Abstract
With the recent approval of small molecule drugs such as upadacitinib in adult inflammatory bowel disease (IBD), their utilization is becoming more common; however, there is limited data on perioperative risks or optimal timing of cessation and resumption to mitigate flares. Current recommendations suggest holding these medications for 14 days postoperatively for IBD-related surgeries. We present a 17-year-old female with severe fistulizing perianal and rectosigmoid Crohn's disease who required diverting sigmoidostomy for her perianal disease. Her disease was controlled on upadacitinib for 1 year; however, she had reoccurrence of fistulizing disease with perianal abscess after stopping upadacitinib for 14 days following sigmoidostomy takedown. This 14-day timeline puts patients at risk of resumption of active disease, with fistula recurrence being a disease subset that may not be able to be salvaged with medication resumption alone. Shared decision-making is crucial before deciding how long to withhold these medications, but more research is needed to provide concrete guidelines.