The effect of immune therapy on surgical site infection following Crohn's Disease resection

First Mexican Consensus on Crohn's disease

INTRODUCTION

Crohn's disease (CD) is a subtype of chronic and incurable inflammatory bowel disease. It can affect the entire gastrointestinal tract and its etiology is unknown.

OBJECTIVE

The aim of this consensus was to establish the most relevant aspects related to definitions, diagnosis, follow-up, medical treatment, and surgical treatment of Crohn's disease in Mexico.

MATERIAL AND METHODS

Mexican specialists in the areas of gastroenterology and inflammatory bowel disease were summoned. The consensus was divided into five modules, with 69 statements. Applying the Delphi panel method, the pre-meeting questions were sent to the participants, to be edited and weighted. At the face-to-face meeting, all the selected articles were shown, underlining their level of clinical evidence; all the statements were discussed, and a final vote was carried out, determining the percentage of agreement for each statement.

RESULTS

The first Mexican consensus on Crohn's disease was produced, in which recommendations for definitions, classifications, diagnostic aspects, follow-up, medical treatment, and surgical treatment were established.

CONCLUSIONS

Updated recommendations are provided that focus on definitions, classifications, diagnostic criteria, follow-up, and guidelines for conventional medical treatment, biologic therapy, and small molecule treatment, as well as surgical management.

Comparison of Post-Operative Outcomes of Right Colectomy between Crohn's Disease and Adenocarcinoma of the Right Colon: A Retrospective Cohort Study

(1) Background: Crohn's disease (CD) and right-sided colorectal-carcinoma (CRC) are two common indications for right colectomies. Many studies have tried to identify risk factors associated with post-operative complications for both CD and CRC. However, data directly comparing the outcomes of the two are sparse. This study aims to compare the 30-day post-operative outcome after a right colectomy for CD versus CRC. Its secondary aim is to identify the factors associated with these outcomes for each group. (2) Methods: A retrospective cohort study of 123 patients who underwent a right colectomy for CD or CRC in a single institution between March 2011 and March 2016. (3) Results: There were no significant differences between the groups when comparing the overall complication rate, the median Clavien-Dindo score, reoperation rates and the length of hospitalization. The leak rate was higher in the Crohn's group (13.95% (6/43) vs. 3.75% (3/80)), p = 0.049), although the stoma rate was the same (4/43 9.5%; 7/80 9.9%). (4) Conclusions: This study has shown that post-operative complication rate is similar for right colectomy in CD and CRC. However, Crohn's disease patients did have a higher leak rate.

Peri-Operative Optimization of Patients with Crohn's Disease

PURPOSE OF REVIEW

The management of patients with Crohn's disease (CD) undergoing surgery is complex and optimization of modifiable factors perioperatively can improve outcomes. This review focuses on the perioperative management of CD patients undergoing surgery, emphasizing the need for a multi-disciplinary approach.

RECENT FINDINGS

Research highlights the benefits of a comprehensive strategy, involving nutritional optimization, psychological assessment, and addressing septic complications before surgery. Despite many CD patients being on immune-suppressing medications, studies indicate that most of these medications are safe to use and should not delay surgery. However, a personalized approach for each case is needed. This review underscores the importance of multi-disciplinary team led peri-operative management of CD patients. We suggest that this can be done at a dedicated perioperative clinic for prehabilitation, with the potential to enhance outcomes for CD patients undergoing surgery.

The Effect of Anti-Tumor Necrosis Factor-Alpha Therapy within 12 Weeks Prior to Surgery on Postoperative Complications in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

The rate of abdominal surgical interventions and associated postoperative complications in inflammatory bowel disease (IBD) patients is still substantially high. There is an ongoing debate as to whether or not patients who undergo treatment with anti-tumor necrosis factor-alpha (TNF-α) agents may have an increased risk for general and surgical postoperative complications. Therefore, a systematic review and meta-analysis was conducted in order to assess the effect of anti-TNF-α treatment within 12 weeks (washout period) prior to abdominal surgery on 30-day postoperative complications in patients with IBD. The results of previously published meta-analyses examining the effect of preoperative anti-TNF-α treatment on postoperative complications reported conflicting findings which is why we specifically focus on the effect of anti-TNF-α treatment within 12 weeks prior to surgery. PubMed, Cochrane, Scopus, Web of Science, World Health Organization Trial Registry, ClinicalTrials.gov and reference lists were searched (June 1995−February 2022) to identify studies, investigating effects of anti-TNF-α treatment prior to abdominal surgery on postoperative complications in IBD patients. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated and subgroup analyses were performed. In this case, 55 cohort studies (22,714 patients) were included. Overall, postoperative complications (OR, 1.23; 95% CI, 1.04−1.45; p = 0.02), readmission (OR, 1.39; 95% CI, 1.11−1.73; p = 0.004), and intra-abdominal septic complications (OR, 1.89; 95% CI, 1.44−2.49; p < 0.00001) were significantly higher for anti-TNF-α-treated patients. Significantly higher intra-abdominal abscesses and readmission were found for anti-TNF-α-treated CD patients (p = 0.05; p = 0.002). Concomitant treatment with immunosuppressives in <50% of anti-TNF-α-treated patients was associated with significantly lower mortality rates (OR, 0.32; 95% CI, 0.12−0.83; p = 0.02). Anti-TNF-α treatment within 12 weeks prior to surgery is associated with higher short-term postoperative complication rates (general and surgical) for patients with IBD, especially CD.

Interventional inflammatory bowel disease: endoscopic therapy of complications of Crohn's disease

Endoscopic therapy for inflammatory bowel diseases (IBD) or IBD surgery-associated complications or namely interventional IBD has become the main treatment modality for Crohn’s disease, bridging medical and surgical treatments. Currently, the main applications of interventional IBD are (i) strictures; (ii) fistulas and abscesses; (iii) bleeding lesions, bezoars, foreign bodies, and polyps; (iv) post-operative complications such as acute and chronic anastomotic leaks; and (v) colitis-associated neoplasia. The endoscopic treatment modalities include balloon dilation, stricturotomy, strictureplasty, fistulotomy, incision and drainage (of fistula and abscess), sinusotomy, septectomy, banding ligation, clipping, polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection. The field of interventional IBD is evolving with a better understanding of the underlying disease process, advances in endoscopic technology, and interest and proper training of next-generation IBD interventionalists.

Is Hartmann’s Pouch an Option in the Management of Acute Severe Ulcerative Colitis?

Background: The surgical management of remnant rectosigmoid after subtotal colectomy with end ileostomy for acute severe ulcerative colitis remains controversial with respect to the need to perform sigmoidostomy or Hartmann’s pouch. The aim of this retrospective study was to investigate whether Hartmann’s pouch may be a safe option. Methods: Thirty-eight Hartmann’s pouches were performed between January 2003 and December 2015. We looked at morbidity (with a focus on the occurrence of pelvic sepsis and leakage of the rectal stump) and the rate of restored intestinal continuity. Results: Nineteen patients had surgical complications. Seven had an intra-abdominal collection, only one of which was in the pelvis, and the patient had to be reoperated. Only one patient had a reopening of the rectal stump, which was revealed by rectal bleeding. Twenty-six patients (68.4%) underwent further proctectomy with ileal J-pouch anal anastomosis with no difficulty in localizing or mobilizing the rectal stump and no major surgical complications. Conclusions: Hartmann’s pouch may be considered in patients with acute severe ulcerative colitis, with low rates of morbidity and pelvic sepsis. The restoration of intestinal continuity is possible after this procedure without any special difficulty.

Prospective Cohort Study to Investigate the Safety of Preoperative Tumor Necrosis Factor Inhibitor Exposure in Patients With Inflammatory Bowel Disease Undergoing Intra-abdominal Surgery

BACKGROUND & AIMS

Whether preoperative treatment of inflammatory bowel disease (IBD) with tumor necrosis factor inhibitors (TNFis) increases the risk of postoperative infectious complications remains controversial. The primary aim of this study was to determine whether preoperative exposure to TNFis is an independent risk factor for postoperative infectious complications within 30 days of surgery.

METHODS

We conducted a multicenter prospective observational study of patients with IBD undergoing intra-abdominal surgery across 17 sites from the Crohn's & Colitis Foundation Clinical Research Alliance. Infectious complications were categorized as surgical site infections (SSIs) or non-SSIs. Current TNFi exposure was defined as use within 12 weeks of surgery, and serum was collected for drug-level analyses. Multivariable models for occurrence of the primary outcome, any infection, or SSI were adjusted by predefined covariates (age, sex, preoperative steroid use, and disease type), baseline variables significantly associated (P < .05) with any infection or SSI separately, and TNFi exposure status. Exploratory models used TNFi exposure based on serum drug concentration.

