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Abd El Aziz MA, Abdalla S, Calini G, Saeed H, Stocchi L, Merchea A, Colibaseanu DT, Shawki S, Larson DW. Postoperative Safety Profile of Minimally Invasive Ileocolonic Resections for Crohn's Disease in the Era of Biologic Therapy. J Crohns Colitis 2022; 16:1079-1088. [PMID: 35045164 DOI: 10.1093/ecco-jcc/jjac012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 12/02/2021] [Accepted: 01/14/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND There is controversy regarding the postoperative outcomes in Crohn's disease [CD] patients exposed to vedolizumab [VDZ] or ustekinumab [UST]. We aimed to describe our surgical outcomes in patients who underwent minimally invasive ileocolonic resection [MIS-ICR] for CD who had preoperative biologic therapy. METHODS All consecutive adult patients who had MIS-ICR for CD between 2014 and 2021 at our institution were included. Patients were divided into four groups: VDZ, UST, anti-tumour necrosis factor [anti-TNF], and no biologic group. Timing between the last dose of biologics and surgery was per surgeon's discretion. The primary outcome was intra-abdominal septic complications. Secondary outcomes included all 30-day complications. RESULTS A total of 274 patients were identified. Of these, 113 [41.2%] patients had received anti-TNF, 52 [19%] had received UST, and 19 [7%] had received VDZ. There was no difference between the four groups regarding baseline risk factors. There was no difference between the four groups regarding intra-abdominal septic complications [4.4% for no biologic, 5.3% for anti-TNF, 5.8% for UST, and 5.3% for VDZ; p = 0.987], surgical site infection rate, overall 30-day morbidity, overall 30-day readmission, overall surgical and medical complications, urinary tract infection, pulmonary infections, or length of stay. Those results were consistent after a subgroup analysis based on complexity of the disease. CONCLUSIONS This retrospective analysis demonstrates an equivalent postoperative safety profile for patients treated with preoperative anti-TNF, VDZ, or UST versus no biologic therapy within 3 months of MIS-ICR for Crohn's disease. Preoperative biologic therapy may not increase complications after minimally invasive ileocolonic resection in Crohn's disease. Further studies with larger sample sizes are needed to confirm results.
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Affiliation(s)
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Giacomo Calini
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hamadelneel Saeed
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Luca Stocchi
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Sherief Shawki
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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Abstract
Since the introduction of the first anti-tumor necrosis factor antibodies in the late 1990s, biologic therapy has revolutionized the medical treatment of patients with inflammatory bowel disease (IBD). Nevertheless, surgery continues to play a significant role in treating IBD patients. Rates of intestinal resection in patients with Crohn's disease or colectomy in ulcerative colitis are reducing but not substantially over the long term. An increasing variety of biologic medications are now available to treat IBD patients in various clinical situations. Consequently, a number of questions persist about how biologic medications affect the need for surgery and overall course in IBD patients. Given the trend for earlier and more frequent use of biologic medications in IBD patients, a working knowledge of the effects of these medications on surgical decision-making and outcomes is essential for the practicing colorectal surgeon and gastroenterologist. This review seeks to summarize the relevant literature surrounding biologic use and IBD surgery with a focus on the effect of biologics on the frequency, type and complications of surgery in this 'age of biologics'.
