Clin Colon Rectal Surg
DOI: 10.1055/s-0044-1786380
Review Article

Preoperative Optimization of Crohn's Patients before Abdominopelvic Surgery

Moustafa Moussally
1   Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
,
Shirley C. Paski
2   Department of Gastroenterology, Hepatology, and Human Nutrition, Cleveland, Ohio
,
Benjamin Cohen
2   Department of Gastroenterology, Hepatology, and Human Nutrition, Cleveland, Ohio
,
Stefan D. Holubar
1   Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
› Author Affiliations
Funding None.

Abstract

In this article, we review and identify modifiable risk factors associated with postoperative complications of Crohn's disease. We highlight the importance of factors such as nutrition, corticosteroids, immunomodulators, abscesses, ideal timing of surgery, and biologic and small-molecule therapy on surgical outcomes. Herein, we discuss the strategies for attenuating these risk factors. Special consideration is given to venous thromboembolism prophylaxis in this patient population.

Note

S.D.H., consulting fees, Takeda; research funding, American Society of Colon and Rectal Surgeons, Crohn's and Colitis Foundation of America.




Publication History

Article published online:
25 April 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Ng SC, Shi HY, Hamidi N. et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet 2017; 390 (10114): 2769-2778
  • 2 Cosnes J, Gower-Rousseau C, Seksik P, Cortot A. Epidemiology and natural history of inflammatory bowel diseases. Gastroenterology 2011; 140 (06) 1785-1794
  • 3 Bouguen G, Peyrin-Biroulet L. Surgery for adult Crohn's disease: what is the actual risk?. Gut 2011; 60 (09) 1178-1181
  • 4 Patel KV, Darakhshan AA, Griffin N, Williams AB, Sanderson JD, Irving PM. Patient optimization for surgery relating to Crohn's disease. Nat Rev Gastroenterol Hepatol 2016; 13 (12) 707-719
  • 5 Xia K, Gao RY, Wu XC, Yin L, Chen CQ. Timing of individualized surgical intervention in Crohn's disease. World J Gastrointest Surg 2022; 14 (12) 1320-1328
  • 6 Bak MTJ, Ruiterkamp MFE, van Ruler O. et al. Prehabilitation prior to intestinal resection in Crohn's disease patients: An opinion review. World J Gastroenterol 2022; 28 (22) 2403-2416
  • 7 Bak MTJ, van Ruler O, Stassen L. et al; Dutch Initiative Crohn and Colitis (ICC) and Dutch Initiative on Crohn and Colitis – Surgery (ICC-S). Preoperative screening and prehabilitation strategies prior to ileocolic resection in patients with Crohn's disease are not incorporated in routine care. Int J Colorectal Dis 2023; 38 (01) 254
  • 8 Abd-El-Aziz MA, Hübner M, Demartines N, Larson DW, Grass F. Simple clinical screening underestimates malnutrition in surgical patients with inflammatory bowel disease—an ACS NSQIP analysis. Nutrients 2022; 14 (05) 932
  • 9 Casanova MJ, Chaparro M, Molina B. et al. Prevalence of malnutrition and nutritional characteristics of patients with inflammatory bowel disease. J Crohn's Colitis 2017; 11 (12) 1430-1439
  • 10 Adamina M, Bonovas S, Raine T. et al. ECCO guidelines on therapeutics in Crohn's disease: surgical treatment. J Crohn's Colitis 2020; 14 (02) 155-168
  • 11 Sandall AM, Wall CL, Lomer MCE. Nutrition assessment in Crohn's disease using anthropometric, biochemical, and dietary indexes: a narrative review. J Acad Nutr Diet 2020; 120 (04) 624-640
  • 12 Jabłońska B, Mrowiec S. Nutritional status and its detection in patients with inflammatory bowel diseases. Nutrients 2023; 15 (08) 1991
  • 13 Shah RS, Bachour S, Jia X. et al. Hypoalbuminaemia, not biologic exposure, is associated with postoperative complications in Crohn's disease patients undergoing ileocolic resection. J Crohn's Colitis 2021; 15 (07) 1142-1151
  • 14 Brennan GT, Ha I, Hogan C. et al. Does preoperative enteral or parenteral nutrition reduce postoperative complications in Crohn's disease patients: a meta-analysis. Eur J Gastroenterol Hepatol 2018; 30 (09) 997-1002
