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Lee KE, Faye AS, Vermeire S, Shen B. Perioperative Management of Ulcerative Colitis: A Systematic Review. Dis Colon Rectum 2022; 65:S5-S19. [PMID: 36007165 PMCID: PMC9907776 DOI: 10.1097/dcr.0000000000002588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Patients with ulcerative colitis may require colectomy for severe disease unresponsive or refractory to pharmacological therapy. Managing ulcerative colitis is complicated because there are many factors at play, including patient optimization and treatment, as the guidance varies on the ideal perioperative use of corticosteroids, immunomodulators, biologics, and small molecule agents. OBJECTIVE A systematic literature review was performed to describe the current status of perioperative management of ulcerative colitis. DATA SOURCES PubMed and Cochrane databases were used. STUDY SELECTION Studies published between January 2000 and January 2022, in any language, were included. Articles regarding pediatric or endoscopic management were excluded. INTERVENTIONS Perioperative management of ulcerative colitis was included. MAIN OUTCOME MEASURES Successful management, including reducing surgical complication rates, was measured. RESULTS A total of 121 studies were included in this review, including 23 meta-analyses or systematic reviews, 25 reviews, and 51 cohort studies. LIMITATIONS Qualitative review including all study types. The varied nature of study types precludes quantitative comparison. CONCLUSION Indications for colectomy in ulcerative colitis include severe disease unresponsive to medical treatment and colitis-associated neoplasia. Urgent colectomy has a higher mortality rate than elective colectomy. Corticosteroids are associated with postsurgical infectious complications and should be stopped or weaned before surgery. Biologics are not associated with adverse postoperative effects and do not necessarily need to be stopped preoperatively. Additionally, the clinician must assess individuals' comorbidities, nutrition status, and risk of venous thromboembolism. Nutritional imbalance should be corrected, ideally at the preoperative period. Postoperatively, corticosteroids can be tapered on the basis of the length of preoperative corticosteroid use.
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Affiliation(s)
- Kate E. Lee
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Adam S. Faye
- Division of Gastroenterology, NYU Grossman School of Medicine, New York, New York
| | - Séverine Vermeire
- Division of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
| | - Bo Shen
- Center for Inflammatory Bowel Diseases, Digestive Disease and Surgery Institute, Department of Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York
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Cira K, Weber MC, Wilhelm D, Friess H, Reischl S, Neumann PA. The Effect of Anti-Tumor Necrosis Factor-Alpha Therapy within 12 Weeks Prior to Surgery on Postoperative Complications in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11236884. [PMID: 36498459 PMCID: PMC9738467 DOI: 10.3390/jcm11236884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/07/2022] [Accepted: 11/12/2022] [Indexed: 11/24/2022] Open
Abstract
The rate of abdominal surgical interventions and associated postoperative complications in inflammatory bowel disease (IBD) patients is still substantially high. There is an ongoing debate as to whether or not patients who undergo treatment with anti-tumor necrosis factor-alpha (TNF-α) agents may have an increased risk for general and surgical postoperative complications. Therefore, a systematic review and meta-analysis was conducted in order to assess the effect of anti-TNF-α treatment within 12 weeks (washout period) prior to abdominal surgery on 30-day postoperative complications in patients with IBD. The results of previously published meta-analyses examining the effect of preoperative anti-TNF-α treatment on postoperative complications reported conflicting findings which is why we specifically focus on the effect of anti-TNF-α treatment within 12 weeks prior to surgery. PubMed, Cochrane, Scopus, Web of Science, World Health Organization Trial Registry, ClinicalTrials.gov and reference lists were searched (June 1995−February 2022) to identify studies, investigating effects of anti-TNF-α treatment prior to abdominal surgery on postoperative complications in IBD patients. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated and subgroup analyses were performed. In this case, 55 cohort studies (22,714 patients) were included. Overall, postoperative complications (OR, 1.23; 95% CI, 1.04−1.45; p = 0.02), readmission (OR, 1.39; 95% CI, 1.11−1.73; p = 0.004), and intra-abdominal septic complications (OR, 1.89; 95% CI, 1.44−2.49; p < 0.00001) were significantly higher for anti-TNF-α-treated patients. Significantly higher intra-abdominal abscesses and readmission were found for anti-TNF-α-treated CD patients (p = 0.05; p = 0.002). Concomitant treatment with immunosuppressives in <50% of anti-TNF-α-treated patients was associated with significantly lower mortality rates (OR, 0.32; 95% CI, 0.12−0.83; p = 0.02). Anti-TNF-α treatment within 12 weeks prior to surgery is associated with higher short-term postoperative complication rates (general and surgical) for patients with IBD, especially CD.
