134
The use of anti-TNF agents has proved paramount in the remedy of Crohn’s
disease, decreasing the overall need for surgery. However, despite this eminent
introduction in therapy, the reality is 75% of CD will still undergo surgery as a result
of refractory disease or complications. The dilemma for providers has become
determining the safety of biologic therapy preceding surgery and whether biologic
agents such as Infliximab should be stopped. Numerous studies have been per-
formed to answer this question, the majority utilizing infliximab as their anti-TNF
agent. All authors defined preoperative therapy as either two or three months pre-
ceding surgery, with 30-day postoperative follow-up. When evaluating Crohn’s dis-
ease, the consensus has been debated. Several studies such as those performed at
Mayo Clinic, Scottsdale; Mount Sinai Medical Center; and Mayo Clinic, Rochester,
concluded no significant increase in adverse effects and to not delay surgery. At the
Cleveland Clinic however, authors concluded that the use of infliximab 3 months
prior to ileocolonic resection with anastomosis (ICRA) resulted in higher postop-
erative intra-abdominal abscess, sepsis, anastomotic leaks, and readmission rates.
Given this disagreement in safety of biologics prior to surgery, a meta-analysis was
performed incorporating 8 studies with a total of 1641 patients, demonstrating a
trend toward higher total and noninfectious complications, however only significant
difference seen among postoperative infections. We would conclude that infectious
complications in fact are a postoperative risk with anti-TNF therapy in Crohn’s
disease and should consider delaying elective surgery. However, if perioperative
anti-TNF cannot be avoided, consider a defunctionalizing proximal stoma to reduce
adverse effects and to protect the anastomosis.
Chronic ulcerative colitis is an additional debilitating inflammatory bowel dis-
ease. After induction of remission, up to 50% will unfortunately experience a relapse
in one year, and of this group, half will further require surgical management.
Contrasting from Crohn’s disease, surgery in UC offers a chance for cure of intesti-
nal symptoms and eradicates the risk of malignancy. Prior to surgery however, the
ultimate goal is to sustain mucosal healing through medical management. The 2005
Active Ulcerative Colitis Trials 1 and 2 (ACT 1 and ACT 2, respectively) laid the
foundation that has now made infliximab an effective agent in moderate-to-severe
UC, with mucosal healing occurring in significantly more patients than placebo
Table 9.2 Meta-analysis: pooled total complications in infliximab preoperatively with Crohn’s
disease
Study Infliximab (n) Non-infliximab (n) Total (n) Odds ratio
Appau et al. [ 8 ] 60 329 389 5.63 (3.06–10.34)
Indar et al. [ 2 ] 17 95 112 1.37 (0.46–4.09)
Kasparek et al. [ 12 ] 48 48 96 2.20 (0.96–5.06)
Marchal et al. [ 13 ] 40 39 79 1.24 (0.46–3.33)
Nasir et al. [ 9 ] 119 251 370 1.12 (0.69–1.81)
Colombel et al. [ 15 ] 52 218 270 0.98 (0.48–2.01)
Total 336 980 1316 1.72 (0.93–3.19)
Test for heterogeneity: X^2 = 20.94, df = 5(P = 0.0008), I^2 = 76.1%
Adapted from Kopylov et al. [ 10 ]
A. Kamal and B. Lashner