138
Bearing in mind the higher risk of infectious complications in Crohn’s disease
patients after anti-TNF exposure, similar concerns prompted studies in patients
with chronic ulcerative colitis. Numerous studies had been performed investigating
rates of surgical and infectious complications. Given all studies could not be
described in this paper, a few were selected. One study revealed higher overall and
infectious complications when patients were exposed to infliximab plus cyclospo-
rine; however, anti-TNF alone did not demonstrate a significant change in medical,
surgical, or infectious complications. Other studies exposed higher rates of anasto-
motic leaks and wound infections after infliximab up to 6 months preceding sur-
gery and greater rates of pelvic sepsis and pouchitis. Given the heterogeneity in
results, a meta- analysis was created to achieve a better sense in direction on bio-
logic therapy prior to surgery. A total of 13 studies incorporating 2933 patients was
analyzed revealing no significant increase in postoperative infectious, noninfec-
tious, or total complications. Given all these findings, we conclude that in the set-
ting of ulcerative colitis, preoperative biologic therapy may be considered when
undergoing two- or three- stage IPAA.
Despite the introduction of anti-TNF agents in the treatment of Crohn’s disease
and ulcerative colitis, the unfortunate reality is medical therapy may not com-
pletely suppress disease activity. If surgery is indicated, the question arises on the
safety of preoperative biologic therapy. We conclude that in the setting of Crohn’s
disease, surgery should be delayed for at least 30 days. If this cannot be achieved,
then one can consider an ileostomy to protect the anastomosis. However, in ulcer-
ative colitis, given majority of studies demonstrated lack of adverse effects, we
recommend preoperative anti-TNF therapy can be considered prior to a scheduled
two- or three- stage IPAA.
Table 9.4 Meta-analysis: pooled total complications in infliximab preoperatively with ulcerative
colitis
StudyInfliximab
(n)Non-infliximab
(n)Total
(n) Odds ratio
Järnerot et al. [ 26 ] 7 14 21 1.00 (0.13–7.45)
Selvasekar et al. [ 17 ] 47 254 301 1.69 (0.89–3.20)
Schluender et al. [ 4 ] 17 134 151 1.43 (0.49–4.15)
Mor et al. [ 16 ] 46 46 92 2.97 (1.08–8.14)
Coquet-Reinier et al. [ 21 ] 13 13 26 0.48 (0.09–2.65)
Gainsbury et al. [ 22 ] 29 52 81 1.02 (0.41–2.55)
de Silva et al. [ 27 ] 34 628 662 0.82 (0.36–1.84)
Kennedy et al. [ 28 ] 11 27 38 2.51 (0.53–12.04)
Schaufler et al. [ 23 ] 33 18 51 0.30 (0.09–1.00)
Bregnbak et al. [ 24 ] 20 51 71 1.04 (0.37–2.93)
Nørgård et al. [ 29 ] 199 1027 1226 0.89 (0.62–1.28)
Eshuis et al. [ 25 ] 38 34 72 1.88 (0.72–4.92)
Total 494 2298 2792 1.09 (0.87–1.37)
Heterogeneity: X^2 = 15.19; df = 11 (p = 0.17); I^2 = 28%
Adapted by Yang et al. [ 19 ]
A. Kamal and B. Lashner