Use of infliximab within 3 months of ileocolonic resection is associated with adverse postoperative outcomes in Crohn's patients

Salvage surgery after failure of endoscopic balloon dilatation versus surgery first for ileocolonic anastomotic stricture due to recurrent Crohn's disease

BACKGROUND

Both surgical resection and endoscopic balloon dilatation are treatment options for ileocolonic anastomotic stricture caused by recurrent Crohn's disease unresponsive to medications. Perioperative outcomes of salvage surgery owing to failed endoscopic balloon dilatation in comparison with performing surgery first for the same indication are unclear.

METHODS

An analysis of a prospectively maintained Crohn's disease database was carried out to compare perioperative outcomes of patients who had surgery for failure of endoscopic balloon dilatation with outcomes in patients who underwent resection first for ileocolonic anastomotic stricture caused by recurrent Crohn's disease between 1997 and 2013.

RESULTS

Of 194 patients, 114 (58·8 per cent) underwent surgery without previous endoscopic balloon dilatation. The remaining 80 patients had salvage surgery after one or more endoscopic balloon dilatations during a median treatment span of 14·5 months. Patients in the salvage surgery group had a significantly shorter length of anastomotic stricture (P < 0·001). Salvage surgery was associated with increased rates of stoma formation (P = 0·030), overall surgical-site infection (SSI) (P = 0·025) and organ/space SSI (P = 0·030). In multivariable analysis, preoperative endoscopic balloon dilatation was independently associated with both postoperative SSI (odds ratio 3·16, 95 per cent c.i. 1·01 to 9·84; P = 0·048) and stoma diversion (odds ratio 3·33, 1·14 to 9·78; P = 0·028).

CONCLUSION

Salvage surgery after failure of endoscopic balloon dilatation is associated with increased adverse outcomes in comparison with surgery first. This should be discussed with patients being considered for endoscopic balloon dilatation for ileocolonic anastomotic stricture due to recurrent Crohn's disease.

Risk factors for complications after ileocolonic resection for Crohn's disease with a major focus on the impact of preoperative immunosuppressive and biologic therapy: A retrospective international multicentre study

BACKGROUND

Author note: TY, AS, YS, FVT and PGK designed the study. All authors did data collection and gave scientific contribution to the study design and discussion. TY, AS and PGK drafted the article. All authors read and approved the final version of the manuscript.In the era of biologic agents, risk factors for complications following resection for Crohn's disease have not been fully identified. In particular, the association of preoperative use of immunosuppressive and biologic agents with the incidence of complications after resection remains to be elucidated.

AIM

This retrospective multicentre study aimed to identify risk factors for complications after ileocolonic resection for Crohn's disease, with a major focus on the impact of preoperative immunosuppressive and biologic therapy.

METHODS

A total of 231 consecutive patients who underwent ileocolonic resections for active Crohn's disease in seven inflammatory bowel disease referral centres from three countries (Japan, Brazil and Italy) were included. The following variables were investigated as potential risk factors: age at surgery, gender, behaviour of Crohn's disease (perforating vs. non-perforating disease), smoking, preoperative use (within eight weeks before surgery) of steroids, immunosuppressants and biologic agents, previous resection, blood transfusion, surgical procedure (open vs. laparoscopic approach), and type of anastomosis (side-to-side vs. end-to-end). Postoperative complications occurring within 30 days after surgery were recorded.

RESULTS

The rates of overall complications, intra-abdominal sepsis, and anastomotic leak were 24%, 12% and 8%, respectively. Neither immunosuppressive nor biologic therapy prior to surgery was significantly associated with the incidence of overall complications, intra-abdominal sepsis or anastomotic leak. In multivariate analysis, blood transfusion, perforating disease and previous resection were significant risk factors for overall complications (odds ratio [OR] 3.02, 95% confidence interval [CI] 1.21-7.52; P = 0.02), intra-abdominal sepsis (OR 2.67, 95% CI 1.04-6.86; P = 0.04) and anastomotic leak (OR 2.87, 95% CI 1.01-8.18; P = 0.048), respectively.

CONCLUSIONS

Blood transfusion, perforating disease and previous resection were significant risk factors for overall complications, intra-abdominal sepsis and anastomotic leak after ileocolonic resection for Crohn's disease, respectively. Preoperative immunosuppressive or biologic therapy did not increase the risk of postoperative complications.

Effects of anti-inflammatory therapy on bursting pressure of colonic anastomosis in murine dextran sulfate sodium induced colitis

BACKGROUND

The aim of this study was to examine the effect of colitis and anti-inflammatory therapies on the healing of colonic anastomoses in mice.

METHODS

Female C57BL/6 mice were randomized into eight groups; four groups receiving plain tap-water and four groups receiving dextran sulfate sodium. Intra-peritoneal treatment was given therapeutically for 14 days with placebo, prednisolone, azathioprine, or infliximab (IFX). Colonic anastomoses were performed and bursting pressure (BP) measurements were recorded and the inflammation evaluated with histology and zymography.

RESULTS

The mice with colitis had a more active inflammation based on histology and bowel weight compared with the tap water group, 8.3 (7.6-9.5) mg/mm and 5.5 (4.8-6.2) mg/mm respectively (p < 0.0001). Similarly mice with colitis receiving placebo had a more active inflammation, 12.8 (10.6-15.0) mg/mm, which differed significantly from all the other therapy arms among the colitic mice; prednisolone 8.1 (7.5-9.1) mg/mm (p = 0.014), azathioprine 8.2 (7.0-8.5) mg/mm (p = 0.0046), IFX 6.7 (6.4-7.9) mg/mm (p = 0.0055). BP for the placebo group was 90.0 (71.5-102.8) mmHg and did not differ from azathioprine or IFX groups, 84.4 (70.5-112.5) and 92.3 (75.8-122.3) mmHg respectively. In contrast BP for the prednisolone group was significantly decreased compared to placebo, 55.5 (42.8-73.0) mmHg (p = 0.0004).

CONCLUSIONS

All therapies had a beneficial effect on the colitis. An impaired BP of colonic anastomoses was noted after preoperative steroids but not after azathioprine or IFX in this model.

CONSORT: Different End-Points of Preoperative Nutrition and Outcome of Bowel Resection of Crohn Disease: A Randomized Clinical Trial

Nutritional therapy cannot only improve nutritional status but also reduce bowel inflammation in Crohn disease (CD). The benefits of preoperative nutritional therapy on outcomes of surgery for CD have been demonstrated. However, the ideal end-points of preoperative nutrition in CD remain elusive. We conducted this study to figure out whether improvement of malnutrition or reduction of inflammation is the better end-point of preoperative nutrition for CD. This was a prospective, randomized study. All patients enrolled received preoperative nutrition with different end-points (improvement of malnutrition, IOM, or reduction of inflammation, ROI). The end-points were defined using serum albumin and body weight gain, and serum C-reactive protein (CRP), respectively. Postoperative complications, rate of fecal diversion, and postoperative recurrence of the disease were compared. A total of 108 patients were randomized and 91 patients (44 in IOM group and 47 in ROI group) completed this study. It took 25.57 ± 11.68 days to achieve ROI and 45.29 ± 18.47 days for IOM (P = 0.0023). After nutritional therapy, serum CRP, CDAI, and serum albumin in both groups improved significantly. But patients in the IOM group had a higher albumin level and body weight gain compared with ROI group (P = 0.0026, P < 0.0001). When comparing postoperative complications, rate of fecal diversion, and postoperative recurrence, no significant differences were noted. Compared with IOM, ROI as the end-point of preoperative nutrition had the same benefits on operative outcomes in CD patients undergoing resection, but could be achieved in a shorter time (NCT01540942).