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Affiliation(s)
- Daniel J Wong
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Eve M Roth
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph D Feuerstein
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Vitaliy Y Poylin
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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3
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Wong DJ, Roth EM, Feuerstein JD, Poylin VY. Surgery in the age of biologics. Gastroenterol Rep (Oxf) 2019; 7:77-90. [PMID: 30976420 PMCID: PMC6454839 DOI: 10.1093/gastro/goz004] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 11/02/2018] [Indexed: 02/07/2023] Open
Abstract
Since the introduction of the first anti-tumor necrosis factor antibodies in the late 1990s, biologic therapy has revolutionized the medical treatment of patients with inflammatory bowel disease (IBD). Nevertheless, surgery continues to play a significant role in treating IBD patients. Rates of intestinal resection in patients with Crohn's disease or colectomy in ulcerative colitis are reducing but not substantially over the long term. An increasing variety of biologic medications are now available to treat IBD patients in various clinical situations. Consequently, a number of questions persist about how biologic medications affect the need for surgery and overall course in IBD patients. Given the trend for earlier and more frequent use of biologic medications in IBD patients, a working knowledge of the effects of these medications on surgical decision-making and outcomes is essential for the practicing colorectal surgeon and gastroenterologist. This review seeks to summarize the relevant literature surrounding biologic use and IBD surgery with a focus on the effect of biologics on the frequency, type and complications of surgery in this 'age of biologics'.
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Affiliation(s)
- Daniel J Wong
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Eve M Roth
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph D Feuerstein
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Vitaliy Y Poylin
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Shim HH, Ma C, Kotze PG, Seow CH, Al-Farhan H, Al-Darmaki AK, Pang JXQ, Fedorak RN, Devlin SM, Dieleman LA, Kaplan GG, Novak KL, Kroeker KI, Halloran BP, Panaccione R. Preoperative Ustekinumab Treatment Is Not Associated With Increased Postoperative Complications in Crohn's Disease: A Canadian Multi-Centre Observational Cohort Study. J Can Assoc Gastroenterol 2018; 1:115-123. [PMID: 31294352 PMCID: PMC6507292 DOI: 10.1093/jcag/gwy013] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Ustekinumab (UST), an anti-IL12/23 inhibitor is indicated for moderate-to-severe Crohn's disease (CD). However, it is unclear if patients treated with UST are at increased risk for postoperative complications. AIM To evaluate the postoperative safety outcomes in UST-treated CD patients. METHODS A multicentre cohort study of UST-treated CD patients at two tertiary care centres (University of Calgary, University of Alberta, Canada) undergoing abdominal surgery between 2009 and 2016 was performed. Postoperative outcomes were compared against a control cohort of anti-TNF-treated patients over the same time-period. The primary outcome was occurrence of postoperative complications up to six months postoperatively, stratified by timing (early <30 days vs. late complications ≥30 days). RESULTS Twenty UST-treated patients and 40 anti-TNF-treated patients were included with a median preoperative treatment exposure of 6.5 months and 18 months, respectively (p=0.01). Bowel obstruction was the most common surgical indication in both cohorts. UST-treated patients were more likely to require an ostomy (70.0% vs. 12.5%, p<0.001) and be on combination therapy with either systemic corticosteroids or concurrent immunomodulators (azathioprine or methotrexate) (25.0% vs. 2.5%, p=0.01). Despite the increased concomitant use of immunosuppression in the UST-treated cohort, there were no significant differences in early or late postoperative wound infections (1/20 in UST-cohort, 2/40 in anti-TNF cohort, p=1.00), anastomotic leak (0/20 in UST-cohort, 3/40 in anti-TNF cohort, p=0.54), or postoperative ileus/obstruction (3/20 in UST-cohort, 4/40 in anti-TNF cohort, p=0.67). CONCLUSIONS CD patients receiving preoperative UST did not experience an increase in postoperative complications, despite increased use of concurrent immunosuppression.
