"If you get an IBD case and you don’t see a lot of those, how do you decide what to do about it, and should you just refer it to a high-volume center?” said Dr. Whelan.
These patients are often under complex medical management, frequently spanning years, and this is an important factor in surgical decisions. They are often on multiple medications, including steroids, and most patients these days are taking monoclonal antibodies, said Dr. Whelan. The latter in particular can lead patients to be susceptible to infections. “These things can all affect decision making,” said Dr. Whelan.
Sometimes the nutritional status of IBD patients is poor, and most of the time, surgery is elective in these patients. So surgery can often be delayed for a month or more to allow time for nutritional status to improve, and this gives time for a patient to go off monoclonal antibodies, and for the physician to arrange for a referral to a high-volume center, if that seems the wisest course.
Surgery should not be considered without a gastrointestinal specialist who is comfortable in managing these patients. “Having someone who knows when to operate and not to operate, and how to handle medication, is really important,” said Dr. Whelan.
Certain cases should definitely be referred out. Ileal pouches are one. Another is a Crohn’s disease patient with multiple points of obstruction. “That may be one that you’re better off to punt,” said Dr. Whelan. Other cases include patients under complex medical management, when there is no experienced GI specialist available to help.