Risk factors for 30-d readmission after colorectal surgery: a systematic review

BACKGROUND

Readmission rates after colorectal surgery remain an ongoing clinical concern. Recent initiation of penalties for excess readmissions in medical patients has encouraged surgeons to reduce readmissions for surgical patients. We conducted a systematic review of the published literature for the purpose of identifying patient-related risk factors for 30-d readmissions after colorectal surgery.

METHODS

PubMed and Web of Science were queried for relevant English-language studies published before January 1, 2015, evaluating 30-d hospital readmissions after colorectal surgery in adult patients. Studies were included in this review only if they used a multivariable model to assess various patient-associated predictors and were excluded if the study size was less than 100 patients.

RESULTS

A total of 20 clinical research studies made up of 8 (40%) chart reviews and 12 (60%) administrative data met inclusion criteria. Most studies took place in the United States, and a variety of procedures (e.g., colectomy, rectal resection, stoma creation) and indications for surgery (e.g., cancer, inflammatory bowel disease, diverticular disease) were evaluated. The average ages of included patients was between 37 and 78 y and 36%-97% were men. Readmission rates ranged from 9%-25%. Overall, older age, comorbid conditions, preoperative immunosuppressive therapy, postoperative complications, and nonhome discharge were the most consistent and strongest predictors of readmission.

CONCLUSIONS

These identifiable risk factors highlight targets for interventions in an effort to reduce unplanned readmissions. Determining the most efficacious and cost-efficient means to reduce these preventable hospitalizations could save millions of valuable health care dollars.

A review of the impact of biologics on surgical complications in Crohn's disease

Anti-tumor necrosis factor therapy has revolutionized the treatment of Crohn's disease. Despite the increased use in the past decade and a half, a majority of patients with Crohn's disease with ultimately require operative management of their disease. No clear consensus has been made in the literature regarding the surgical outcomes in patients who have been exposed to anti-tumor necrosis factor therapy. This review highlights the most recent and relevant literature regarding the safety and effects of anti-tumor necrosis factor use in the perioperative period.

The impact of preoperative serum anti-TNFα therapy levels on early postoperative outcomes in inflammatory bowel disease surgery

OBJECTIVE

Assess the impact of preoperative serum antitumor necrosis factor-α (anti-TNFα) drug levels on 30-day postoperative morbidity in inflammatory bowel disease (IBD) patients.

BACKGROUND

Studies on the association of anti-TNFα drugs and postoperative outcomes in IBD are conflicting due to variable pharmacokinetics of anti-TNFα drugs. It remains to be seen whether preoperative serum anti-TNFα drug levels correlate with postoperative morbidity.

METHODS

Thirty-day postoperative outcomes of consecutive IBD surgical patients with serum drawn within 7 days preoperatively were studied. The total serum level of 3 anti-TNFα drugs (infliximab, adalimumab, and certolizumab) was measured, with ≥ 0.98 μg/mL considered as detected. Data were also reviewed according to a clinical cutoff value of 3 μg/mL.

RESULTS

A total of 217 patients [123 with Crohn disease (CD) and 94 with ulcerative colitis (UC)] were analyzed; 75 of 150 (50%) treated with anti-TNFα therapy did not have detected levels at the time of surgery. In the UC cohort, adverse postoperative outcome rates between the undetectable and detectable groups were similar when stratified according to type of UC surgery. In the CD cohort, there was a higher but statistically insignificant rate of adverse outcomes in the detectable versus undetectable groups. Using a cut off level of 3 μg/mL, postoperative morbidity (odds ratio [OR] = 2.5, P = 0.03) and infectious complications (OR = 3.0, P = 0.03) were significantly higher in the ≥ 3 μg/mL group. There were higher rates of postoperative morbidity (P = 0.047) and hospital readmissions (P = 0.04) in the ≥ 8 μg/mL compared with <3 μg/mL group.

CONCLUSIONS

Increasing preoperative serum anti-TNFα drug levels are associated with adverse postoperative outcomes in CD but not UC patients.

Risk factors for postoperative intra-abdominal septic complications after surgery in Crohn's disease: A meta-analysis of observational studies

BACKGROUND AND AIMS

Postoperative intra-abdominal septic complications [IASCs] are the most feared risks of surgery for Crohn's disease[CD]. The risk factors for IASCs still remain controversial. The aim of this study was to assess the risk factors for IASCs in CD patients undergoing abdominal surgery.

METHODS

MEDLINE, Cochrane Library, and EMBASE were searched to identify observational studies reporting the risk factors for IASCs in CD patients. A meta-analysis was conducted to investigate the impact of various risk factors on IASCs in CD. The GRADE [Grading of Recommendations Assessment, Development and Evaluation] approach was used for quality assessment of evidence on outcome levels.

RESULTS

This review included 15 studies evaluating 3807 patients undergoing 4189 operations. The meta-analyses found that low albumin levels (odds ratio [OR]: 1.93; 95% confidence interval [CI]: 1.362.75), preoperative steroids use [OR: 1.99; 95% CI: 1.54-2.57], a preoperative abscess [OR: 1.94; 95% CI: 1.263.0], previous surgery history [OR: 1.50; 95% CI: 1.151.97] may be risk factors for IASCs. There were no associations between anastomosis methods [OR: 0.94; 95% CI: 0.58-1.53], biologics therapy [OR: 1.29; 95% CI: 0.792.11], and immunomodulator use [OR: 1.07; 95% CI: 0.661.73] with the risk of IASCs. Due to observational design, the quality of evidence was regarded low or moderate for these risk factors by the GRADE approach.

CONCLUSIONS

This meta-analysis provides some evidence that steroids use, previous surgical history, a preoperative abscess, and low albumin levels may be associated with higher rates of IASCs in CD. Knowledge about those risk factors may influence treatment and procedure-related decisions, and possibly reduce the ss rate.

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.

Surgical treatment of complex small bowel Crohn disease

INTRODUCTION

The clinical presentations of Crohn disease of the small bowel vary from low to high complexity. Understanding the complexity of Crohn disease of the small bowel is important for the surgeon and the gastroenterologist caring for the patient and may be relevant for clinical research as a way to compare outcomes. Here, we present a categorization of complex small bowel Crohn disease and review its surgical treatment as a potential initial step toward the establishment of a definition of complex disease.

RESULTS

The complexity of small bowel Crohn disease can be sorted into several categories: technical challenges, namely, fistulae, abscesses, bowel or ureteral obstruction, hemorrhage, cancer and thickened mesentery; extensive disease; the presence of short gut; a history of prolonged use of medications, particularly steroids, immunomodulators, and biological agents; and a high risk of recurrence.

