Preoperative infliximab is not associated with an increased risk of short-term postoperative complications after restorative proctocolectomy and ileal pouch-anal anastomosis

Should biologic agents be stopped before surgery for inflammatory bowel disease?

Despite the widespread use of anti-TNF agents for inflammatory bowel disease (IBD), the need for surgical intervention remains high. As a result, many IBD patients undergoing surgery have recently been exposed to biologic agents. There is considerable controversy regarding the potential adverse effects of biologic agents on surgical outcomes in IBD patients undergoing major colorectal surgery with studies showing conflicting results. There appears to be discordance in the systemic bioavailability of anti-TNF-α in patients with Crohn's disease (CD) versus ulcerative colitis, with greater systemic absorption in CD. In patients with CD, preoperative serum anti-TNF-α levels may help guide timing of surgery as patients with elevated serum anti-TNF-α levels appear to be at higher risk for complications. In patients with ulcerative colitis there is likely no need for stopping biologic agents before surgery as there is poor systemic bioavailability of the drug in a majority of patients.

Effect of preoperative biologic drugs on complications and function after restorative proctocolectomy with primary ileal pouch formation: systematic review and meta-analysis

BACKGROUND

Debate exists concerning the presumed risk of postoperative complications in patients with ulcerative colitis (UC) receiving preoperative infliximab (IFX). Meta-analyses are contrasting because of many confounders included into analysis. Our aim was to determine the impact of IFX on pouch-related postoperative complications in patients with UC undergoing surgery with primary ileal pouch-anal anastomosis.

METHODS

We performed a systematic review to identify studies comparing the outcomes of patients undergoing surgery for UC with or without previous IFX exposure. The primary end points were (1) early ileal pouch-anal anastomosis-related complications after surgery with primary pouch formation and (2) those occurring after ileostomy closure. Secondary end points were the effects of IFX on total, infectious, and noninfectious complications in patients with UC undergoing any type of surgery. Results are reported as pooled odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

Seven papers, including 162 patients receiving biologics and 468 controls all undergoing primary pouch formation, were included for the primary aim. Patients receiving IFX were more likely developing early (OR = 4.12; 95% CI, 2.37-7.15; P < 0.001) and post-ileostomy closure (OR = 2.27; 95% CI, 1.27-4.05; P = 0.005) ileal pouch-anal anastomosis-related complications. Number needed to harm was calculated to be 5 and 4, respectively. Having received at least 3 IFX effusions increased the risk of early complications (OR = 9.59; 95% CI, 2.92-31.44; P = 0.0002), whereas an interval of <12 weeks since last effusion did not (OR = 2.35; 95% CI, 0.98-5.64; P = 0.06). Meta-analyses of 14 studies reporting on any type of surgery found that IFX showed a trend toward higher total and infectious complications, but no significant differences were observed. Biologics were associated with lower surgical site infection (OR = 0.67; 95% CI, 0.45-0.99; P = 0.04).

CONCLUSIONS

IFX exposure increases early pouch-specific complications and complications after ileostomy closure in UC. Avoiding primary pouch formation could be a prudent approach.

Surgical management of ulcerative colitis in the era of biologicals

PURPOSE

Proctocolectomy has been a curative option for patients with severe ulcerative colitis. In recent years, there has been a growing use of medical salvage therapy in the management of patients with moderate to severe ulcerative colitis. We aimed at reviewing the role of surgical management in a time of intensified medical management on the basis of published trial data. The aim was to determine the efficacy of aggressive medical versus surgical management in achieving multifaceted treatment goals.

METHODS

A comprehensive search of Pubmed, Medline, the Cochrane database was performed. Abstracts were evaluated for relevance. Selected articles were then reviewed in detail, including references. Recommendations were then drafted based on evidence and conclusions in the selected articles.

