Preoperative anti-TNF Therapy Research Articles

Effects of Preoperative Anti-TNF Therapy on Specimen Length in Crohn’s Disease and Beyond

Effects of Preoperative Anti-TNF Therapy on Specimen Length in Crohn’s Disease and Beyond

Preoperative Anti-TNF Therapy is Associated with a Shorter Length of Resected Bowel in Patients Undergoing Ileocolic Resection for Crohn’s Disease

Background Massive or repeated intestinal resections for Crohn’s disease (CD) could lead to disabling consequences. The present study aimed to assess the effect of preoperative anti-TNF therapy on the length of resected bowel and identify risk factors for postoperative morbidity following ileocolic resection for CD. Methods Patients undergoing elective ileocolic resection for CD were included prospectively. Medical variables including demographics, Montréal classification, preoperative treatment, surgical details and 30-day postoperative morbidity were collected. Potential impact of preoperative anti-TNF treatment on length of ileocolic specimen and risk factors for postoperative morbidity were investigated. Results One hundred and eight-four patients were included in this study, and 66 (35.9%) of them received anti-TNF agents within 8 weeks prior to surgery. Primary anastomosis was performed in 145 patients (78.8%). The mean length of resected intestine was 10 cm shorter in subjects receiving preoperative anti-TNF treatment than those without preoperative anti-TNF therapy (P < 0.001). The rates of postoperative overall, infectious and intra-abdominal septic morbidity were 29.9%, 19.0% and 7.6%, respectively. In multivariate analysis, anti-TNF therapy < 8 weeks before surgery was independently associated with a shorter length of resected bowel but didn’t increase overall and septic complications, while systemic steroids use within 8 weeks prior to surgery independently increased overall complications and intra-abdominal sepsis. Conclusions Preoperative anti-TNF therapy was associated with a shorter length of resected bowel but not the overall and septic postoperative complications in ileocolic resection for CD. Weaning off systemic steroids before surgery may improve postoperative outcomes in patients with CD.

Increased Risk of Infections with Anti-TNF Agents in Patients with Crohn's Disease After Elective Surgery: Meta-Analysis.

Postoperative complication rates in patients with inflammatory bowel disease (IBD) receiving preoperative biologics have been analyzed without considering the surgical context. Emergency surgery may be associated with an increased risk of infectious complications, compared to elective operations. To conduct a systematic review and meta-analysis investigating the relationship between preoperative biologic therapy and postoperative outcomes in Crohn's disease (CD) and ulcerative colitis (UC), focusing on elective surgery. Electronic databases were searched up to February 12, 2020, for studies of patients with IBD undergoing elective abdominal surgery receiving biologic therapy within 3months before surgery compared to no therapy, or another biologic therapy. Certainty of evidence was evaluated using GRADE. The primary outcomes were the rate of infections and total complications within 30days. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Thirty-three studies were included. Preoperative treatment with anti-tumor necrosis factor (TNF) therapy in patients with CD undergoing elective surgery was associated with increased odds of infection (OR 2.05; 95% CI 1.40-3.01), but not total complications (OR 1.03; 95% CI 0.71-1.51). In elective surgery for UC, preoperative anti-TNF therapy was not associated with infectious (OR 1.03; 95% CI 0.34-3.07) or total complications (OR 0.67; 95% CI 0.29-1.58). Limited data indicate that emergency surgery did not significantly affect the rate of complications. Anti-TNF therapy prior to elective surgery may increase the odds of postoperative infection in CD, although the certainty of evidence is very low. More evidence is needed, particularly for newer biologics.

Systematic review and meta-analysis: risks of postoperative complications with preoperative use of anti-tumor necrosis factor-alpha biologics in inflammatory bowel disease patients.