RESULTS

A total of 947 patients were enrolled from September 2014 through June 2017. Current TNFi exposure was reported by 382 patients. Any infection (18.1% vs 20.2%, P = .469) and SSI (12.0% vs 12.6%, P = .889) rates were similar in patients currently exposed to TNFis and those unexposed. In multivariable analysis, current TNFi exposure was not associated with any infection (odds ratio, 1.050; 95% confidence interval, 0.716-1.535) or SSI (odds ratio, 1.249; 95% confidence interval, 0.793-1.960). Detectable TNFi drug concentration was not associated with any infection or SSI.

CONCLUSIONS

Preoperative TNFi exposure was not associated with postoperative infectious complications in a large prospective multicenter cohort.

Systematic review and meta-analysis: risks of postoperative complications with preoperative use of anti-tumor necrosis factor-alpha biologics in inflammatory bowel disease patients

OBJECTIVE

The preoperative use of anti-tumor necrosis factor-alpha (anti-TNF) in inflammatory bowel disease (IBD) patients undergoing surgery has been controversial due to concern for increased risks of postoperative complications. We aimed to determine the effect of preoperative anti-TNF therapy on postoperative complications in IBD patients undergoing abdominal surgery.

METHODS

A literature search of Google Scholar, PubMed, The Cochrane Library, EMBASE, and CINAHL was performed through October 2019. Studies reporting postoperative complication rates of Crohn's disease (CD), ulcerative colitis (UC), and IBD-unspecified patients with preoperative anti-TNF treatment undergoing abdominal surgery compared to controls without preoperative anti-TNF treatment were included. The main outcomes measured were overall, infectious, and noninfectious postoperative complications.

RESULTS

Forty-one studies totaling 20 274 patients were included. There was a significant increase in overall complications in all patients treated with anti-TNF vs. controls [odds ratio (OR) = 1.13, 95% confidence interval (CI), 1.01-1.25, P = 0.03, I2 = 6%] with an absolute risk increase (ARI) of 5.5% and a number needed to harm (NNH) of 18. There was also a significant increase in infectious complications in CD patients (OR = 1.44; 95% CI 1.02-2.03, P = 0.04, I2 = 49%, ARI = 5.5%, NNH = 20) only. Contrastingly, there was a significant increase in noninfectious complications in all patients (OR = 1.44, 95% CI 1.13-1.85, P = 0.003, I2 = 8%, ARI = 6.4%, NNH = 16) and UC patients (OR = 1.57, 95% CI 1.15-2.14, P = 0.005, I2 = 25%, ARI = 8.5%, NNH = 12) only.

CONCLUSION

Preoperative use of anti-TNF agents in IBD patients undergoing abdominal surgery is associated with increases in overall postoperative complications in all patients, infectious postoperative complications in CD patients, and noninfectious postoperative complications in UC patients.

Postoperative complication rates between Crohn's disease and Colorectal cancer patients after ileocolic resections: a comparative study

Introduction Ileocolic resection (ICR) is the most common surgical procedure performed for Crohn's disease (CD). Similarly, right-sided Colorectal cancer (CRC) is treated by the same operation. The primary aim of this study was to analyze and compare the frequency and profile of early postoperative complications of ICR between patients with CD and CRC.

Methods Retrospective and observational study with patients submitted to ICR from two Brazilian tertiary referral units in colorectal surgery. We included patients with diagnosis of CD or CRC, treated with ICR, at any stage of follow-up. Variables analyzed: age at surgery, gender, diagnosis, surgical approach (open or laparoscopy), type of anastomosis (hand-sewn/stapled; end-to-end/side-to-side), presence and type of early postoperative complications (30 days) and mortality, among others.

Results 109 patients were included, 73 with CD (67%) and 36 with CRC (33%). CD patients were younger (42.44 ± 12.73 years vs. 66.14 ± 11.02 years in the CRC groups, p < 0.0001) and had more previous resections (20 ± 27.4 in CD and 0 in CCR, p = 0.001). There were no significant differences between the groups in terms of overall early postoperative complications [17/73 (23.3%) in the CD and 5/36 (13.9%) in the CRC groups (p = 0.250)]. There was no significant difference between the groups in relation to anastomotic leakage (p = 0.185), surgical site infections (p = 0.883), other complications (0.829) and deaths (p = 0.069).

Conclusions There was no significant difference in early postoperative complications in patients with CD or CRC submitted to ICR.

Impact of anti-TNF agents in postoperative complications in Crohn's disease: a review

The real impact of biological therapy (anti-TNF agents) in abdominal operations secondary to Crohn's disease is a matter of debate in the international literature. Several studies demonstrated that there can be an increase in postoperative complications in patients previously treated with these agents. On the other hand, the majority of studies published over the last years question this effect, and did not demonstrate any relationship between biologics and outcomes related to surgical postoperative complications. Some meta-analyses were published, with different outcomes and different conclusions. Experimental studies in animals were also recently published, with opposite results, despite similar methodology. In this review, the authors resume all the relevant papers in the international literature with respect to the theme, and demonstrate the heterogeneity of the studies, as well as the disparity of their results and outcomes. The real impact of anti-TNF agents on postoperative complications in Crohn's disease is still controversial, and needs to be better elucidated. Controlled trials must be performed to better address this issue.

A systemic review and metaanalysis of postoperative outcomes in urgent and elective bowel resection in patients with Crohn's disease

PURPOSE

The study examined whether urgency of surgical intervention affects postoperative outcomes in patients with Crohn's disease (CD) undergoing bowel resection.

METHOD

The review was conducted according to a predefined, published study protocol in Prospero which is an international database of prospectively registered systematic reviews in health. The study reported according to PRIMSMA guidelines. We searched Embase and Pubmed for articles reporting postoperative outcome after urgent and elective surgery in patients with CD undergoing bowel resection. Primary outcome variable was 30-day overall postoperative complications while secondary outcome variables were intraabdominal septic complications (IASCs), mortality, reoperation, and readmission. Assessment of bias was performed using Newcastle-Ottawa score. Two authors independently extracted data on each study, patients, and outcome measures.

RESULTS

The search identified 22 studies in which 955 patients underwent urgent surgeries while 6518 patients underwent elective surgeries. Based on the quality assessment, 19 studies were classified as having high risk of bias, one study as having a medium risk of bias and 2 studies as having low risk of bias (≥ 8 stars). Random-effect metaanalysis showed urgent surgery was associated with ~ 40% increase in overall complications compared to elective surgery (RR = 1.43, 95% CI [1.09; 1.87], p = 0.010). IASCs also increased in patients who had urgent surgery (RR = 1.44, 95% CI [1.08; 1.92], p = 0.013). No significant difference was shown in mortality and readmission rates.

CONCLUSION

Urgent bowel resection in patients with CD is associated with higher risk of overall postoperative complications and IASCs.

Risk of Postoperative Infectious Complications From Medical Therapies in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

To assess the impact of inflammatory bowel disease (IBD) medications on postoperative infection risk within 30 days of surgery.

METHODS

We searched multiple electronic databases and reference lists of articles dating up to August 2018 for prospective and retrospective studies comparing postoperative infection risk in patients treated with an IBD medication perioperatively with the risk in patients who were not taking that medication. Outcomes were overall infectious complications and intra-abdominal infections within 30 days of surgery.

RESULTS

Sixty-three studies were included. Overall infectious complications were increased in patients who received anti-tumor necrosis factor (TNF) agents (odds ratio [OR] 1.26; 95% confidence interval [CI], 1.07-1.50) and corticosteroids (OR 1.34; 95% CI, 1.25-1.44) and decreased in those who received 5-aminosalicylic acid (OR 0.63; 95% CI, 0.46-0.87). No difference was observed in those treated with immunomodulators (OR 1.08; 95% CI, 0.94-1.25) or anti-integrin agents (OR 1.06; 95% CI, 0.67-1.69). Both corticosteroids and anti-TNF agents were associated with increased intra-abdominal infection risk (OR 1.63; 95% CI, 1.33-2.00 and OR 1.46; 95% CI, 1.08-1.97, respectively), whereas no impact was observed with 5-aminosalicylates, immunomodulators, or anti-integrin therapy. Twenty-two studies had low risk of bias while the remaining studies had very high risk.

CONCLUSIONS

Corticosteroids and anti-TNF agents were associated with increased overall postoperative infection risk as well as intra-abdominal infection in IBD patients, whereas no increased risk was observed for immunomodulators or anti-integrin therapy. Although these results may result from residual confounding rather than from a true biological effect, prospective studies that control for potential confounding factors are required to generate higher-quality evidence.