RESULTS

The majority of patients with UC will not need surgery. However, steroid-refractoriness and steroid-dependence signal a subset of patients with more challenging disease. Biological therapy has been shown to achieve short-term improvement and temporarily reduce the need for a colectomy. However, there is a substantial financial and medical price to pay because a high fraction of these salvaged patients will still need a curative colectomy but may be exposed to the negative impact of prolonged immunosuppression, chronic illness, and a higher probability to require 3 rather than 2 operations. Proctocolectomy with ileo-anal pouch anastomosis-performed in 1, 2, or 3 steps depending on the patient's condition-remains the surgical procedure of choice. Even though it has its share of possible complications, it has been associated with excellent long-term outcomes and high levels of satisfaction, such that in the majority of patients they become indistinguishable from unaffected normal individuals.

CONCLUSIONS

The current data demonstrate that use of medical salvage therapy in the treatment of UC will likely continue to grow and evolve. Consensus is being developed to better define and predict failure of medical therapy and clarify the role of the different treatment modalities. For many patients, sacrificing the nonresponsive diseased colon is an underused or unnecessarily delayed chance to normalize their health and life. Biologicals in many instances may have to be considered the bridge to that end.

Initial surgical management of ulcerative colitis in the biologic era

BACKGROUND

The initial minimum operation for ulcerative colitis is a total abdominal colectomy. Healthy patients may undergo proctectomy at the same time; however, for ill patients, proctectomy is delayed. Since the introduction of biologic medications in 2005, ulcerative colitis medical management has changed dramatically.

OBJECTIVE

We examined how operative management for ulcerative colitis has changed from the prebiologic to biologic eras.

DESIGN

We conducted a retrospective review of data on patients with ulcerative colitis who were included in the Nationwide Inpatient Sample database.

SETTINGS

This study was conducted at a single university.

PATIENTS

A total of 1,547,852 patients with ulcerative colitis who were admitted to a US hospital from 1991 to 2011 were included in the study.

MAIN OUTCOME MEASURES

We examined patients whose initial operation consisted of total abdominal colectomy without proctectomy versus a total proctocolectomy with or without a pouch. We also examined which operation was done at the time of the construction of an ileoanal pouch. Patients who underwent colectomy and pouch construction in the same hospitalization were compared with those who received pouch formation at a subsequent hospitalization.

RESULTS

Ulcerative colitis-related admissions rose by 170% during the years examined, and the number of patients who required total abdominal colectomy increased by 44%. Total abdominal colectomy increased by 15%, as opposed to total proctocolectomy (p < 0.001). Pouch construction at a subsequent operation increased by 16% (p = 0.002). Since 2008, total abdominal colectomy has surpassed total proctocolectomy as the most common initial surgical intervention for ulcerative colitis.

LIMITATIONS

The Nationwide Inpatient Sample is a retrospective database, and we were limited to examining the variables within it.

CONCLUSIONS

Total abdominal colectomy is currently the most common initial operation for patients with ulcerative colitis, and an ileoanal pouch is more frequently constructed at a subsequent hospitalization. These trends coincide with the initiation of biologic treatments and may imply that patients are acutely ill at the time of initial operation. Alternately, there may be surgeon-perceived bias of increased surgical risk or a shift in care to specialized surgeons for pouch construction.

Anti-TNF alpha in the treatment of ulcerative colitis: A valid approach for organ-sparing or an expensive option to delay surgery?

Ulcerative colitis (UC) is an inflammatory bowel disease affecting large bowel with variable clinical course. The history of disease has been modified by the introduction of biologic therapy, in particular Infliximab (IFX), that has demonstrated efficacy in inducing fast symptoms remission, promoting mucosal healing and maintaining long-term remission. However, surgery is still needed for UC patients: in case of failure of medical therapy and if acute complications or a malignancy occurred. Surgical treatment is associated with a short-term post-operative mortality and morbidity respectively of 0%-4% and 30%. In this study we systematically analyzed: the role of IFX in reducing the colectomy rate, the risk of post-operative morbidity in pre-operatively IFX-treated patients and the cost-effectiveness of IFX therapy. Four of 5 analyzed randomized controlled trials demonstrated that therapy with IFX significantly reduces the colectomy rate. Moreover, pre-operative treatment with IFX doesn’t seem to increase post-operative infectious complications. By an economic point of view, the cost-effectiveness of IFX-therapy was demonstrated for UC patients suffering from moderate to severe UC in a study based on a cost estimation of the National Health Service of England and Wales. However, the argument is debated.