  • 15 Forbes A, Escher J, Hébuterne X. et al. ESPEN guideline: clinical nutrition in inflammatory bowel disease. Clin Nutr 2017; 36 (02) 321-347
  • 16 Jacobson S. Early postoperative complications in patients with Crohn's disease given and not given preoperative total parenteral nutrition. Scand J Gastroenterol 2012; 47 (02) 170-177
  • 17 Lin A, Micic D. Nutrition considerations in inflammatory bowel disease. Nutr Clin Pract 2021; 36 (02) 298-311
  • 18 Yamamoto T, Nakahigashi M, Shimoyama T, Umegae S. Does preoperative enteral nutrition reduce the incidence of surgical complications in patients with Crohn's disease? A case-matched study. Colorectal Dis 2020; 22 (05) 554-561
  • 19 Abdalla S, Benoist S, Maggiori L. et al; GETAID Chirurgie group. Impact of preoperative enteral nutritional support on postoperative outcome in patients with Crohn's disease complicated by malnutrition: Results of a subgroup analysis of the nationwide cohort registry from the GETAID Chirurgie group. Colorectal Dis 2021; 23 (06) 1451-1462
  • 20 Myrelid P, Söderholm JD, Olaison G, Sjödahl R, Andersson P. Split stoma in resectional surgery of high-risk patients with ileocolonic Crohn's disease. Colorectal Dis 2012; 14 (02) 188-193
  • 21 Yu Y, Chen KC, Chen J. Exclusive enteral nutrition versus corticosteroids for treatment of pediatric Crohn's disease: a meta-analysis. World J Pediatr 2019; 15 (01) 26-36
  • 22 Ashton JJ, Gavin J, Beattie RM. Exclusive enteral nutrition in Crohn's disease: Evidence and practicalities. Clin Nutr 2019; 38 (01) 80-89
  • 23 de Sire R, Nardone OM, Testa A, Calabrese G, Caiazzo A, Castiglione F. Exclusive enteral nutrition in adult Crohn's disease: an overview of clinical practice and perceived barriers. Clin Exp Gastroenterol 2021; 14: 493-501
  • 24 Kovacevich DS, Corrigan M, Ross VM, McKeever L, Hall AM, Braunschweig C. American Society for Parenteral and Enteral Nutrition Guidelines for the selection and care of central venous access devices for adult home parenteral nutrition administration. JPEN J Parenter Enteral Nutr 2019; 43 (01) 15-31
  • 25 Swaminathan L, Flanders S, Horowitz J, Zhang Q, O'Malley M, Chopra V. Safety and outcomes of midline catheters vs peripherally inserted central catheters for patients with short-term indications: a multicenter study. JAMA Intern Med 2022; 182 (01) 50-58
  • 26 Cotogni P, Mussa B, Degiorgis C, De Francesco A, Pittiruti M. Comparative complication rates of 854 central venous access devices for home parenteral nutrition in cancer patients: a prospective study of over 169,000 catheter-days. JPEN J Parenter Enteral Nutr 2021; 45 (04) 768-776
  • 27 Dhaliwal A, Quinlan JI, Overthrow K. et al. Sarcopenia in inflammatory bowel disease: a narrative overview. Nutrients 2021; 13 (02) 656
  • 28 Palmese F, Del Toro R, Di Marzio G, Cataleta P, Sama MG, Domenicali M. Sarcopenia and vitamin D deficiency in patients with Crohn's disease: pathological conditions that should be linked together. Nutrients 2021; 13 (04) 1378
  • 29 Xue QL. The frailty syndrome: definition and natural history. Clin Geriatr Med 2011; 27 (01) 1-15
  • 30 Collaborators GBDIBD. GBD 2017 Inflammatory Bowel Disease Collaborators. The global, regional, and national burden of inflammatory bowel disease in 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Gastroenterol Hepatol 2020; 5 (01) 17-30
  • 31 Huang X, Xiao M, Jiang B. et al. Prevalence of frailty among patients with inflammatory bowel disease and its association with clinical outcomes: a systematic review and meta-analysis. BMC Gastroenterol 2022; 22 (01) 534
  • 32 Kochar B, Jylhävä J, Söderling J. et al; SWIBREG Study Group. Prevalence and implications of frailty in older adults with incident inflammatory bowel diseases: a nationwide cohort study. Clin Gastroenterol Hepatol 2022; 20 (10) 2358-2365.e11
