Risk of post-operative complications associated with anti-TNF therapy in inflammatory bowel disease

Potential therapeutic effects of baicalin and baicalein

Objective

Baicalin and baicalein are natural flavonoids reported for the first time from Scutellaria baicalensis Georgi. Recently, attention has been paid to these valuable flavonoids due to their promising effects. This paper aims to have a comprehensive review of their pharmacological effects.

Materials and Methods

An extensive search through scientific databases including Scopus, PubMed, and ISI Web of Science was established.

Results

According to literature, these compounds have been mainly effective in the treatment of neurological and neurodegenerative diseases, hepatic and cardiovascular disorders, metabolic syndrome, and cancers through anti-inflammatory and antioxidant pathways. Induction of apoptosis and autophagy, and inhibition of migration and metastasis are the main mechanisms for their cytotoxic and antitumor activities. Decreasing inflammation, reducing oxidative stress, regulating the metabolism of lipids, and decreasing fibrosis, apoptosis, and steatosis are their main hepatoprotective mechanisms. Inhibiting the development of cardiac fibrosis and reducing inflammation, oxidative stress, and apoptosis are also the mechanisms suggested for cardioprotective activities. Decreasing the accumulation of inflammatory mediators and improving cognitive function and depressive-like behaviours are the main mechanisms for neurological and neurodegenerative activities.

Conclusion

The findings suggest the therapeutic potential of baicalin and baicalein. However, complementary research in different in vitro and in vivo models to investigate their mechanisms of action as well as clinical trials to evaluate their efficacy and safety are suggested.

Biological therapy prior to repeat ileocolic resection in Crohn's disease can reduce the postoperative complication rate

BACKGROUND

The aim of this study was to assess the effect of preoperative biologic therapy on the surgical outcome of Crohn's disease (CD) patients undergoing repeat ileocolic resection.

METHODS

This was a retrospective analysis of all CD patients who underwent repeat ileocolic resection at Cleveland Clinic Florida between January 2011 and April 2021. Patients were divided into two groups: treatment biologic therapy prior to surgery and controls.

RESULTS

Sixty-five patients (31males, median age 54 [range 23-82] years) were included in the study. Twenty nine (44.6%) were treated with biologic therapy prior to repeat ileocolic resection. No demographic differences were found between the biologic therapy and control groups. In addition, no differences were found in mean time from index ileocolic resection (p = 0.9), indication for surgery (p = 0.11), and preoperative albumin (p = 0.69). The majority of patients (57; 87.7%) were operated on laparoscopically, and mean overall operation time was 225 (SD 49.27) min. Overall, the postoperative complication rate was 43.1% (28 patients) and median length of stay was 5 (range 2-21) days. Postoperative complications were more common in the control group, compared to the biologic therapy group (55.6 vs 27.5%; p = 0.04). Conversion rate (35.7 vs 20.7%; p = 0.24), operation time (223 vs 219 min; p = 0.75), length of stay (5.2 vs 5.9 days; p = 0.4), and readmission (16.6 vs 11.1%; p = 0.72) were similar between the two groups. Multivariate analysis of risk factors for postoperative complications showed that biologic treatment was correlated with a lower risk (HR -0.28, CI 95% -0.5596 to -0.01898, p = 0.03).

CONCLUSIONS

Patients treated with biologic therapy for CD who underwent repeat ileocolic resection had fewer postoperative complications.

Preoperative Neutrophil-to-Lymphocyte Ratio Is Correlated with Severe Postoperative Complications After Emergency Surgery for Ulcerative Colitis

Introduction

The incidence of postoperative severe complications is reported to be high in patients undergoing emergency surgery for severe ulcerative colitis (UC). It has also been reported that the preoperative inflammatory status is associated with the frequency of postoperative complications. The neutrophil-to-lymphocyte ratio (NLR) is a simple and useful parameter for determining the inflammatory status.

Methods

In the present study, we retrospectively investigated the correlation between the NLR and the incidence of severe postoperative complications in patients undergoing emergency surgery for severe UC. A total of 105 UC patients who underwent emergency or semi-emergency surgery were enrolled. Various clinical factors and NLR values were evaluated to identify the risk factors for severe complications. Postoperative complications were stratified by their severity according to the Clavien-Dindo Classification (CD). A postoperative complication of CD IIIb or higher was defined as severe postoperative complications. The incidence of severe complications was 16.2%.

Results

A multivariate analysis revealed the ASA score, toxic megacolon, and NLR to be independent risk factors for severe postoperative complications.

