137Statistically adjusting for extent and severity of colitis, steroid dose, and use of
immunomodulators, use of infliximab leads to greater rates of overall early
complications (OR, 3.54; 95% CI 1.51–8.31), specifically rate of pelvic sepsis and
pouchitis. Thus, the authors concluded that the use of infliximab therapy in moder-
ate-to-severe UC prior to RP increased rate of early and late postoperative compli-
cations [ 16 ].
From the above studies, infectious complications were found as the leading
adverse effect after preoperative anti-TNF treatment in chronic ulcerative colitis
and however were not shared among all studies. Thus, authors at the Xijing
Hospital of Digestive Diseases in Xi’an, China, created a meta-analysis to pro-
vide further insight into this dilemma [ 19 ]. A total of 13 observational studies
was included comprising 2933 patients analyzing total, infectious, and noninfec-
tious complications within short time after surgery, generally 30 days. Definition
of preoperative infliximab was within 12 weeks preceding surgery in seven stud-
ies with postoperative effects determined at 30 days in ten studies and 60 days in
one study; the other two omitted this data. Heterogeneity was considered signifi-
cant when chi-squared- based Q-test had a p-value <0.10 or I^2 >50%.
By delineating complications into infectious, total, and noninfectious, the study
provided separate pooled OR comparing infliximab preoperatively vs. controls.
Outcomes of the study revealed a pooled OR of 1.10 (95% CI 0.51–2.38; I^2 = 67%) for
infectious complications (Table 9.3), pooled OR of 1.09 (95% CI 0.87–1.37; I^2 = 28%)
for total complications (Table 9.4), and pooled OR of 1.10 (95% CI 0.76–1.59;
I^2 = 31%) for noninfectious complications, all three lacking significant associations
with preoperative infliximab and significant heterogeneity among infectious outcomes.
Subsequently low-quality studies by the Newcastle-Ottawa Scale (NOS <7) were
removed, continuing to demonstrate no clinical difference between infliximab and
non-infliximab adverse effects. The authors concluded that preoperative infliximab did
not increase risk of postoperative complications in chronic UC prior to surgery [ 19 ].
Table 9.3 Meta-analysis: pooled infectious complications in infliximab preoperatively with
ulcerative colitis
Study Infliximab (n) Non-infliximab (n) Total (n) Odds ratio
Selvasekar et al. [ 17 ] 47 254 301 3.50 (1.64–7.50)
Schluender et al. [ 4 ] 17 134 151 2.40 (0.60–9.63)
Mor et al. [ 16 ] 46 46 92 12.50 (1.53–102.26)
Ferrante et al. [ 20 ] 22 119 141 0.31 (0.07–1.41)
Coquet-Reinier et al. [ 21 ] 13 13 26 0.46 (0.04–5.79)
Gainsbury et al. [ 22 ] 29 52 81 0.57 (0.18–1.77)
Schaufler et al. [ 23 ] 33 18 51 0.48 (0.10–2.22)
Bregnbak et al. [ 24 ] 20 51 71 0.36 (0.10–1.22)
Eshuis et al. [ 25 ] 38 34 72 1.57 (0.53–4.66)
Total 265 721 986 1.10 (0.51–2.38)
Heterogeneity: X^2 = 23.91; df = 8 (p = 0.002); I^2 = 67%
Adapted by Yang et al. [ 19 ]
9 Use of Biologics in Crohn’s Disease and Ulcerative Colitis Prior to Surgery