Rescue therapy with cyclosporine or infliximab is not associated with an increased risk for postoperative complications in patients hospitalized for severe steroid-refractory ulcerative colitis

BACKGROUND

Cyclosporine and infliximab (IFX) are effective medical therapies for inducing remission in patients with steroid-refractory ulcerative colitis (UC). Patients with acute severe disease who do not respond to these therapies require colectomy, however, the risk of postoperative complications in such patients is not known. Analyzing patients with acute severe UC, we compared the incidence of postoperative complications in patients who failed rescue therapy with cyclosporine or IFX with that in patients who received intravenous (IV) corticosteroids alone.

METHODS

We performed a retrospective cohort study of UC patients who underwent colectomy after inpatient treatment with cyclosporine plus IV corticosteroids (CsA+IVS), infliximab plus IV corticosteroids (IFX+IVS), or IV corticosteroids alone (IVS) at the University of Chicago Hospitals from October 1, 2006 to October 1, 2012. Primary endpoints were infectious, noninfectious, and total complications occurring within 30 days of colectomy.

RESULTS

Of 78 patients, 19 were treated with CsA+IVS, 24 with IFX+IVS, 4 with both CsA and IFX+IVS, and 31 with IVS alone. Patients treated with rescue therapy plus IVS had no difference in total postoperative complications compared with those receiving IVS alone (CsA+IVS: relative risk (RR) = 0.63, 95% confidence interval (CI), 0.33-1.23; IFX+IVS: RR = 0.65, 95% CI, 0.36-1.17). There remained no difference in postoperative complications between the rescue therapy and IVS alone groups when subcategorizing overall complications into infectious (CsA+IVS: RR = 0.54, 95% CI, 0.17-1.76; IFX+IVS: RR = 0.86, 95% CI, 0.36-2.09) and noninfectious (CsA+IVS: RR = 0.88, 95% CI, 0.43-1.80; IFX+IVS: RR = 0.40, 95% CI, 0.15-1.07) causes.

CONCLUSIONS

Cyclosporine and IFX are not associated with an increased risk for postoperative complications in patients hospitalized for severe UC refractory to corticosteroids.

Preoperative use of anti-TNF therapy and postoperative complications in inflammatory bowel diseases: a meta-analysis

BACKGROUND AND AIMS

About one-third of inflammatory bowel disease (IBD) patients still require surgery. A growing number of them receive anti-tumor necrosis factor (TNF) therapy before surgery. The present meta-analysis studied the risk of postoperative complications in IBD patients treated with anti-TNF.

METHODS

MEDLINE was searched (up to January 2012) to identify observational studies reporting the prevalence of postoperative complications in IBD patients. The prevalence of overall, infectious, and non-infectious postoperative complications was extracted for all studies, and according to preoperative anti-TNF treatment where reported. Pooled prevalence, as well as odds ratios (ORs), with 95% confidence intervals (CIs) was calculated.

RESULTS

The search identified 86 citations. Twenty-one studies, containing 4251 subjects, reported the prevalence of postoperative complications according to preoperative anti-TNF treatment. Pooled prevalence of any postoperative complication was 21%, 35%, and 26% in Crohn's disease (CD), ulcerative colitis (UC) or inflammatory bowel disease unspecified (IBD-U) and IBD, respectively. The prevalence of any postoperative complication was increased in IBD patients who underwent preoperative anti-TNF therapy (OR: 1.25; 95% CI: 1.02-1.53). Pooled prevalence of infectious postoperative complications was 16%, 17%, and 15% in CD, UC/IBD-U and IBD, respectively. The prevalence of infectious postoperative complications was increased in CD patients who underwent preoperative anti-TNF therapy (OR: 1.45; 95% CI: 1.03-2.05). The confounding effect of concomitant therapies could not be studied.

