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Ulcerative Colitis: Do Anti-TNF Medications Before Surgery Increase Complications?

Treatment for ulcerative colitis can consist of medications and/or surgery. Receiving both have raised concerns in the medical community for their role in causing adverse effects.

Ulcerative colitis is a chronic disease of the large intestine that is characterized by inflammation and ulcers in the colon. The clinical course of care varies tremendously for those affected with this inflammatory bowel disease. As one of the main interventions to treat the disease, surgery is usually the choice of care for those who require hospitalization.

Increased inflammation in the colon and rectal areas is caused by an increase in a pro-inflammatory cytokine called tumor necrosis factor (TNF).  A biologic agent known as anti-TNF interferes with the inflammatory cascade and is thus used for treating inflammatory bowel disease. Anti-TNF is comprised of antibodies that specifically target tumor necrosis factor and is known to improve mucosal healing, induce and maintain remission, and reduce the need for corticosteroids. However, surgery can disturb these important inflammatory mechanisms and interfere with wound healing and infection defense.

The Follow-up Approach

Referred to as the “top-down approach,” early use of anti-TNF medications, such as infliximab and adalimumab, help to induce remission for ulcerative colitis patients.

Anti-tumor necrosis factor therapy has increased over the last years. However, its postoperative effects were unclear to the medical community. What was known was that patients who received anti-TNF agents before surgery, experienced a series of adverse effects after surgery. And for most, surgery follows the recent use of anti-TNF agents. Therefore, a medical conflict arises because patients who are good candidates for anti-TNF therapy are also at a high risk for subsequent surgical treatment.

With this in mind, a group of researchers at Pennsylvania State University set out to determine the potential effects of administered anti-TNF agents to patients who also were treated with surgery. Published in JAMA Surgery, this research study set out to assess the association of preoperative use of anti-TNF agents with adverse postoperative outcomes.

Investigating the Effects of Anti-TNF Agents

A large national claims database was used to investigate the effects of anti-TNF agents on surgical patients with ulcerative colitis. Insurance claims identified 2,476 patients that were 18 years of age or older and had a diagnosis of ulcerative colitis. All the insured patients had inpatient and/or outpatient claims for a subtotal colectomy or total abdominal colectomy, a total proctocolectomy with end ileostomy, or ileal pouch-anal anastomosis. Adverse effects after surgery consisted of 90-day complications, emergency department visits, and readmissions.

Study Finds No Increase in Complications

The results showed no increase in complications among the colectomy or proctocolectomy groups. However, an increase in postoperative complications and an increase in overall complications were observed among patients in the ileal pouch group and who had received anti-TNF agents within 90 days of surgery.

Overall, this investigation sheds light on surgery after administration of anti-TNF therapy and shows that anti-TNF agent use within 90 days of surgery for patients undergoing ileal pouch-anal anastomosis is associated with increased postoperative complications. This important finding can provide guidance to health care providers when treating patients who may need surgery for ileal pouch-anal anastomosis.

Written by Viola Lanier PhD, MSc


Association of Preoperative Anti–Tumor Necrosis Factor Therapy With Adverse Postoperative Outcomes in Patients Undergoing Abdominal Surgery for Ulcerative Colitis, Audrey S. Kulaylat, MD; Afif N. Kulaylat, MD; EricW. Schaefer, MS; Andrew Tinsley, MD; Emmanuelle Williams, MD; Walter Koltun, MD; Christopher S. Hollenbeak, PhD; Evangelos Messaris, MD, PhD, JAMA Surg. doi:10.1001/jamasurg.2017.1538

Published online June 14, 2017.



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