Laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis and impact of anti-tumor necrosis factor on postoperative outcomes

Abstract

The anti-tumor necrosis factor alpha (infliximab) has become an effective drug in the medical treatment of moderate or severe ulcerative colitis [1]. Infliximab can delay the incidence of complications and disease progression. However, the definitive treatment of ulcerative colitis is a surgical approach. Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) remains the standard of care for most patients with ulcerative colitis [2]. The short-term postoperative outcomes can substantially be improved by laparoscopic surgery for gastrointestinal diseases, including colorectal cancer and gastric cancer [3–9]. This advance in laparoscopic surgery has been translated into laparoscopic restorative proctocolectomy (LRPC) with IPAA for the treatment of ulcerative colitis [10]. However, the impact of medical treatment with infliximab on a subsequent surgical treatment is unclear and because the data are still scarce, there is debate whether infliximab increases postoperative complications. Given this uncertainty, Coquet-Reinier and colleagues [11] evaluated the effect of infliximab on postoperative morbidity after LRPC with IPAA in patients who were previously treated with this anti-tumor necrosis factor. In this report published in the August issue of Surgical Endoscopy, the authors compared the results regarding operating time, complications, and hospital stay between patients with LRPC and IPAA with or without preoperative treatment with infliximab. There was no significant difference between patients treated with and those treated without infliximab regarding mean operative time (353 vs. 355 min), complication rate (23 vs. 38%), and mean hospital stay (22 vs. 25 days). Coquet-Reinier and colleagues concluded that there was no adverse impact of infliximab previous therapy on postoperative morbidity of patients with ulcerative colitis treated with laparoscopic restorative proctocolectomy with IPAA. Laparoscopic restorative proctocolectomy with IPAA is a highly demanding procedure. It can be safe and effective only when it is performed in specialized institution by high-volume surgeons. The difficulties in both disease management and laparoscopic surgery are reflected by the long hospital stay, more than 3 weeks, and a mean operating time of approximately 6 hours in this study. Although it is hard to draw conclusions from a small retrospective analysis, this study provides useful information that infliximab does not likely increase postoperative complications after laparoscopic RPC and IPAA. Certainly further evaluation is needed. Given the aggressiveness of surgery with adverse effects in quality of life, current research is focused on how to design and develop novel biologic agents that would be effective in reversing the progression of disease or even associated with cure-sparing large surgical procedures and adverse effects. However, ulcerative colitis and morbus Crohn are complex multifactorial disorders, such as cancer, and there are still major challenges for the development of novel biomarkers and biologic drugs that may successfully treat complicated disorders. The advent of next-generation sequencing technology for partial or complete sequencing of human genomes advances in genome-wide association studies, genetics, and personal genomics along with E. Hanisch Klinik fur Allgemein-Viszeral-und Endokrine Chirurgie, Asklepios Klinik Langen, Akademisches Lehrkrankenhaus der JWG, Universitat Frankfurt, Rontgenstr 20, 63225 Langen, Germany