Preoperative Parenteral Nutrition Necessary for Patients With Predominantly Ileal Crohn's Disease? Is
Christopher Steffes, MD,
patients with Crohn's dispredominantly affecting the ileum who specifically underwent right-sided ileocolectomy with primary anastomosis. All had a primary ileocolic anastomosis done by suture in a single-layer closed fashion. Of these 46 patients, 19.6% had overt intra-abdominal sepsis, 30.4% had prior surgery, and 95.7% were taking corticosteroid drugs just before their operation. The mean (\m=+-\SE)age was 31.5\m=+-\2.0 \s=b\
We reviewed 46 consecutive
ease
years. The serum albumin level was less than 35 g/L in 93.5% of patients; all had a hematocrit value less than 0.36, and 80.4% lost more than 15% of their normal body weight. No patient received parenteral nutrition either preoperatively or postoperatively. No change in the preoperative, intraoperative, or postoperative approach to treating patients with predominantly ileal Crohn's disease occurred during the 10-year period of review. There was a 2.2% incidence of perioperative complications (one superficial wound infection) and a 6.5% incidence of late (>1.49 months) complications (two suture sinuses and one wound abscess unassociated with a fistula). Our findings suggest that preoperative parenteral nutrition is unnecessary in the majority of patients with predominantly ileal Crohn's disease specifically undergoing right-sided ileocolectomy and primary ileocolic anastomosis.
(Arch Surg. 1992;127:1210-1212)
number of patients with Crohn's disease who require operation A substantial thought suffer from believed be of nutritional to
are
to depletion, a state associated with increased postoperative morbidity. A pre¬ operative course of parenteral nutrition may decrease the incidence of postoperative complications, but this is con¬ troversial in patients with Crohn's disease. The incidence of morbidity is difficult to evaluate, because the majority of series reporting complications after operation for Crohn's disease include varying extents of disease requir¬ ing a number of different operations. Thus, it is unclear which patients with Crohn's disease will benefit from a preoperative nutritional approach. Similarly, it is unclear some
degree
Accepted for publication April 12, From the
1992.
Department of Surgery, Wayne
Medicine, Detroit, Mich.
Read before the Scientific
Symposium
State
University School of
in Honor of Dr William
Silen,
Boston, Mass, May 16, 1991. Reprint requests to the Department of Surgery, 6C\p=m-\UniversityHealth Center, 4201 St Antoine, Detroit, MI 48201 (Dr Fromm).
David Fromm, MD
morbidity as a result of forego¬ allowing spontaneous nu¬ ing preoperative tritional repletion to occur orally after operation. We reviewed the results of the latter approach in patients spe¬ cifically with Crohn's disease predominantly affecting the ileum and requiring right-sided ileocolectomy for symp¬ toms unresponsive to nonoperative management. whether there is increased
nutrition and
PATIENTS AND METHODS and office records were reviewed for all charts hospital patients with predominantly ileal Crohn's disease operated on consecutively by or under the direction of a single surgeon (D.F.) between January 1980 and February 1990 at either University Hospital, Syracuse, NY, or Harper Hospital, Detroit, Mich. Only those patients who required partial right-sided ileocolectomy and had a primary ileocolic anastomosis were included in our anal¬ The
ysis.
All patients received only intravenous broad-spectrum antibi¬ otics during the perioperative period. Patients who received prednisone within 12 months before the operation were given a total of 250 to 300 mg of intramuscular hydrocortisone sodium succinate per 24 hours on the first and second postoperative days, after which the dose was rapidly tapered. All anastomoses were done by suture in a single-layer closed fashion. Multifilament nonabsorbable suture was used to close the abdominal wall fas¬ cia in clean contaminated cases (65.2%). Monofilament suture was used for the fascia in contaminated cases (34.8%), in which the skin and subcutaneous tissues were left open for at least 48 hours. All patients were followed up for 1 to 10 years by a single surgeon (D.F.). No change in the preoperative, intraoperative, or postop¬ erative approach to treating patients with predominantly ileal Crohn's disease occurred during the period of review.