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Affiliation(s)
- Kamacay Cira
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Marie-Christin Weber
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Dirk Wilhelm
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Helmut Friess
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Stefan Reischl
- Institute of Diagnostic and Interventional Radiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Philipp-Alexander Neumann
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
- Correspondence:
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Cohen BL, Fleshner P, Kane SV, Herfarth HH, Palekar N, Farraye FA, Leighton JA, Katz JA, Cohen RD, Gerich ME, Cross RK, Higgins PDR, Tinsley A, Glover S, Siegel CA, Bohl JL, Iskandar H, Ji J, Hu L, Sands BE. Prospective Cohort Study to Investigate the Safety of Preoperative Tumor Necrosis Factor Inhibitor Exposure in Patients With Inflammatory Bowel Disease Undergoing Intra-abdominal Surgery. Gastroenterology 2022; 163:204-221. [PMID: 35413359 DOI: 10.1053/j.gastro.2022.03.057] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/24/2022] [Accepted: 03/31/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Whether preoperative treatment of inflammatory bowel disease (IBD) with tumor necrosis factor inhibitors (TNFis) increases the risk of postoperative infectious complications remains controversial. The primary aim of this study was to determine whether preoperative exposure to TNFis is an independent risk factor for postoperative infectious complications within 30 days of surgery. METHODS We conducted a multicenter prospective observational study of patients with IBD undergoing intra-abdominal surgery across 17 sites from the Crohn's & Colitis Foundation Clinical Research Alliance. Infectious complications were categorized as surgical site infections (SSIs) or non-SSIs. Current TNFi exposure was defined as use within 12 weeks of surgery, and serum was collected for drug-level analyses. Multivariable models for occurrence of the primary outcome, any infection, or SSI were adjusted by predefined covariates (age, sex, preoperative steroid use, and disease type), baseline variables significantly associated (P < .05) with any infection or SSI separately, and TNFi exposure status. Exploratory models used TNFi exposure based on serum drug concentration. RESULTS A total of 947 patients were enrolled from September 2014 through June 2017. Current TNFi exposure was reported by 382 patients. Any infection (18.1% vs 20.2%, P = .469) and SSI (12.0% vs 12.6%, P = .889) rates were similar in patients currently exposed to TNFis and those unexposed. In multivariable analysis, current TNFi exposure was not associated with any infection (odds ratio, 1.050; 95% confidence interval, 0.716-1.535) or SSI (odds ratio, 1.249; 95% confidence interval, 0.793-1.960). Detectable TNFi drug concentration was not associated with any infection or SSI. CONCLUSIONS Preoperative TNFi exposure was not associated with postoperative infectious complications in a large prospective multicenter cohort.