CONCLUSIONS

Although the principles of modern surgical treatment of Crohn disease have evolved to bowel conservation such as strictureplasty techniques and limited resection margins, such practices by themselves are often not sufficient for the management of complex small bowel Crohn disease. This manuscript reviews each category of complex small bowel Crohn disease, with special emphasis on appropriate surgical strategy.

Role of exclusive enteral nutrition in the preoperative optimization of patients with Crohn's disease following immunosuppressive therapy

We conducted a study to evaluate the impact of the exclusive enteral nutrition (EEN) on perioperative outcome in Crohn's disease (CD) patients following immunosuppressive therapy. Patients with CD followed at a referral center between January 2001 and March 2014 who underwent abdominal surgery were identified. Patients were divided into 4 groups: patients not exposed to immunosuppressive agents in the previous 8 weeks before surgery (group 1); patients received immunosuppressive medications without preoperative drug-free interval (group 2); patients had preoperative immunosuppressants-free interval (group 3); patients treated with adding EEN to preoperative immunosuppressants-free interval regimen (group 4). Urgent operation requirement, stoma creation, postoperative complications, readmission, and reoperation were compared in patients among groups. Overall, 708 abdominal surgeries performed in 498 CD patients were identified. Three hundred seventy-six (53.11%) surgeries performed in those receiving preoperative immunosuppressive medications. Compared with other groups, group 2 had increased postoperative complications, more frequent urgent operation, and higher rate of stoma creation. Patients in group 4 were found to have better outcome including lower rate of stoma creation (P < 0.05), and decreased incidence of postoperative complications (P < 0.05) compared with group 2 and group 3. Additionally, decreased urgent operation requirement (P < 0.05) and extended preoperative drug-free interval (P < 0.001) were observed in the group 4 than those in the group 3. Preoperative optimization of CD following immunosuppressive therapy by EEN prolongs the immunosuppressants-free interval, reduces the risk of urgent surgery and reoperation, and most importantly, decreases complications after abdominal surgery.

Clinical and financial impact of hospital readmissions after colorectal resection: predictors, outcomes, and costs

BACKGROUND

After passage of the Affordable Care Act, 30 -day hospital readmissions have come under greater scrutiny. Excess readmissions for certain medical conditions and procedures now result in penalizations on all Medicare reimbursements.

OBJECTIVE

The purpose of this work was to define the risk factors, outcomes, and costs of 30-day readmissions after colorectal surgery.

DESIGN

Adults undergoing colorectal surgery were studied using data from the University HealthSystem Consortium. Univariate and multivariable analyses were used to identify patient-related risk factors for, and 30-day outcomes of, readmission after colorectal surgery.

SETTINGS

This study was conducted at an academic hospital and its affiliates.

PATIENTS

Adults ≥18 years of age who underwent colorectal surgery for cancer, diverticular disease, IBD, or benign tumors between 2008 and 2011 were included in this study.

MAIN OUTCOME MEASURES

Readmission within 30 days of index discharge was the main outcome measured.

RESULTS

A total of 70,484 patients survived the index hospitalization after colorectal surgery; 9632 (13.7%) were readmitted within 30 days of discharge. The strongest independent predictors of readmission were length of stay ≥4 days (OR 1.44; 95% CI 1.32-1.57), stoma (OR 1.54; 95% CI 1.46-1.51), and discharge to skilled nursing (OR 1.62; 95% CI 1.49-1.76) or rehabilitation facility (OR 2.93; 95% CI 2.53-3.40). Of those readmitted, half of the readmissions occurred within 7 days, 13% required the intensive care unit, 6% had a reoperation, and 2% died during the readmission stay. The median combined total direct hospital cost was more than 2 times higher ($26,917 vs $13,817; p < 0.001) for readmitted than for nonreadmitted patients.

LIMITATIONS

Follow-up was limited to 30 days after initial discharge.

CONCLUSIONS

Readmissions after colorectal resection occur frequently and incur a significant financial burden on the health-care system. Future studies aimed at targeted interventions for high-risk patients may reduce readmissions and curb escalating health-care costs.

Review article: optimal preparation for surgery in Crohn's disease

BACKGROUND

One-third of Crohn's disease (CD) patients will undergo abdominal surgery within the first 5 years of diagnosis.

AIM

To review the available evidence on pre-operative optimisation of CD patients.

METHODS

The literature regarding psychological support, radiological imaging, abdominal abscess management, nutritional support, thromboembolic prophylaxis and immunosuppression in the perioperative setting was reviewed.

RESULTS

For diagnosis of fistulas, abscesses and stenosis, ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) have a high diagnostic accuracy. Under either CT or US guidance, it is possible to perform abscess percutaneous drainage (PD), which, with systemic antibiotic therapy, should be the first-line approach to intra-abdominal abscesses. CD patients with weight loss <10% within the last 3-6 months, body mass index < 18.5 kg/m(2) and/or albumin levels <30 g/L, are at an increased risk of post-operative complications. Pre-operative nutritional support should be used in these patients. IBD patients undergoing surgery have a higher risk of venous thromboembolic disease than patients with colorectal cancer, and current guidelines recommend that they should receive prophylaxis with heparin. Whether the use of anti-TNF agents before surgery increases the likelihood of post-operative complications, is the subject of much debate. To date, cumulative evidence from most studies (all retrospective) suggests that there is no such risk increment. Prospective studies are necessary to firmly establish this conclusion.

CONCLUSIONS

Preparation for surgery requires close interaction between surgeons, gastroenterologist, radiologists, psychologists and the patient. Correct pre-operative planning of surgical treatment has a major impact on the outcome of such treatment.

Length of hospital stay and associated hospital costs with infliximab versus cyclosporine in severe ulcerative colitis

BACKGROUND

Cyclosporine and infliximab (IFX) seem equally effective as rescue therapy in hospitalized patients with severe ulcerative colitis (UC), although associated hospital stay and costs may differ.

AIM

The aim of this study was to compare the duration of hospital stay and associated costs from initiation of rescue therapy to time of discharge in hospitalized patients with corticosteroid-refractory UC receiving cyclosporine or IFX. Colectomy rates after 6 months were used as the outcome parameter for treatment success.

PATIENTS AND METHODS

Hospital records of patients admitted between November 2003 and August 2012 at a tertiary referral center were analyzed.

RESULTS

Forty-two patients were included (cyclosporine group: 26 patients; IFX group: 16 patients). Patient characteristics were comparable, with the exception that cyclosporine-treated patients more often had a pancolitis (89 vs. 63%, P=0.046). The median length of hospital stay was 11.0 (interquartile range 7.75-13.25) versus 4.0 days (interquartile range 4.0-5.75) in the cyclosporine and IFX group (P<0.01), respectively. The mean in-hospital costs were significantly higher in the cyclosporine-treated versus IFX-treated patients (6121 vs. 4853 euros, P<0.05), whereas the total costs up to 3 months after initiation of rescue therapy were significantly higher in the IFX group (6787 vs. 9983 euros, P<0.01). There were no significant differences in colectomy rates at 6 months (23 and 31% for cyclosporine and IFX, P=0.50). More side-effects were observed during treatment with cyclosporine.