Risk of postoperative infectious complications from medical therapies in inflammatory bowel disease

BACKGROUND

Medications used to treat inflammatory bowel disease (IBD) have significantly improved patient outcomes and delayed time to surgery. However, some of these therapies are recognized to increase the general risk of infection and have an unclear impact on postoperative infection risk.

OBJECTIVES

To assess the impact of perioperative IBD medications on the risk of postoperative infections within 30 days of surgery.

SEARCH METHODS

We searched the Cochrane IBD Group's Specialized Register (29 October 2019), MEDLINE (January 1966 to October 2019), Embase (January 1985 to October 2019), the Cochrane Library, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform from inception up to October 2019, and reference lists of articles.

SELECTION CRITERIA

Randomized controlled trials, quasi-randomized controlled trials, non-randomized controlled trials, prospective cohort studies, retrospective cohort studies, case-control studies and cross-sectional studies comparing participants treated with an IBD medication preoperatively or within 30 days postoperatively to those who were not taking that medication (either another active medication, placebo, or no treatment). We included published study reports and abstracts.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts and extracted data. The primary outcome was postoperative infection within 30 days of surgery. Secondary outcomes included incisional infections and wound dehiscence, intra-abdominal infectious complications and extra-abdominal infections. Three review authors assessed risks of bias using the Newcastle-Ottawa Scale. We contacted authors for additional information when data were missing. For the primary and secondary outcomes, we calculated odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) using the generic inverse variance method. When applicable, we analyzed adjusted and unadjusted data separately. We evaluated the certainty of the evidence using GRADE.

MAIN RESULTS

We included 68 observational cohort studies (total number of participants unknown because some studies did not report the number of participants). Of these, 48 studies reported including participants with Crohn's disease, 36 reported including participants with ulcerative colitis and five reported including participants with indeterminate colitis. All 42 studies that reported urgency of surgery included elective surgeries, with 31 (74%) of those also including emergency surgeries. Twenty-four studies had low risk of bias while the rest had very high risk. Based on pooling of adjusted data, we calculated ORs for postoperative total infection rates in participants who received corticosteroids (OR 1.70, 95% CI 1.38 to 2.09; low-certainty evidence), immunomodulators (OR 1.29, 95% CI 0.95 to 1.76; low-certainty evidence), anti-TNF agents (OR 1.60, 95% CI 1.20 to 2.13; very low-certainty evidence) and anti-integrin agents (OR 1.04, 95% CI 0.79 to 1.36; low-certainty evidence). We pooled unadjusted data to assess postoperative total infection rates for the use of aminosalicylates (5-ASA) (OR 0.76, 95% CI 0.51 to 1.14; very low-certainty evidence). One secondary outcome examined was wound-related complications in participants using: corticosteroids (OR 1.41, 95% CI 0.72 to 2.74; very low-certainty evidence), immunomodulators (OR 1.35, 95% CI 0.96 to 1.89; very low-certainty evidence), anti-TNF agents (OR 1.18, 95% CI 0.83 to 1.68; very low-certainty evidence) and anti-integrin agents (OR 1.64, 95% CI 0.77 to 3.50; very low-certainty evidence) compared to controls. Another secondary outcome examined the odds of postoperative intra-abdominal infections in participants using: corticosteroids (OR 1.53, 95% CI 1.28 to 1.84; very low-certainty evidence), 5-ASA (OR 0.77, 95% CI 0.45 to 1.33; very low-certainty evidence), immunomodulators (OR 0.86, 95% CI 0.66 to 1.12; very low-certainty evidence), anti-TNF agents (OR 1.38, 95% CI 1.04 to 1.82; very low-certainty evidence) and anti-integrin agents (OR 0.40, 95% CI 0.14 to 1.20; very low-certainty evidence) compared to controls. Lastly we checked the odds for extra-abdominal infections in participants using: corticosteroids (OR 1.23, 95% CI 0.97 to 1.55; very low-certainty evidence), immunomodulators (OR 1.17, 95% CI 0.80 to 1.71; very low-certainty evidence), anti-TNF agents (OR 1.34, 95% CI 0.96 to 1.87; very low-certainty evidence) and anti-integrin agents (OR 1.15, 95% CI 0.43 to 3.08; very low-certainty evidence) compared to controls.

AUTHORS' CONCLUSIONS

The evidence for corticosteroids, 5-ASA, immunomodulators, anti-TNF medications and anti-integrin medications was of low or very low certainty. The impact of these medications on postoperative infectious complications is uncertain and we can draw no firm conclusions about their safety in the perioperative period. Decisions on preoperative IBD medications should be tailored to each person's unique circumstances. Future studies should focus on controlling for potential confounding factors to generate higher-quality evidence.

Perioperative management of ileocecal Crohn's disease in the current era

INTRODUCTION

The ileocecal region is most commonly involved in patients with Crohn's disease (CD).

AREAS COVERED

In the management of ileocecal CD, this review discusses the underlying clinical issues with perioperative management and surgical intervention.

EXPERT OPINION

Despite advances in medical treatments, surgery is required in a proportion of patients. Preoperative optimization including weaning of corticosteroids, initiation of enteral feeds, venous thromboembolism prophylaxis and smoking cessation may lead to improved postoperative outcomes. Several surgical approaches regarding anastomotic technique and range of mesentery division are now attempted to reduce the incidence of postoperative recurrence. Disease recurrence is common after surgery for CD. Early endoscopic assessment and subsequent treatment adjustment are optimal strategies for the prevention of recurrence after ileocolonic resection.

Surgery for Inflammatory Bowel Disease in the Era of Biologics

INTRODUCTION

The advent of monoclonal antibody therapy for the treatment of inflammatory bowel disease has greatly changed the multidisciplinary management of these patients, including surgical approaches. As an increasing number of inflammatory bowel disease patients are being medically managed with monoclonal antibody therapy or combination therapy with immunomodulators, more patients are coming to the operating room having been exposed to these medical therapies.

METHODS

A search of the relevant literature regarding monoclonal antibody therapy and postoperative outcomes was performed.

RESULTS

Significant controversy remains regarding the association between monoclonal antibodies and postoperative outcomes. Different classes of monoclonal antibodies may have different impacts on infectious complications. Operations for Crohn's disease and ulcerative colitis alter how we think about a change in care in the era of monoclonal antibodies.

CONCLUSION

In Crohn's disease, intestinal diversion may be considered in patient and disease specific scenarios and in ulcerative colitis, the use of a 3-stage approach to an ileal pouch is now more often used.

Perioperative Dietary Therapy in Inflammatory Bowel Disease

BACKGROUND AND AIMS

The incidence of inflammatory bowel disease [IBD] is rising worldwide and no cure is available. Many patients require surgery and they often present with nutritional deficiencies. Although randomised controlled trials of dietary therapy are lacking, expert IBD centres have long-established interdisciplinary care, including tailored nutritional therapy, to optimise clinical outcomes and resource utilisation. This topical review aims to share expertise and offers current practice recommendations to optimise outcomes of IBD patients who undergo surgery.

METHODS

A consensus expert panel consisting of dietitians, surgeons, and gastroenterologists, convened by the European Crohn's and Colitis Organisation, performed a systematic literature review. Nutritional evaluation and dietary needs, perioperative optimis ation, surgical complications, long-term needs, and special situations were critically appraised. Statements were developed using a Delphi methodology incorporating three successive rounds. Current practice positions were set when ≥80% of participants agreed on a recommendation.

RESULTS

A total of 26 current practice positions were formulated which address the needs of IBD patients perioperatively and in the long term following surgery. Routine screening, perioperative optimisation by oral, enteral, or parenteral nutrition, dietary fibre, and supplements were reviewed. IBD-specific situations, including management of patients with a restorative proctocolectomy, an ostomy, strictures, or short-bowel syndrome, were addressed.

CONCLUSIONS

Perioperative dietary therapy improves the outcomes of IBD patients who undergo a surgical procedure. This topical review shares interdisciplinary expertise and provides guidance to optimise the outcomes of patients with Crohn's disease and ulcerative colitis. taking advantage of contemporary nutrition science.