CONCLUSIONS

Preoperative anti-TNF use slightly increases the occurrence of overall postoperative complications in IBD patients, and particularly infectious complications in CD patients. Postoperative complications are not increased in UC.

The positioning of colectomy in the treatment of ulcerative colitis in the era of biologic therapy

The position of surgery in the treatment of ulcerative colitis (UC) has changed in the era of biologics. Several important questions arise in determining the optimal positioning of surgery in the treatment of UC, which has long been a challenge facing gastroenterologists and surgeons. Surgery is life-saving in some patients and leads to better bowel function and better quality of life in most patients. The benefits of surgery, however, must be weighed against the potential surgical morbidity and compromised functioning that clearly can occur. The introduction of biologic therapy has added further complexity to decisions about medical management, surgery, and the relative timing of these choices. Appropriate medical management of UC may induce and maintain remission and may prevent surgery. However, medical management also carries risks of adverse effects, and recent data suggest that delay of surgery during ineffective medical therapy can increase the chances of negative surgical outcomes. To make individualized timely treatment decisions, early collaboration between gastroenterologists and surgeons is important and more data on predictors of treatment response and positive outcomes are needed. Early identification of patients who would benefit from biologic therapy or surgery is challenging.

Operative strategy modifies risk of pouch-related outcomes in patients with ulcerative colitis on preoperative anti-tumor necrosis factor-α therapy

BACKGROUND

Whether preoperative biological therapy increases postoperative complications after restorative proctocolectomy remains controversial.

OBJECTIVE

This study aims to evaluate the influence of preoperative use of biologics on outcomes after restorative proctocolectomy and to assess whether a staged approach modifies any negative influence of these medications.

SETTING

The study was conducted at a single tertiary institution.

DESIGN AND PATIENTS

Patients who were operated on for medically refractory ulcerative or indeterminate colitis were identified and classified by initial surgery, whether subtotal colectomy or total proctocolectomy, then categorized into biologics user and nonuser groups. Demographics, perioperative data, postoperative complications, pouch function, and quality of life were collected.

OUTCOME MEASURE

Cumulative 1-year complication rates were estimated by using the Kaplan-Meier curve, and independent predictors for infectious complications were identified by using Cox proportional hazards regression models.

RESULTS

From 2006 to 2010, 407 and 181 patients underwent initial subtotal colectomy with end ileostomy or total proctocolectomy with IPAA. For the 181 patients who underwent total proctocolectomy straightaway, pre- and perioperative data were comparable for biologics users (n = 25) and nonusers (n = 156). Cumulative 1-year pelvic sepsis rate was significantly greater in patients on biologics (32% vs 16%, p = 0.012). Multivariate analysis demonstrated that preoperative anti-tumor necrosis factor therapy (HR, 2.62; p = 0.027) was an independent risk factor for postoperative pelvic sepsis after total proctocolectomy. After subtotal colectomy, no differences occurred in both 30-day and cumulative 1-year postoperative complications between biologics users (n = 142) and nonusers (n = 265). Outcomes were also similar when biologics users (n = 88) and nonusers (n = 164) underwent subsequent completion proctectomy with ileal pouch creation after initial colectomy.

LIMITATIONS

The retrospective nature of this study and physician's preference were limitations.

CONCLUSIONS

Preoperative exposure to biologics is associated with an increased risk of pelvic sepsis after total proctocolectomy with IPAA. This risk is mitigated by the performance of an initial subtotal colectomy.

Meta-analysis: peri-operative anti-TNFα treatment and post-operative complications in patients with inflammatory bowel disease

BACKGROUND

The impact of peri-operative use of TNFα antagonists on post-operative complications such as infection and wound healing is controversial.