CONCLUSION

Length of hospital stay and in-hospital costs have been reduced significantly since the introduction of IFX as rescue therapy for severe UC instead of cyclosporine. However, the total treatment costs are higher in IFX-treated patients.

Anastomotic leakage after gastrointestinal surgery: diagnosis and management

Anastomotic leakage represents a major complication of gastrointestinal surgery, leading to increased postoperative morbidity; it the foremost cause of mortality after intestinal resection. Identification of risk factors is essential for the prevention of AL. AL can present with various clinical pictures, ranging from the absence of symptoms to life-threatening septic shock. Contrast-enhanced CT scan is the most complete investigation to define AL and its consequences. Early and optimal multidisciplinary management is based on three options: medical management, radiologic or endoscopic intervention, or surgical re-intervention. Prompt treatment should help decrease postoperative morbidity and mortality, with the choice depending on the septic status of the patient. If the patient is asymptomatic, treatment can be medical only, coupled with close surveillance. Interventional management is indicated when the fistula is symptomatic but not life-threatening. On the other hand, when the vital prognosis is engaged, surgery is indicated, emergently, associated with intensive care. Even more than their prevention, early and appropriate management counts most to decrease their consequences.

A preoperative low nutritional prognostic index correlates with the incidence of incisional surgical site infections after bowel resection in patients with Crohn's disease

PURPOSE

The incidence of incisional surgical site infections (SSIs) is reported to be higher among patients with Crohn's disease (CD) than among those with colorectal cancer. It has also been reported that the preoperative nutritional and inflammatory status is associated with the frequency of postoperative complications. Onodera's prognostic nutritional index (OPNI) is a simple and useful parameter for determining the nutritional and inflammatory status. In the present study, we retrospectively investigated the correlation between the OPNI and the incidence of incisional SSI in patients with CD who had undergone bowel resection.

METHODS

A total of 177 CD patients who underwent abdominal surgery were enrolled. Various clinical factors and the OPNI values were evaluated to identify risk factors for incisional SSIs.

RESULTS

The incidence of incisional SSIs was 19.8 %. A multivariate analysis indicated that the OPNI was an independent risk factor for incisional SSIs.

CONCLUSIONS

The results of this retrospective study suggest that the OPNI is an independent risk factor for incisional SSIs in patients with a history of bowel resection for CD.

Biologic therapy and surgery for crohn disease

In 1998, infliximab, an antitumor necrosis factor alpha (anti-TNF-α) antibody, was approved for use in the treatment of Crohn disease (CD). Since then, other biologic therapies, including adalimumab and certolizumab pegol (newer anti-TNF-α antibodies), and natalizumab, an antibody against alpha-4 integrin, have also been approved. Here, we review the published studies that examine the relationship between pre- and postoperative biologic therapy and postoperative complications in patients with CD. This body of literature is composed of numerous small, retrospective, heterogeneous studies that demonstrate conflicting and varied results. Overall, the receipt of biologic therapy in the pre- or postoperative period does not appear to significantly increase the risk of postoperative complications. It is, however, difficult to draw any firm conclusions based on the existing level of data. In the future, larger prospective studies are needed to better elucidate the true risks, if any, that the use of biologic therapy poses to patients with CD requiring operation.

Preoperative optimization of crohn disease

Crohn disease is a chronic disease that is treated with aminosalicylates, antibiotics, and immunosuppressant agents. Most patients ultimately require surgical intervention and many will require additional surgery for recurrent disease. Consequently, surgery is generally performed only when medical management fails; however, these patients are often malnourished and immunosuppressed. Preoperative optimization is necessary to minimize morbidity, including intra-abdominal septic complications and anastomotic leaks. In this article, the authors review some considerations to improve the surgical outcome in Crohn disease.

The impact of peri-operative anti-TNF treatment on anastomosis-related complications in Crohn's disease patients. A critical review

INTRODUCTION

Tumor necrosis factor (TNF)α is a cytokine exerting pleiotropic effects on critical cell functions and, most importantly, is the main regulator of pro-inflammatory cytokine production and a key player in the pathophysiology of numerous autoimmune diseases, including Crohn's disease.

METHODS

TNFα became a therapeutic target and TNFα blocking agents are currently used in the treatment of inflammatory diseases. Beyond the therapeutic benefits deriving from TNFα neutralization, amendments in the cellular functions of the immune system may as well induce potent immunosuppressive effects. An attenuated immune response may compromise the intestinal healing ability, thus leading to weaker anastomosis and increased risk of anastomotic leak and septic complications.

RESULTS

This hypothesis raises great concerns about the safety of perioperative administration of anti-TNF and has been the endpoint of numerous studies.

CONCLUSION

The aim of this review is to critically evaluate the evidence regarding the role of TNFα in anastomosis related complications after abdominal surgery in Crohn's disease patients.

Impact of preoperative immunosuppressive agents on postoperative outcomes in Crohn's disease

BACKGROUND

Immunosuppressive agents are essential in the management of Crohn's disease. Their safety before surgery, however, is still controversial.

OBJECTIVE

The aim of this study is to evaluate whether the preoperative use of immunosuppressive agents is associated with increased postoperative complications in Crohn's disease.

DATA SOURCES

A literature search of PubMed, EMBASE, and The Cochrane Library was undertaken in February 2013.

STUDY SELECTION

All studies describing postoperative outcomes of patients undergoing bowel resections for Crohn's disease were included if they reported data comparing patients on preoperative immunosuppressive agents with an appropriate control group.

INTERVENTIONS

All immunosuppressive agents used to manage Crohn's disease were studied.

MAIN OUTCOME MEASURES

The main outcomes measured were total overall complications and total infectious complications.

RESULTS

Twenty-one eligible studies (20 retrospective and 1 prospective) with 6899 patients were included. When individual studies were examined, only 2/14 (14%), 4/13 (31%), and 1/8 (13%) studies found an association between postoperative complications and preoperative anti-tumor necrosis factor agents, corticosteroids, and thiopurines. In meta-analyses, patients on anti-tumor necrosis factor agents (risk ratio, 1.29; 95% CI, 1.07-1.55), and corticosteroids (risk ratio, 1.55; 95% CI, 1.23-1.95) were found to have a higher risk of postoperative infectious complications. The use of anti-tumor necrosis factor agents was also significantly associated with wound infection (risk ratio, 1.62; 95% CI, 1.12-2.34) and septic shock (risk ratio, 1.81; 95% CI, 1.03-3.17). There was no association between the use of thiopurines or combined immunomodulator drugs and postoperative complications.

LIMITATIONS

Most studies were retrospectively designed, and there were large variations in the patient populations and outcome definitions.

CONCLUSIONS

Patients with Crohn's disease on preoperative immunosuppressive agents are at higher risk for complications. Both corticosteroids and anti-tumor necrosis factor agents may increase the risk of infections and septic shock. A preoperative drug-free interval, when feasible, might be considered to reduce the risk of infections. The adoption of any operative strategies that modify these outcomes may additionally counter these risks.