The preoperative use of anti-tumor necrosis factor-alpha (anti-TNF) in inflammatory bowel disease (IBD) patients undergoing surgery has been controversial due to concern for increased risks of postoperative complications. We aimed to determine the effect of preoperative anti-TNF therapy on postoperative complications in IBD patients undergoing abdominal surgery. A literature search of Google Scholar, PubMed, The Cochrane Library, EMBASE, and CINAHL was performed through October 2019. Studies reporting postoperative complication rates of Crohn's disease (CD), ulcerative colitis (UC), and IBD-unspecified patients with preoperative anti-TNF treatment undergoing abdominal surgery compared to controls without preoperative anti-TNF treatment were included. The main outcomes measured were overall, infectious, and noninfectious postoperative complications. Forty-one studies totaling 20 274 patients were included. There was a significant increase in overall complications in all patients treated with anti-TNF vs. controls [odds ratio (OR) = 1.13, 95% confidence interval (CI), 1.01-1.25, P = 0.03, I2 = 6%] with an absolute risk increase (ARI) of 5.5% and a number needed to harm (NNH) of 18. There was also a significant increase in infectious complications in CD patients (OR = 1.44; 95% CI 1.02-2.03, P = 0.04, I2 = 49%, ARI = 5.5%, NNH = 20) only. Contrastingly, there was a significant increase in noninfectious complications in all patients (OR = 1.44, 95% CI 1.13-1.85, P = 0.003, I2 = 8%, ARI = 6.4%, NNH = 16) and UC patients (OR = 1.57, 95% CI 1.15-2.14, P = 0.005, I2 = 25%, ARI = 8.5%, NNH = 12) only. Preoperative use of anti-TNF agents in IBD patients undergoing abdominal surgery is associated with increases in overall postoperative complications in all patients, infectious postoperative complications in CD patients, and noninfectious postoperative complications in UC patients.

S0764 Systematic Review and Meta-Analysis: Risks of Postoperative Complications With Preoperative Use of Anti-Tumor Necrosis Factor-Alpha Biologics in Inflammatory Bowel Disease Patients

INTRODUCTION: The advent of biologic therapy has revolutionized the medical approach to IBD and has played an integral role in the treatment of both Crohn’s disease (CD) and ulcerative colitis (UC), becoming the cornerstone of treatment. However, the preoperative use of anti-tumor necrosis factor-alpha (anti-TNF) therapy in IBD patients undergoing surgery has been controversial due to concern for increased risks of postoperative complications. The purpose of this study was to determine the effect of preoperative anti-TNF therapy on postoperative complications in IBD patients undergoing abdominal surgery. METHODS: A literature search of Google Scholar, PubMed, The Cochrane Library, EMBASE, and CINAHL was performed through October 2019. Studies reporting postoperative complication rates of Crohn’s disease (CD), ulcerative colitis (UC), and inflammatory bowel disease-unspecified (IBD-U) patients with preoperative anti-TNF treatment undergoing abdominal surgery compared to controls without preoperative anti-TNF treatment were included. The main outcomes measured were overall, infectious, and non-infectious postoperative complications. A meta-analysis was completed using the Mantel-Haenszel and DerSimonian and Laird models. RESULTS: 41 studies totaling 20274 patients were included. There was a significant increase in overall complications in all patients treated with anti-TNF vs controls (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.01–1.25, P = 0.03, I2 = 6%) with an absolute risk increase (ARI) of 5.5% and a number needed to harm (NNH) of 18. There was also a significant increase in infectious complications in CD patients (OR, 1.44; 95% CI, 1.02–2.03, P = 0.04, I2 = 49%, ARI = 5.5%, NNH = 20) only. Contrastingly, there was a significant increase in noninfectious complications in all patients (OR, 1.44; 95% CI, 1.13–1.85, P = 0.003, I2 = 8%, ARI = 6.4%, NNH = 16) and UC patients (OR, 1.57; 95% CI, 1.15–2.14, P = 0.005, I2 = 25%, ARI = 8.5%, NNH = 12) only. CONCLUSION: Preoperative use of anti-TNF agents in IBD patients undergoing abdominal surgery is associated with increases in overall postoperative complications in all IBD patients, infectious postoperative complications in CD patients, and noninfectious postoperative complications in UC patients. As such, a preoperative drug-free period may be warranted to reduce the risk of postoperative complications. Large, prospective studies are needed to further assess the impact of anti-TNF agents on postoperative complications.Figure 1.: Forrest plot of overall postoperative complications in anti-TNF vs control in all IBD patients.Figure 2.: Forrest plot of infectious postoperative complications in anti-TNF vs control in CD and UC patients after sensitivity analysis.Figure 3.: Forrest plot of noninfectious postoperative complications in anti-TNF vs control in all IBD patients.

2019 Canadian Surgery Forum Abstracts.

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

Systematic review with meta-analysis: risk of post-operative complications associated with pre-operative exposure to anti-tumour necrosis factor agents for Crohn's disease.

