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INTRODUCTION: Patients with moderate to severe inflammatory bowel disease (IBD) have a high likelihood of being exposed to anti-tumor necrosis factor (TNF) therapy as well as undergoing an operative resection. Studies looking at preoperative anti-TNF therapy effects on the early post-operative period have shown contradictory findings. Some physicians time operations with the nadir of the anti-TNF therapy to minimize their immunosuppressive effect; however it is unclear if this practice improves outcomes.
AIMS: 1) Determine early post-operative complication (EPC) rates in IBD patients on anti-TNF therapy compared to patients on immunomodulators (IM) alone and 2) assess the effect of remote versus immediate anti-TNF pre-operative therapy on EPC rates.
METHODS: A retrospective review of a prospectively collected database of pts with IBD who underwent resection of small or large intestine from July 1st, 2005 to July 1st, 2010 was performed. Main outcome of interest was the combined EPC rate, defined as any of the following secondary outcomes: infection, anastomotic leak, re-admission, reoperation, thrombosis, acute kidney injury (AKI), ileus, or new drain within 30 days after surgery. All pts on anti-TNF therapy (ALLT) were compared to pts on IM alone. The ALLT group was divided into remote preoperative (RP) and immediate preoperative (IP) groups; pts receiving a TNF dose greater than and less than ½ of their dosing interval prior to the operation, respectively.
RESULTS: A total of 114 pts (60% F; 86.8% Crohn’s Disease) had resections, 76 ALLT pts (46 IP and 30 RP pts) and 38 IM pts. All groups were similar in terms of age, gender, race, smoking, and disease duration; except ALLT had a higher prevalence of penetrating CD than the IM group (43% vs. 29.4%; p=0.05). Comparison of the ALLT to the IM alone group showed no difference (43.4% vs. 26.3%, p=0.08) in terms of the combined EPC rates, or in individual secondary outcome rates. Comparison of the IP and RP groups showed no significant difference (21.7% vs. 30.0% p=0.16) in the combined EPC rate, or in individual secondary outcome complication rates. The average length of post-operative stay was similar in all groups. Use of steroids was not associated with a difference in EPC or length of stay in any group, removing patients on budesonide alone had no effect. However, a greater proportion of ALLT pts were on steroids 43.4% vs. 18.4%, p=0.001 compared to the IM group at the time of surgery.
CONCLUSION: Despite an increased likelihood of being exposed to steroids and having more severe CD, patients on pre-operative anti-TNF therapy had similar EPC rates compared to IM only patients. Further investigation of anti TNF therapy timing in the pre-operative period is warranted to recognize its contribution to EPC rates and to optimize treatment in the peri-operative period.