Infliximab's influence on anastomotic strength and degree of inflammation in intestinal surgery in a rabbit model

Background

Infliximab, a TNF-α inhibitor, is a potent anti-inflammatory drug in the treatment of inflammatory bowel diseases. Recent studies have investigated the effect of infliximab treatment on postoperative complications such as anastomotic leakage, however, with conflicting results and conclusions. The purpose of this study was to investigate whether a single dose infliximab has an adverse effect on the anastomotic healing process, observed as reduced anastomotic breaking strength and histopathologically verified lower grade of inflammatory response, in the small intestine of a rabbit.

Methods

Thirty New Zealand rabbits (median weight 2.5 kg) were allocated to treatment with an intravenous bolus of either 10 mg/kg infliximab (n = 15) or placebo (n = 15). One week later all rabbits underwent two separate end-to-end anastomoses in the jejunum under general anesthesia. At postoperative day three, the anastomotic breaking strength was determined and histopathological changes were examined.

Results

The mean value of anastomotic breaking strength in the placebo group was 1.89 ± 0.36 N and the corresponding value was 1.81 ± 0.33 N in the infliximab treated rabbits. There was no statistically significant difference between the groups (p = 0.51). The infliximab-treated rabbits had a significant lower degree of inflammatory infiltration response compared to the placebo group (p = 0.047).

Conclusions

Our conclusion, limited by the small sample sizes in both groups, is that a single dose of infliximab, given one week prior to surgery, does not have an impact on the anastomotic breaking strength on the third postoperative day in the small intestine of rabbits.

Complications in surgery for Crohn's disease after preoperative antitumour necrosis factor therapy

BACKGROUND

The use of biological therapy (biologicals) is established in the treatment of Crohn's disease. This study aimed to determine whether preoperative treatment with biologicals is associated with an increased rate of complications following surgery for Crohn's disease with intestinal anastomosis.

METHODS

All patients receiving biologicals and undergoing abdominal surgery with anastomosis or strictureplasty were identified at six tertiary referral centres. Demographic data, and preoperative, operative and postoperative details were registered. Patients who were treated with biologicals within 2 months before surgery were compared with a control group who were not. Postoperative complications were classified according to anastomotic, infectious or other complications, and graded according to the Clavien-Dindo classification.

RESULTS

Some 111 patients treated with biologicals within 2 months before surgery were compared with 187 patients in the control group. The groups were well matched. There were no differences between the treatment and control groups in the rate of complications of any type (34·2 versus 28·9 per cent respectively; P = 0·402), anastomotic complications (7·2 versus 8·0 per cent; P = 0·976) and non-anastomotic infectious complications (16·2 versus 13·9 per cent; P = 0·586). In univariable regression analysis, biologicals were not associated with an increased risk of any complication (odds ratio (OR) 1·33, 95 per cent confidence interval 0·81 to 2·20), anastomotic complication (OR 0·89, 0·37 to 2·17) or infectious complication (OR 1·09, 0·62 to 1·91).

CONCLUSION

Treatment with biologicals within 2 months of surgery for Crohn's disease with intestinal anastomosis was not associated with an increased risk of complications.

Successful treatment of postoperative fistula with infliximab in a patient with Crohn's disease

Nearly 80% of patients with Crohn's disease (CD) require surgical treatment for complications or failure of medical management. We managed a 31-year-old man with CD who presented with a post-operative fistula. The patient had undergone surgery due to multiple strictures and a fistula. However, a new fistula developed that connected to the intraperitoneal abscess. Intravenous antibiotics were started and multiple percutaneous drainage tubes were inserted to treat the abdominal abscess. However, the amount of drainage was consistently high, even one month after the operation. To treat the postoperative fistula, 5 mg/kg of infliximab was started, and the amount of drainage decreased dramatically to less than 10 cc a day. Some studies have reported that infliximab decreases the recurrence of CD after surgery. The effect of infliximab on post-operative fistulas in patients with CD has not been sufficiently studied. Our results indicated that the use of infliximab to treat post-operative fistula should be explored further in future clinical studies.

Preoperative infliximab use and postoperative complications in Crohn's disease: a systematic review and meta-analysis

BACKGROUND

Infliximab revolutionized the treatment paradigm of Crohn's disease (CD), but did not reduce the need for surgery. The impact of biologic agents on surgical complication rates remains debated. The aim of this study was to determine the effect of preoperative infliximab use on early postoperative complications in patients with CD undergoing abdominal surgery.

METHOD

PubMed and Embase databases were searched to identify comparative studies that investigated postsurgical morbidity in CD patients receiving infliximab preoperatively with those not on infliximab. We used meta-analysis with random-effects model to calculate the pooled odds ratios (ORs) with 95% confidence intervals (CIs) for total complication rate as well as major, minor, infectious, and non-infectious complications.

RESULTS

A total of 18 studies involving 5769 patients included in this systematic review. There was significant association between infliximab therapy prior to surgery and total (OR = 1.45, 95% CI 1.04-2.02; 13 studies, 2538 patients), infectious (OR = 1.47, 95% CI 1.08-1.99; 10 studies, 2116 patients) and non-infectious (OR = 2.29, 95% CI 1.14-4.61; 3 studies, 729 patients) postoperative complications respectively. There was no significant disparity in the major (OR = 1.39, 95% CI 0.85-2.27; 9 studies, 3696 patients) and minor (OR = 1.39, 95% CI 0.57-3.40; 5 studies, 753 patients) complication rates between infliximab and control groups. No publication bias was detected.

CONCLUSION

Preoperative infliximab use modestly increases the risk of total early postoperative complications, and particularly infectious complications in CD patients.

The impact of Hispanic ethnicity and race on post-surgical complications in patients with inflammatory bowel disease

BACKGROUND

Surgery for inflammatory bowel disease (IBD) is common and represents a large portion of the cost of IBD treatment. There are multiple risk factors for post-operative complications after IBD surgery, but the role of ethnicity remains unclear. The aim of our study was to compare the rate of post-operative complications in Hispanic and non-Hispanic patients with equal access to health care.

METHODS

We designed a case-control study including patients enrolled in a health plan available to uninsured patients at Jackson Memorial Hospital (Miami, FL, USA) who had access to health care for at least 24 consecutive months prior to surgery. Sixty-seven Hispanic patients (cases) and 75 non-Hispanic patients (controls) met criteria and were compared with respect to demographics, type of surgery, disease phenotype, and laboratory markers. Primary outcome was the development of a medical or surgical complication.

RESULTS

A slight numerical increase in post-operative complications was seen in Hispanic patients; this did not reach statistical significance [1.06 (95 % CI 0.48-2.36; p = 0.88)]. Factors independently associated with post-operative complications included diagnosis of ulcerative colitis [OR 5.4 (95 % CI 1.67-20.58; p = 0.004)], pre-operative albumin levels <3 mg/dL [OR: 8.2 (95 % CI 2.3-35.5; p < 0.001)], smoking [OR 15.7 (95 % CI 4.2-72.35; p < 0.001)], and use of ≥20 mg of prednisone [OR 6.7 (95 % CI 2.15-24.62; p < 0.001)].

CONCLUSIONS

In a group of patients with equal access to medical care and follow-up, Hispanics and non-Hispanics with IBD that underwent surgery had no significant differences in types of IBD surgeries or post-surgical outcomes.