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Affiliation(s)
- Hang Hock Shim
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Paulo G Kotze
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
- Inflammatory Bowel Disease Outpatient Clinics, Catholic University of Paraná (PUCPR), Curitiba, Brazil
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Heba Al-Farhan
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Ahmed K Al-Darmaki
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Jack X Q Pang
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Richard N Fedorak
- Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Shane M Devlin
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | | | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Karen I Kroeker
- Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | | | - Remo Panaccione
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
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Kamel AY, Ayoub F, Banerjee D, Chaudhry N, Ader Y, Tan S, Zimmermann EM, Glover SC, Iqbal A. Effects of Preoperative Use of Biologic Agents on Operative Outcomes in Crohn's Disease Patients. Am Surg 2018. [DOI: 10.1177/000313481808400962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although the effects of biologic agents on postoperative outcomes in Crohn's disease patients have been extensively studied, the effects on intraoperative outcomes, including blood loss, operative time, and length of small bowel resection, remain to be determined. This was a retrospective cohort study at a single tertiary referral center. Crohn's disease (CD) patients who underwent major abdominal surgery were identified. Patients receiving preoperative biologic agents were compared with controls. We compare operative outcomes between groups. A total of 144 patients who underwent major abdominal surgery at the University of Florida between March 2007 and March 2017 were included. One hundred and ten patients (76%) who received pre-operative biologic therapy were compared with 34 controls. On univariate analysis, preoperative biologic use was associated with a significantly shorter length of small bowel resection (21.2 cm in biologic group vs 34.5 cm, P = 0.01). There were no significant differences in intraoperative blood loss (100 vs 87.5 mL, P = 0.40) or total operative time (142 vs 154 minutes, P = 0.39) between groups. On multivariate analysis controlling for variables reflecting severity of disease and malnutrition, biologic use remained significantly associated with shorter length of bowel resection (incident rate ratio 0.58, P = 0.04). Preoperative biologic use is associated with a significantly shorter length of bowel resection in CD patients undergoing major abdominal surgery. No negative effects were noted on operative blood loss or total operative time. Our findings allow improved preoperative planning for surgeons and informed decision-making for CD patients undergoing major abdominal surgery.
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Affiliation(s)
- Amir Y. Kamel
- Department of Pharmacy, University of Florida, Gainesville, Florida
| | - Fares Ayoub
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Debdeep Banerjee
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Naueen Chaudhry
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Florida, Gainesville, Florida
| | - Yan Ader
- Department of Pharmacy, University of Florida, Gainesville, Florida
| | - Sanda Tan
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Ellen M. Zimmermann
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Florida, Gainesville, Florida
| | - Sarah C. Glover
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Florida, Gainesville, Florida
| | - Atif Iqbal
- Department of Surgery, University of Florida, Gainesville, Florida
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Tsui JJ, Huynh HQ. Is top-down therapy a more effective alternative to conventional step-up therapy for Crohn's disease? Ann Gastroenterol 2018; 31:413-424. [PMID: 29991886 PMCID: PMC6033752 DOI: 10.20524/aog.2018.0253] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 02/02/2018] [Indexed: 12/17/2022] Open
Abstract
The management of Crohn's disease involves immunosuppressive protocols in a step-up approach that progresses through a therapeutic pyramid with several tiers of medication. Medications at the top are considered more potent but present greater risk. A new top-down approach to therapy inverts this procedure, using top-tier drugs for initial treatment. A critical appraisal of the current literature relating to top-down therapy was performed to evaluate its merit. A literature search was conducted on PubMed, Ovid, and PubMed Central to identify studies of the efficacy of top-down therapy. Papers were appraised critically using the Scottish Intercollegiate Guidelines Network score to evaluate current evidence for the use of top-down therapy. Nineteen studies were identified, including six randomized controlled trials, thirteen cohort studies, and two cost-benefit studies. Early combined therapy involving both biologics and immunomodulators was found to be effective at improving patient outcomes; however, early biologics alone were not shown to have a clear benefit over step-up therapy. Likewise, the early use of immunomodulators alone showed inconsistent results with respect to efficacy in terms of both remission and surgical outcomes. Evidence for application in pediatric populations was also inconclusive. The cost-benefit analyses found that top-down therapy merits investigation, as it proved to be economical given current data. Top-down therapy has the potential of being a viable alternative to step-up therapy, but further studies are needed to determine the most appropriate patients to receive this treatment.
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Affiliation(s)
- Jonathan Jenkin Tsui
- Edinburgh Medical School, University of Edinburgh, Edinburgh, UK (Jonathan Jenkin Tsui)
| | - Hien Q Huynh
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada (Hien Q. Huynh)
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