Association between preoperative tumor necrosis factor alpha inhibitor and surgical site infection after surgery for inflammatory bowel disease: a systematic review and meta-analysis

Tumor necrosis factor-alpha inhibitor (TNFi) treatment is effective for ulcerative colitis (UC) and Crohn's disease (CD). Although several meta-analyses have been performed to evaluate the association between TNFi treatment and surgical morbidity, the results are controversial. We conducted a systematic review and meta-analysis of the prevention of surgical site infection (SSI) after surgery for UC and CD in patients on TNFis, based on literature published between January 2000 and May 2019 (registered on PROSPERO, No. CRD42019134156). Overall, 2175 UC patients in 13 observational studies (OBSs) and 7084 CD patients in 16 OBSs were included. The incidences of incisional (INC) SSI and organ/space (O/S) SSI after surgery for UC were 179/1985 (9.0%) and 176/2175 (8.1%), respectively. TNFi use was not associated with the incidences of INC SSI (odds ratio (OR) 1.04, 95% confidence interval (CI) (0.47-2.32) or O/S SSI (OR 1.85, 95% CI (0.82-4.20)) after surgery for UC. The INC SSI and O/S SSI incidences after surgery for CD were 289/3089 (9.4%) and 526/7,084 (7.4%), respectively. Preoperative TNFi use was not associated with INC SSI (OR 0.98, 95% CI (0.52-1.83)) or O/S SSI incidence (OR 1.09, 95% CI (0.78-1.52)) after surgery for CD. We did not find a significant association between preoperative TNFi use and SSI in surgery for UC or CD.

ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment

This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of previous guidelines.

Biologics and 30-Day Postoperative Complications After Abdominal Operations for Crohn's Disease: Are There Differences in the Safety Profiles?

BACKGROUND

The evidence regarding the association of preoperative biologic exposure and postoperative outcomes remains controversial for both antitumor necrosis factor agents and vedolizumab and largely unknown for ustekinumab.

OBJECTIVE

The purpose of this study was to determine differences in the rates of 30-day postoperative overall infectious complications and intra-abdominal septic complications among the 3 classes of biologic therapies as compared with no biologic therapy.

DESIGN

This was a retrospective review.

SETTINGS

The study was conducted at an IBD referral center.

PATIENTS

Adult patients with Crohn's disease who received an antitumor necrosis factor, vedolizumab, ustekinumab, or no biologic therapy within 12 weeks of a major abdominal operation between May 20, 2014, and December 31, 2017, were included.

MAIN OUTCOMES MEASURES

Thirty-day overall postoperative infectious complications and intra-abdominal septic complications were measured.

RESULTS

A total of 712 patients with Crohn's disease were included; 272 patients were exposed to an antitumor necrosis factor agents, 127 to vedolizumab, 38 to ustekinumab, and 275 to no biologic therapy within the 12 weeks before an abdominal operation. Patients exposed to a biologic were more likely to be taking a concurrent immunomodulator, but there was no difference in concurrent corticosteroid usage. The particular class of biologic was not independently associated with total overall infectious complications. Vedolizumab was associated with an increased rate of intra-abdominal sepsis on univariate analysis but not on multivariable analysis. Combination immunosuppression was associated with both an increased rate of overall postoperative infectious complications and intra-abdominal sepsis.

LIMITATIONS

The study was limited by its retrospective design and single-center data.

CONCLUSIONS

The overall rate of total infectious complications or intra-abdominal septic complications was not increased based on preoperative exposure to a particular class of biologic. Rates increased with combination immunosuppression of biologic therapy with corticosteroids and previous abdominal resection. See Video Abstract at http://links.lww.com/DCR/B24. BIOLÓGICOS Y COMPLICACIONES POSTOPERATORIAS DE 30 DÍAS DESPUÉS DE LAS OPERACIONES ABDOMINALES PARA LA ENFERMEDAD DE CROHN: ¿EXISTEN DIFERENCIAS EN LOS PERFILES DE SEGURIDAD?:: La evidencia sobre la asociación de la exposición biológica preoperatoria y los resultados postoperatorios sigue siendo controvertida controversial tanto para los agentes del factor de necrosis tumoral (anti-TNF) como para el vedolizumab, y en gran parte desconocida para el ustekinumab.Determinar las diferencias en las tasas de complicaciones infecciosas generales postoperatorias de 30 días y complicaciones sépticas intraabdominales entre las tres clases de terapias biológicas en comparación con ninguna terapia biológica.Revisión retrospectiva.centro de referencia de la enfermedad inflamatoria intestinal.Pacientes adultos con enfermedad de Crohn que recibieron un factor de necrosis antitumoral, vedolizumab, ustekinumab o ningún tratamiento biológico dentro de las 12 semanas de una operación abdominal mayor entre el 5/20/2014 y el 12/31/2017.Complicaciones infecciosas postoperatorias generales de 30 días, complicaciones sépticas intraabdominales.Se incluyeron setecientos doce pacientes con enfermedad de Crohn; 272 pacientes fueron expuestos a un anti-TNF, 127 a vedolizumab, 38 a ustekinumab y 275 a ninguna terapia biológica dentro de las 12 semanas previas a una operación abdominal. Los pacientes expuestos a un producto biológico tenían más probabilidades de tomar un inmunomodulador concurrente, pero no hubo diferencias en el uso simultáneo de corticosteroides. La clase particular de productos biológicos no se asoció de forma independiente con las complicaciones infecciosas totales. Vedolizumab se asoció con una mayor tasa de sepsis intraabdominal en el análisis univariable, pero no en el análisis multivariable. La inmunosupresión combinada se asoció tanto con una mayor tasa de complicaciones infecciosas postoperatorias generales como con sepsis intraabdominal.Diseño retrospectivo, datos de centro único.La tasa general de complicaciones infecciosas totales o complicaciones sépticas intraabdominales no aumentó en función de la exposición preoperatoria a una clase particular de productos biológicos. Las tasas aumentaron con la combinación de inmunosupresión de la terapia biológica con corticosteroides y resección abdominal previa. Vea el Resumen del Video en http://links.lww.com/DCR/B24.

Anti-TNF biologic therapy does not increase postoperative morbidity in pediatric Crohn's patients

INTRODUCTION

Limited knowledge exists as to what impact preoperative biologic therapy has on postoperative complications in pediatric patients undergoing abdominal surgery for Crohn's disease (CD). Therefore, we sought to determine the 30-day postoperative infectious complication rate among pediatric CD patients who received biologic therapy within 12 weeks of an abdominal operation.

METHODS

A retrospective chart review was performed on pediatric (<18 years of age) CD patients who underwent an abdominal operation between 1/1/2008 and 12/31/2017. Patients were grouped according to whether they received an anti-TNF (infliximab, adalimumab, certolizumab pegol) or no biologic therapy within 12 weeks prior to the operation. The primary outcome was the overall 30-day postoperative infectious complication rate. Secondary outcomes included 30-day readmission rate and return to the operating room (ROR).

RESULTS

A total of 69 pediatric CD patients met inclusion criteria (n = 54 anti-TNF therapy, n = 15 received no biologic therapy). There were no differences between the anti-TNF and no biologic cohorts with respect to demographics or CD characteristics. No significant differences in overall 30-day postoperative infectious complications existed between patients exposed to anti-TNF agents and those with no preoperative exposure, or in its subcategories of surgical infectious complications and nonsurgical infectious complications. There was also no difference in the rate of ileus, readmission, or ROR.

CONCLUSIONS

Preoperative exposure to anti-TNF biologic therapy does not add to overall or infectious 30-day postoperative morbidity in pediatric CD patients.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Retrospective review.

Biological Treatment and the Potential Risk of Adverse Postoperative Outcome in Patients With Inflammatory Bowel Disease: An Open-Source Expert Panel Review of the Current Literature and Future Perspectives

Background

There is widespread concern that treatment with biologic agents may be associated with suboptimal postoperative outcome after surgery for inflammatory bowel diseases (IBD).

Aim

We aimed to search and analyze the literature regarding the potential association of biologic treatment on adverse postoperative outcome in patients with IBD. We used the subject as a case in point for surgical research. The aim was not to conduct a new systematic review.

Method

This is an updated narrative review written in a collaborative method by authors invited through Twitter via the following hashtags (#OpenSourceResearch and #SoMe4Surgery). The manuscript was presented as slides on Twitter to allow discussion of each section of the paper sequentially. A Google document was created, which was shared across social media, and comments and edits were verified by the primary author to ensure accuracy and consistency.

Results

Forty-one collaborators responded to the invitation, and a total of 106 studies were identified that investigated the potential association of preoperative biological treatment on postoperative outcome in patients with IBD. Most of these studies were retrospective observational cohorts: 3 were prospective, 4 experimental, and 3 population-based studies. These studies were previously analyzed in 10 systematic/narrative reviews and 14 meta-analyses. Type of biologic agents, dose, drug concentration, antidrug antibodies, interval between last dose, and types of surgery varied widely among the studies. Adjustment for confounders and bias control ranged from good to very poor. Only 10 studies reported postoperative outcome according to Clavien–Dindo classification.

Conclusion

Although a large number of studies investigated the potential effect of biological treatment on postoperative outcomes, many reported divergent results. There is a need for randomized controlled trials. Future studies should focus on the avoiding the weakness of prior studies we identified. Seeking collaborators and sharing information via Twitter was integral to widening the contributors/authors and peer review for this article and was an effective method of collaboration.