AIM

To conduct a systematic review and meta-analysis to assess the impact of peri-operative use of TNFα antagonists on post-operative complications such as infection and wound healing in patients with inflammatory bowel disease (IBD).

METHODS

A literature search identified studies that investigated post-operative outcomes in patients with IBD using TNFα antagonists. The primary outcome was the rate of post-operative infectious complications. Secondary outcomes included the rates of non-infectious complications and total complications. Odds ratios (OR) with 95% confidence intervals (CI) are reported.

RESULTS

Overall, 18 studies with 4659 participants were eligible for inclusion. Patients with IBD using preoperative anti-TNFα therapies had significant increases in post-operative infectious [OR 1.56 (95% CI, 1.09-2.24)], non-infectious [OR 1.57 (95% CI, 1.14-2.17)] and total complications [OR 1.73 (95% CI, 1.23-2.43)]. Studies limited to patients with Crohn's disease demonstrated a statistically significant increase in infectious (OR 1.93, 95% CI 1.28-2.89) and total (OR 2.19, 95% CI 1.69-2.84) complications, and a trend towards increase in non-infectious complications (OR 1.73, 95% CI 0.94-3.17). Studies of patients with ulcerative colitis did not demonstrate significant increases in infectious (OR 1.39, 95% CI 0.56-3.45), non-infectious (OR 1.40, 95% CI 0.68-2.85), or total complications (OR 1.10, 95% CI 0.81-1.47).

CONCLUSION

Anti-TNFα therapies appear to increase the risk of post-operative complications. The increase in risk is small, and may well reflect residual confounding rather than a true biological effect. Nevertheless, physicians should exercise caution when continuing biological therapies during the peri-operative period.

Preoperative infliximab therapy does not increase morbidity and mortality after laparoscopic resection for inflammatory bowel disease

BACKGROUND

The impact of infliximab on the postoperative course of patients with IBD is under debate.

OBJECTIVE

The aim of this study was to evaluate the influence of infliximab on perioperative outcomes in patients undergoing elective laparoscopic resection for IBD.

DESIGN

This study is a retrospective analysis of a prospectively collected, institutional review board-approved database. SETTING, PATIENTS, INTERVENTIONS: Patients undergoing laparoscopic resection on preoperative infliximab (infliximab group) were compared with patients who did not receive infliximab (noninfliximab group).

MAIN OUTCOME MEASURES

The short-term and long-term morbidity and mortality rates were assessed.

RESULTS

Elective laparoscopic resection for IBD was performed on 518 patients from January 2004 through June 2011; 142 patients were treated with infliximab preoperatively. Both groups had similar demographics, type and severity of IBD, comorbidities, and type of surgery. A significantly higher number of patients in the infliximab group had been on aggressive medical therapy to control symptoms of IBD during the month preceding surgery, including steroids (73.9 vs 58.8%, p = 0.002) and immunosuppressors (32.4 vs 20.5%, p = 0.006). Operative time and blood loss were similar (p = 0.50 and p = 0.34). Intraoperative complication rate was 2.1% in both groups. No significant differences were observed in terms of the conversion rate to laparotomy (6.3% vs 9.3%, p = 0.36), overall 30-day postoperative morbidity (p = 0.93), or mortality (p = 0.61). The rates of anastomotic leak (2.1% vs 1.3%, p = 0.81), infections (12% vs 11.2%, p = 0.92), and thrombotic complications (3.5% vs 5.6%, p = 0.46) were similar. Subgroup analyses confirmed similar rates of overall, infectious, and thrombotic complications regardless of whether patients had ulcerative colitis or Crohn's disease.

LIMITATIONS

This study is subject to the limitations of a retrospective design.

CONCLUSIONS

Infliximab is not associated with increased rates of postoperative complications after laparoscopic resection.

Previous infliximab therapy and postoperative complications after proctocolectomy with ileum pouch anal anastomosis

BACKGROUND AND AIMS

It is unclear whether infliximab treatment induces increased complication rates after surgery for ulcerative colitis. Aim was to compare complication rates after pouch surgery in refractory ulcerative colitis patients with versus without previous infliximab therapy.

