Comment on: Risk of malnutrition increases in the year prior to surgery among patients with inflammatory bowel disease

Chaudhary et al. ¹ present valuable data demonstrating the worsening nutritional and infectious burden in the year preceding intestinal resection for inflammatory bowel disease (IBD). Their findings strengthen the argument that prolonged deferral of surgery can contribute to preoperative frailty. However, while the study rightly highlights risks associated with surgical delays, I would urge caution in adopting an overly deterministic view that earlier surgery should universally be favored.

First, the heterogeneity of IBD must be emphasized. The cited benefits of early resection derive largely from selected cohorts with specific disease phenotypes.^2,3 For many patients, medical therapy remains effective in inducing remission, sparing them from operative morbidity altogether. To suggest that deferral inevitably results in worse outcomes risks oversimplifying a nuanced clinical trajectory.

Second, the definition of “malnutrition” in Chaudhary et al. relies on ICD coding, which may not capture subclinical or functional decline. Validated nutritional screening tools, such as GLIM or MUST, offer greater sensitivity and consistency. Without them, the degree to which malnutrition accelerated specifically due to surgical delay versus underlying disease progression remains uncertain.

Third, the authors note that infection rates rose to 74% in the month before surgery. While compelling, it is unclear whether these infections were a cause for surgery, a consequence of deteriorating disease, or a coincident comorbidity. Prior literature has shown that immunosuppressive regimens, including corticosteroids, independently elevate infection risk, regardless of surgical timing. Thus, attributing infection solely to surgical deferral may be overly reductive.

Finally, while the study underscores the hazards of waiting too long, an equally important perspective is optimizing perioperative readiness through prehabilitation, nutritional intervention, and shared decision-making. Trials in non-IBD populations indicate that multimodal prehabilitation can reduce postoperative complications. Rather than reframing the paradigm as “earlier is always better,” a more balanced conclusion is that earlier surgical referral, coupled with structured preoperative optimization, may best safeguard outcomes.

In summary, Chaudhary et al. provide timely evidence on the risks of prolonged preoperative decline in IBD. Yet, the decision to operate should remain individualized, integrating disease severity, medical response, patient preference, and opportunities for prehabilitation. A data-driven approach that balances timely intervention with patient-centered optimization may ultimately yield the best surgical outcomes.