Management of Biological Therapy Before Elective Inflammatory Bowel Disease Surgeries

Increasing uptake of biologic therapy has contributed to declining surgical rates for inflammatory bowel disease (IBD). However, a significant number of patients on biologic therapy will go on to require surgery. The literature is conflicted with regard to the preoperative management of biologic therapy before urgent or elective IBD surgery. This article reviews the available data on postoperative complications following preoperative treatment with anti-tumor necrosis factor alpha therapy, anti-integrin therapy, and anti-interleukin therapy.

The Influence of Preoperative Medications on Postoperative Complications in Patients After Intestinal Surgery for Crohn's Disease

BACKGROUND

Many patients with Crohn's disease (CD) are treated with medications, including steroids, immunomodulators, and anti-tumor necrosis factor alpha (anti-TNF-α) agents, at the time of surgery. This study evaluated the effects of these medications on postoperative complications in CD patients.

METHODS

This retrospective study analyzed patients who underwent bowel resection for CD between January 2006 and December 2015. Postoperative complications were defined as a Clavien-Dindo classification of grade 2A or higher within the first 30 days after surgery.

RESULTS

Of the 817 patients enrolled, 687 patients received bowel resection and anastomosis without stoma formation. Of 687 patients, 381 (55.5%) were being treated with preoperative medications at the time of surgery (medication group) and 306 (44.5%) were not (nonmedication group). The overall rate of postoperative complications was not different between the medication and nonmedication groups (23.4% vs 21.9%, P = 0.36). Preoperative treatments with immunomodulators plus anti-TNF-α agents (relative risk [RR], 2.314; 95% confidence interval [CI], 1.126-4.753; P = 0.022) and treatment with immunomodulators plus steroids (RR, 2.536; 95% CI, 1.124-5.725; P = 0.025) were risk factors for infectious complications. Preoperative treatments with immunomodulators plus anti-TNF-α agents (RR, 2.731; 95% CI, 1.102-6.769; P = 0.03) and treatment with immunomodulators plus steroids (RR, 3.118; 95% CI, 1.169-8.320; P = 0.023) were significantly associated with increased risk of intra-abdominal sepsis.

CONCLUSIONS

Preoperative treatments with immunomodulators plus anti-TNF-α agents or steroids were risk factors for infectious complications, especially intra-abdominal sepsis in patients who underwent bowel resection and anastomosis.

Postoperative Outcomes in Ustekinumab-Treated Patients Undergoing Abdominal Operations for Crohn’s Disease: Single-Center Series

Introduction

The impact of ustekinumab on adverse postoperative outcomes in Crohn’s disease (CD) remains largely unknown. We determined the difference in 90-day postoperative complication rates among CD patients exposed to ustekinumab within 12 weeks prior to an abdominal operation as compared to patients not exposed to biologic therapy.

Methods

A retrospective chart review of all adults with CD who underwent an abdominal operation between October 1, 2017 and December 31, 2018 at a single tertiary medical center was performed. Data collection included patient demographics, concurrent immunosuppression, serum laboratory values, operative values, and 90-day outcomes including superficial surgical site infection (sSSI), intra-abdominal sepsis, overall infectious complications, readmission, and reoperation rates. The primary outcome was the 90-day rate of intra-abdominal sepsis.

Results

Fifty-seven CD patients received ustekinumab and 277 received no biologic therapy in the 12 weeks prior to major abdominal surgery. Ustekinumab-exposed patients were younger, less likely to have diabetes mellitus or active tobacco exposure, were more often obese, and more often taking a concurrent immunomodulator. Ustekinumab remained an independent predictor of intra-abdominal sepsis on multivariable logistic regression. Immunomodulator exposure was associated with significantly increased rates of sSSI and overall complication rates.

Conclusions

Ustekinumab is associated with increased rates of 90-day postoperative intra-abdominal sepsis following a major abdominal operation for CD.

Prevalence and predictors of surgical site infections after bowel resection for Crohn's disease: the role of dual-ring wound protector

PURPOSE

Surgical site infections (SSIs) have become a leading cause of preventable morbidity and mortality in surgery. The aim was to evaluate the efficacy of a dual-ring wound protector to prevent the SSIs in Crohn's disease (CD) after bowel resection.

METHODS

This retrospective observational study included all CD patients undergoing bowel resection at the Inflammatory Bowel Disease Center between January 2015 and June 2018 at Sir Run Run Shaw Hospital. Risk factors of SSIs were evaluated by assessing preoperative clinical characteristics and perioperative treatments in univariate and multivariate analyses. Outcomes for CD patients with and without the wound protector were compared.

RESULTS

Three hundred forty-four CD patients were enrolled in this study, 121 (35.2%) patients had postoperative complications, of whom, 72 (20.9%) patients developed SSIs (12.8% patients with incisional SSI and 8.1% patients with organ/space SSI). There was a significant reduction in the incidence of incisional SSI in the wound protector group (8.1% vs 16.8%, p < 0.05). No significant differences were identified in organ/space SSI between groups with and without wound protector (6.3% vs 9.8%, p = 0.232). Incisional SSI correlated with preoperative albumin, C-reactive protein, white blood cell, age (≤ 16), penetrating disease behavior, surgical history, open surgery, stoma creation, estimated blood loss, infliximab, and wound protector (p < 0.05). Multivariate analysis identified the wound protector to be one of independent factors for preventing incisional SSIs (OR 0.357, 95% CI 0.161-0.793, p < 0.05).

CONCLUSION

Among the CD patients with bowel resection, the use of a dual-ring wound protector during surgery significantly reduced the risk of incisional SSI.

Systematic review with meta-analysis: risk of post-operative complications associated with pre-operative exposure to anti-tumour necrosis factor agents for Crohn's disease

BACKGROUND

Post-operative complications after anti-tumour necrosis agent treatment for Crohn's disease (CD) have been analysed with conflicting results.

AIM

To assess the effects of pre-operative anti-tumour necrosis factor (TNF) therapy on post-operative complications within 30 days post-operatively in patients with CD undergoing abdominal surgery.

METHODS

Systematic review with meta-analysis was performed on articles found in MEDLINE, Embase, Cochrane Library, Scopus, and the International Clinical Trials Registry Platform until September 2018.

RESULTS

Twenty studies (7115 patients) were included. Without confounder adjustment, pre-operative anti-TNF therapy in patients with CD undergoing abdominal surgery was associated with increased rates of infectious complications (unadjusted odds ratio, OR, 1.49; 95% CI, 1.08-2.06). After confounder adjustment, Pre-operative anti-TNF therapy was significantly associated with both increased rates of total and infectious complications (adjusted OR, 1.53 and 2.09; 95% CI, 1.11-2.09 and 1.19-3.65, respectively). After subgroup analyses, the association between anti-TNF agents and total complications was significant in high incidence countries (adjusted OR, 1.86; 95% CI, 1.43-2.42) but not in low incidence countries (adjusted OR, 0.77; 95% CI, 0.48-1.25).

CONCLUSIONS

Exposure to anti-TNF agents is an independent risk factor for post-operative infectious complications in patients with CD, especially in countries with a high incidence of Crohn's disease. We suggest postponing elective surgery or carefully monitoring these patients post-operatively.

Changing trends in surgery for abdominal Crohn's disease

AIM

The introduction of biological agents and laparoscopy are, arguably, the most important developments for the treatment of Crohn's disease (CD) in the last two decades. Due to the efficacy of biological agents in treating mild disease, it is likely that the percentage of surgery for complex cases may have increased. The objective of this study was to analyse the changing characteristics and results of the surgical treatment of patients with CD over the past 13 years.

METHODS

All patients who underwent abdominal surgery for CD between 2004 and 2016 were retrospectively identified. Data were compared between two periods (2004-2010 and 2011-2016).

RESULTS

A total of 908 procedures were performed (48% men, mean age 43 ± 16 years). Demographic and CD characteristics changed significantly over time: comorbidities were more frequent (35% vs 46%, P < 0.0001), and preoperative steroids (28% vs 36%, P < 0.01) and anti-tumour necrosis factor (20% vs 40%, P < 0.0001) treatments were more frequently used in the second period. Smoking (14% vs 8%, P < 0.0001) and use of immunosuppressors (32% vs 22%, P < 0.001) decreased significantly. More cases of penetrating disease (22% vs 32%, P < 0.001) were operated upon in the second period. The laparoscopic approach (49% vs 57%, P < 0.04) was more frequently performed and mean blood loss (167 ± 222 vs 123 ± 243 ml, P < 0.01) decreased significantly. Postoperative morbidity did not change between the two periods.