METHODS

We performed a retrospective study evaluating all patients who underwent an ileoanal J-pouch for refractory ulcerative colitis over a four-year period. Postoperative complications, infliximab use and time between last infliximab administration and restorative surgery were assessed. 1-stage procedures (proctocolectomy with pouch, with or without temporary diversion) and 2-stage procedures (emergency colectomy and subsequent completion proctectomy with pouch, with or without temporary diversion) were analyzed separately.

RESULTS

Seventy-two patients were included; 33 underwent 1-stage procedure and 39 had 2-stage surgery. In the 1-stage group, 21 patients (64%) had previous infliximab therapy (median time between last infusion and surgery: 7.1 months (IQR 2.6-8.3)). Infliximab-treated patients had higher incidence of pelvic sepsis (5/21 vs. 0/12; risk difference 24%; 95% CI: 6 to 42, p=0.067) and non-infectious complications (8/21 vs. 1/12; risk difference 30%; 95% CI: 4 to 56, p=0.065). In the 2-stage group, 17 (44%) had previous infliximab therapy (median time between last infusion and surgery: 11.8 months (IQR 7.3-15.5)). Total, infectious, non-infectious complication rates and pelvic sepsis rates were similar for infliximab and non-infliximab patients in the 2-stage group.

CONCLUSIONS

This small study suggests that infliximab use prior to 1-stage restorative proctocolectomy in patients with UC is associated with increased incidence of pelvic sepsis. A 2-stage procedure in these patients should be considered.

Strategies for the care of adults hospitalized for active ulcerative colitis

Ulcerative colitis is a chronic inflammatory disease of the colon; as many as 25% of patients with this disease require hospitalization. The goals of hospitalization are to assess disease severity, exclude infection, administer rapidly acting and highly effective medication regimens, and determine response. During hospitalization, patients should be given venous thromboembolism prophylaxis and monitored for the development of toxic megacolon. Patients who do not respond to intravenous corticosteroids should be considered for rescue therapy with infliximab or cyclosporine. Patients who are refractory to medical therapies or who develop toxic megacolon should be evaluated promptly for colectomy. Patients who do respond to medical therapies should be discharged on an appropriate maintenance regimen when they meet discharge criteria. We review practical evidence-based management principles and propose a day-by-day algorithm for managing patients hospitalized for ulcerative colitis.

Meta-analysis: effect of preoperative infliximab use on early postoperative complications in patients with ulcerative colitis undergoing abdominal surgery

BACKGROUND

Infliximab is widely used in severe and refractory ulcerative colitis (UC). The results of clinical studies are inconsistent on whether preoperative infliximab use increases early postoperative complications in UC patients.

AIM

To determine the clinical safety and efficacy of preoperative infliximab treatment in UC patients with regard to short-term outcomes following abdominal surgery.

METHODS

PubMed, Embase databases were searched for controlled observational studies comparing postsurgical morbidity in UC patients receiving infliximab preoperatively with those not on infliximab. The primary endpoint was total complication rate. Secondary endpoints included the rate of infectious and non-infectious complications. We calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs) as summary measures.

RESULTS

A total of 13 studies involving 2933 patients were included in our meta-analysis. There was no significant association between infliximab therapy preoperatively and total (OR = 1.09, 95% CI: 0.87-1.37, P = 0.47), infectious (OR = 1.10, 95% CI: 0.51-2.38, P = 0.81) and non-infectious (OR = 1.10, 95% CI: 0.76-1.59, P = 0.61) postoperative complications respectively. Infliximab might be a protective factor against infection for the use within 12 weeks prior to surgery (OR = 0.43, 95% CI: 0.22-0.83, P = 0.01). No publication bias was found.

CONCLUSION

Preoperative infliximab use does not increase the risk of early postoperative complications in patients with ulcerative colitis undergoing abdominal surgery.

