Perioperative use of immunosuppressive medications in patients with Crohn's disease in the new "biological era"

Abstract

Crohn's disease (CD) is characterized by transmural inflammation of the gastrointestinal tract leading to inflammatory, stricturing and/or and fistulizing disease. Once a patient develops medically refractory disease, mechanical obstruction, fistulizing disease or perforation, surgery is indicated. Unfortunately, surgery is not curative in most cases, underscoring the importance of bowel preservation and adequate perioperative medical management. As many of the medications used to treat CD are immunosuppressive, the concern for postoperative infectious complications and anastomotic healing are particularly concerning; these concerns have to be balanced with preventing and treating residual or recurrent disease. We herein review the available literature and make recommendations regarding the preoperative, perioperative and postoperative administration of immunosuppressive medications in the current era of biological therapy for CD. Standardized algorithms for perioperative medical management would greatly assist future research for optimizing surgical outcomes and preventing disease recurrence in the future.

Keywords: Crohn’s disease; biological therapy; medical management; perioperative period.

Figure 1.

Colonoscopy of post-ileocolonic resection and anastomosis in Crohn’s disease. A) Mild anastomotic stricture with suture line ulcers; B) Normal neoterminal ileum.

Figure 2.

Colonoscopy of post-ileocolonic resection and anastomosis in Crohn’s disease. A) Friable mucosa at the anastomosis. Normal neoterminal ileum in distal view; B) Suture line leak (green arrow) at the blind end of the ileum of the side-to-end anastomosis.

Figure 3.

Colonoscopy of post-ileocolonic resection and anastomosis in Crohn’s disease. A) Stricture at the anastomosis; B) Ulcers and inflammation in the neoterminal ileum, a classic example of recurrent Crohn’s disease after the surgery.