RESULTS The characteristics of the 46 patients included in this study are shown in Table 1. Although every patient was anemic (hematocrit value
Christopher Steffes, MD,
patients with Crohn's dispredominantly affecting the ileum who specifically underwent right-sided ileocolectomy with primary anastomosis. All had a primary ileocolic anastomosis done by suture in a single-layer closed fashion. Of these 46 patients, 19.6% had overt intra-abdominal sepsis, 30.4% had prior surgery, and 95.7% were taking corticosteroid drugs just before their operation. The mean (\m=+-\SE)age was 31.5\m=+-\2.0 \s=b\
We reviewed 46 consecutive
ease
years. The serum albumin level was less than 35 g/L in 93.5% of patients; all had a hematocrit value less than 0.36, and 80.4% lost more than 15% of their normal body weight. No patient received parenteral nutrition either preoperatively or postoperatively. No change in the preoperative, intraoperative, or postoperative approach to treating patients with predominantly ileal Crohn's disease occurred during the 10-year period of review. There was a 2.2% incidence of perioperative complications (one superficial wound infection) and a 6.5% incidence of late (>1.49 months) complications (two suture sinuses and one wound abscess unassociated with a fistula). Our findings suggest that preoperative parenteral nutrition is unnecessary in the majority of patients with predominantly ileal Crohn's disease specifically undergoing right-sided ileocolectomy and primary ileocolic anastomosis.
(Arch Surg. 1992;127:1210-1212)
number of patients with Crohn's disease who require operation A substantial thought suffer from believed be of nutritional to
are
to depletion, a state associated with increased postoperative morbidity. A pre¬ operative course of parenteral nutrition may decrease the incidence of postoperative complications, but this is con¬ troversial in patients with Crohn's disease. The incidence of morbidity is difficult to evaluate, because the majority of series reporting complications after operation for Crohn's disease include varying extents of disease requir¬ ing a number of different operations. Thus, it is unclear which patients with Crohn's disease will benefit from a preoperative nutritional approach. Similarly, it is unclear some
degree
Accepted for publication April 12, From the
1992.
Department of Surgery, Wayne
Medicine, Detroit, Mich.
Read before the Scientific
Symposium
State
University School of
in Honor of Dr William
Silen,
Boston, Mass, May 16, 1991. Reprint requests to the Department of Surgery, 6C\p=m-\UniversityHealth Center, 4201 St Antoine, Detroit, MI 48201 (Dr Fromm).
David Fromm, MD
morbidity as a result of forego¬ allowing spontaneous nu¬ ing preoperative tritional repletion to occur orally after operation. We reviewed the results of the latter approach in patients spe¬ cifically with Crohn's disease predominantly affecting the ileum and requiring right-sided ileocolectomy for symp¬ toms unresponsive to nonoperative management. whether there is increased
nutrition and
PATIENTS AND METHODS and office records were reviewed for all charts hospital patients with predominantly ileal Crohn's disease operated on consecutively by or under the direction of a single surgeon (D.F.) between January 1980 and February 1990 at either University Hospital, Syracuse, NY, or Harper Hospital, Detroit, Mich. Only those patients who required partial right-sided ileocolectomy and had a primary ileocolic anastomosis were included in our anal¬ The
ysis.
All patients received only intravenous broad-spectrum antibi¬ otics during the perioperative period. Patients who received prednisone within 12 months before the operation were given a total of 250 to 300 mg of intramuscular hydrocortisone sodium succinate per 24 hours on the first and second postoperative days, after which the dose was rapidly tapered. All anastomoses were done by suture in a single-layer closed fashion. Multifilament nonabsorbable suture was used to close the abdominal wall fas¬ cia in clean contaminated cases (65.2%). Monofilament suture was used for the fascia in contaminated cases (34.8%), in which the skin and subcutaneous tissues were left open for at least 48 hours. All patients were followed up for 1 to 10 years by a single surgeon (D.F.). No change in the preoperative, intraoperative, or postop¬ erative approach to treating patients with predominantly ileal Crohn's disease occurred during the period of review.
RESULTS The characteristics of the 46 patients included in this study are shown in Table 1. Although every patient was anemic (hematocrit value
