131At the Mayo Clinic in Scottsdale, Arizona, 30-day postoperative complications
were measured through historical cohorts between January 1999 and May 2007 on
CD patients exposed to immunosuppressive therapy before intestinal resection [ 2 ].
Definition of perioperative treatment included exposure of corticosteroids or immu-
nomodulators [azathioprine (Imuran©), 6-mercaptopurine (Purinethol©)] longer
than 1 week within 1 month of surgery or if one dose of infliximab was infused
within 2 months of surgery. Differing from parallel studies was the allowance of
multiple surgery types, with ileocecal resection being the most common but also
included total abdominal colectomy, small intestine resection, strictureplasty, and
closure of colostomy and ileostomies. Surgical complications were grouped into
major and minor, with the former classified as either abdominal intervention (surgi-
cal or percutaneous) or requiring monitoring within an intensive care unit.
An aggregate of 112 patients were included in the study—69 of whom received
perioperative therapy including anti-TNF agents (24.6%), corticosteroids (68%),
and immunomodulators (56.5%). The most common indication for surgery was fail-
ure of medical management (28%) closely followed by obstruction (27%). The bulk
of patients underwent ileocecal resection (48%), followed by small intestinal resec-
tion (21%) and total abdominal colectomy (6%). Of those on immunosuppressive
therapy, 22 (32%) experienced postoperative complications (45% major, 64%
minor). A small number of patients in the study were on anti-TNF therapy alone
(n = 2) with only one suffering a complication. As the number of combination drugs
was used, the potential likelihood of adverse effects increased—for example, in
patients receiving one drug (corticosteroids, immunomodulators, or anti-TNF
agents), major complications occurred in five patients (13%, OR—2.0; p = 0.36),
whereas in patients on three drugs (steroids/immunomodulators/anti-TNF agents),
major complications occurred in one patient (33%, OR 6.7; p = 0.16). Overall the
association between complications and perioperative immunosuppressive therapy
was not found to be significant. The authors concluded that complication risks did
not increase with number of immunosuppressive therapy and use of anti-TNF for
Crohn’s disease in the months prior to surgery did not significantly increase short-
term postoperative outcomes [ 2 ].
In a small retrospective study at Mount Sinai Medical Center in New York,
30-day postoperative complication rates (septic, intra-abdominal, and non-septic),
hospital length of stay, and readmission rates were studied between June 1999 and
May 2010 on CD patients on immunosuppressive therapy prior to surgery [ 1 ].
Definition of perioperative treatment included receiving thiopurines and anti-TNF
agents within 3 months of surgery or corticosteroid more than 7 days within 6 weeks
of surgery. Types of surgeries were grouped into ileocolic resection, small bowel
resection, segmental colectomy, low anterior resection, and diverting stoma.
Procedures were grouped into either “elective” or “urgent” with the latter defined as
less than 24 h of an unplanned surgery.
A total of 127 procedures had exposure to immunosuppressive medications—
anti-TNF agents in 18%, corticosteroids in 37%, and thiopurines in 35%— compared
to 69 procedures without treatment exposure. Anti-TNF agents were not broken
down by name. Groups were similar in Crohn’s disease behavior per Montreal B
9 Use of Biologics in Crohn’s Disease and Ulcerative Colitis Prior to Surgery