The impact of preoperative biologic therapy on anastomotic complications after surgery for Crohn's disease

Abstract

We read with interest the recent article on the impact of preoperative biologic therapy on anastomotic complications after surgery for Crohn’s disease (CD) by El-Hussuna, et al. [1]. This is a retrospective study on 417 operations for CD performed at four Danish hospitals in 2000–2007. Thirty-two patients (7.7%) were preoperatively treated with biologics and 166 (39.8%) were on immunomodulation. Preoperative biologic treatment or immunomodulation had no influence on anastomotic complications. In contrast, preoperative treatment with prednisolone (‡ 20 mg), operation time, and a colo-colic anastomosis were independent significant risk factors for anastomotic complications. Although this study is retrospective, it is the largest study evaluating the impact of biologic therapy on postoperative complications [1]. Several studies [2–6] have investigated the relationship between preoperative use of anti-tumor necrosis factor antibodies and postoperative complications in patients with CD. There are several limitations in the previous studies including this study. Firstly, not all the studies clarified the duration between last infusion of infliximab and surgery. Some patients had received a last infusion of infliximab more than 12 weeks before surgery. Biological effect of infliximab may not be sustained over a period of 12 weeks. Secondly, most patients received a combined medication (e.g., corticosteroids, immunosuppressants) with biologics before surgery. Furthermore, other factors than biologic use itself may be associated with the risk of postoperative complications: poor nutritional status, and the presence of enteric fistula and intra-abdominal abscess at laparotomy [7,8]. Recently, a meta-analysis of comparative cohort studies was conducted to assess postoperative complication rates in CD patients who were treated with anti-tumor necrosis factor antibodies within 3 months before surgery versus patients who were not [9]. The primary outcome was overall complication rate within one month of surgery. Secondary outcomes included the rate of infectious and noninfectious complications. A total of eight studies including 1,641 patients were included in the metaanalysis. Preoperative infliximab therapy in CD patients undergoing abdominal surgery was associated with a trend toward an increased rate of total complications (odds ratio [OR] 1.72). Anti-tumor necrosis factor treatments were associated with a modestly increased risk of infectious complications (OR 1.50), mostly remote from the surgical site (OR 2.07) and with a trend toward a higher rate of non-infectious complications (OR 2.00). The metaanalysis concluded that preoperative infliximab therapy is associated with an increased risk of postoperative infectious complications, mostly remote from the surgical site. Furthermore, a trend toward an increased risk of non-infectious and overall complications was also observed. In the surgical management of CD, anastomotic complications seriously impair the patient’s quality of life. Surgeons should create a temporary covering stoma to protect anastomosis, or avoid anastomosis for patients at a significantly high risk of anastomotic complications. Patients with malnutrition and preexisting intraabdominal abscess during biologic therapy may have an increased risk of anastomotic complications. Further prospective