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Affiliation(s)
- Benjamin L Cohen
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Phillip Fleshner
- Division of Colorectal Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Nicole Palekar
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida
| | - Francis A Farraye
- Department of Medicine and Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Jonathan A Leighton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Jeffry A Katz
- Division of Gastroenterology, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Russell D Cohen
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois
| | - Mark E Gerich
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Raymond K Cross
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Andrew Tinsley
- Department of Medicine, Division of Gastroenterology & Hepatology, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Sarah Glover
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida
| | - Corey A Siegel
- Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jaime L Bohl
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Surgery, Division of Colon and Rectal Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Heba Iskandar
- Department of Medicine, Division of Digestive Diseases, Emory University, Atlanta, Georgia
| | - Jiayi Ji
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Liangyuan Hu
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bruce E Sands
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
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Hanzel J, Almradi A, Istl AC, Yang ML, Fleshner KA, Parker CE, Guizzetti L, Ma C, Singh S, Jairath V. Increased Risk of Infections with Anti-TNF Agents in Patients with Crohn's Disease After Elective Surgery: Meta-Analysis. Dig Dis Sci 2022; 67:646-660. [PMID: 33634430 DOI: 10.1007/s10620-021-06895-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative complication rates in patients with inflammatory bowel disease (IBD) receiving preoperative biologics have been analyzed without considering the surgical context. Emergency surgery may be associated with an increased risk of infectious complications, compared to elective operations. AIMS To conduct a systematic review and meta-analysis investigating the relationship between preoperative biologic therapy and postoperative outcomes in Crohn's disease (CD) and ulcerative colitis (UC), focusing on elective surgery. METHODS Electronic databases were searched up to February 12, 2020, for studies of patients with IBD undergoing elective abdominal surgery receiving biologic therapy within 3 months before surgery compared to no therapy, or another biologic therapy. Certainty of evidence was evaluated using GRADE. The primary outcomes were the rate of infections and total complications within 30 days. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. RESULTS Thirty-three studies were included. Preoperative treatment with anti-tumor necrosis factor (TNF) therapy in patients with CD undergoing elective surgery was associated with increased odds of infection (OR 2.05; 95% CI 1.40-3.01), but not total complications (OR 1.03; 95% CI 0.71-1.51). In elective surgery for UC, preoperative anti-TNF therapy was not associated with infectious (OR 1.03; 95% CI 0.34-3.07) or total complications (OR 0.67; 95% CI 0.29-1.58). Limited data indicate that emergency surgery did not significantly affect the rate of complications. CONCLUSIONS Anti-TNF therapy prior to elective surgery may increase the odds of postoperative infection in CD, although the certainty of evidence is very low. More evidence is needed, particularly for newer biologics.
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Affiliation(s)
- Jurij Hanzel
- Department of Gastroenterology, UMC Ljubljana, University of Ljubljana, Japljeva ulica 2, 1000, Ljubljana, Slovenia.,Alimentiv Inc. (Formerly Robarts Clinical Trials Inc.), 100 Dundas Street, Suite 200, London, ON, 27N6A 5B6, Canada
| | - Ahmed Almradi
- Alimentiv Inc. (Formerly Robarts Clinical Trials Inc.), 100 Dundas Street, Suite 200, London, ON, 27N6A 5B6, Canada.,Department of Medicine, Division of Gastroenterology, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Alexandra C Istl
- Division of General Surgery, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Mei Lucy Yang
- Division of General Surgery, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Katherine A Fleshner
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Claire E Parker
- Alimentiv Inc. (Formerly Robarts Clinical Trials Inc.), 100 Dundas Street, Suite 200, London, ON, 27N6A 5B6, Canada
| | - Leonardo Guizzetti
- Alimentiv Inc. (Formerly Robarts Clinical Trials Inc.), 100 Dundas Street, Suite 200, London, ON, 27N6A 5B6, Canada
| | - Christopher Ma
- Alimentiv Inc. (Formerly Robarts Clinical Trials Inc.), 100 Dundas Street, Suite 200, London, ON, 27N6A 5B6, Canada.,Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, 2500 University Dr NW, Calgary, AB, T2N 1N4, Canada
| | - Siddharth Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA
| | - Vipul Jairath
- Alimentiv Inc. (Formerly Robarts Clinical Trials Inc.), 100 Dundas Street, Suite 200, London, ON, 27N6A 5B6, Canada. .,Department of Medicine, Division of Gastroenterology, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada. .,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
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5
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Byrne LW, McKay D. Does perioperative biological therapy increase 30-day post-operative complication rates in inflammatory bowel disease patients undergoing intra-abdominal surgery? A systematic review. Surgeon 2021; 19:e153-e167. [PMID: 34581275 DOI: 10.1016/j.surge.2020.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/29/2020] [Accepted: 09/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biopharmaceuticals revolutionised inflammatory bowel disease (IBD) treatment. However, it is postulated they compromise immunity, collagen production and angiogenesis resulting in infective post-operative complications and altered wound/anastomotic healing. Research has failed to agree on risks associated with perioperative biologics therefore it was anticipated that a systematic review may provide a consensus and contribute recommendations for clinical practice. METHODS A systematic review conducted as per PRISMA guidelines included a methodical search of PubMed, Google Scholar, EMBASE/Ovid and Cochrane Library using MeSH and/or keywords for papers published between 01/01/1998 and 04/02/2019.The population analysed included adult ulcerative colitis, Crohn's disease, Indeterminate Colitis or IBD unclassified patients. The intervention was intra-abdominal surgery in patients treated with biological therapy in the preceding 12 weeks compared to patients who had intra-abdominal surgery without biological therapy within the defined timeframe. The primary outcome was surgical site infection (SSI) with secondary outcomes including wound dehiscence, intra-abdominal sepsis/abscess, systemic infection and anastomotic breakdown within 30 days post-procedure. Papers were evaluated by two independent reviewers and those included were assessed for quality/bias using the Newcastle-Ottowa scale. RESULTS 2064 UC, Crohn's and IC patients were analysed across 8 included studies. Several studies' multivariate analyses demonstrated corticosteroids to be independent predictors of morbidity. There are no increased complications associated with anti-TNFα exposure while vedolizumab increased SSI and small bowel obstruction. CONCLUSION Prospective studies and randomised control trials are required to clarify study outcomes and recommendations published to date. Presently, biologics should continue to be used and considered beneficial in this population.