CONCLUSION

Despite a higher incidence of comorbidities and the use of biologics postoperative morbidity remained unchanged. An increased use of laparoscopy and a decreased intra-operative blood loss may have contributed to offsetting the impact of increased comorbidity.

Anti-TNF Therapy Is Associated With an Increased Risk of Postoperative Morbidity After Surgery for Ileocolonic Crohn Disease: Results of a Prospective Nationwide Cohort

OBJECTIVE

To determine the risk factors of morbidity after surgery for ileocolonic Crohn disease (CD).

SUMMARY BACKGROUND DATA

The risk factors of morbidity after surgery for CD, particularly the role of anti-TNF therapy, remain controversial and have not been evaluated in a large prospective cohort study.

METHODS

From 2013 to 2015, data on 592 consecutive patients who underwent surgery for CD in 19 French specialty centers were collected prospectively. Possible relationships between anti-TNF and postoperative overall morbidity were tested by univariate and multivariate analyses. Because treatment by anti-TNF is possibly dependent on the characteristics of the patients and disease, a propensity score was calculated and introduced in the analyses using adjustment of the inverse probability of treatment-weighted method.

RESULTS

Postoperative mortality, overall and intra-abdominal septic morbidity rates in the entire cohort were 0%, 29.7%, and 8.4%, respectively; 143 (24.1%) patients had received anti-TNF <3 months prior to surgery. In the multivariate analysis, anti-TNF <3 months prior to surgery was identified as an independent risk factor of the overall postoperative morbidity (odds-ratio [OR] =1.99; confidence interval [CI] 95% = 1.17-3.39, P = 0.011), with preoperative hemoglobin <10 g/dL (OR = 4.77; CI 95% = 1.32-17.35, P = 0.017), operative time >180 min (OR = 2.71; CI 95% = 1.54-4.78, P < 0.001) and recurrent CD (OR = 1.99; CI 95% = 1.13-3.36, P = 0.017). After calculating the propensity score and adjustment according to the inverse probability of treatment-weighted method, anti-TNF <3 months prior to surgery remained associated with a higher risk of overall (OR = 2.98; CI 95% = 2.04-4.35, P <0.0001) and intra-abdominal septic postoperative morbidities (OR = 2.22; CI 95% = 1.22-4.04, P = 0.009).

CONCLUSIONS

Preoperative anti-TNF therapy is associated with a higher risk of morbidity after surgery for ileocolonic CD. This information should be considered in the surgical management of these patients, particularly with regard to the preoperative preparation and indication of temporary defunctioning stoma.

Intra-abdominal Sepsis After Ileocolic Resection in Crohn's Disease: The Role of Combination Immunosuppression

BACKGROUND

Intra-abdominal sepsis complicates <10% of ileocolic resections for Crohn's disease, but the impact of combination immunosuppression and repeat resection on its development remains unknown.

OBJECTIVE

The purpose of this study was to determine risk factors for intra-abdominal sepsis after ileocolic resection, specifically examining the role of combination immunosuppression and repeat intestinal resection.

DESIGN

This was a retrospective review of patient records from 2007 to 2017.

SETTINGS

The study was conducted at a single-institution IBD tertiary referral center.

PATIENTS

Patients with a diagnosis of Crohn's disease who were undergoing ileocolic resection with primary anastomosis were included. Diverted patients were excluded.

MAIN OUTCOME MEASURES

Preoperative and intraoperative variables, including preoperative immunosuppressive regimens and previous intestinal resection, were evaluated as potential risk factors for intra-abdominal sepsis.

RESULTS

A total of 621 patients (55% women) underwent ileocolic resection for Crohn's disease; 393 (63%) were first-time resections. The rate of 30-day intra-abdominal sepsis was 8% (n = 50). On univariate analysis, triple immunosuppression (combination of a corticosteroid, immunomodulator, and biological) and previous intestinal resection were significantly associated with intra-abdominal sepsis. Both risk factors remained significant on multivariable analysis (OR for triple immunosuppression (vs none) = 3.53 (95% CI, 1.27-9.84); previous intestinal resection OR = 2.27 (95% CI, 1.25-4.13)). A significant trend was seen between an increasing number of these risk factors (triple immunosuppression and previous intestinal resection) and rate of intra-abdominal sepsis (5%, 12%, and 22% for 0, 1, and 2 risk factors; p < 0.01). A trend was observed between increasing number of previous intestinal resections and the rate of intra-abdominal sepsis (p < 0.01).

LIMITATIONS

This study is limited by its single-institution tertiary referral center scope.

CONCLUSIONS

Combination immunosuppression and previous intestinal resection were both associated with the development of intra-abdominal sepsis. In light of these results, surgeons should consider the effects of combination immunosuppression and a history of previous intestinal resection, in addition to other risk factors, when deciding which patients warrant temporary intestinal diversion. See Video Abstract at http://links.lww.com/DCR/A664.

Preoperative Ustekinumab Treatment Is Not Associated With Increased Postoperative Complications in Crohn's Disease: A Canadian Multi-Centre Observational Cohort Study

BACKGROUND

Ustekinumab (UST), an anti-IL12/23 inhibitor is indicated for moderate-to-severe Crohn's disease (CD). However, it is unclear if patients treated with UST are at increased risk for postoperative complications.

AIM

To evaluate the postoperative safety outcomes in UST-treated CD patients.

METHODS

A multicentre cohort study of UST-treated CD patients at two tertiary care centres (University of Calgary, University of Alberta, Canada) undergoing abdominal surgery between 2009 and 2016 was performed. Postoperative outcomes were compared against a control cohort of anti-TNF-treated patients over the same time-period. The primary outcome was occurrence of postoperative complications up to six months postoperatively, stratified by timing (early <30 days vs. late complications ≥30 days).

RESULTS

Twenty UST-treated patients and 40 anti-TNF-treated patients were included with a median preoperative treatment exposure of 6.5 months and 18 months, respectively (p=0.01). Bowel obstruction was the most common surgical indication in both cohorts. UST-treated patients were more likely to require an ostomy (70.0% vs. 12.5%, p<0.001) and be on combination therapy with either systemic corticosteroids or concurrent immunomodulators (azathioprine or methotrexate) (25.0% vs. 2.5%, p=0.01). Despite the increased concomitant use of immunosuppression in the UST-treated cohort, there were no significant differences in early or late postoperative wound infections (1/20 in UST-cohort, 2/40 in anti-TNF cohort, p=1.00), anastomotic leak (0/20 in UST-cohort, 3/40 in anti-TNF cohort, p=0.54), or postoperative ileus/obstruction (3/20 in UST-cohort, 4/40 in anti-TNF cohort, p=0.67).

CONCLUSIONS

CD patients receiving preoperative UST did not experience an increase in postoperative complications, despite increased use of concurrent immunosuppression.

Thickness of Subcutaneous Fat Is a Predictive Factor of Incisional Surgical Site Infection in Crohn's Disease Surgery: A Retrospective Study

Background

Incisional surgical site infection (iSSI) is a frequent postoperative complication of abdominal surgeries in patients with Crohn's disease (CD). In this study, we investigated the association between thickness of subcutaneous fat (TSF) and iSSI in patients with CD undergoing intestinal resections.

Patients and Methods

Patients with CD who had undergone abdominal surgery from January 2014 to January 2017 were included in this retrospective study. Patients' TSF and other possible predictors of iSSI, including clinical characteristics, preoperative medications, hematological index, surgery-related data, and postoperative outcomes, were collected. Univariate and multivariate statistical analyses were used to examine the potential factors. Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive value of factors.

Results

The patient cohort comprised 246 patients (167 male (67.9%); mean age 35.7 ± 12.4 years; mean disease duration 69.6 ± 60.8 months). The incidence of iSSI was 24.8% (61/246). TSF was a significant predictor of iSSI (OR 1.079, 95% CIs (1.020, 1.142), P = 0.008), being 13.7 mm in patients with iSSI and 9.9 mm in those without iSSI (P < 0.001). Additionally, C-reactive protein (CRP) concentrations (OR 1.059, P = 0.003) were also possible predictors of iSSI, as indicated by both univariate and multivariate analysis. A model of iSSI comprising TSF and CRP concentrations was moderately accurate (AUC 0.827, CIs (0.766, 0.888)).

Conclusions

Preoperative TSF and CRP independently affect iSSI in patients with CD undergoing intestinal resections.

Glasgow prognostic score is a practical predictive index for postoperative intra-abdominal septic complications after bowel resection in Crohn's disease patients

PURPOSE

Postoperative intra-abdominal septic complications (IASCs) are not uncommon in patients with Crohn's disease (CD). The appropriate index to predict postoperative IASCs in these individuals remains unknown. This study investigates whether the inflammation-based Glasgow prognostic score (GPS) is predictive in the setting of postoperative IASC CD patients who underwent elective bowel resection.

