Letter: surgery for ulcerative colitis mostly follows anti‐TNF drugs ‐ a new ‘therapeutic package’?

Abstract

We read with interest Nørgård et al. article ‘Pre-operative use of anti-TNF-α agents and the risk of post-operative complications in patients with ulcerative colitis – a nationwide cohort study’.1 This is a very interesting study, with a good design and including a high number of patients. The results confirm the feelings of most gastroenterologists about the absence of more post-operative complications in ulcerative colitis (UC) patients who received anti-TNF before a colectomy. Undoubtedly, these results will help in the future when we -gastroenterologists- have to ‘convince’ surgeons, classically more sceptical in this issue due to the results of previous studies.2, 3 What we find rather interesting in the article is the progressive increase in the use of anti-TNFs before colectomy, with nearly 90% of patients treated with these drugs in the last 3 years. Anti-TNF indications in UC are progressively increasing; nowadays they are not only used for steroid-refractory UC 4 but also for some patients after ciclosporin failure.5 Anti-TNF drugs are commonly used in steroid-dependent UC patients after thiopurines failure,6, 7 and if in this indication anti-TNFs do not work, the next step should be colectomy.8 We think that in the near future most UC patients who are going to be colectomised, perhaps with the exception of those having a very severe flare or those having high-grade dysplasia, could have previously been treated with anti-TNF drugs. Nevertheless, in a slightly more distant future, the increased use of anti-TNF drugs before colectomy may not be as beneficial. It is known that about 30% of UC patients who undergo a colectomy will develop pouchitis.9 In recent years, anti-TNF drugs have been more commonly used for the treatment of chronic refractory pouchitis, but in a recent Spanish (GETECCU) multicenter study we have observed that patients who had received infliximab before colectomy, when treated for chronic refractory pouchitis with the same drug, had a poorer response and developed more adverse events.10 Declaration of personal and funding interests: None.