Does Imuran (azathioprine) need to be discontinued for an elective laparoscopic cholecystectomy?

Perioperative Management of Azathioprine (Imuran) for Elective Laparoscopic Cholecystectomy

Azathioprine (Imuran) does not need to be discontinued for elective laparoscopic cholecystectomy in most patients, as the infection risk with modern laparoscopic cholecystectomy is extremely low (approximately 1%) and does not justify the substantial risk of disease flare from stopping immunosuppression.

Evidence-Based Rationale

Infection Risk with Modern Laparoscopic Cholecystectomy is Minimal

• Surgical site infection occurs in only 1.0% of elective laparoscopic cholecystectomy cases in contemporary practice, with Clostridium difficile infection in just 0.1% 1
• This infection rate is comparable to clean surgical cases and represents a dramatic improvement from historical open cholecystectomy data 1
• The overall complication rate for laparoscopic cholecystectomy is low (15%), with biliary tract injuries occurring in only 0.66% of cases 2

Risk of Stopping Azathioprine is Substantial

• Discontinuing azathioprine carries a relapse rate of nearly 60% at one year in patients who were in corticosteroid-free clinical remission, compared to 36% in those continuing therapy 3
• Even in patients with prolonged remission (minimum 3 years of therapy), stopping azathioprine results in a 37% relapse rate after mean follow-up of 55 months 3
• The British Society of Gastroenterology guidelines indicate that stopping thiopurines should only be considered in patients with 5-10 years or more of documented clinical, endoscopic, and histological remission 3

Clinical Decision Algorithm

Continue Azathioprine If:

• Patient has been on therapy for less than 5-10 years of complete remission 3
• Patient has any history of disease flares or incomplete remission 3
• Surgery is truly elective and can proceed safely with immunosuppression on board 4

Consider Holding Only If:

• Patient meets criteria for septic shock or has absolute anesthesiology contraindications (which are the only reasons to avoid laparoscopic cholecystectomy per World Society of Emergency Surgery guidelines) 4, 5
• Patient has documented 5-10+ years of complete clinical, endoscopic, and histological remission 3

Important Caveats

The Risk-Benefit Analysis Strongly Favors Continuation

• The 1% infection risk with modern laparoscopic technique 1 is far outweighed by the 37-60% risk of disease relapse from stopping azathioprine 3
• Antibiotic prophylaxis does not significantly reduce infection rates in low-risk elective laparoscopic cholecystectomy (OR 0.79,95% CI 0.44-1.41), suggesting the baseline infection risk is already minimal 6, 7

Coordinate with Gastroenterology

• If there is any consideration of holding azathioprine, ensure the patient is maintained on 5-ASA therapy, as relapse rates are lower in those continuing 5-ASA when thiopurines are stopped 3
• Document the patient's current disease status, duration of remission, and recent endoscopic/histological findings 3

Optimize Surgical Timing

• Proceed with surgery when the patient's underlying inflammatory bowel disease is in optimal control 3
• Avoid surgery during active disease flares when possible 3