Post-operative complications after anti-tumour necrosis agent treatment for Crohn's disease (CD) have been analysed with conflicting results. To assess the effects of pre-operative anti-tumour necrosis factor (TNF) therapy on post-operative complications within 30days post-operatively in patients with CD undergoing abdominal surgery. Systematic review with meta-analysis was performed on articles found in MEDLINE, Embase, Cochrane Library, Scopus, and the International Clinical Trials Registry Platform until September 2018. Twenty studies (7115 patients) were included. Without confounder adjustment, pre-operative anti-TNF therapy in patients with CD undergoing abdominal surgery was associated with increased rates of infectious complications (unadjusted odds ratio, OR, 1.49; 95% CI, 1.08-2.06). After confounder adjustment, Pre-operative anti-TNF therapy was significantly associated with both increased rates of total and infectious complications (adjusted OR, 1.53 and 2.09; 95% CI, 1.11-2.09 and 1.19-3.65, respectively). After subgroup analyses, the association between anti-TNF agents and total complications was significant in high incidence countries (adjusted OR, 1.86; 95% CI, 1.43-2.42) but not in low incidence countries (adjusted OR, 0.77; 95% CI, 0.48-1.25). Exposure to anti-TNF agents is an independent risk factor for post-operative infectious complications in patients with CD, especially in countries with a high incidence of Crohn's disease. We suggest postponing elective surgery or carefully monitoring these patients post-operatively.

P082 PREOPERATIVE ANTI-TNFS ARE ASSOCIATED WITH A SHORTER INTERVAL TO DE NOVO CROHN’S DISEASE AFTER ILEAL POUCH-ANAL ANASTOMOSIS FOR ULCERATIVE COLITIS

Anti-tumor necrosis factor (anti-TNF) agents are widely used in the treatment of moderate to severe ulcerative colitis (UC) since commercial approval in 1998. Many patients however ultimately require surgery with ileal pouch-anal anastomosis (IPAA). Conversion of UC to Crohn’s disease (CD) following IPAA is a devastating complication termed de novo Crohn’s disease (DNCD). Despite increasing adoption, few prior studies have evaluated the effect of preoperative anti-TNFs on DNCD development. As we have noticed an increasing incidence of DNCD, we hypothesized that preoperative utilization of anti-TNFs may be associated with the development of DNCD after IPAA. A prospective inflammatory bowel disease (IBD) registry was queried for consecutive UC patients undergoing IPAA during the 25-year period ending 2018. Patients with preoperative CD or IBD unclassified were excluded. De novo CD after IPAA was diagnosed when 5 or more ulcers involving the small-bowel proximal to the ileal pouch or a pouch fistula or other perianal complication developed >3 months after ileostomy closure. Preoperative anti-TNF therapy and development of DNCD was compared between 3 chronologic periods throughout the study: period 1: 1993-1998 (pre-approval of anti-TNFs for UC), period 2: 1999-2008, and period 3: 2009-2018. Cox proportional-hazards model was used to identify predictors of DNCD development. The study cohort consisted of 400 patients (38.5 ± 16 years; males n=205, 51%; Table 1). Sixty-two patients (16%), 31 (50%) of whom were male, developed DNCD after IPAA during a mean follow-up period of 98 ± 67 months. The incidence of DNCD was similar between periods (n=8 [15%] during period 1; n=37 [20%] during period 2; n=17 [11%] during period 3; p=0.07). Usage of anti-TNFs increased during each successive period (n=0 [0%] during period 1, n=40 [22%] during period 2, n=125 [79%] during period 3; p<0.001) while time to DNCD decreased (mean time 87 ± 104 months during period 1; 53 ± 52 months during period 2; 18 ± 22 months during period 3; p=0.01). Incidence of DNCD was similar in anti-TNF treated (45%) compared to anti-TNF naïve patients (41%; p=0.58) but the time to de novo CD was significantly shorter in anti-TNF treated (27 ± 39 months) versus anti-TNF naïve patients (64 ± 66 months; p=0.008). Cox proportional hazards model identified preoperative anti-TNF therapy as an independent risk factor for development of DNCD after IPAA (HR 2.82; 95% CI 1.65 – 4.83; p<0.001). A Kaplan-Meier survival curve illustrates the significant difference in CD-free survival between anti-TNF treated compared to anti-TNF naïve patients (Figure 1; Log rank p=0.007). Preoperative utilization of anti-TNFs may play a significant role in the earlier development of DCND following IPAA. Figure 2. De novo Crohn’s Disease-Free Survival Based on Treatment with Anti-TNF

P082 PREOPERATIVE ANTI-TNFS ARE ASSOCIATED WITH A SHORTER INTERVAL TO DE NOVO CROHN’S DISEASE AFTER ILEAL POUCH-ANAL ANASTOMOSIS FOR ULCERATIVE COLITIS