The risks of post-operative complications following pre-operative infliximab therapy for Crohn's disease in patients undergoing abdominal surgery: a systematic review and meta-analysis

BACKGROUND

Infliximab is an anti-TNF alpha blocker frequently utilized in the management of moderate to severe Crohn's Disease. The immunosuppressive effects of infliximab may increase the risk for post-operative complications among Crohn's Disease patients undergoing abdominal surgery. We conducted a systematic review and meta-analysis of studies comparing the rates of post-operative complications among Crohn's disease patients treated with Infliximab therapy versus alternative therapies.

METHODS

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and searched 4 electronic databases along with major conference abstract databases from inception of database until November, 2012. English-language articles and abstracts evaluating post-operative complications among Crohn's disease patients were considered eligible. We applied meta-analysis with random effects model to calculate the overall odds ratio for total major complications as well as several secondary outcomes.

RESULTS

Data were extracted from six studies including 1159 patients among whom 413 complications were identified. The most common complications were wound infections, anastomotic leak and sepsis. There was no significant difference in the major complication rate (OR=1.59[95% CI: 0.89-2.86]; p=0.15), minor complication rate (OR=1.80 [CI: 0.87-3.71]; p=0.11), reoperation rate (OR=1.33 [CI: 0.55-3.20]; p=0.52) or 30 day mortality rate (OR=3.74 [CI: 0.56-25.16]; p=0.13) between the Infliximab and control groups.

CONCLUSIONS

This meta analysis provides some evidence that infliximab may be safe to continue in the pre-operative period without increasing the risk of post-operative complications for Crohn's disease patients undergoing abdominal surgery.

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 effect of anti-tumor necrosis factor alpha agents on postoperative anastomotic complications in Crohn's disease: a systematic review

BACKGROUND

Patients with Crohn's disease treated with anti-tumor necrosis factor alpha agents may have an increased risk of surgical complications.

OBJECTIVE

We assessed the effect of anti-tumor necrosis factor alpha on postoperative complications in patients with Crohn's disease undergoing abdominal surgery.

DATA SOURCES

Studies were identified through electronic and manual searches.

STUDY SELECTION

Observational studies on patients with Crohn's disease undergoing laparoscopic or open abdominal surgery were included.

INTERVENTIONS

Anti-tumor necrosis factor alpha agents were administered within 3 months before surgery.

MAIN OUTCOME MEASURES

The primary outcome was anastomotic complications including overt dehiscence, intra-abdominal abscess, and enteric fistulas.

RESULTS

Fourteen studies on 679 patients in the intervention (anti-tumor necrosis factor alpha) group and 2363 controls were included. Random-effects meta-analysis found no difference in anastomotic complications between the 2 groups (7.6% versus 8.2%; risk ratio, 0.91; 95% CI, 0.56-1.48). There was clear heterogeneity between studies. In subgroup analyses, the anti-tumor necrosis factor alpha increased anastomotic complications in trials with a lower risk of bias, but not in the studies with a higher bias risk (risk ratio, 1.63; 95% CI, 1.03-2.60 and risk ratio, 0.17; 95% CI, 0.05-0.60). In the overall analysis and in studies with a lower bias risk, anti-tumor necrosis factor alpha agents increased the risk of nonanastomotic surgical complications, major medical complications, and minor medical complications.

LIMITATIONS

Limitations of observations studies.

CONCLUSIONS

In studies with a low risk of bias, anti-tumor necrosis factor alpha agents increased the risk of anastomotic complications. Inadequate bias control may lead to an underestimated risk of anastomotic complications.

[Multimodal oncological therapy concepts, chemotherapy and immunosuppressive drugs: effects on surgical morbidity and mortality]

Systemic chemotherapy, targeted therapies and radiotherapy for patients with malignant tumors lead to unfavorable surgical conditions with increased risks of postoperative complications. For gastric cancer and cancer of the esophagogastric junction, surgery after neoadjuvant treatment is associated with a mortality of approximately 5 %. Given the increase in metastatic surgery for colorectal carcinoma, surgeons should be aware of the specific side effects of therapeutic drugs to ensure an optimal course of treatment. The impact of chemotherapy-induced hepatic lesions on postoperative development is unclear. Bevacizumab treatment should be stopped at least 5 weeks before surgery to reduce the risk of thromboembolic events, bleeding and wound healing complications. Immunosuppressive and immunomodulating agents alter wound healing and preoperative alterations should be carefully evaluated. For patients with chronic corticosteroid therapy, perioperative supplementation should be considered when planning surgery as well as routine dosages.

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.

Surgery for Crohn's disease and anti-TNF agents: the changing scenario

Surgery has been a mainstay of therapy for Crohn's disease for a long time, essentially as a consequence of the fairly modest efficacy of traditional medications such as immunomodulators, antibiotics and 5-ASA, especially in severe cases. However, in the past decade and half, the advent of anti-TNF agents has greatly changed the medical approach to this disease and may modify its general management as well. Here, we have reviewed the current literature on incidence of surgery, timing of surgery and postoperative recurrence of Crohn's disease before and after the advent of anti-TNF agents. In addition, we have reviewed the risk of perioperative complications in patients on anti-TNF agents before surgery. The data show that the use of these medications is changing or expecting to change shortly a number of surgical aspects of Crohn's disease management.

Immunosuppressive therapy does not increase operative morbidity in patients with Crohn's disease

GOALS

The aim of this study was to examine the impact of immunosuppressive therapy on the morbidity of intestinal surgery in patients with Crohn's disease.

BACKGROUND

An increasing number of immunomodulating agents are being used in the treatment of Crohn's disease. The effect of these medications on surgical morbidity is controversial.

STUDY

We performed a retrospective review of our prospectively maintained database of patients with Crohn's disease who underwent intestinal surgery between June 1999 and May 2010. The effect of perioperative immunomodulation on postoperative outcomes, specifically anastomotic complications, was evaluated. Predictors of postoperative morbidity among demographic and surgical variables were identified. Length of hospitalization and rate of hospital readmission were compared between groups. Comparisons were made using Student t test and Fisher exact test.

RESULTS

One hundred ninety-six intestinal procedures were performed. One hundred twenty-seven (64.8%) of these were performed among patients who received perioperative immunomodulation. Forty-six (23.5%) procedures were in patients who received >1 immunomodulating medication perioperatively. Complications occurred in 45 (23.0%) cases. There were 20 (10.2%) anastomotic complications, including 8 (4.1%) intra-abdominal abscesses, 8 (4.1%) anastomotic leaks, and 4 (2%) enterocutaneous fistulas. Preoperative treatment with steroids (P=0.21), 6-MP (P=0.10), and anti-tumor necrosis factor biologics (P=1.0) was not associated with increased postoperative anastomotic complications. Combination immunosuppressive therapy also did not increase morbidity (P=0.39).

CONCLUSIONS

In our series, single agent and combination immunosuppressive therapy given around the time of intestinal surgery did not increase the incidence of surgical complications in patients with Crohn's disease.

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.

Impact of inflammatory bowel disease on post-cholecystectomy complications and hospitalization costs: a Nationwide Inpatient Sample study

BACKGROUND AND AIM

Our previous single-center study showed that patients with underlying inflammatory bowel disease (IBD) had a higher risk for post-cholecystectomy complications. The aim of the current population-based study was to verify whether concomitant IBD was indeed associated with an increased risk of post-cholecystectomy complications.