  • 33 Fons A, Kalisvaart K, Maljaars J. Frailty and inflammatory bowel disease: a scoping review of current evidence. J Clin Med 2023; 12 (02) 533
  • 34 Molenaar CJL, Minnella EM, Coca-Martinez M. et al; PREHAB Study Group. Effect of multimodal prehabilitation on reducing postoperative complications and enhancing functional capacity following colorectal cancer surgery: the PREHAB randomized clinical trial. JAMA Surg 2023; 158 (06) 572-581
  • 35 Wilson A, Reyes E, Ofman J. Prevalence and outcomes of anemia in inflammatory bowel disease: a systematic review of the literature. Am J Med 2004; 116 (suppl 7A): 44S-49S
  • 36 Mahadea D, Adamczewska E, Ratajczak AE. et al. Iron deficiency anemia in inflammatory bowel diseases—a narrative review. Nutrients 2021; 13 (11) 4008
  • 37 Dignass AU, Gasche C, Bettenworth D. et al; European Crohn's and Colitis Organisation [ECCO]. European consensus on the diagnosis and management of iron deficiency and anaemia in inflammatory bowel diseases. J Crohn's Colitis 2015; 9 (03) 211-222
  • 38 Michailidou M, Nfonsam VN. Preoperative anemia and outcomes in patients undergoing surgery for inflammatory bowel disease. Am J Surg 2018; 215 (01) 78-81
  • 39 Talboom K, Borstlap WAA, Roodbeen SX. et al; FIT collaborative group. Ferric carboxymaltose infusion versus oral iron supplementation for preoperative iron deficiency anaemia in patients with colorectal cancer (FIT): a multicentre, open-label, randomised, controlled trial. Lancet Haematol 2023; 10 (04) e250-e260
  • 40 Khalafallah AA, Yan C, Al-Badri R. et al. Intravenous ferric carboxymaltose versus standard care in the management of postoperative anaemia: a prospective, open-label, randomised controlled trial. Lancet Haematol 2016; 3 (09) e415-e425
  • 41 Battat R, Kopylov U, Szilagyi A. et al. Vitamin B12 deficiency in inflammatory bowel disease: prevalence, risk factors, evaluation, and management. Inflamm Bowel Dis 2014; 20 (06) 1120-1128
  • 42 The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General. Reports of the Surgeon General. Atlanta (GA); 2014
  • 43 Chong C, Rahman A, Loonat K, Sagar RC, Selinger CP. Current smoking habits in British IBD patients in the age of e-cigarettes. BMJ Open Gastroenterol 2019; 6 (01) e000309
  • 44 Rozich JJ, Holmer A, Singh S. Effect of lifestyle factors on outcomes in patients with inflammatory bowel diseases. Am J Gastroenterol 2020; 115 (06) 832-840
  • 45 Yamamoto T, Lightner AL, Spinelli A, Kotze PG. Perioperative management of ileocecal Crohn's disease in the current era. Expert Rev Gastroenterol Hepatol 2020; 14 (09) 843-855
  • 46 To N, Gracie DJ, Ford AC. Systematic review with meta-analysis: the adverse effects of tobacco smoking on the natural history of Crohn's disease. Aliment Pharmacol Ther 2016; 43 (05) 549-561
  • 47 Yeo H, Park H. Benefits of a single-session, in-hospital preoperative education program for patients undergoing ostomy surgery: a randomized controlled trial. J Wound Ostomy Continence Nurs 2023; 50 (04) 313-318
  • 48 Goyer P, Alves A, Bretagnol F, Bouhnik Y, Valleur P, Panis Y. Impact of complex Crohn's disease on the outcome of laparoscopic ileocecal resection: a comparative clinical study in 124 patients. Dis Colon Rectum 2009; 52 (02) 205-210
  • 49 Everhov AH, Kalman TD, Söderling J. et al. Probability of stoma in incident patients with Crohn's disease in Sweden 2003-2019: a population-based study. Inflamm Bowel Dis 2022; 28 (08) 1160-1168
  • 50 Celentano V, Perrott C, Tejedor P. et al. The INTESTINE study: INtended TEmporary STomas In crohN's diseasE. Protocol for an international multicentre study. Updates Surg 2022; 74 (05) 1691-1696
  • 51 Malik T, Lee MJ, Harikrishnan AB. The incidence of stoma related morbidity—a systematic review of randomised controlled trials. Ann R Coll Surg Engl 2018; 100 (07) 501-508
  • 52 Ambe PC, Breuing J, Grohnmann E. et al. [Quality of life of ostomates in Germany]. Z Gastroenterol 2023; (e-pub ahead of print) DOI: 10.1055/a-2163-5299.