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Affiliation(s)
| | - Damian McKay
- Craigavon Area Hospital, 68 Lurgan Rd, Portadown, Craigavon, BT63 5QQ, UK
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6
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Law CCY, Koh D, Bao Y, Jairath V, Narula N. Risk of Postoperative Infectious Complications From Medical Therapies in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. Inflamm Bowel Dis 2020; 26:1796-1807. [PMID: 32047894 DOI: 10.1093/ibd/izaa020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the impact of inflammatory bowel disease (IBD) medications on postoperative infection risk within 30 days of surgery. METHODS We searched multiple electronic databases and reference lists of articles dating up to August 2018 for prospective and retrospective studies comparing postoperative infection risk in patients treated with an IBD medication perioperatively with the risk in patients who were not taking that medication. Outcomes were overall infectious complications and intra-abdominal infections within 30 days of surgery. RESULTS Sixty-three studies were included. Overall infectious complications were increased in patients who received anti-tumor necrosis factor (TNF) agents (odds ratio [OR] 1.26; 95% confidence interval [CI], 1.07-1.50) and corticosteroids (OR 1.34; 95% CI, 1.25-1.44) and decreased in those who received 5-aminosalicylic acid (OR 0.63; 95% CI, 0.46-0.87). No difference was observed in those treated with immunomodulators (OR 1.08; 95% CI, 0.94-1.25) or anti-integrin agents (OR 1.06; 95% CI, 0.67-1.69). Both corticosteroids and anti-TNF agents were associated with increased intra-abdominal infection risk (OR 1.63; 95% CI, 1.33-2.00 and OR 1.46; 95% CI, 1.08-1.97, respectively), whereas no impact was observed with 5-aminosalicylates, immunomodulators, or anti-integrin therapy. Twenty-two studies had low risk of bias while the remaining studies had very high risk. CONCLUSIONS Corticosteroids and anti-TNF agents were associated with increased overall postoperative infection risk as well as intra-abdominal infection in IBD patients, whereas no increased risk was observed for immunomodulators or anti-integrin therapy. Although these results may result from residual confounding rather than from a true biological effect, prospective studies that control for potential confounding factors are required to generate higher-quality evidence.