Conclusions

The results of this retrospective study suggest that the NLR is an independent risk factor for severe postoperative complications in patients undergoing emergency surgery for UC.

Exploring the Relationship between Biologics and Postoperative Surgical Morbidity in Ulcerative Colitis: A Review

BACKGROUND

With the paradigm shift related to the overspread use of biological agents in the treatment of inflammatory bowel diseases (IBD), several questions emerged from the surgical perspective. Whether the use of biologicals would be associated with higher rates of postoperative complications in ulcerative colitis (UC) patients still remains controversial.

AIMS

We aimed to analyze the literature, searching for studies that correlated postoperative complications and preoperative exposure to biologics in UC patients, and synthesize these data qualitatively in order to check the possible impact of biologics on postoperative surgical morbidity in this population.

METHODS

Included studies were identified by electronic search in the PUBMED database according to the PRISMA (Preferred Items of Reports for Systematic Reviews and Meta-Analysis) guidelines. The quality and bias assessments were performed by MINORS (methodological index for non-randomized studies) criteria for non-randomized studies.

RESULTS

608 studies were initially identified, 22 of which were selected for qualitative evaluation. From those, 19 studies (17 retrospective and two prospective) included preoperative anti-TNF. Seven described an increased risk of postoperative complications, and 12 showed no significant increase postoperative morbidity. Only three studies included surgical UC patients with previous use of vedolizumab, two retrospective and one prospective, all with no significant correlation between the drug and an increase in postoperative complication rates.

CONCLUSIONS

Despite conflicting results, most studies have not shown increased complication rates after abdominal surgical procedures in patients with UC with preoperative exposure to biologics. Further prospective studies are needed to better establish the impact of preoperative biologics and surgical complications in UC.

Herbal pair Huangqin-Baishao: mechanisms underlying inflammatory bowel disease by combined system pharmacology and cell experiment approach

BACKGROUND

Inflammatory bowel disease (IBD) is a severe digestive system condition, characterized by chronic and relapsing inflammation of the gastrointestinal tract. Scutellaria baicalensis Georgi (Huangqin, HQ) and Paeonia lactiflora Pall (Baishao, BS) from a typical herbal synergic pair in traditional Chinese medicine (TCM) for IBD treatments. However, the mechanisms of action for the synergy are still unclear. Therefore, this paper aimed to predict the anti-IBD targets and the main active ingredients of the HQ-BS herbal pair.

METHODS

A systems pharmacology approach was used to identify the bioactive compounds and to delineate the molecular targets and potential pathways of HQ-BS herbal pair. Then, the characteristics of the candidates were analyzed according to their oral bioavailability and drug-likeness indices. Finally, gene enrichment analysis with DAVID Bioinformatics Resources was performed to identify the potential pathways associated with the candidate targets.

RESULTS

The results showed that, a total of 38 active compounds were obtained from HQ-BS herbal pair, and 54 targets associated with IBD were identified. Gene Ontology and pathway enrichment analysis yielded the top 20 significant results with 54 targets. Furthermore, the integrated IBD pathway revealed that the HQ-BS herbal pair probably acted in patients with IBD through multiple mechanisms of regulation of the nitric oxide biosynthetic process and anti-inflammatory effects. In addition, cell experiments were carried out to verify that the HQ-BS herbal pair and their Q-markers could attenuate the levels of nitric oxide (NO), prostaglandin E2 (PGE2), inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) in lipopolysaccharide (LPS)-stimulated THP-1-derived macrophage inflammation. In particular, the crude materials exerted a much better anti-inflammatory effect than their Q-markers, which might be due to their synergistic effect.

CONCLUSION

This study provides novel insight into the molecular pathways involved in the mechanisms of the HQ-BS herbal pair acting on IBD.

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

Background

There is widespread concern that treatment with biologic agents may be associated with suboptimal postoperative outcome after surgery for inflammatory bowel diseases (IBD).

Aim

We 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.

Method

This 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.

Results

Forty-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.

Conclusion

Although 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.

ANALYSIS OF RISK FACTORS AND POSTOPERATIVE COMPLICATIONS IN PATIENTS WITH CROHN'S DISEASE

BACKGROUND

The post-operative complications rate is greater in patients with Crohn's disease than in other abdominal surgeries due to other benign conditions. Prevention and management of such complications are important factors in the care of these patients.

OBJECTIVE

The objectives of this research are to analyze the rate of postoperative complications and the major risk factors in patients with Crohn's disease.

