, it includes reoperation, infection afterwards, but if you look particularly at the older adult, they're at an even higher risk, with some studies actually showing mortality can be 10 times higher than younger adults with IBD, and looking at re-operation and readmission and infection rates are even higher in the older adults, with about maybe a third of our older adults having this outcome within 30 days. And the question was really, what is driving this overall risk within the entire inflammatory bowel disease population? But also specifically, are there things that are attributable to the older adults being at higher risk? And even further, are there things that are potentially modifiable in the preoperative state, so that we could actually reduce this risk? And that's essentially what drove our research question.

Speaker 2:

That's great. Okay. So would you be able to describe your study, in terms of number of patients, the parameters, et cetera?

Dr. Adam Faye:

Of course. So we looked at the NSQIP, which is the National Surgical Quality Improvement Project. And what this does is it's actually a consortium of hospitals across the US, I believe now it includes 49 states and almost 750 hospitals. And it's basically a uniform way for individuals to capture data pertaining to all the surgical variables, including all the outcomes. So we actually accessed this database, and we looked at it from 2005 to 2019. And we looked at all the surgeries, particularly I will say, intestinal resections. So removing a piece of bowel from all the patients who had inflammatory bowel disease. And the reason to specifically look at resections, as opposed to all intestinal surgeries, is because as you can imagine, risks can vary based on procedure type. If someone with inflammatory bowel disease is coming in for a smaller procedure, like a hernia repair to an ostomy, that may be a very different risk than someone who's getting a large portion of their small and large intestine resected.

So in order to kind of more normalize that risk or make it a more homogenous patient population, we looked at those individuals who were undergoing resection. And what we asked the question were, what are the factors that drive 30 day outcomes? So looking again at mortality, so risk of death, risk of readmission, so needing to come back to the hospital, whether you had an infection or needed another surgery, whether you developed a blood clot, had a heart attack or stroke afterwards. And we looked at all individuals who had inflammatory bowel disease. And then, we actually looked at younger individuals and looked at the differences between younger and older individuals.

GLN:

Okay, and what did you find?

Dr. Adam Faye:

Absolutely. So some of the preoperative factors we looked at included age. We looked at inflammatory bowel disease subtype, Crohn's disease, ulcerative colitis. We looked at race. We also looked at other preoperative factors, so albumin, body mass index or BMI, sepsis, malnutrition. And essentially, what we found interestingly was that a couple of items were particularly impactful when you look at postoperative outcomes. So overall, sepsis. So if you had, before you went into surgery, if you had an infection and you were septic, you had a higher risk of an adverse 30 day outcome. If you were going for an emergency surgery, you had a high risk of an adverse outcome. Additionally, if you were malnourished or if you had what we call dependent functional status, so you maybe needed some help with ambulation, these are all factors and potentially modifiable ones, which I'll kind of emphasize here, that actually led to adverse 30 day outcomes.

And this was for all individuals with IBD. And interestingly, when you now substratify, so if we look at younger individuals versus older individuals, you can actually see that the risk factors are very similar. So if you look at the adjusted odds ratios, you can see that, if you had preoperative sepsis, it gave the same odds of developing an adverse outcome, whether a young adult or an older adult. Same for malnutrition, same for emergency surgery. But when you look a little bit more granular, you can see that the older adult, a higher proportion of them actually have sepsis preoperatively and are going for emergency surgery. So kind of pointing to this idea that, perhaps, we are delaying surgery too long in older individuals and really using age as this factor to decide whether to send someone for surgery. But in reality, it doesn't really seem to be age, because the factors seem to be similar between our age group individuals. But it's these other factors that really impact risk.

And so, if we can consider surgery earlier in patients who are older with IBD who need it, we can perhaps reduce the number who have preoperative sepsis, reduce the number who are required to have an emergency surgery, and in fact, improve outcomes. So this 33% that we're seeing having an adverse outcome at 30 days, we might actually be able to reduce. And I will say, I didn't mention, but the overall cohort was about 50,000 procedures, with about 10,000 in older adults. So fairly well powered to look at those outcomes and those preoperative risk factors.

GLN:

Okay. You actually answered the next question, where I was going to ask you about trends across demographic differences, such as age, gender, race. So thank you.

Dr. Adam Faye:

Of course. I will say, there was one additional interesting finding, which this database is not the best to look at, but we actually did find that, particularly in younger individuals, those who identified as non-Hispanic Black were at higher risk than those who identified as non-Hispanic white. And again, we don't have a lot of other variables within here. So environmental data is not captured, socioeconomic data is not really captured, but this is an important area that obviously needs to be prospectively looked at within a different database as well.