METHODS

In this cross-sectional study, all 1,155,432 patients from the Nationwide Inpatient Sample (NIS) with a primary procedure of cholecystectomy were examined, and 5891 patients with IBD were compared with 1,149,541 patients without IBD from 2006 to 2008.

RESULTS

There were no significant differences in age, gender, frequency of obesity, and post-operative mortality between the two groups. More patients in the IBD group had post-operative complications than the non-IBD group [398/5891 (6.8%) vs. 55,202/1,149,541 (4.8%), p=0.002)]. On multivariate analysis, the presence of Crohn's disease (CD) was associated with an increased risk for post-operative complications (odds ratio [OR]=1.6; 95% confidence interval [CI], 1.2-2.1, p=0.003). The other risk factors for post-cholecystectomy complications were older age, male gender, African-American race, malnutrition and patients with higher co-morbidity index. The presence of ulcerative colitis (UC) was associated with a trend for increased complications (OR=1.3, 95% CI 0.8-2.1, p=0.08). Patients with IBD who underwent cholecystectomy incurred higher mean hospital costs ($39,651 vs. $35,196, p=0.006) and also stayed in the hospital 1.2 days longer than those without underlying IBD.

CONCLUSIONS

CD patients undergoing cholecystectomy were shown to have a significantly increased risk for postoperative complications, have a longer stay in the hospital, and incur higher hospitalization costs.

The effect of immune therapy on surgical site infection following Crohn's Disease resection

BACKGROUND

Patients with Crohn's disease are increasingly receiving antitumour necrosis factor α (anti-TNF-α) therapy. Whether anti-TNF-α therapy increases the risk of postoperative infectious complications in Crohn's disease is a matter of debate.

METHODS

This was a retrospective study of three referral centres. The charts of patients who underwent ileocaecal or ileocolonic resection for Crohn's disease between 2000 and 2011 were reviewed. The impact of baseline characteristics and Crohn's disease-related medications on the risk of postoperative intra-abdominal infectious complications was investigated by univariable and multivariable analysis.

RESULTS

A total of 217 patients were included in the study. Median age at the time of surgery was 36·8 (range 15-78) years. A postoperative intra-abdominal infection occurred in 24 (11·1 per cent) of 217 patients. No deaths were reported. On univariable analysis, age less than 25 years (P = 0·023), steroid use (P = 0·017), anti-TNF-α therapy (P = 0·043) and anti-TNF-α treatment in combination with steroids (P = 0·004) were associated with an increased risk of postoperative intra-abdominal infectious complications. On multivariable analysis, only anti-TNF-α therapy in combination with steroids significantly increased this risk (odds ratio 8·03, 95 per cent confidence interval 1·93 to 33·43; P = 0·035).

CONCLUSION

Combined use of steroids and anti-TNF-α therapy was associated with an increased risk of postoperative intra-abdominal infectious complications.

Surgical management of IBD--from an open to a laparoscopic approach

Surgery is a key feature of IBD management. Up to 70% of patients with Crohn's disease and 35% of patients with ulcerative colitis will require surgery during the course of their disease. This Review provides an overview of IBD surgical management, focusing on the potential benefits and drawbacks of laparoscopy compared with open surgery. Emergency and elective indications for both laparoscopic and open surgery are detailed for patients with ulcerative colitis and Crohn's disease. Evidence-based comparative results of these surgical approaches are discussed, along with factors that influence patient outcomes. Upcoming new techniques for IBD surgical management, including single-port surgery, are also presented.

Anti-tumor necrosis factor therapy is associated with infections after abdominal surgery in Crohn's disease patients

OBJECTIVES

Anti-tumor necrosis factor (anti-TNF) therapy effects on postoperative complications in Crohn's disease (CD) patients are unclear. We examined a retrospective cohort to clarify this relationship.

METHODS

CD patients followed at a referral center between July 2004 and May 2011 who underwent abdominal surgery were identified. Postoperative complications (major infection, intra-abdominal abscess, peritonitis, anastomotic leak, wound infection, dehiscence, fistula, thrombotic, and death) were compared in patients exposed and unexposed to anti-TNF ≤8 weeks preoperatively. Demographics, surgical history, comorbidities, corticosteroid (CS) and immunomodulator use, Montreal classification, operative details, and preoperative nutritional status were assessed. Multivariate analysis measured the independent effect of preoperative anti-TNF on postoperative complications.

RESULTS

Overall, 325 abdominal surgeries were performed; 150 (46%) with anti-TNF ≤8 weeks before surgery. The anti-TNF group developed overall infectious (36% vs. 25%, P=0.05) and a trend toward surgical site complications (36% vs. 25%, P=0.10) more frequently. Major postoperative and intra-abdominal septic complications did not differ between groups. Multivariable analysis showed that preoperative anti-TNF was an independent predictor of overall infectious (odds ratio (OR) 2.43; 95% confidence interval (CI) 1.18-5.03) and surgical site (OR 1.96; 95% CI 1.02-3.77) complications.

CONCLUSIONS

In a tertiary referral center, use of anti-TNF therapy in CD patients ≤8 weeks before intestinal resection or any intra-abdominal surgery was independently associated with increases in infectious and surgical complications.

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.

Control of AA amyloidosis complicating Crohn's disease: a clinico-pathological study

BACKGROUND

Immunosuppressive drugs may prevent or partially reverse progression of renal AA-amyloidosis, a rare complication of Crohn's disease, often fatal due to renal failure.

MATERIALS AND METHODS

The clinical, biological and pathological data of 16 patients treated since 1976 were reviewed. Serum amyloid A was determined in surviving patients.

RESULTS

The median age of the 16 patients (13 men) was 23·5 years (range 16-69). At Crohn's disease onset, Montreal phenotypes were similar to reported data. Out of 15 patients with renal insufficiency, 8 developed a nephrotic syndrome and 7 a low grade proteinuria. The single patient without renal insufficiency had nephrotic syndrome. A significant correlation (P < 0·05) between the extension of renal amyloid A and sclerosis was found in 12 patients. One patient had a 10 year remission of nephrotic syndrome with immunosuppressive drugs. In 6 patients treated with anti-TNF-α (Tumor-Necrosis-Factor-α) agents, anaphylactic reaction (1/6), death from septic shock (1/6), 5-year remission (1/6) or reduction of nephrotic syndrome (1/6) and stabilization of renal insufficiency (2/6) were observed. Surgery was performed in 10 patients. Kidney transplantation was performed in 5 of the 8 patients dialysed for end-stage renal failure. Among 6/16 patients (37%) still alive, 3 belong to the 5 transplanted patients (survival: 3-20 years) and 3 to the anti-TNF-α drugs treated patients; all but one exhibited a low serum amyloid A level.

CONCLUSIONS

Suppression of Crohn's disease inflammation potentially leads to the control of amyloid A production, assessed by a decrease of serum amyloid A. Kidney transplantation provides a long survival.