METHODS

A descriptive and retrospective study based on analysis of medical records of patients with Crohn's disease undergoing ileal and/or colonic resection, which analyzed the main surgical complications and their major risk factors.

RESULTS

Forty-four surgical procedures and thirty-seven patients were analyzed. Most were female (56.7%). Postoperative complications were observed in 18 (40.9%) surgeries. The disease duration (P=0.04), the penetrating behavior (P=0.013), the time between diagnosis and the first surgery (P=0.04), malnutrition with low body mass index (BMI), duration of surgery (P=0.016), and the size of the removed specimen (P=0.014) were associated with higher rates of complications. The use of drugs blocking tumor necrosis factor up to eight weeks before surgery was not significantly associated with higher complications rates or increased need for reoperation.

CONCLUSION

The complication rate observed in this study is similar to published data. The duration of the disease, the penetrating behavior, the size of the removed specimen, the duration of the surgery, and BMI are important risk factors for perioperative complications in Crohn's disease.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Adverse events in IBD therapy: the 2018 update

Crohn's disease and ulcerative colitis affect an increasing number of patients, and utilization of immune suppressant and biologic therapies is also increasing. These agents are linked to adverse events ranging from mild nuisance symptoms to potentially life-threatening complications including infections and malignancies. Areas covered: This review provides an updated discussion on adverse events associated with immunomodulator, anti-TNF-α, anti-integrin, and anti-IL 12/IL-23 antibody therapies. In addition, we review the risk profile of the currently widely available infliximab biosimilar medication. Expert commentary: Providers should engage in risk-benefit discussion with information specific to each medication discussed, and consider individualized risk factors when selecting therapeutic agents. Drug monitoring and shared decision-making results in more personalized medical management of inflammatory bowel disease.

Preoperative Ustekinumab Treatment Is Not Associated With Increased Postoperative Complications in Crohn's Disease: A Canadian Multi-Centre Observational Cohort Study

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.

Postoperative Morbidity Risks Following Ileocolic Resection for Crohn's Disease Treated With Anti-TNF Alpha Therapy: A Retrospective Study of 360 Patients

BACKGROUND

Despite the effectiveness of anti-TNF alpha (ATA) treatment to induce and maintain remission in Crohn's disease, surgical intervention is frequently required. Results of previous studies on the impact of anti-TNF on postoperative course are discordant. The aim of this study was to evaluate the impact of ATA on postoperative morbidity following ileocolic resection for Crohn's disease.

METHODS

A retrospective review of Crohn's disease patients undergoing ileocolic resection was performed. Patients receiving medical treatment ≤8 weeks prior to surgery were included and followed up for postoperative morbidity. The Clavien-Dindo classification was used for grading complications. Risk factors for postoperative morbidity were assessed on multivariable analysis.

RESULTS

A total of 360 patients underwent ileocolic resection for Crohn's disease between 2002 and 2013; 15.3% of patients had ATA ≤8 weeks prior to surgery. Laparoscopic resections were performed in 110 cases (31%), of which 6% were converted to an open operation. Primary anastomosis without the formation of a diverting ileostomy was performed in 301 cases. Overall morbidity was 24.2%, with a mortality rate of 0.8%. ATA use prior to surgery was identified as an independent risk factor for overall morbidity (odds ratio [OR], 2.05; 95% confidence interval [CI], 1.08-3.82; P = 0.027) and septic complications (OR, 2.14; 95% CI, 1.03-4.29; P = 0.04). In subgroup analysis of patients with a primary anastomosis, ATA use had no significant impact on septic or overall morbidity.

CONCLUSIONS

Preoperative ATA use is a risk factor for overall postoperative morbidity and septic complications. However, the formation of a primary anastomosis should not be influenced by preoperative ATA use.

Baicalein ameliorates TNBS-induced colitis by suppressing TLR4/MyD88 signaling cascade and NLRP3 inflammasome activation in mice

