Dr. Colombel’s Observed Future Directions
A study involving a prospective, multicenter cohort of patients undergoing intra-abdominal surgery for IBD is recommended to clarify the independent risk factors for infectious complications, and thereby provide critically needed information to rationally guide surgical and perioperative management. To identify these variables, Benjamin Cohen, MD and Bruce Sands, MD are coordinating the Prospective Cohort of Ulcerative Colitis and Crohn’s Disease Patients Undergoing Surgery to Identify Risk Factors for Post-Operative Infection (PUCCINI) study at Mount Sinai Hospital (New York).17 This is a prospective, multicenter, observational study designed to determine if preoperative exposure to anti-TNF agents is a risk factor for postoperative infectious complications within 30 days of surgery in patients with IBD. Secondary outcomes to be measured include surgical-site infection defined by the Centers for Disease Control and Prevention (CDC) criteria within 30 days of surgery; non-surgical-site infections within 30 days of surgery; pouch-specific complication within 30 days of surgery for patients in whom an ileal-pouch anal anastomosis surgery has been performed; hospital readmission within 30 days of surgery; re-operation within 30 days of surgery; 30-day postoperative mortality; thrombotic complication within 30 days of surgery; duration of postoperative hospitalization; and hypomotility complication postoperatively.17
Meanwhile, urgent surgery should not be delayed in patients who are receiving anti-TNF therapy. When not urgent, it is probably best practice to perform surgery as long after the last perfusion/injection of an anti-TNF agent as possible, especially in patients who are receiving concomitant therapy with either steroids or immunosuppressants.
References
Narula N, Charleton D, Marshall JK. Meta-analysis: peri-operative anti-TNFα treatment and post-operative complications in patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2013;37:1057-1064.
Renna S, Cottone M, Orlando A. Optimization of the treatment with immunosuppressants and biologics in inflammatory bowel disease. World J Gastroenterol. 2014;20:9675-9690.
Waterman M, Xu W, Dinani A, et al. Preoperative biological therapy and short-term outcomes of abdominal surgery in patients with inflammatory bowel disease. Gut 2013;62:387-394.
Cohen B. Risk of post-operative infections with anti-TNF therapy. In: Rogler G, Herfarth H, Hibi T, Nielsen OH, eds. Anti-tumor necrosis factor therapy in inflammatory bowel disease. Frontiers of Gastrointestinal Research Vol 34. Basel, Switzerland: S. Karger; 2015: 152-158.
Kopylov U, Ben-Horin S, Zmora O, et al. Anti-tumor necrosis factor and postoperative complications in Crohn's disease: Systematic review and meta-analysis. Inflamm Bowel Dis. 2012;18:2404-2413.
Yang ZP, Wu Q, Wang F, et al. Meta-analysis: effect of preoperative infliximab use on early postoperative complications in patients with ulcerative colitis undergoing abdominal surgery. Aliment Pharmacol Ther. 2012;36:922-928.
Billioud V, Ford AC, Tedesco ED, et al. Preoperative use of anti-TNF therapy and postoperative complications in inflammatory bowel diseases: A meta-analysis. J Crohns Colitis 2013;7:853-867.
Mor IJ, Vogel JD, da Luz Moreira A, et al. Infliximab in ulcerative colitis is associated with an increased risk of postoperative complications after restorative proctocolectomy. Dis Colon Rectum 2008;51:1202-1207.
Nasir BS, Dozois EJ, Cima RR, et al. Perioperative anti-tumor necrosis factor therapy does not increase the rate of early postoperative complications in Crohn's disease. J Gastrointest Surg. 2010;14:1859-1865.
Kunitake H, Hodin R, Shellito PC, et al. Perioperative treatment with infliximab in patients with Crohn's disease and ulcerative colitis is not associated with an increased rate of postoperative complications. J Gastrointest Surg. 2008;12:1730-1736.
Syed A, Cross RK, Flasar MH. Anti-tumor necrosis factor therapy is associated with infections after abdominal surgery in Crohn's disease patients. Am J Gastroenterol. 2013;108:583-593.
Myrelid P, Marti-Gallostra M, Ashraf S, et al. Complications in surgery for Crohn's disease after preoperative antitumour necrosis factor therapy. Br J Surg. 2014;101:539-545.
Krane MK, Allaix ME, Zoccali M, et al. Preoperative infliximab therapy does not increase morbidity and mortality after laparoscopic resection for inflammatory bowel disease. Dis Colon Rectum 2013;56:449-457..
Nørgard BM, Nielsen J, Qvist N, et al. Pre-operative use of anti-TNF-α agents and the risk of post-operative complications in patients with ulcerative colitis – a nationwide cohort study. Aliment Pharmacol Ther. 2012;35:1301-1309.
Nørgard BM, Nielsen J, Qvist N, et al. Pre-operative use of anti-TNF-α agents and the risk of post-operative complications in patients with Crohn's disease--a nationwide cohort study. Aliment Pharmacol Ther. 2013;37:214-224.
Lau C, Dubinsky M, Melmed G, et al. The impact of preoperative serum anti-TNFalpha therapy levels on early postoperative outcomes in inflammatory bowel disease surgery. Ann Surg. 2015;261:487-496.
Clinical trials.gov. Study to determine risk factors for Post-operative Infection in inflammatory bowel disease (PUCCINI). NCT02054533. Last updated December 22, 2015. Available at https://clinicaltrials.gov/ct2/show/NCT02054533. Accessed March 3, 2016.