Speaker 2:

And of all the resections identified for your study, were there any specific patterns among patients with ulcerative colitis versus Crohn's disease?

Dr. Adam Faye:

Yeah, so that's a great question. So if we're looking at ulcerative colitis to Crohn's disease, did we actually see a difference? And the answer is not really. So if you look at the patients who have ulcerative colitis, so those undergoing a total colectomy for that, or if you look at Crohn's disease, you can see, overall, the risk factors are similar. But what you do notice is that, if you have Crohn's disease, the risk of an adverse outcome is slightly higher. So I believe the adjusted odds ratio was about 1.15, so about a 15% higher risk if you have Crohn's disease. And this is likely, we don't know exactly what, but this is likely because of the complexity of the surgery. You can imagine individuals with Crohn's disease may require small bowel resections, plus large bowel resections, as opposed to the individuals with ulcerative colitis, who are more often undergoing large bowel resections.

We actually try to look at a subset of individuals, to see if we could tell whether there's differences between those undergoing a small bowel resection versus large bowel versus both a small and large bowel. And there did seem to be some differences there, but in some instances, the procedure codes don't allow you to differentiate whether it was a small or large bowel or both resection. So it was really only within a subset. We did, however, look at whether you had an ostomy or not. So in some individuals, whether you had a resection and had a ostomy perhaps either permanently or for a temporary amount of time or whether you didn't, and we actually didn't see much of a difference in terms of outcomes, whether the ostomy was there or not.

GLN:

Okay. So I know you touched upon factors, such as sepsis, malnutrition, dependent functional status. So does your research prompt for a multi-department collaboration, something like that would require geriatricians, nutritionist, physical therapists, for example, to come together and work together?

Dr. Adam Faye:

Yes, absolutely. And I think this is one of the most important and key elements. So there are things, when you look at our findings and when you look at other studies, comorbidities, other things do drive outcomes. But when we hone in on the modifiable factors, so if you look at BMI, either over or underweight, and malnutrition, when you look at dependent functional status, sepsis, emergency surgery, these are all things that, potentially, we can impact in the preoperative state and actually improve outcomes. And in order to do that, a multidisciplinary team, that's kind of focused on this, is really the way to approach it. There's actually been some data in the geriatrics literature as well, where patients are going for surgery and they have these multimodal multidisciplinary approaches.

And you can actually see quite a large impact in overall outcomes. So again, trying to move away from this idea that we should not just do surgery in older adults ever, but really, if our older adults are eventually going to need surgery, doing it earlier and more promptly before they develop all of these complications, like preoperative sepsis, emergency surgery. We know that the longer they have untreated inflammation, the higher risk they are for malnutrition, to functionally and cognitively decline. So if we can intervene earlier and perhaps we can have this multidisciplinary approach with their geriatricians, physical therapists, nutritionists, and do what we call prehab, which is prehabilitation before surgery, we can actually improve outcomes.

GLN:

Nice. Okay. And do you have any plans to expand this to a broader study?

Dr. Adam Faye:

Absolutely. So we're actually, as part of some of my research that's funded by a ACG and also by the National Institute of Aging, we're actually looking to study this prospectively. So we've started to enroll older individuals, as well as some younger individuals, into a cohort and do some validated assessments of physical functioning, nutrition, and other assessments preoperatively, to understand really, rather than a retrospective look, now prospectively, to understand the attributable risk to each of these individual elements. And further, I've actually been in touch with some other centers across the US, who are very interested in developing a prehab or prehabilitation approach to surgical care in IBD. And we'll hopefully be one of the sites that will be piloting that as well, where we can start to think about implementing, for all adults going for surgery, physical therapy, nutrition. And also, a key, key emphasis is on timely surgery for all adults, but particularly for older adults, who are really at a much higher risk and a faster risk to develop frailty and functional cognitive malnutrition decline over time.

GLN:

That's great to know. Thank you so much. I don't have any other questions. Would you like to add something?

Dr. Adam Faye:

No, I appreciate you for taking the time. Again, really what prompted this and what I hope from people to take away is that the risk factors are not different for older and younger adults. So we should be thinking about surgery in our older adults, if it is needed, in a timely fashion. And I think doing so and implementing some of these approaches, and hopefully, with some future research, we'll really be able to move the needle and change this paradigm shift away from the idea of avoidance of surgery in older adults and to really optimize our entire adult population, but particularly the older adults who will and do need surgery for inflammatory bowel disease.

GLN:

Thank you. Thank you. Thank you so much for taking the time to talk to us. Once again, for our listeners, that was Dr. Adam Faye, emphasizing the importance of preoperative factors leading to improved post-operative outcomes. Thank you, Dr. Faye.

Dr. Adam Faye:

Of course. Thanks for having me.