Nutrition and IBD-Related Surgery

Reasons for Surgery in IBD

50% to 80% of patients with Crohn’s disease (CD) and 10% to 30% of patients with ulcerative colitis (UC) may need surgery at some point to:^3-5

• Reduce the risk of acute flares refractory to drugs
• Help patients achieve the best possible quality of life
• Minimize the risk of developing cancer
• Alleviate disease complications
  (Abscesses (pockets of infection), bowel obstruction, fistulas (abnormal connections between organs), strictures (areas of narrowing in the bowel), uncontrolled bleeding in the colon, megacolon (expansion of the bowel), and perforation of the bowel.)

While surgery for patients with IBD can be life-saving and even a cure for patients with UC, complications occurring after surgery remain a major challenge.

Patients with IBD who are undergoing surgery are at high nutritional risk,⁶  likely consuming insufficient amounts of protein, omega-3 fatty acids, fiber, iron, folate, vitamin B12, calcium, vitamin D, potassium, magnesium, and zinc.^7-11

Malnutrition affects up to 85% of patients with IBD and is a predictor of less effective medical therapy and worse post-operative outcomes.^12-15

The European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Crohn’s and Colitis Organization (ECCO) state that correction of malnutrition is advised in patients with IBD before planned surgery (body mass index and unintentional weight loss are considered minimum markers for nutritional screening).^1,2

Nutrition Care Before an IBD Surgery

Restoring and preserving nutrition status before surgery for IBD can improve surgical outcomes and reduce postoperative complications.
Preoperative nutritional strategies and optimization involve:

• ‍Consider 1-2 oral nutrition supplements twice a day, in addition to a regular diet, for 2 weeks before surgery to benefit patients who may not meet more than 50% of their nutrient needs from everyday foods for more than 7 days.

• Oral nutrition supplements containing immune-enhancing nutrients (arginine, glutamine, omega-3 fatty acids, nucleotides, vitamin C, and zinc) alongside the patient’s regular diet may decrease hospital stays that last more than 4 days.

• Guided by a dietitian, choose the right nutritionally complete formula and meet calorie needs gradually to avoid re-feeding syndrome (a condition which appears when food is introduced quickly after surgery or a period of malnourishment)

• Consider exclusive enteral nutrition, a liquid-only diet (typically covering at least 90% of calories) for 4-6 weeks before surgery, to:‍
  
  • Ensure patients meet their nutrient needs
  • Reduce surgery complications (it may decrease skin and soft tissue infections 1.6 fold, and intra-abdominal infections 2.1 fold)¹⁹‍
  • Decrease inflammation
  • Reduce steroid exposure
  • Avoid surgery in some patients with Crohn’s disease
• Reserve intravenous nutrition for these situations:
  • As a supplement to enteral nutrition ‍
  • As an alternative, if enteral nutrition is not possible or contraindicated
  • If less than 150 cm of small bowel remains

2. Avoid long periods of fasting timing leading up to surgery/anesthesia ^{1,2,20,21,22,23}

• ‍Limit time without eating and drinking before the surgery.
• Personalize the type, amount, and time of ingestion of solids and liquids based on patient risk factors, surgery type, and use of medications that lower blood sugar.‍
• Encourage 2-3 immunonutrition shakes containing high-quality protein, L-arginine, L-glutamine, and omega-3 fatty acids daily up to 5 days before surgery to help mitigate inflammation, support tissue repair and wound healing, and shorten hospital length of stay after surgery in patients with IBD.‍
• ‍Consider a carbohydrate “boost”, known as carbohydrate loading, the night before surgery and two to three hours before surgery as a means to preserve muscle mass.
  For adults: a carbohydrate drink containing at least 45 g of carbohydrate (a complex carbohydrate when available) to improve insulin sensitivity (except in type I diabetics due to their insulin deficiency state).²⁰

2. Individualizing hydration advice.²⁴‍

• Oral rehydration solutions contain a specific ratio of salt and sugar and help the body adapt to a short bowel.
• Consider increasing salt intake in patients without a colon.
• Avoid soda, sugar-sweetened teas and juices, sugar-free mineral waters, plain tea, and coffee which increase colostomy output and diarrhea, and worsen dehydration.
• Consider avoiding beverages containing sugar alcohols (e.g., xylitol, erythritol, sorbitol, maltitol, mannitol) which may cause diarrhea, uncomfortable bloating, and gas.