Baicalein (5,6,7-trihydroxyflavone), a predominant bioactive component isolated from the root of Scutellaria baicalensis Georgi, has established potent anti-inflammatory activity via multi-targeted mechanisms. However, little is known about the effect of baicalein on 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced colitis, which shares pathology related to human Crohn’s disease (CD). The present study demonstrated that baicalein alleviated the severity of TNBS-induced colitis in mice by decreasing the activity of myeloperoxidase (MPO) and the expression of pro-inflammatory mediators. The decline in the activation of nuclear factor-kappa B (NF-κB) and p38 mitogen-activated protein kinase (MAPK) correlated with a decrease in the expression of mucosal toll-like receptor 4 (TLR4) and its adaptor myeloid differentiation factor 88 (MyD88). In vitro, baicalein down-regulated the TLR4/MyD88 signaling cascades (NF-κB and MAPKs) in lipopolysaccharide (LPS)-stimulated macrophages. At the upstream level, baicalein bound to the hydrophobic region of the myeloid differentiation protein-2 (MD-2) pocket and inhibited the formation of the LPS-induced MD-2/TLR4 complex. Furthermore, baicalein reduced NOD-like receptor 3 (NLRP3) inflammasome activation and downstream interleukin-1β expression in a dose-dependent manner. Our study provided evidence for the first time that baicalein attenuated TNBS-induced colitis, at least in part, via inhibition of TLR4/MyD88 signaling cascade as well as inactivation of NLRP3 inflammasome.

Cost of Ulcerative Colitis in Quebec, Canada: A Retrospective Cohort Study

BACKGROUND

Ulcerative colitis (UC) is associated with significant health care utilization and costs. We assessed UC direct medical costs in Quebec, Canada, in 2 time periods (1998-2004 and 2005-2011) and determined changes over time.

METHODS

Because the introduction of anti-tumor necrosis factor α may have influenced the UC cost, we used the Quebec health services administrative databases and the same inclusion criteria to create 2 separate UC cohorts, before (1998-2004) and after (2005-2011) anti-tumor necrosis factor α introduction.

RESULTS

The postcohort included 801 patients and the precohort 716 patients. Overall, cohorts were predominately women and were comparable in terms of patient's demographics and comorbidities. Corticosteroid use, emergency department visits and hospitalizations for colectomies, and other gastrointestinal disorders were fewer in the postcohort versus precohort. The median daily cost (interquartile range) was $16.96 ($6.80-$48.16) for the postcohort and $18.65 ($7.82-$53.31) for the precohort. In generalized linear models with log link and gamma distribution, the adjusted daily cost ratios (95% confidence interval) in the postcohort versus precohort was 0.75 (0.67-0.85). Older age at inclusion, low income, lower socioeconomic status, and previous use of gastroprotective agents, antidepressants, and sulfasalazine, methotrexate, or cyclosporine were associated with increased costs. Women and those who visited a gastroenterologist in the previous year incurred lower costs.

CONCLUSIONS

The mean UC daily cost decreased from 2005 to 2011 as compared to 1998 to 2004 because of a decrease in rates of colectomy and other gastrointestinal hospitalizations and emergency department visits. Further investigation is required to determine the reasons for these changes.

Risk factors of surgical site infections in patients with Crohn's disease complicated with gastrointestinal fistula

PURPOSE

Surgical site infection (SSI) is the most common complication following surgical procedures. This study aimed to determine risk factors associated with SSI in patients with Crohn's disease (CD) complicated with gastrointestinal fistula.

METHODS

This was a retrospective review of patients who underwent surgical resection in gastrointestinal fistula patients with CD between January 2013 and January 2015, identified from a prospectively maintained gastrointestinal fistula database. Demographic information, preoperative medication, intraoperative findings, and postoperative outcome data were collected. Univariate and multivariate analysis was carried out to assess possible risk factors for SSI.

RESULTS

A total of 118 patients were identified, of whom 75.4% were men, the average age of the patients was 34.1 years, and the average body mass index (BMI) was 18.8 kg/m². The rate of SSI was 31.4%. On multivariate analysis, preoperative anemia (P = 0.001, OR 7.698, 95% CI 2.273-26.075), preoperative bacteria present in fistula tract (P = 0.029, OR 3.399, 95% CI 1.131-10.220), and preoperative enteral nutrition (EN) <3 months (P < 0.001, OR 11.531, 95% CI 3.086-43.079) were predictors of SSI. Notably, preoperative percutaneous abscess drainage was shown to exert protection against SSI in fistulizing CD (P = 0.037, OR 0.258, 95% CI 0.073-0.920).

CONCLUSION

Preoperative anemia, bacteria present in fistula tract, and preoperative EN <3 months significantly increased the risk of postoperative SSI in gastrointestinal fistula complicated with CD. Preoperative identification of these risk factors may assist in risk assessment and then to optimize preoperative preparation and perioperative care.

Preoperative Use of Methotrexate and the Risk of Early Postoperative Complications in Patients with Inflammatory Bowel Disease

BACKGROUND

Preoperative immunosuppressive use among patients with Crohn's disease or ulcerative colitis may lead to an increased risk of postoperative complications. There is limited information on the preoperative safety profile of methotrexate (MTX) in inflammatory bowel disease (IBD).

