What can be done pre-operatively to manage pre-existing conditions like Gastroesophageal Reflux Disease (GERD), Peptic Ulcer Disease (PUD), Inflammatory Bowel Disease (IBD), and Liver Disease?

Pre-Operative Management of Gastrointestinal Conditions Before Surgery

For patients with pre-existing gastrointestinal conditions like GERD, PUD, IBD, and liver disease, optimization of medical therapy and nutritional status before surgery is essential to reduce perioperative morbidity and mortality.

Inflammatory Bowel Disease (IBD) Management

Medication Management

• Biological treatments can be safely continued during the perioperative period in IBD patients 1
• Immunomodulators (azathioprine, mercaptopurine, methotrexate) can be continued during the perioperative period as they do not increase postoperative complications 1
• Corticosteroids should be stopped or tapered to the lowest possible dose before surgery 1
  • If complete withdrawal is not achievable, taper to below 20 mg prednisolone or equivalent 1, 2
  • For patients on steroids during surgery, provide intravenous hydrocortisone until oral intake resumes (prednisolone 5 mg = hydrocortisone 20 mg) 1
  • Implement standardized steroid-taper protocols postoperatively 1
• Tofacitinib requires special consideration due to increased risk of venous thromboembolism; extended thromboprophylaxis is recommended 1

Nutritional Optimization

• Assess nutritional status in all IBD patients before elective surgery 1
• Malnutrition is more prevalent in active disease and Crohn's disease compared to ulcerative colitis 1
• Consider exclusive or partial enteral nutrition for at least 6 weeks preoperatively in patients with penetrating or stricturing Crohn's disease or malnutrition 1
• Correct anemia preoperatively to reduce risk of postoperative complications 1

Management of Sepsis/Abscesses

• Drain intra-abdominal abscesses percutaneously before surgery 3
• Treat active infections before proceeding with surgery 1

GERD Management

• Optimize PPI therapy before surgery 4, 5
  • Ensure proper timing of PPI doses (30 minutes before meals) 6
  • For persistent symptoms, consider increasing to twice daily dosing 4
• Complete diagnostic workup before antireflux surgery 5:
  • Upper endoscopy to assess for esophagitis, Barrett's esophagus, or other pathology
  • Barium esophagram to evaluate anatomy
  • pH testing to document abnormal acid exposure
  • Esophageal manometry to evaluate motility
• Continue PPI therapy until the day of surgery 6, 4
• Monitor for and address potential PPI adverse effects 6:
  • Bone fracture risk with long-term use
  • Hypomagnesemia
  • Vitamin B12 deficiency
  • Clostridium difficile infection risk

Liver Disease Management

• Assess severity of liver disease using validated scoring systems 1, 7
• For patients with liver disease 1:
  • Provide thromboprophylaxis as these patients have increased risk of thrombosis
  • Consider steroid administration before hepatectomy in normal liver parenchyma to decrease liver injury (avoid in diabetic patients) 1
  • Ensure adequate nutritional status; malnourished patients should receive oral nutritional supplements for seven days prior to surgery 1
• Avoid prolonged fasting:
  • Limit preoperative fasting to 6 hours for solids and 2 hours for liquids 1
  • Consider carbohydrate loading the evening before surgery and 2 hours before anesthesia 1

Peptic Ulcer Disease (PUD) Management

• Ensure H. pylori eradication if positive 7
• Continue PPI therapy through the perioperative period 6, 7
• For patients on NSAIDs or antiplatelet therapy, maintain gastroprotection with PPIs 6
• Monitor for potential drug interactions between PPIs and other medications (e.g., methotrexate, digoxin) 6

General Considerations for All GI Conditions

• Thromboprophylaxis is essential, particularly for major hepatectomy and IBD surgery 1
• Antimicrobial prophylaxis should be administered as a single dose before skin incision 1
• Avoid mechanical bowel preparation as it is not supported by evidence 3
• Smoking cessation is beneficial for wound healing 3
• Manage comorbidities appropriately before surgical intervention 3, 7

Pitfalls to Avoid

• Don't abruptly stop biologics before IBD surgery as this may trigger disease flare 1
• Don't continue high-dose steroids if possible, as they increase risk of infectious complications and anastomotic leaks 1, 2
• Don't overlook nutritional assessment in IBD patients, as malnutrition worsens clinical outcomes 1
• Don't rely solely on symptoms for GERD diagnosis before antireflux surgery; objective testing is required 5
• Don't neglect extended thromboprophylaxis in patients on tofacitinib 1

By systematically addressing these pre-existing gastrointestinal conditions before surgery, perioperative morbidity and mortality can be significantly reduced, leading to improved surgical outcomes and quality of life.