Resection of a methicillin-resistant Staphylococcus aureus liver abscess in a patient with Crohn's disease under infliximab treatment: a case report

Introduction

A liver abscess in Crohn’s disease is a rare but important entity that is associated with a poor prognosis and high mortality when treatment is delayed. We report a case of successful liver segmentectomy for a methicillin-resistant Staphylococcus aureus liver abscess in a patient with Crohn’s disease under infliximab treatment.

Case presentation

A 31-year-old Japanese man, who had been treated with infliximab infusions for Crohn’s disease, was referred to our hospital presenting with an abrupt onset of high fever and an elevated white blood cell count and serum C-reactive protein level. Computed tomography revealed a liver abscess occupying segment 8. The limited effect of percutaneous transhepatic abscess drainage and antibiotics led us to perform radical resection of the abscess. The patient recovered quickly after surgery and the postoperative course was uneventful.

Conclusion

The present case suggests that surgical removal of an abscess should be considered for patients under immunosuppression or refractory to conventional treatment.

Pre-operative use of anti-TNF-α agents and the risk of post-operative complications in patients with Crohn's disease--a nationwide cohort study

BACKGROUND

A possible negative role of pre-operative use of antitumour necrosis factor-alpha (anti-TNF-α) agents on post-operative outcomes in Crohn's disease (CD) patients is still debated.

AIM

To examine the impact of pre-operative anti-TNF-α agents on post-operative outcomes 30 and 60 days after CD surgery in a nationwide Danish cohort. Outcomes were death, reoperation, anastomosis leakage, intra-abdominal abscess and bacteraemia.

METHODS

We identified all patients having surgical procedures from 1 January 2000 to 31 December 2010 (n = 2293). Patients were classified according to use of anti-TNF-α agents within 12 weeks before surgery (exposed) or not (unexposed). Outcomes were obtained from nationwide registries and a bacteraemia registry. Sub-analyses were performed for bacteraemia and for impact of pre-operative timing of anti-TNF-α agents.

RESULTS

Among surgical procedures for CD, 214 were exposed and 2079 were not. We found no increased relative risks of death or abscess drainage 30 or 60 days after follow-up. Among exposed, 7.5% had a reoperation within 30 days vs. 8.6% among unexposed, adjusted odds ratio (OR) = 0.92, 95% confidence interval (CI): 0.52-1.63. Among exposed, 3.8% had an anastomosis leakage within 30 days after surgery vs. 2.8% among unexposed, adjusted OR = 1.33, 95% CI: 0.59-3.02. No further cases of anastomosis leakages appeared within 60 days. Sub-analyses indicated no increased risk of bacteraemia after 30 days and no increased risks when anti-TNF-α agents were given ≤14 days before surgery.

CONCLUSION

We found no significantly increased relative risks of post-operative complications after use of anti-TNF-α agents either 12 weeks or ≤14 days before surgery for Crohn's disease.

Minimally invasive approaches for the treatment of inflammatory bowel disease

Despite significant improvements in medical management of inflammatory bowel disease, many of these patients still require surgery at some point in the course of their disease. Their young age and poor general conditions, worsened by the aggressive medical treatments, make minimally invasive approaches particularly enticing to this patient population. However, the typical inflammatory changes that characterize these diseases have hindered wide diffusion of laparoscopy in this setting, currently mostly pursued in high-volume referral centers, despite accumulating evidences in the literature supporting the benefits of minimally invasive surgery. The largest body of evidence currently available for terminal ileal Crohn’s disease shows improved short term outcomes after laparoscopic surgery, with prolonged operative times. For Crohn’s colitis, high quality evidence supporting laparoscopic surgery is lacking. Encouraging preliminary results have been obtained with the adoption of laparoscopic restorative total proctocolectomy for the treatment of ulcerative colitis. A consensus about patients’ selection and the need for staging has not been reached yet. Despite the lack of conclusive evidence, a wave of enthusiasm is pushing towards less invasive strategies, to further minimize surgical trauma, with single incision laparoscopic surgery being the most realistic future development.

Anti-tumor necrosis factor and postoperative complications in Crohn's disease: systematic review and meta-analysis

BACKGROUND

Anti-tumor necrosis factor (TNF) antibodies are efficacious in patients with Crohn's disease (CD) but the influence of these medications on surgical outcomes in CD patients has been frequently debated. The aim was to evaluate the impact of preoperative treatment with anti-TNF antibodies on postoperative complications in CD patients undergoing abdominal surgery.

METHODS

A systematic review and meta-analysis of comparative cohort studies was performed assessing postoperative complication rates in CD patients who were treated with anti-TNF antibodies within 3 months before surgery versus patients who were not. The primary outcome was overall complication rate within 1 month of surgery. Secondary outcomes included the rate of infectious and noninfectious complications. The quality of studies was assessed based on selection of patients and controls, comparability of the study groups, and assessment of outcomes. Odds ratios (OR) with 95% confidence intervals (CIs) were computed.

RESULTS

A total of eight studies including 1641 patients were included in our meta-analysis. Preoperative infliximab therapy in CD patients undergoing abdominal surgery was associated with a trend toward an increased rate of total complications (OR 1.72, 95% CI, 0.93-3.19). Anti-TNF treatments were associated with a modestly increased risk of infectious complications (OR 1.50, 95% CI 1.08-2.08), mostly remote from the surgical site (OR 2.07 95% CI 1.30-3.30) and with a trend toward a higher rate of noninfectious complications (OR 2.00, 95% CI 0.89-4.46).

CONCLUSION

Preoperative infliximab treatment is associated with an increased risk of postoperative infectious complications, mostly nonlocal. A trend toward an increased risk of noninfectious and overall complications was also observed.

Presence of concomitant inflammatory bowel disease is associated with an increased risk of postcholecystectomy complications

BACKGROUND

Surgery in patients with inflammatory bowel disease (IBD) is often associated with complications. The aim of our study was to evaluate whether concomitant IBD was associated with an increased risk of postcholecystectomy complications.

METHODS

The study group consisted of 82 consecutive IBD patients who underwent cholecystectomy from January 2001 to October 2010. The control group included 296 cholecystectomy patients without IBD who were randomly selected from the cholecystectomy database. Variables were analyzed by univariate and multivariate analyses.

RESULTS

There were no significant differences in age, gender, body mass index, presence of gallstones/common bile duct stones, indication for cholecystectomy, and postoperative mortality between the study and control groups. More patients in the study group had postoperative complications than in the control group (17.1% vs. 6.8%, P = 0.005). On multivariate analysis, the presence of concomitant IBD was independently associated with an increased risk for postoperative complications (odds ratio [OR] = 4.64; 95% confidence interval [CI], 1.63-13.20, P = 0.004) after adjusting for age, the presence of cirrhosis, diabetes, body mass index, the use of corticosteroids, immunomodulators, total parental nutrition, or biologics, the presence of primary sclerosing cholangitis (PSC), acute or chronic cholecystitis, cholelithiasis, or prior abdominal surgeries, and indication for surgery (elective vs. emergent).

CONCLUSIONS

IBD patients undergoing cholecystectomy have a significantly increased risk of postoperative complications. Although further studies are warranted to clarify the reason for these differences, caution should be taken to determine the need and timing of cholecystectomy in IBD patients.