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classification, type of surgery, and number of intestinal anastomoses. However,
patients without perioperative treatment were found to be younger (mean 38.0 vs.
42.9 years, p = 0.01) and requiring more urgent procedures (27.6% vs. 13.0%,
p = 0.02). The study uncovered 45 total complications (23%) at 30 days, further
broken down into intra-abdominal septic complications including anastomotic leaks
(n = 8, 4.1%), intra-abdominal abscesses (n = 8, 4.1%), and enterocutaneous fistulas
(n = 4, 2%). Non-septic complications is comprised of small bowel obstructions
(n = 5, 2.6%) and postoperative intra-abdominal hemorrhage (n = 2, 1%). There
were no postoperative deaths. Despite these complications when matched against
treatment vs. nontreatment arms, no significant difference in overall morbidity or
septic complications was seen. To point out, anti-TNF agents were matched by pres-
ence of complications vs. none, revealing a nonsignificant difference (n = 7, 15.6%
vs. n = 28, 18.5%, p = 1.0). The study concluded that immunosuppressive therapy,
including anti-TNF agents, did not increase postoperative morbidity in patients with
Crohn’s disease [ 1 ].
At the Mayo Clinic in Rochester, Minnesota, a retrospective analysis investi-
gated 30-day infectious and noninfectious complications with anti-TNF therapy
before undergoing surgery for CD between January 2005 and February 2009 [ 9 ].
Perioperative treatment was defined as anti-TNF within 8 weeks of surgery or up to
30 days postoperative. The authors intended to study anastomotic complications;
thus, surgeries included only procedures that left sutures or staple lines at risk for
infection. Total proctocolectomy with end ileostomy was excluded given no suture/
staple lines would be placed at risk. Emergency procedures and patients with proxi-
mal diversions were also excluded. Postoperative complications were grouped into
either infectious or noninfectious.
A total of 119 patients treated with anti-TNF was compared to 251 controls
observing infectious complications related to the anastomosis and overall complica-
tions, including wound infection, pneumonia, and urosepsis. Disease severity was
stratified based on ACG categories of disease, identifying the presence of penetrat-
ing complications (fistulae or abscess) at time of surgery. Anti-TNF therapy included
infliximab at varying doses although majority were at 5 mg/kg every 8 weeks, in
addition to adalimumab 40 mg every 2 weeks and certolizumab pegol 400 mg every
4 weeks. Of note prior studies did not utilize other anti-TNF agents beyond inflix-
imab. Between the two groups, overall complication rates were similar—30.3% in
the anti-TNF vs. 27.9% in the non-anti-TNF group (p = 0.63). A larger fraction of
the treated group fell under “severe disease” according to the ACG criteria, whereas
the nontreated group was found to have a higher percentage of steroid exposure.
Rates of intra-abdominal abscess or anastomotic leak were low (2.4%) with no dif-
ference between the groups (1.99% anti-TNF vs. 3.36% non-anti-TNF, p = 0.44).
Univariate analysis demonstrated age and presence of penetrating disease as the
only predictors for intra-abdominal infectious complications. The study did not find
a relationship between perioperative anti-TNF therapy and postoperative
complications.
From these results, the authors concluded against delaying surgery in patients
exposed to anti-TNF 8–12 weeks prior to surgery and discouraged creating a
A. Kamal and B. Lashner