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Affiliation(s)
- Cindy C Y Law
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Deborah Koh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Yueyang Bao
- Department of Biology, McMaster University, Hamilton, Ontario, Canada
| | - Vipul Jairath
- Departments of Medicine, Epidemiology, and Biostatistics, Western University, London, Ontario, Canada
| | - Neeraj Narula
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
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Law CC, Bell C, Koh D, Bao Y, Jairath V, Narula N. Risk of postoperative infectious complications from medical therapies in inflammatory bowel disease. Cochrane Database Syst Rev 2020; 10:CD013256. [PMID: 33098570 PMCID: PMC8094278 DOI: 10.1002/14651858.cd013256.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Medications used to treat inflammatory bowel disease (IBD) have significantly improved patient outcomes and delayed time to surgery. However, some of these therapies are recognized to increase the general risk of infection and have an unclear impact on postoperative infection risk. OBJECTIVES To assess the impact of perioperative IBD medications on the risk of postoperative infections within 30 days of surgery. SEARCH METHODS We searched the Cochrane IBD Group's Specialized Register (29 October 2019), MEDLINE (January 1966 to October 2019), Embase (January 1985 to October 2019), the Cochrane Library, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform from inception up to October 2019, and reference lists of articles. SELECTION CRITERIA Randomized controlled trials, quasi-randomized controlled trials, non-randomized controlled trials, prospective cohort studies, retrospective cohort studies, case-control studies and cross-sectional studies comparing participants treated with an IBD medication preoperatively or within 30 days postoperatively to those who were not taking that medication (either another active medication, placebo, or no treatment). We included published study reports and abstracts. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts and extracted data. The primary outcome was postoperative infection within 30 days of surgery. Secondary outcomes included incisional infections and wound dehiscence, intra-abdominal infectious complications and extra-abdominal infections. Three review authors assessed risks of bias using the Newcastle-Ottawa Scale. We contacted authors for additional information when data were missing. For the primary and secondary outcomes, we calculated odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) using the generic inverse variance method. When applicable, we analyzed adjusted and unadjusted data separately. We evaluated the certainty of the evidence using GRADE. MAIN RESULTS We included 68 observational cohort studies (total number of participants unknown because some studies did not report the number of participants). Of these, 48 studies reported including participants with Crohn's disease, 36 reported including participants with ulcerative colitis and five reported including participants with indeterminate colitis. All 42 studies that reported urgency of surgery included elective surgeries, with 31 (74%) of those also including emergency surgeries. Twenty-four studies had low risk of bias while the rest had very high risk. Based on pooling of adjusted data, we calculated ORs for postoperative total infection rates in participants who received corticosteroids (OR 1.70, 95% CI 1.38 to 2.09; low-certainty evidence), immunomodulators (OR 1.29, 95% CI 0.95 to 1.76; low-certainty evidence), anti-TNF agents (OR 1.60, 95% CI 1.20 to 2.13; very low-certainty evidence) and anti-integrin agents (OR 1.04, 95% CI 0.79 to 1.36; low-certainty evidence). We pooled unadjusted data to assess postoperative total infection rates for the use of aminosalicylates (5-ASA) (OR 0.76, 95% CI 0.51 to 1.14; very low-certainty evidence). One secondary outcome examined was wound-related complications in participants using: corticosteroids (OR 1.41, 95% CI 0.72 to 2.74; very low-certainty evidence), immunomodulators (OR 1.35, 95% CI 0.96 to 1.89; very low-certainty evidence), anti-TNF agents (OR 1.18, 95% CI 0.83 to 1.68; very low-certainty evidence) and anti-integrin agents (OR 1.64, 95% CI 0.77 to 3.50; very low-certainty evidence) compared to controls. Another secondary outcome examined the odds of postoperative intra-abdominal infections in participants using: corticosteroids (OR 1.53, 95% CI 1.28 to 1.84; very low-certainty evidence), 5-ASA (OR 0.77, 95% CI 0.45 to 1.33; very low-certainty evidence), immunomodulators (OR 0.86, 95% CI 0.66 to 1.12; very low-certainty evidence), anti-TNF agents (OR 1.38, 95% CI 1.04 to 1.82; very low-certainty evidence) and anti-integrin agents (OR 0.40, 95% CI 0.14 to 1.20; very low-certainty evidence) compared to controls. Lastly we checked the odds for extra-abdominal infections in participants using: corticosteroids (OR 1.23, 95% CI 0.97 to 1.55; very low-certainty evidence), immunomodulators (OR 1.17, 95% CI 0.80 to 1.71; very low-certainty evidence), anti-TNF agents (OR 1.34, 95% CI 0.96 to 1.87; very low-certainty evidence) and anti-integrin agents (OR 1.15, 95% CI 0.43 to 3.08; very low-certainty evidence) compared to controls. AUTHORS' CONCLUSIONS The evidence for corticosteroids, 5-ASA, immunomodulators, anti-TNF medications and anti-integrin medications was of low or very low certainty. The impact of these medications on postoperative infectious complications is uncertain and we can draw no firm conclusions about their safety in the perioperative period. Decisions on preoperative IBD medications should be tailored to each person's unique circumstances. Future studies should focus on controlling for potential confounding factors to generate higher-quality evidence.
