Steroid Management in Patients Undergoing Surgery for IBD

P (patients)

I (intervention)

C (comparator)

O (outcomes)

Steroid-treated patients with or without IBD undergoing colorectal or non-colorectal surgery

Low-dose perioperative steroids

High-dose or stress-dose perioperative steroids

Perioperative hemodynamic instability, adrenal insufficiency, morbidity, mortality, infectious complications

Patients with or without IBD, previously treated with steroids within 1 year undergoing colorectal or non-colorectal surgery

No corticosteroids

High-dose or stress-dose perioperative steroids

Perioperative hemodynamic instability, adrenal insufficiency, morbidity, mortality, infectious complications

Results

Over the years, several studies have been performed to assess the clinical utility and optimal dose of perioperative corticosteroids in steroid-treated patients undergoing surgery (Table 9.2). Initial studies challenging the concept of stress-dose steroids were performed in an era where there were serious concerns about operative wound healing. In these studies, patients underwent surgery without any perioperative steroids, and clinical parameters and HPA function were evaluated. In 1962, Solem and Lund reported 30 patients whose steroids had been stopped more than 4 weeks before surgery undergoing various surgical procedures (IBD undergoing major colorectal surgery, n = 4) without perioperative steroid cover and showed no impending hemodynamic collapse with this management [9]. Two studies investigated patients on steroids at the time of surgery who were operated on without perioperative steroids, measured HPA axis testing and clinical parameters. Hypotension attributed to AI occurred in 4 out of 125 patients combined [10, 11].

Table 9.2

Studies evaluating perioperative steroid dosing

First author (year)	Patients studied	Intervention	Study design	N	Outcome	Quality of evidence
Solem (1962) [9]	Patients previously treated with steroids/various surgeries (n = 4 IBD/CRS).	No periop steroids	R	30	No unexplained death attributed to AI	Very low
Jasani (1968) [10]	RA/anterior synovectomy	No periop steroids	PO	21 steroid treated vs. 20 controls	1 patient with abnormal preop ACTH had hypotension responsive to steroids.	Very low
Kehlet (1973) [11]	Steroid-treated patients undergoing various major/minor operations	No periop steroids	PO	104	3 patients with hypotension and low cortisol thought to be AI	Low
Knudsen (1981) [13]	IBD/CRS	200 with no periop steroids, 50 received steroids	R	250	11 cases of hypotension treated with steroids/possible AI	Very low
Lloyd (1981) [14]	RA/Orthopedic surgery	Stress-dose vs. usual daily dose.	PO	61	No difference in periop steroid supplementation between the 2 groups	Very low
Symreng (1981) [15]	Various patients (n = 7 IBD, n = 16, CRS)	If impaired ACTH stim test > HC 25 mg IV preop then 100 mg IV/24 h. If normal ACTH stim test: no periop steroids. Return to usual daily dose postop.	PO	14 steroid-treated patients and 8 steroid-naïve controls	No hemodynamic instability	Very low
Bromberg (1991) [16]	Renal transplant patients admitted w/significant physiologic stress	Usual daily dose	PO	40	No unexplained hemodynamic instability	Very low
Bromberg (1995) [17]	Renal transplant patients/various surgeries	Usual daily dose	PO	52	No clinical or laboratory evidence of adrenocortical insufficiency	Very low
Friedman (1995) [18]	Renal-transplant or RA/major orthopedic surgery	Usual daily dose	PO	28	All patients with endogenous adrenal function. No unexplained hemodynamic instability.	Very low
Glowniak (1997) [20]	Various (colorectal n = 2) with positive ACTH stim test	Stress-dose vs. placebo. Return to usual daily dose postop.	RCT	18	No episodes of AI. One in each group with hypotension.	Very low
Thomason (1999) [21]	Organ transplant/gingival surgery	Stress-dose vs. placebo. Return to usual daily dose postop.	RCT	20	No hemodynamic instability	Very low
Mathis (2004) [19]	Organ transplant/lymphocele drainage	Stress-dose vs. no steroid. Return to usual daily dose postop.	R	58	No hypotension, arthralgia, ileus, mental status changes. Blood glucose higher with stress-dose	Very low
Zaghiyan (2011) [24]	IBD/CRS previously on steroids within 1 year	No periop steroids	R	49	No difference in hemodynamic instability	Low
Zaghiyan (2012) [22]	IBD/CRS	HDS vs. LDS	RO	32	No unexplained hemodynamic instability	Very low
Zaghiyan (2012) [23]	IBD/CRS	HDS vs. LDS	R	97	No difference in hemodynamic instability	Moderate
Aytac (2013) [25]	IBD/CRS	Stress-dose vs. usual daily dose	R	235	More tachycardia with stress-dose otherwise no difference in hemodynamic instability	Moderate
Zaghiyan (2014) [26]	IBD/CRS	HDS vs. LDS	RCT	92	Non-inferiority of LDS vs. HDS with respect to postural hypotension; no difference in hemodynamic instability. More infections with HDS.	High

IBD inflammatory bowel disease, CRS colorectal surgery, RA rheumatoid arthritis, ACTH adrenocorticotropic hormone, HDS high-dose steroids, LDS low-dose steroids, R retrospective, PO prospective observational, RO retrospective observational, RCT randomized controlled trial

We recommend that steroid-treated patients undergoing major colorectal surgery be managed with low-dose perioperative steroids in the perioperative period (evidence quality high; strong recommendation)

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