METHODS

A consecutive cohort of 163 CD patients who underwent elective intestinal resection from July 2012 to March 2016 was retrospectively analyzed. Patients were divided into two GPS groups, one lower and one higher. The GPS was defined by serum levels of C-reactive protein and albumin. Univariate and multivariate analyses were conducted to identify risk factors for postoperative IASCs.

RESULTS

Postoperative IASCs occurred in 25 (15.3%) patients. Compared with patients in the lower GPS group, patients with a higher GPS had a higher incidence of postoperative IASCs (9.85 vs. 38.71%, P < 0.001) and experienced longer postoperative hospital stay (10.53 ± 7.00 vs. 15.71 ± 9.17, P = 0.001). Univariate and multivariate analyses revealed preoperative GPS [odds ratio (OR) 5.016, 95% confidence interval (CI) 1.134-22.193, P = 0.034] and penetrating behavior (OR 4.495, 95% CI 1.377-14.670, P = 0.013) to be independent risk factors for postoperative IASCs.

CONCLUSIONS

A preoperative GPS can serve as a useful index for predicting manifestation of postoperative IASCs after bowel resection in patients with CD. Perioperative optimization is required to improve postoperative outcomes for patients with higher GPS.

Anti-TNF therapy is not associated with an increased risk of post-colectomy complications, a population-based study

AIM

Previous studies have raised concerns that the use of anti-tumour necrosis factor (anti-TNF) therapy in patients with ulcerative colitis (UC) undergoing surgery may increase the risk of postoperative complications. We have taken a population-based approach to investigate whether there is an association between anti-TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy.

METHOD

Hospital Episode Statistics (HES) data and procedural coding were used to identify all patients in England between April 2006 and March 2015 undergoing subtotal colectomy for UC. Patients were grouped into those who received anti-TNF therapy within 12 or 4 weeks of surgery and those who did not. The incidence of postoperative complications was evaluated by HES coding and compared between groups.

RESULTS

In all, 6225 UC patients underwent subtotal colectomy. 753 patients received anti-TNF therapy within 12 weeks prior to surgery (418 within 4 weeks). There was no difference in postoperative complications between groups although groups were not comparable for age and comorbidities. Logistic regression with complications as the outcome variable did not show any significant association between anti-TNF therapy and complications. Colectomy performed during an unplanned admission (vs planned admission) and smoking were associated with complications.

CONCLUSION

This large population-based study does not demonstrate any association between preoperative anti-TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy. The only variables associated with complications were colectomy performed during an unplanned admission and smoking.

Postoperative Morbidity Risks Following Ileocolic Resection for Crohn's Disease Treated With Anti-TNF Alpha Therapy: A Retrospective Study of 360 Patients

BACKGROUND

Despite the effectiveness of anti-TNF alpha (ATA) treatment to induce and maintain remission in Crohn's disease, surgical intervention is frequently required. Results of previous studies on the impact of anti-TNF on postoperative course are discordant. The aim of this study was to evaluate the impact of ATA on postoperative morbidity following ileocolic resection for Crohn's disease.

METHODS

A retrospective review of Crohn's disease patients undergoing ileocolic resection was performed. Patients receiving medical treatment ≤8 weeks prior to surgery were included and followed up for postoperative morbidity. The Clavien-Dindo classification was used for grading complications. Risk factors for postoperative morbidity were assessed on multivariable analysis.

RESULTS

A total of 360 patients underwent ileocolic resection for Crohn's disease between 2002 and 2013; 15.3% of patients had ATA ≤8 weeks prior to surgery. Laparoscopic resections were performed in 110 cases (31%), of which 6% were converted to an open operation. Primary anastomosis without the formation of a diverting ileostomy was performed in 301 cases. Overall morbidity was 24.2%, with a mortality rate of 0.8%. ATA use prior to surgery was identified as an independent risk factor for overall morbidity (odds ratio [OR], 2.05; 95% confidence interval [CI], 1.08-3.82; P = 0.027) and septic complications (OR, 2.14; 95% CI, 1.03-4.29; P = 0.04). In subgroup analysis of patients with a primary anastomosis, ATA use had no significant impact on septic or overall morbidity.

CONCLUSIONS

Preoperative ATA use is a risk factor for overall postoperative morbidity and septic complications. However, the formation of a primary anastomosis should not be influenced by preoperative ATA use.

Value of cross-sectional imaging in assessing active Crohn's disease before stoma reversal

BACKGROUND

There are currently no guidelines on the need to assess disease activity before stoma reversal in Crohn's disease (CD). We sought to determine the value of cross-sectional imaging for detecting active CD before stoma reversal.

METHODS

38 CD patients underwent cross-sectional imaging before stoma reversal. CD activity was blindly evaluated by an independent radiologist. Postoperative outcomes were recorded.

RESULTS

Before stoma reversal, cross-sectional imaging identified active CD in 20 of the 38 study participants (52.6%). In 9 out of 10 tested patients, radiologic and endoscopic assessments gave concordant findings with regard to CD recurrence before stoma reversal. Stoma reversal was delayed in half of the patients with active CD and in none of the patients without active CD. Before stoma reversal, tumor necrosis factor alpha antagonists or immunosuppressants were initiated in 45% of the patients with active CD and 5.6% of the patients without active CD. In the year following stoma reversal, the recurrence rate (in a radiologic assessment) was higher in patients with active CD than in patients without active CD (75.0% vs. 30.8%, respectively; p=0.04).

CONCLUSION

Cross-sectional imaging revealed postoperative recurrence in about a quarter of patients before stoma reversal; this finding may influence the postoperative treatment strategy and outcomes.

Perioperative blood transfusion is associated with post-operative infectious complications in patients with Crohn's disease

Background

We have previously demonstrated that blood transfusion (BT) was associated with post-operative complications in patients undergoing surgery for Crohn’s disease (CD), based on our institutional data registry. The aim of this study was to verify the association between perioperative BT and infectious complications in CD patients enrolled in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

Methods

All CD patients undergoing surgery between 2005 and 2013 were identified from NSQIP. Variables were defined according to the ACS NSQIP guidelines. The primary outcome was infectious complications, including superficial, deep and organ/space surgical site infection, wound dehiscence, urinary tract infection, pneumonia, systemic sepsis and septic shock. Multivariate analyses were performed to assess the risk factors for post-operative infections.

Results

All 10 100 eligible patients were included and 611 (6.0%) received perioperative BT. BT patients were older, lighter in weight and more likely to be functionally dependent. BT patients were more likely to have post-operative infectious complications than those without BT, including superficial surgical site infection (SSI) (10.8% vs 7.4%, p=0.002), deep SSI (3.3% vs 1.6%, p=0.003), organ/space SSI (14.2% vs 5.4%, p<0.001), pneumonia (3.8% vs 1.3%, p<0.001), urinary tract infection (3.9% vs 2.2%, p=0.006), sepsis (11.5% vs 4.5%, p<0.001) and sepsis shock (3.1% vs 0.8%, p<0.001). Multivariate analysis showed that intra- and/or post-operative BT was an independent risk factor for post-operative infectious complications (odds ratio [OR] = 2.2; 95% confidence interval [CI]: 1.8–2.7; p<0.001) and the risk increased with each administered unit of red blood cell (OR = 1.3, 95% CI: 1.2–1.5). Other independent factors were history of smoking, chronic heart disease, diabetes, hypertension and the use of corticosteroids. Pre-operative BT, however, was not found to be a risk factor to post-operative infections.

Conclusions

Intra- and/or post-operative, not pre-operative, BT was found to be associated with an increased risk for post-operative infectious complications in this CD cohort. Therefore, the timing and risks and benefits of BT should be carefully balanced.

Risk factors of surgical site infections in patients with Crohn's disease complicated with gastrointestinal fistula

PURPOSE

Surgical site infection (SSI) is the most common complication following surgical procedures. This study aimed to determine risk factors associated with SSI in patients with Crohn's disease (CD) complicated with gastrointestinal fistula.

METHODS

This was a retrospective review of patients who underwent surgical resection in gastrointestinal fistula patients with CD between January 2013 and January 2015, identified from a prospectively maintained gastrointestinal fistula database. Demographic information, preoperative medication, intraoperative findings, and postoperative outcome data were collected. Univariate and multivariate analysis was carried out to assess possible risk factors for SSI.