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Affiliation(s)
- Cindy Cy Law
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Conor Bell
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Deborah Koh
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Yueyang Bao
- Department of Biology, McMaster University, Hamilton, Canada
| | - Vipul Jairath
- Department of Medicine, University of Western Ontario, London, Canada
| | - Neeraj Narula
- Division of Gastroenterology, McMaster University, Hamilton, Canada
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Tang S, Dong X, Liu W, Qi W, Ye L, Yang X, Cao Q, Ge X, Zhou W. Compare risk factors associated with postoperative infectious complication in Crohn's disease with and without preoperative infliximab therapy: a cohort study. Int J Colorectal Dis 2020; 35:727-737. [PMID: 32060607 DOI: 10.1007/s00384-019-03481-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2019] [Indexed: 02/04/2023]
Abstract
PURPOSES The incidence of postoperative complication is higher in Crohn's disease (CD) compared with other intestinal disease. There is less published data yet on the comparison of risk factors to predict postoperative complications in CD exposed and unexposed to previous infliximab therapy. Also the relationship between infliximab and postoperative infectious complications is still controversial. Our aim is to compare the risk factors to predict infectious complications in CD with and without preoperative infliximab and to clarify relationship between infliximab and infectious complications. METHODS This retrospective study included 390 patients from June 2014 to June 2018. Postoperative complications were compared in patients with and without preoperative infliximab. Univariate and multivariable analyses were performed to identify risk factors. RESULTS Eighty-five patients received infliximab within 8 weeks of surgery. A total of 129 patients had postoperative complications, with 35 receiving infliximab. No significant differences of whole postoperative complications were found in CD with and without infliximab (p = 0.073). However, patients receiving infliximab suffered more infectious complications (p = 0.010). Preoperative infliximab was confirmed to be an independent risk factor in infectious complications (p = 0.042). Multivariate analysis suggested that increased erythrocyte sedimentation rate (ESR) was an independent risk factor for infectious complications in patients receiving preoperative infliximab (p = 0.022), and increased C-reactive protein was an independent risk factor in patients not receiving preoperative infliximab (p = 0.019). CONCLUSIONS Preoperative use of infliximab ≤ 8 weeks was independently associated with infectious complications in CD. Risk factors were different in predicting postoperative complications in CD with and without infliximab, and preoperative ESR and C-reactive protein were risk factors, respectively.
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Affiliation(s)
- Shasha Tang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, Zhejiang, China
| | - Xue Dong
- Department of Radiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, Zhejiang, China
| | - Wei Liu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, Zhejiang, China
| | - Weilin Qi
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, Zhejiang, China
| | - Lingna Ye
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, Zhejiang, China
| | - Xiaoyan Yang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, Zhejiang, China
| | - Qian Cao
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, Zhejiang, China
| | - Xiaolong Ge
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, Zhejiang, China.
| | - Wei Zhou
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, Zhejiang, China.
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Kassel L, Hutton A, Zumach G, Rand J. Systematic review of perioperative use of immunosuppressive agents in patients undergoing bariatric surgery. Surg Obes Relat Dis 2019; 16:144-157. [PMID: 31735569 DOI: 10.1016/j.soard.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 09/14/2019] [Accepted: 10/02/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients who qualify for bariatric surgery are increasingly experiencing co-morbid conditions, which often require management through the use of immunosuppressive agents, such as corticosteroids, tumor necrosis factor-alpha inhibitors, or other immunomodulators, which may increase the risk of infection or wound healing complications. Perioperative management of these agents in bariatric surgery is challenging because of the lack of research in this patient population. With the use of immunosuppressive agents on the rise, the effects of these medications must be understood, both the risks posed in the perioperative period, and the benefit their sustained use may have for co-morbidity management. OBJECTIVES To describe the safety of immunosuppressive agents prior to bariatric surgery. SETTING United States of America. METHODS A systematic review was conducted to answer these questions about commonly encountered immunosuppressive agents. This review includes information from 37 studies to present recommendations and reasoning for the discontinuation and postoperative reinitiation of immunosuppressive agents including, tumor necrosis alpha factor-a inhibitors, methotrexate, and more. RESULTS Research addressing complications of these medications in patients undergoing bariatric surgery is sparse. Information from abdominal or general surgical complications may serve as a basis for conservative recommendations. Data specific to each agent or class are presented below. CONCLUSIONS The use of these agents may be critical for patients' chronic disease management, and the consequences of their impact should be considered by bariatric surgeons. While their immune system effects ultimately lead to disease management, each agent must be handled individually due to the varying effects and the potential for perioperative untoward effects.