  • 53 Ambe PC, Kugler CM, Breuing J. et al. The effect of preoperative stoma site marking on risk of stoma-related complications in patients with intestinal ostomy—a systematic review and meta-analysis. Colorectal Dis 2022; 24 (08) 904-917
  • 54 Spinelli A, Allocca M, Jovani M, Danese S. Review article: optimal preparation for surgery in Crohn's disease. Aliment Pharmacol Ther 2014; 40 (09) 1009-1022
  • 55 El-Hussuna A, Iesalnieks I, Horesh N, Hadi S, Dreznik Y, Zmora O. The effect of pre-operative optimization on post-operative outcome in Crohn's disease resections. Int J Colorectal Dis 2017; 32 (01) 49-56
  • 56 Łodyga M, Eder P, Gawron-Kiszka M. et al. Guidelines for the management of patients with Crohn's disease. Recommendations of the Polish Society of Gastroenterology and the Polish National Consultant in Gastroenterology. Prz Gastroenterol 2021; 16 (04) 257-296
  • 57 Subramanian V, Saxena S, Kang JY, Pollok RC. Preoperative steroid use and risk of postoperative complications in patients with inflammatory bowel disease undergoing abdominal surgery. Am J Gastroenterol 2008; 103 (09) 2373-2381
  • 58 Huang W, Tang Y, Nong L, Sun Y. Risk factors for postoperative intra-abdominal septic complications after surgery in Crohn's disease: a meta-analysis of observational studies. J Crohn's Colitis 2015; 9 (03) 293-301
  • 59 Barnes EL, Lightner AL, Regueiro M. Perioperative and postoperative management of patients with Crohn's disease and ulcerative colitis. Clin Gastroenterol Hepatol 2020; 18 (06) 1356-1366
  • 60 Zangenberg MS, Horesh N, Kopylov U, El-Hussuna A. Preoperative optimization of patients with inflammatory bowel disease undergoing gastrointestinal surgery: a systematic review. Int J Colorectal Dis 2017; 32 (12) 1663-1676
  • 61 Phillips JD, Kim CS, Fonkalsrud EW, Zeng H, Dindar H. Effects of chronic corticosteroids and vitamin A on the healing of intestinal anastomoses. Am J Surg 1992; 163 (01) 71-77
  • 62 Polcz ME, Barbul A. The role of vitamin A in wound healing. Nutr Clin Pract 2019; 34 (05) 695-700
  • 63 Zaghiyan K, Melmed GY, Berel D, Ovsepyan G, Murrell Z, Fleshner P. A prospective, randomized, noninferiority trial of steroid dosing after major colorectal surgery. Ann Surg 2014; 259 (01) 32-37
  • 64 Khazen BF, El-Hussuna A. The use of a perioperative supra-physiological dose of glucocorticoid is not supported by evidence—a systematic review. Dan Med J 2018; 65 (06) A5488
  • 65 Marik PE, Varon J. Requirement of perioperative stress doses of corticosteroids: a systematic review of the literature. Arch Surg 2008; 143 (12) 1222-1226
  • 66 Afzali A, Park CJ, Zhu K. et al. Preoperative use of methotrexate and the risk of early postoperative complications in patients with inflammatory bowel disease. Inflamm Bowel Dis 2016; 22 (08) 1887-1895
  • 67 Morar PS, Hodgkinson JD, Thalayasingam S. et al. Determining predictors for intra-abdominal septic complications following ileocolonic resection for Crohn's disease-considerations in pre-operative and peri-operative optimisation techniques to improve outcome. J Crohn's Colitis 2015; 9 (06) 483-491
  • 68 Appau KA, Fazio VW, Shen B. et al. Use of infliximab within 3 months of ileocolonic resection is associated with adverse postoperative outcomes in Crohn's patients. J Gastrointest Surg 2008; 12 (10) 1738-1744
