Prehabilitation prior to intestinal resection in Crohn’s disease patients: An opinion review

Table 1 Recommendations on screening for prehabilitation prior to intestinal surgery in Crohn’s disease

Screening
Nutritional status	Screening in all patients: Body mass index, evaluation of unintentional weight loss and assessment of dietary intake with nutritional or immunological screening tools (e.g., GLIM and OPNI). Preferably assess the muscle mass (e.g., with handgrip strength or consider available imaging techniques) to complement the measures of nutritional status
Physical fitness	Screening in all patients to estimate aerobic fitness with validated self-reporting questionnaire (e.g., Duke activity status index, veterans-specific activity questionnaire). Consider referral of patients at risk for impaired physical fitness for comprehensive objective assessment by an exercise specialist
CD medication	Critically revise all current CD medication on a case-by-case basis
Laboratory assessment	Preoperative assessment of full blood count, CRP, and serum albumin. Assessment of vitamins and other trace elements may only be indicative in patients with biochemical remission
Smoking psychological status	Screen all patients on active smoking
	Discussion of expectations and potential fears for the perioperative course by treating physicians IBD team members

CD: Crohn’s disease; CRP: C-reactive protein; GLIM: Global Leadership Initiative on Malnutrition; IBD: Inflammatory bowel disease; OPNI: Onodera’s prognostic nutritional index.

Table 2 Recommendations for prehabilitation interventions prior to intestinal surgery in Crohn’s disease

Intervention
Nutritional	Nutritional support may be considered in case of impaired nutritional status and/or inadequate intake with regard to proteins and calories. Minimum duration of nutritional support is 1-2 wk and may be extended to 6-8 wk to fully benefit from the dietary intervention. EEN may be considered as nutritional support for immunomodulatory effect and reduction of postoperative complications. TPN seems a valid option only when enteral nutrition is contraindicated, not effective or tolerated
Physical fitness	Physical exercise aerobic activity and muscular resistance training may be considered to improve physical fitness in the preoperative course. High-intensity physical exercise should be avoided due to risk of exacerbation of inflammation and symptoms
CD medication	Wean off corticosteroids to a minimal dose (preferably < 20 mg) 6 wk prior to surgery. Consider cessation of anti-TNF-α agents (especially in case of therapy-refractory disease). If considered, a time-interval of 4 wk (ADA) or 6-8 wk (IFX) seems appropriate
Laboratory assessment	Preoperative intravenous iron therapy is recommended in case of iron deficiency anemia in the preoperative course. In case of hypoalbuminemia and an impaired nutritional status, nutritional support is advised (see nutritional and physical status)
Smoking	Preoperative cessation is recommended (e.g., within smoking cessation program)
Psychological status	Provide individualized psychosocial support or refer to psychologist

CD: Crohn’s disease; ADA: Adalimumab; EEN: Exclusive enteral nutrition; IFX: Infliximab; TNF-α: Tumor necrosis factor-alpha; TPN: Total parenteral nutrition.