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Affiliation(s)
- Lynn Kassel
- Drake University College of Pharmacy & Health Sciences, Des Moines, Iowa; MercyOne West Des Moines Hospital, West Des Moines, Iowa.
| | | | - Gregory Zumach
- Oregon State University College of Pharmacy, Oregon Health & Science University, Corvallis, Oregon; Good Samaritan Regional Medical Center, Corvallis, Oregon
| | - Joel Rand
- MercyOne West Des Moines Hospital, West Des Moines, Iowa; MercyOne Bariatric Surgery, West Des Moines, Iowa
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El-Hussuna A, Myrelid P, Holubar SD, Kotze PG, Mackenzie G, Pellino G, Winter D, Davies J, Negoi I, Grewal P, Gallo G, Sahnan K, Rubio-Perez I, Clerc D, Demartines N, Glasbey J, Regueiro M, Sherif AE, Neary P, Pata F, Silverberg M, Clermont S, Chadi SA, Emile S, Buchs N, Millan M, Minaya-Bravo A, Elfeki H, De Simone V, Shalaby M, Gutierrez C, Ozen C, Yalçınkaya A, Rivadeneira D, Sturiale A, Yassin N, Spinelli A, Warusavitarne J, Ioannidis A, Wexner S, Mayol J. Biological Treatment and the Potential Risk of Adverse Postoperative Outcome in Patients With Inflammatory Bowel Disease: An Open-Source Expert Panel Review of the Current Literature and Future Perspectives. CROHN'S & COLITIS 360 2019; 1. [DOI: 10.1093/crocol/otz021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2023] Open
Abstract
AbstractBackgroundThere is widespread concern that treatment with biologic agents may be associated with suboptimal postoperative outcome after surgery for inflammatory bowel diseases (IBD).AimWe aimed to search and analyze the literature regarding the potential association of biologic treatment on adverse postoperative outcome in patients with IBD. We used the subject as a case in point for surgical research. The aim was not to conduct a new systematic review.MethodThis is an updated narrative review written in a collaborative method by authors invited through Twitter via the following hashtags (#OpenSourceResearch and #SoMe4Surgery). The manuscript was presented as slides on Twitter to allow discussion of each section of the paper sequentially. A Google document was created, which was shared across social media, and comments and edits were verified by the primary author to ensure accuracy and consistency.ResultsForty-one collaborators responded to the invitation, and a total of 106 studies were identified that investigated the potential association of preoperative biological treatment on postoperative outcome in patients with IBD. Most of these studies were retrospective observational cohorts: 3 were prospective, 4 experimental, and 3 population-based studies. These studies were previously analyzed in 10 systematic/narrative reviews and 14 meta-analyses. Type of biologic agents, dose, drug concentration, antidrug antibodies, interval between last dose, and types of surgery varied widely among the studies. Adjustment for confounders and bias control ranged from good to very poor. Only 10 studies reported postoperative outcome according to Clavien–Dindo classification.ConclusionAlthough a large number of studies investigated the potential effect of biological treatment on postoperative outcomes, many reported divergent results. There is a need for randomized controlled trials. Future studies should focus on the avoiding the weakness of prior studies we identified. Seeking collaborators and sharing information via Twitter was integral to widening the contributors/authors and peer review for this article and was an effective method of collaboration.