  • 69 Fumery M, Seksik P, Auzolle C. et al; REMIND study group investigators. Postoperative complications after ileocecal resection in Crohn's disease: a prospective study from the REMIND group. Am J Gastroenterol 2017; 112 (02) 337-345
  • 70 Cohen BL, Fleshner P, Kane SV. et al. Prospective cohort study to investigate the safety of preoperative tumor necrosis factor inhibitor exposure in patients with inflammatory bowel disease undergoing intra-abdominal surgery. Gastroenterology 2022; 163 (01) 204-221
  • 71 Hyman NH, Cheifetz AS. PUCCINI: safety of anti-TNF in the perioperative setting. Gastroenterology 2022; 163 (01) 44-46
  • 72 Loftus Jr EV, Panés J, Lacerda AP. et al. Upadacitinib induction and maintenance therapy for Crohn's disease. N Engl J Med 2023; 388 (21) 1966-1980
  • 73 Rogler G. Efficacy of JAK inhibitors in Crohn's disease. J Crohn's Colitis 2020; 14 (Suppl. 02) S746-S754
  • 74 An V, Cohen L, Lawrence M, Thomas M, Andrews J, Moore J. Early surgery in Crohn's disease a benefit in selected cases. World J Gastrointest Surg 2016; 8 (07) 492-500
  • 75 Ahmed Ali U, Kiran RP. Surgery for Crohn's disease: upfront or last resort?. Gastroenterol Rep (Oxf) 2022; 10: goac063
  • 76 Lamb CA, Kennedy NA, Raine T. et al; IBD guidelines eDelphi consensus group. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68 (Suppl. 03) s1-s106
  • 77 Ponsioen CY, de Groof EJ, Eshuis EJ. et al; LIR!C study group. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn's disease: a randomised controlled, open-label, multicentre trial. Lancet Gastroenterol Hepatol 2017; 2 (11) 785-792
  • 78 Stevens TW, Haasnoot ML, D'Haens GR. et al; LIR!C study group. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn's disease: retrospective long-term follow-up of the LIR!C trial. Lancet Gastroenterol Hepatol 2020; 5 (10) 900-907
  • 79 de Groof EJ, Stevens TW, Eshuis EJ. et al; LIR!C study group. Cost-effectiveness of laparoscopic ileocaecal resection versus infliximab treatment of terminal ileitis in Crohn's disease: the LIR!C Trial. Gut 2019; 68 (10) 1774-1780
  • 80 Neary PM, Aiello AC, Stocchi L. et al. High-risk ileocolic anastomoses for Crohn's Disease: when is diversion indicated?. J Crohn's Colitis 2019; 13 (07) 856-863
  • 81 Meima-van Praag EM, Buskens CJ, Hompes R, Bemelman WA. Surgical management of Crohn's disease: a state of the art review. Int J Colorectal Dis 2021; 36 (06) 1133-1145
  • 82 Tzivanakis A, Singh JC, Guy RJ, Travis SP, Mortensen NJ, George BD. Influence of risk factors on the safety of ileocolic anastomosis in Crohn's disease surgery. Dis Colon Rectum 2012; 55 (05) 558-562
  • 83 Myrelid P, Soop M, George BD. Surgical planning in penetrating abdominal Crohn's Disease. Front Surg 2022; 9: 867830
  • 84 Yuhara H, Steinmaus C, Corley D. et al. Meta-analysis: the risk of venous thromboembolism in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2013; 37 (10) 953-962
  • 85 Arvanitakis KD, Arvanitaki AD, Karkos CD, Zintzaras EΑ, Germanidis GS. The risk of venous thromboembolic events in patients with inflammatory bowel disease: a systematic review and meta-analysis. Ann Gastroenterol 2021; 34 (05) 680-690
