Pyoderma gangrenosum and reversal of ileostomy

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


  • 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


  • 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.


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


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


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