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Affiliation(s)
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Stefan D Holubar
- Director of Research, Department of Colon & Rectal Surgery, Cleveland, OH
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Parana (PUCPR), Curitiba, Brazil
| | | | - Gianluca Pellino
- Department of Surgery, Università della Campania Luigi Vanvitelli, Aversa, Italy
| | - Des Winter
- Centre for Colorectal Disease, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland
| | - Justin Davies
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Ionut Negoi
- Carol Davila University of Medicine and Pharmacy Bucharest, Romania
| | - Perbinder Grewal
- Department of Cardiovascular, University Hospital Southampton, UK
| | - Gaetano Gallo
- Department of General Surgery, “Magna Graecia” University, Catanzaro, Italy
| | - Kapil Sahnan
- Imperial College Faculty of Medicine, Department of Surgery and St Marks Hospital, London, UK
| | - Ines Rubio-Perez
- General and Digestive Surgery Department, La Paz University Hospital, Madrid, Spain
| | - Daniel Clerc
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - James Glasbey
- Academic Department of Surgery, University of Birmingham Heritage Building, UK
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH
| | - Ahmed E Sherif
- Department of Clinical Surgery, University of Edinburgh, UK
| | - Peter Neary
- South East Cancer Governance Lead, University Hospital Waterford/Cork, Ireland
| | - Francesco Pata
- Department of Surgery, Sant’Antonio Abate Hospital, Gallarate, Italy
| | - Mark Silverberg
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, University of Toronto, ON, Canada
| | | | - Sami A Chadi
- Division of General Surgery, University Health Network, Toronto, Ontario, Canada
| | - Sameh Emile
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Nicolas Buchs
- Department of Surgery, University Hospitals of Geneva, Switzerland
| | - Monica Millan
- Department of Surgery, Joan XXIII University Hospital, Tarragona, Spain
| | | | - Hossam Elfeki
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Veronica De Simone
- Proctology Unit, Catholic University, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Mostafa Shalaby
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Celestino Gutierrez
- Department of Suregry, Centre Hospitalier de Redon Ille-et-Vilaine Bretagne-France
| | - Cihan Ozen
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | | | - David Rivadeneira
- Colorectal Surgery & Surgical Services, Northwell Health in Huntington, NY, USA
| | - Alssandro Sturiale
- Proctological and Perineal Surgical Unit, Cisanello University Hospital, Pisa, Italy
| | - Nuha Yassin
- Department of surgery, Royal Wolverhampton Hoaspital, UK
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Humanitas University, Milan, Italy
| | | | - Argyrios Ioannidis
- Department of General, Laparoscopic and Robotic Surgery, Athens Medical Center
| | - Steven Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL
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Qiu Y, Zheng Z, Liu G, Zhao X, He A. Effects of preoperative anti-tumour necrosis factor alpha infusion timing on postoperative surgical site infection in inflammatory bowel disease: A systematic review and meta-analysis. United European Gastroenterol J 2019; 7:1198-1214. [PMID: 31700633 DOI: 10.1177/2050640619878998] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 09/03/2019] [Indexed: 12/15/2022] Open
Abstract
Background Anti-tumour necrosis factor alpha agents (anti-TNF-α) have been widely used in patients with inflammatory bowel disease (IBD). However, few published meta-analyses have focused on timing of the last infusion before surgery. We evaluated the relationship between preoperative anti-TNF-α timing and postoperative surgical site infection to provide additional evidence for surgeons to choose appropriate dates for surgery. Methods We searched from inception until January 2019 for studies that documented postoperative complications of adults with IBD who underwent preoperative anti-TNF-α treatment. Primary outcomes of included studies were the odds ratios of preoperative anti-TNF-α time frames (4, 8 and 12 weeks). In addition, surgical site infection and its subtypes (anastomotic leakage, abscesses and wound infection) were analysed. Results Twenty-seven publications were included. No significant difference between anti-TNF-α and control cohorts was observed for most postoperative surgical site infections (or its subtypes) when the preoperative anti-TNF-α infusion time window was within 4, 8 or 12 weeks. Additionally, no significant difference in postoperative complications was observed between preoperative anti-TNF-α windows of within four weeks and more than four weeks. Conclusions In terms of surgical site infection and its subtypes, anti-TNF-α may be safe for ulcerative colitis and Crohn's disease patients who receive their last infusion of anti-TNF-α more than four weeks before surgery. We also found no evidence that anti-TNF-α was a risk factor when administered within four weeks, with the exception of subgroup results from a single study. Stratified by time window, use of anti-TNF-α until surgery has the potential to become a more considered strategy in clinical practice.
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Affiliation(s)
- YuJie Qiu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China.,Tianjin General Surgery Institute, Tianjin, PR China
| | - ZiCheng Zheng
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China.,Tianjin General Surgery Institute, Tianjin, PR China
| | - Gang Liu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China.,Tianjin General Surgery Institute, Tianjin, PR China
| | - XinYu Zhao
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China.,Tianjin General Surgery Institute, Tianjin, PR China
| | - AnQi He
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China.,Tianjin General Surgery Institute, Tianjin, PR China
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