P454 A protocol to avoid corticosteroids in Crohn's disease requiring luminal surgery
K.V. Patel*1, C.I. Amadi1, D.V. O'Hanlon2, S. Fong1, I. Nasr1, E. Westcott3, A.B. Williams3, A.A. Darakhshan3, J.D. Dunn1, P.M. Irving1, S.H. Anderson1, J.D. Sanderson1
1Guy's and St Thomas' NHS Foundation Trust, Gastroenterology, London, United Kingdom, 2Guy's and St Thomas' NHS Foundation Trust, Dietetics, London, United Kingdom, 3Guy's and St Thomas' NHS Foundation Trust, Colorectal Surgery, London, United Kingdom
Corticosteroids (CS) are prescribed to control inflammatory and obstructive symptoms in Crohn's disease (CD). Preoperative CS are associated with higher risk of all complications post-operatively including sepsis, anastomotic breakdown and venous thromboembolic disease. High doses of CS also preclude a primary anastomosis.
In January 2013 we implemented a protocol to avoid CS administration or allow a rapid wean in patients requiring ileal/ileocaecal resection, with use of exclusive enteral nutrition (EEN) or parenteral nutrition (PN). Where tolerated, this also enables nutritional optimisation.
EEN (with either Modulen IBD Nestle or Fortisip Nutricia as tolerated, as tolerated) is prescribed to a target dose of 30kcal/kg, and sepsis controlled with intravenous, then oral antibiotics. This approach provides relief for obstructive symptoms and treats acute infection. If EEN is not tolerated due to ongoing obstructive symptoms, parenteral nutrition is considered or surgery is expedited. Patients on CS are advised to wean. This protocols primary aim is to avoid corticosteroid exposure for more than 4 weeks prior to surgery.
Patients requiring surgery were not offered this protocol if they had minimal symptoms, adequate nutritional status and not on CS.
In total, 39 patients with CD had ileal/ileocaecal resection from January 2013 - September 2014.
17 were excluded from protocol implementation. 9 emergency surgeries all with penetrating and/or stricturing disease or suspected cancer; 4 operations on CS (45%). 8 patients with stable symptoms secondary to fibrotic stricture (4 on biologic, 4 on immunomodulator) and adequate nutritional status not requiring CS.
22 patients with acute symptoms suitable for above protocol, all with penetrating and/or stricturing disease. 8 patients on pre-existing CS. 7 successfully weaned off CS for more than 4 weeks with EEN, 1 did not tolerate, and proceeded to surgery on CS. 11 patients successfully treated via protocol to avoid CS (7 with EEN / 4 with PN). 3 patients did not tolerate/declined EEN and proceeded to expedited surgery avoiding CS.
Where the protocol was implemented, CS administration was not required (14/14 patients, 100%) and wean >4 weeks successful in majority (7/8 patients, 87.5%). CS exposure was limited to 1 patient via protocol (4.5%).
The above protocol provides and alternative approach to control acute symptoms in patients requiring ileal/ileocaecal resection, avoiding CS exposure and optimising nutrition. The implementation of the protocol requires close liaison between gastroenterologists, colorectal surgeons and dietetics. The protocol should not delay emergency operations.