Preoperative Preparation
Careful preoperative preparation can make the difference between a successful CD operation and a disaster, particularly in the setting of complex severe disease. Bowel preparation with purgatives and oral antibiotics is particularly important. We bowel prepare patients with colonic disease,
TABLE 68-1. Preoperative Preparation for Crohn's Disease Surgery
Consultation with gastroenterologist
Consider possible additional Crohn's disease sites
Appropriate imaging
Nutritional repletion
Prepare for (possible) stoma
Bowel preparation/cleansing and those with SB disease, as many of these patients have dilated partially obstructed bowel with stagnant stool predisposed to bacterial overgrowth. Patients with high grade obstruction are prepared with an extended preoperative period of a clear liquid diet (to include tube feeding formula if the duration is long), with administration of the routine oral antibiotics. Partially obstructed patients often need to undergo their bowel preparation in the hospital with the support of intravenous fluids and antiemetics.
Nutritional Support
When preoperative studies reveal significant intra-abdominal inflammation, we will often elect to treat the patient with parenteral support and bowel rest for 4 to 8 weeks. Physical examination of the abdomen can be a guide as to whether bowel rest will be of value. If the abdomen is soft and pliable to palpation, the tissues will likely be safe to dissect. if, however, the abdomen is hard and sclerotic, either locally or throughout the abdomen, the dissection is likely to be difficult. in this case, the prolonged bowel rest might avert operative complications. Parenteral support is, of course, vital in the patient with moderate to severe malnutrition. The CD patient with high grade obstruction and severe inflammation is a case, in our judgement, where parenteral support is superior to enteral support. Nutritional support increases the number of patients who can be considered for a laparoscop-ically assised procedure.
Inflixamab
We are beginning to have some experience with inflixamib (Remicade) in the setting of surgery for inflammatory bowel disease. it appears that patients with aggressive fis-tulizing CD may best be prepared for surgery by a period of treatment with Remicade to minimize inflammation and "cool off" areas of extensive fistulization. Thus far, operating upon patients recently treated with Remicade does not appear to have significant risks. The experience is early, however. A few of these patients with fistulization have been left on inflixamab postoperatively.
Ostomy Nurse
Patients who will or might need a stoma, be it temporary or permanent, need to counsel with an enterostomal therapy nurse. The nurse provides an appropriate site for the stoma, and follows the patient through their adjustment to a stoma devise.
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