METHODS

A retrospective study of patients who underwent abdominal surgery for IBD between 1993 and 2012 was performed and records abstracted, including preoperative use of MTX, azathioprine/6-mercaptopurine, antitumor necrosis factor, and corticosteroids. Early postoperative complications, including death, septic, and nonseptic complications were identified. A meta-analysis was also performed on the use of preoperative MTX in patients with IBD or rheumatoid arthritis.

RESULTS

A total of 180 patients with IBD underwent abdominal surgery. A total of 15 patients received MTX either monotherapy or in combination therapy. Total early postoperative complications were identified in 71 (39%) patients, specifically 5 patients on oral MTX. A total of 51 cases (28%) of septic complications and 20 (11%) nonseptic. No significant association between the use of MTX and early postoperative complications was found. The odds ratio (OR) of complications versus no complications associated with MTX was 0.75 (95% CI, 0.25-2.29) and with azathioprine/6-mercaptopurine, OR 1.48 (95% CI, 0.77-2.84). The odds of a septic complication associated with MTX were 0.58 (95% CI, 0.09-3.73), and higher in azathioprine/6-mercaptopurine, OR 3.97 (95% CI, 1.03-15.3). Our meta-analysis also did not reveal an increased risk of postoperative complications in IBD or rheumatoid arthritis on preoperative MTX (OR 0.62, 95% CI, 0.34-1.15).

CONCLUSIONS

Preoperative MTX use does not seem to be associated with early postoperative complications in IBD.

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).

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.

Safety issues and concerns of new immunomodulators in rheumatology

INTRODUCTION

The development of biologic therapies has been an enormous leap in the management of patients with rheumatoid and psoriatic arthritis. Since the first anti-TNF-α therapies, numerous molecules have been identified as targets of immunomodulatory therapies, such as IL-1 (anakinra, canakinumab), IL-6 (tocilizumab), CD20(+) B cells (rituximab), CTLA4 (abatacept) and two additional anti-TNF-α therapies (certolizumab pegol, golimumab).

AREAS COVERED

In the present review, we will describe the safety issues related to the immunosuppressive action of these biologic drugs that are mainly represented by infection and malignancy. The risk of infection should be identified before initiating a biologic treatment and markers checked over time, in particular for tuberculosis and hepatitis B and C viruses. Other infections (bacterial, viral, parasitic; opportunistic; surgery-related) and safety issues may require temporary interruption of the treatment until complete resolution. No significantly increased risk of malignancy, both hematological and solid, has been associated with the use of biologic agents. In all cases, it is difficult to dissect the risks related to biologics from those related to baseline treatments.

EXPERT OPINION

Detailed medical history and laboratory screening should be performed before starting biologic therapies. Clinicians should be aware of the different safety profiles associated with different molecules and they should follow up data coming out of the existing registries for biologics in regard to new or old side effects.

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.

An update on anti-TNF agents in ulcerative colitis

Anti-tumor necrosis factor-α agents are key therapeutic options for the treatment of ulcerative colitis. Their efficacy and safety have been shown in large randomized controlled trials. The key evidence gained from these trials of infliximab, adalimumab, and golimumab is reviewed along with their effect on mucosal healing and long-term outcomes. Also reviewed are methods for optimizing their effectiveness, including therapeutic drug monitoring and treat-to-target strategies. Finally, remaining unresolved questions regarding their role and effectiveness are considered including how these may be addressed in future clinical trials.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Role of mast cells in the pathogenesis of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a group of recurrent chronic intestinal inflammatory diseases with incompletely understood pathogenesis. Increasing evidence has shown that mast cells are markedly increased in inflamed mucosa of IBD patients and involved in the pathogenesis of IBD. Upon activation mast cells release multiple proinflammatory cytokines, chemokines and mediators that play an important role in the occurrence and development of IBD. Understanding the role of mast cell-derived mediators and cytokines in IBD can provide new avenues for the development of new approaches to the treatment of this disease.

Complications of colorectal anastomoses: leaks, strictures, and bleeding

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

Surgical management of Crohn's disease

Although medical management can control symptoms in a recurring incurable disease, such as Crohn's disease, surgical management is reserved for disease complications or those problems refractory to medical management. In this article, we cover general principles for the surgical management of Crohn's disease, ranging from skin tags, abscesses, fistulae, and stenoses to small bowel and extraintestinal disease.