41-year-old man for reversal of ileostomy and repair of parastomal hernia

Background

• Pyoderma Gangrenosum affecting most of body
• Crohns disease – previous perforated ileum requiring emergency ileocolic resection
• Complex postoperative course with return to OT and long ICU stay. Total 6 months in hospital
• Non-ischaemic Cardiomyopathy, HFrEF 40%. Diagnosed during ICU stay ?Tachycardia induced due to sepsis ??steroid or infliximab-induced

Issues

• Significant deconditioning – chronic pain, parastomal hernia, osteoporosis
• Immunosuppressed on long-term steroids and infliximab therapy
• Infliximab management: should be ceased vs perform surgery mid- dosing cycle? Currently achieving reasonable disease control.

Discussion

Perioperative optimization

• Consider prehabilitation, some degree of deconditioning which may be reversible
• CPET  referral – ascertain baseline cardiorespiratory function and if further cardiac and respiratory investigations indicated
• Surgery may be more complex than usual – multiple previous laparotomies, should prepare for long and complex procedure

Immunosuppression

• Suggestion that ceasing the infliximab perioperatively may be more appropriate
• Need to liaise with dermatologist and gastroenterologist

Plan

• CPET and prehabilitation
• Discussion between treating teams regarding management of immunosuppression