RESULTS

A total of 118 patients were identified, of whom 75.4% were men, the average age of the patients was 34.1 years, and the average body mass index (BMI) was 18.8 kg/m². The rate of SSI was 31.4%. On multivariate analysis, preoperative anemia (P = 0.001, OR 7.698, 95% CI 2.273-26.075), preoperative bacteria present in fistula tract (P = 0.029, OR 3.399, 95% CI 1.131-10.220), and preoperative enteral nutrition (EN) <3 months (P < 0.001, OR 11.531, 95% CI 3.086-43.079) were predictors of SSI. Notably, preoperative percutaneous abscess drainage was shown to exert protection against SSI in fistulizing CD (P = 0.037, OR 0.258, 95% CI 0.073-0.920).

CONCLUSION

Preoperative anemia, bacteria present in fistula tract, and preoperative EN <3 months significantly increased the risk of postoperative SSI in gastrointestinal fistula complicated with CD. Preoperative identification of these risk factors may assist in risk assessment and then to optimize preoperative preparation and perioperative care.

Perioperative use of immunosuppressive medications in patients with Crohn's disease in the new "biological era"

Crohn’s disease (CD) is characterized by transmural inflammation of the gastrointestinal tract leading to inflammatory, stricturing and/or and fistulizing disease. Once a patient develops medically refractory disease, mechanical obstruction, fistulizing disease or perforation, surgery is indicated. Unfortunately, surgery is not curative in most cases, underscoring the importance of bowel preservation and adequate perioperative medical management. As many of the medications used to treat CD are immunosuppressive, the concern for postoperative infectious complications and anastomotic healing are particularly concerning; these concerns have to be balanced with preventing and treating residual or recurrent disease. We herein review the available literature and make recommendations regarding the preoperative, perioperative and postoperative administration of immunosuppressive medications in the current era of biological therapy for CD. Standardized algorithms for perioperative medical management would greatly assist future research for optimizing surgical outcomes and preventing disease recurrence in the future.

Safety of treatments for inflammatory bowel disease: Clinical practice guidelines of the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD)

Inflammatory bowel diseases are chronic conditions of unknown etiology, showing a growing incidence and prevalence in several countries, including Italy. Although the etiology of Crohn's disease and ulcerative colitis is unknown, due to the current knowledge regarding their pathogenesis, effective treatment strategies have been developed. Several guidelines are available regarding the efficacy and safety of available drug treatments for inflammatory bowel diseases. Nevertheless, national guidelines provide additional information adapted to local feasibility, costs and legal issues related to the use of the same drugs. These observations prompted the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) to establish Italian guidelines on the safety of currently available treatments for Crohn's disease and ulcerative colitis. These guidelines discuss the use of aminosalicylates, systemic and low bioavailability corticosteroids, antibiotics (metronidazole, ciprofloxacin, rifaximin), thiopurines, methotrexate, cyclosporine A, TNFα antagonists, vedolizumab, and combination therapies. These guidelines are based on current knowledge derived from evidence-based medicine coupled with clinical experience of a national working group.

Hepatitis B reactivation in HBsAg-negative/HBcAb-positive patients receiving immunosuppressive therapy for glomerulonephritis: a retrospective analysis

PURPOSE

The aim of this study is to investigate the prevalence and risk factors for hepatitis B virus (HBV) reactivation in HBsAg-negative/HBcAb-positive patients receiving immunosuppressive therapy for glomerulonephritis.

METHODS

We performed a retrospective study of 745 HBsAg-negative/HBcAb-positive patients undergoing immunosuppressive therapy for glomerulonephritis from years 2003 to 2012 at the department of nephrology, China-Japan Friendship Hospital, Beijing, China. The patients were divided into HBV reactivation group (n = 27) and non-HBV reactivation group (n = 718).

RESULTS

The prevalence of HBV reactivation in patients receiving immunosuppressive therapy for glomerulonephritis was up to 3.62% in serological status of HBsAg-negative/HBcAb-positive. HBV reactivation was associated with several findings: greater proportion of lupus nephritis (25.93 vs. 9.61%, p = 0.014), much higher percentage of HBsAb-negative (74.07 vs. 23.82%, p < 0.001), longer duration of immunosuppressive treatment (100 vs. 70.06%, p < 0.001), as well as more cases of combined immunosuppressant (92.59 vs. 61.56%, p = 0.001). After univariate and multivariate analysis, three variables remained as independent risk factors for HBV reactivation: serological status of HBsAb-negative (OR 8.375, 95% CI 3.674-19.776, p = 0.001), length of immunosuppressive treatment more than 1 year (OR 1.308, 95% CI 1.121-1.358, p = 0.024), and combined immunosuppressant (OR 6.342, 95% CI 1.675-30.166, p = 0.003).

CONCLUSIONS

HBV reactivation is not uncommon in HBsAg-negative/HBcAb-positive glomerulonephritis patients treated with immunosuppressant, and the prevalence was up to 3.62%. Patients with serological status of HBsAb-negative, more than 1 year of immunosuppressive therapy, and combined immunosuppressant are independent risk factors for HBV reactivation.

Effect of Anti-TNF Agents on Postoperative Outcomes in Inflammatory Bowel Disease Patients: a Single Institution Experience

BACKGROUND

Anti-tumor necrosis factor (TNF) agents have been an integral part in the treatment of inflammatory bowel disease. However, a subset of inflammatory bowel disease patients ultimately requires surgery and up to 30 % of them have undergone treatment with anti-TNF agents. Studies assessing the effect of anti-TNF agents on postoperative outcomes have been inconsistent. The aim of this study is to assess postoperative morbidity in inflammatory bowel disease patients who underwent surgery with anti-TNF therapy prior to surgery.

METHODS

This is a retrospective review of 282 patients with inflammatory bowel disease undergoing intestinal surgery between 2013 and 2015 at the Mount Sinai Hospital. Patients were divided into two groups based on treatment with anti-TNF agents (infliximab, adalimumab, certolizumab) within 8 weeks of surgery. Thirty-day postoperative outcomes were recorded. Univariate and multivariate statistical analyses were carried out.

RESULTS

Seventy-three patients were treated with anti-TNF therapy within 8 weeks of surgery while 209 patients did not have exposure. Thirty-day anastomotic leak, intra-abdominal abscess, wound infection, extra-abdominal infection, readmission, and mortality rates were not significantly different between the two groups.

CONCLUSIONS

The use of anti-TNF medications in inflammatory bowel disease patients within 2 months of intestinal surgery is not associated with an increased risk of 30-day postoperative complications.

NASPGHAN Clinical Report: Surveillance, Diagnosis, and Prevention of Infectious Diseases in Pediatric Patients With Inflammatory Bowel Disease Receiving Tumor Necrosis Factor-α Inhibitors

Children and adolescents with inflammatory bowel disease (IBD) receiving therapy with tumor necrosis factor α inhibitors (anti-TNFα) pose a unique challenge to health care providers in regard to the associated risk of infection. Published experience in adult populations with distinct autoinflammatory and autoimmune diseases treated with anti-TNFα therapies demonstrates an increased risk of serious infections with intracellular bacteria, mycobacteria, fungi, and some viruses; however, there is a paucity of robust pediatric data. With a rising incidence of pediatric IBD and increasing use of biologic therapies, heightened knowledge and awareness of infections in this population is important for primary care pediatricians, pediatric gastroenterologists, and infectious disease (ID) physicians. This clinical report is the result of a consensus review performed by pediatric ID and gastroenterology physicians detailing relevant published literature regarding infections in pediatric patients with IBD receiving anti-TNFα therapies. The objective of this document is to provide comprehensive information for prevention, surveillance, and diagnosis of infections based on current knowledge, until additional pediatric data are available to inform evidence-based recommendations.

Self-medication with steroids in inflammatory bowel disease

BACKGROUND

The self-prescribing rates of corticosteroids in inflammatory bowel disease (IBD) patients treated with biologicals are unknown.

AIM

To investigate the frequency and modalities of self-medication with steroids in adult IBD patients.

METHODS

Patients with IBD who attended Nancy University Hospital between November 2012 and May 2013 were included in the study. Patients were interviewed using an 11 item questionnaire.

RESULTS

100 patients participated in the survey. In total 15 patients (15%) had already used corticosteroids without medical prescription since their IBD diagnosis and 4 patients of them (27%) used steroids as self-medication while on anti-TNF treatment. The mean total duration of corticosteroid treatment was 24 days (range 1.5-105). In total 4 patients (27%) used corticosteroids more than 10 times without medical prescription (range 1-20). The two main reasons were the need for quick relief of symptoms (n=6) and the unwillingness to consult a physician (n=3).

CONCLUSION

A relatively high proportion of patients with IBD use corticosteroids without medical prescription. Due to their side effects, self-medication may include 'steroid dependency' as it may reflect uncontrolled disease. As steroids have significant side effects and patients may have active disease it is important to counsel patients and to monitor their self-prescribing patterns in IBD patients.