Complications of colorectal anastomoses: leaks, strictures, and bleeding

Intestinal anastomosis is an essential part of surgical practice, and with it comes the inherent risk of complications including leaks, strictures, and bleeding, which result in significant morbidity and occasional mortality. Understanding the myriad of risk factors and the strength of the data helps guide a surgeon as to the safety of undertaking an operation in which a primary anastomosis is to be considered. This article reviews the risk factors, management, and outcomes associated with anastomotic complications.

Inflammatory bowel disease surgery in the biologic therapy era

PURPOSE OF REVIEW

The relationship between surgery and biologic agents in the management of patients with inflammatory bowel disease continues to be a source of interest for both surgeons and clinicians.

RECENT FINDINGS

The role of biologic agents in patients with varying presentations of Crohn's disease or ulcerative colitis continues to evolve. However, the currently available biologic therapies are clearly not the panacea we have desired because they have only marginally decreased the frequency with which operative intervention is required and may have increased the risk for infectious postoperative complications in the nonelective setting. Compared to surgery, biologic agents are also significantly more costly and may not provide any greater gain in quality of life.

SUMMARY

Future studies must focus on the use of surgery and emerging biologic agents as complementary therapies designed to safely control inflammatory disease while providing objective value.

Pre-operative use of anti-TNF-α agents and the risk of post-operative complications in patients with ulcerative colitis - a nationwide cohort study

BACKGROUND

It is still controversial whether pre-operative anti-tumour necrosis factor-alpha (anti-TNF-α) agents increase post-operative complications in patients with ulcerative colitis (UC).

AIM

In a nationwide Danish cohort of patients with UC, we aimed to examine the impact of pre-operative use of anti-TNF-α agents on post-operative adverse outcomes after colectomy for UC. Outcomes (within 30 and 60 days after surgery) were reoperation, anastomosis leakage, intra-abdominal abscess, bacteremia and death.

METHODS

Based on the Danish National Patient Registry we identified all UC patients, aged ≥15 years, having their first surgery for UC in the period of 1 January 2003-31 December 2010 (n = 1226). Patients were classified according to use of anti-TNF-α agents within 12 weeks before surgery or not. Outcome data were obtained from Danish registries. Logistic regression analyses were used to estimate adjusted risks [with 95% confidence intervals (CI)] of post-operative outcomes among patients treated with anti-TNF-α agents, relative to those not treated.

RESULTS

A total of 199 UC patients were exposed to anti-TNF-α agents within 12 weeks before colectomy, and 1027 were not. Among exposed, the adjusted odds ratio of reoperation and anastomosis leakage within 30 days after colectomy was 1.07 (95% CI: 0.71-1.59) and 0.52 (95% CI: 0.06-4.11) respectively. No deaths, cases of abscess drainage or bacteremia occurred among exposed within 30 days. Furthermore, no increased relative risks were found within 60 days after colectomy.

CONCLUSIONS

Based on nationwide data on UC patients having colectomies, pre-operative use of anti-TNF-α agents did not increase the risk of post-operative complications.

Surgical treatment of ulcerative colitis in the biologic therapy era

Recently introduced in the treatment algorithms and guidelines for the treatment of ulcerative colitis, biological therapy is an effective treatment option for patients with an acute severe flare not responsive to conventional treatments and for patients with steroid dependent disease. The reduction in hospitalization and surgical intervention for patients affected by ulcerative colitis after the introduction of biologic treatment remains to be proven. Furthermore, these agents seem to be associated with increase in cost of treatment and risk for serious postoperative complications. Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice in ulcerative colitis patients. Surgery is traditionally recommended as salvage therapy when medical management fails, and, despite advances in medical therapy, colectomy rates remain unchanged between 20% and 30%. To overcome the reported increase in postoperative complications in patients on biologic therapies, several surgical strategies have been developed to maintain long-term pouch failure rate around 10%, as previously reported. Surgical staging along with the development of minimally invasive surgery are among the most promising advances in this field.