  • 86 Chu TPC, Grainge MJ, Card TR. The risk of venous thromboembolism during and after hospitalisation in patients with inflammatory bowel disease activity. Aliment Pharmacol Ther 2018; 48 (10) 1099-1108
  • 87 Lightner AL, Sklow B, Click B. et al. Venous thromboembolism in patients admitted for IBD: an enterprise-wide experience of 86,000 hospital encounters. Dis Colon Rectum 2023; 66 (03) 410-418
  • 88 McCurdy JD, Kuenzig ME, Smith G. et al. Risk of venous thromboembolism after hospital discharge in patients with inflammatory bowel disease: a population-based study. Inflamm Bowel Dis 2020; 26 (11) 1761-1768
  • 89 Alatri A, Schoepfer A, Fournier N. et al; Swiss IBD Cohort Study Group. Prevalence and risk factors for venous thromboembolic complications in the Swiss inflammatory bowel disease cohort. Scand J Gastroenterol 2016; 51 (10) 1200-1205
  • 90 McCurdy JD, Ellen Kuenzig M, Spruin S. et al. Surgery and the subtype of inflammatory bowel disease impact the risk of venous thromboembolism after hospital discharge. Dig Dis Sci 2022; 67 (06) 2471-2479
  • 91 Kaddourah O, Numan L, Jeepalyam S, Abughanimeh O, Ghanimeh MA, Abuamr K. Venous thromboembolism prophylaxis in inflammatory bowel disease flare-ups. Ann Gastroenterol 2019; 32 (06) 578-583
  • 92 Johannesdottir SA, Horváth-Puhó E, Dekkers OM. et al. Use of glucocorticoids and risk of venous thromboembolism: a nationwide population-based case-control study. JAMA Intern Med 2013; 173 (09) 743-752
  • 93 Nguyen GC, Bernstein CN. Duration of anticoagulation for the management of venous thromboembolism in inflammatory bowel disease: a decision analysis. Am J Gastroenterol 2013; 108 (09) 1486-1495
  • 94 Scarpa M, Pilon F, Pengo V. et al. Deep venous thrombosis after surgery for inflammatory bowel disease: is standard dose low molecular weight heparin prophylaxis enough?. World J Surg 2010; 34 (07) 1629-1636
  • 95 Bryant RV, Jairath V, Curry N, Travis SP. Thrombosis in inflammatory bowel disease: are we tailoring prophylaxis to those most at risk?. J Crohn's Colitis 2014; 8 (02) 166-171
  • 96 Itabashi M, Ikeuchi H, Kimura H. et al. Perioperative venous thromboembolism in ulcerative colitis: a multicenter prospective study in Japan. Crohns Colitis 360 2021; 3 (03) otab024
  • 97 Lee KE, Lim F, Colombel JF, Hur C, Faye AS. Cost-effectiveness of venous thromboembolism prophylaxis after hospitalization in patients with inflammatory bowel disease. Inflamm Bowel Dis 2022; 28 (08) 1169-1176
  • 98 Ore AS, Vigna C, Fabrizio A, Cataldo TE, Messaris E, Crowell K. Are IBD patients underscored when determining postoperative VTE risk?. J Gastrointest Surg 2023; 27 (02) 347-353
  • 99 Patel SV, Liberman SA, Burgess PL. et al. The American Society of Colon and rectal surgeons clinical practice guidelines for the reduction of venous thromboembolic disease in colorectal surgery. Dis Colon Rectum 2023; 66 (09) 1162-1173
  • 100 Schlick CJR, Yuce TK, Yang AD. et al. A postdischarge venous thromboembolism risk calculator for inflammatory bowel disease surgery. Surgery 2021; 169 (02) 240-247
  • 101 Ogilvie Jr JW, Khan MT, Hayakawa E, Parker J, Luchtefeld MA. Low dose rivaroxaban as extended prophylaxis reduces postdischarge venous thromboembolism in patients with malignancy and inflammatory bowel disease. Dis Colon Rectum 2024; 67 (03) 457-465