Infliximab and complications after colectomy in patients with ulcerative colitis

BACKGROUND

Infliximab treatment may increase the risk of subsequent postoperative complications in patients with ulcerative colitis. The main purpose of the present study therefore was to assess postoperative complications in patients who have undergone colectomy for ulcerative colitis with and without previous infliximab treatment.

METHODS

Through a database search within a five-year period ulcerative colitis patients in a single highly specialized department, who had undergone colectomy, were identified. In total 71 ulcerative colitis patients were identified and analyzed according to pretreatment with infliximab or not. Twenty patients who had received infliximab within 12 weeks prior to colectomy were compared to 51 patients on standard treatment. Data on patient background, concomitant medication, endoscopic and the laboratory results, clinical activity, and complications within 30 days after colectomy were recorded.

RESULTS

At primary surgery, patient groups were similar with respect to distribution on gender, age, smoking behavior and concomitant medication. There were significant differences in partial Mayo-scores (7,95 (IFX) vs. 7,64, P=0.032); preoperative CRP-levels (42,72 (IFX) vs. 63,2, P=0.05); postoperative hospitalization time (10,9 (IFX) vs. 11,3 days, P=0.039); and in number of patients who underwent elective surgery (10% vs. 37,3%, P=0.015). There was no short-term mortality in either group and no significant difference in terms of postoperative complications between patients treated with IFX or not. However, the number of postoperative infectious complications was increased in corticosteroid-treated patients irrespective of IFX or not (45,8% in CS group vs. 13,0%, P=0.028).

CONCLUSIONS

The use of infliximab does not seem to associate with an increased risk of short-term postoperative complications in ulcerative colitis.

Pediatric chronic ulcerative colitis: does infliximab increase post-ileal pouch anal anastomosis complications?

BACKGROUND

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) is a common surgical approach to chronic ulcerative colitis (CUC). Preoperative use of Infliximab (IFX) has raised concern of increased postoperative complications. We sought to compare outcomes of pediatric patients (≤ 18 years) who were treated with IFX before IPAA to those who did not.

METHODS

Patients (≤ 18 years of age) who underwent IPAA from 2003 to 2008 for CUC were included, and their records were retrospectively reviewed for preoperative medications, operative technique, and 1-year postoperative complications (leak, wound infection, small bowel obstruction, pouchitis). Subjects were divided into 2 groups--those who received IFX preoperatively and those who did not.

RESULTS

Eleven patients received IFX preoperatively, and 27 children did not. All complications following IPAA were more frequent in the IFX group compared to controls (55% vs 26%). Small bowel obstruction was significantly higher in the IFX group (55% vs 7%). Long-term complications occurred in 64% of the IFX group and 61% of the controls.

CONCLUSION

Children that were treated with IFX prior to IPAA suffered twice as many postoperative complications. Long-term outcomes are similar. Currently, we recommend colectomy with end ileostomy for patients that receive IFX within 8 weeks of colectomy for CUC.

Inflammatory bowel disease: perioperative pharmacological considerations

The perioperative management of patients with inflammatory bowel disease is challenging given the altered immune system that results from a variety of biologic and immunomodulator therapies. Clinicians are often faced with challenges and complicated equations when deciding on the type and dose of medication. To understand the effect of these medications and review the evidence regarding the management of these medications in the perioperative setting, a PubMed-based literature search (January 1, 1960, through April 1, 2011) was conducted using the following search terms: perioperative management, risk, outcome, inflammatory bowel disease, ulcerative colitis, Crohn's disease, aminosalicylates, glucocorticoids, purine analogues, cyclosporine, methotrexate, biologic therapy, infliximab, and thromboembolism. The 414 articles identified were manually sorted to exclude those that did not address perioperative risk, outcomes, and medications in the abstracts, yielding 84 articles for review. Additional references were obtained from the citations within the retrieved articles. This review surveys the findings of the selected articles and presents guidelines and resources for perioperative medication management for patients with inflammatory bowel disease undergoing surgery.