Anti-tumor necrosis factor (anti-TNF) agents are widely used in the treatment of moderate to severe ulcerative colitis (UC) since commercial approval in 1998. Many patients however ultimately require surgery with ileal pouch-anal anastomosis (IPAA). Conversion of UC to Crohn’s disease (CD) following IPAA is a devastating complication termed de novo Crohn’s disease (DNCD). Despite increasing adoption, few prior studies have evaluated the effect of preoperative anti-TNFs on DNCD development. As we have noticed an increasing incidence of DNCD, we hypothesized that preoperative utilization of anti-TNFs may be associated with the development of DNCD after IPAA. A prospective inflammatory bowel disease (IBD) registry was queried for consecutive UC patients undergoing IPAA during the 25-year period ending 2018. Patients with preoperative CD or IBD unclassified were excluded. De novo CD after IPAA was diagnosed when 5 or more ulcers involving the small-bowel proximal to the ileal pouch or a pouch fistula or other perianal complication developed >3 months after ileostomy closure. Preoperative anti-TNF therapy and development of DNCD was compared between 3 chronologic periods throughout the study: period 1: 1993-1998 (pre-approval of anti-TNFs for UC), period 2: 1999-2008, and period 3: 2009-2018. Cox proportional-hazards model was used to identify predictors of DNCD development. The study cohort consisted of 400 patients (38.5 ± 16 years; males n=205, 51%; Table 1). Sixty-two patients (16%), 31 (50%) of whom were male, developed DNCD after IPAA during a mean follow-up period of 98 ± 67 months. The incidence of DNCD was similar between periods (n=8 [15%] during period 1; n=37 [20%] during period 2; n=17 [11%] during period 3; p=0.07). Usage of anti-TNFs increased during each successive period (n=0 [0%] during period 1, n=40 [22%] during period 2, n=125 [79%] during period 3; p<0.001) while time to DNCD decreased (mean time 87 ± 104 months during period 1; 53 ± 52 months during period 2; 18 ± 22 months during period 3; p=0.01). Incidence of DNCD was similar in anti-TNF treated (45%) compared to anti-TNF naïve patients (41%; p=0.58) but the time to de novo CD was significantly shorter in anti-TNF treated (27 ± 39 months) versus anti-TNF naïve patients (64 ± 66 months; p=0.008). Cox proportional hazards model identified preoperative anti-TNF therapy as an independent risk factor for development of DNCD after IPAA (HR 2.82; 95% CI 1.65 – 4.83; p<0.001). A Kaplan-Meier survival curve illustrates the significant difference in CD-free survival between anti-TNF treated compared to anti-TNF naïve patients (Figure 1; Log rank p=0.007). Preoperative utilization of anti-TNFs may play a significant role in the earlier development of DCND following IPAA.Figure 2De novo Crohn’s Disease-Free Survival Based on Treatment with Anti-TNF.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Anti-TNF therapy is not associated with an increased risk of post-colectomy complications, a population-based study.

Previous studies have raised concerns that the use of anti-tumour necrosis factor (anti-TNF) therapy in patients with ulcerative colitis (UC) undergoing surgery may increase the risk of postoperative complications. We have taken a population-based approach to investigate whether there is an association between anti-TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy. Hospital Episode Statistics (HES) data and procedural coding were used to identify all patients in England between April 2006 and March 2015 undergoing subtotal colectomy for UC. Patients were grouped into those who received anti-TNF therapy within 12 or 4weeks of surgery and those who did not. The incidence of postoperative complications was evaluated by HES coding and compared between groups. In all, 6225 UC patients underwent subtotal colectomy. 753 patients received anti-TNF therapy within 12weeks prior to surgery (418 within 4weeks). There was no difference in postoperative complications between groups although groups were not comparable for age and comorbidities. Logistic regression with complications as the outcome variable did not show any significant association between anti-TNF therapy and complications. Colectomy performed during an unplanned admission (vs planned admission) and smoking were associated with complications. This large population-based study does not demonstrate any association between preoperative anti-TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy. The only variables associated with complications were colectomy performed during an unplanned admission and smoking.

Systematic Review and Meta-Analysis: Preoperative Vedolizumab Treatment and Postoperative Complications in Patients with Inflammatory Bowel Disease.

The impact of vedolizumab, a gut-selective monoclonal antibody, on postoperative outcomes is unclear. This study aimed to assess the impact of preoperative vedolizumab treatment on the rate of postoperative complications in patients with inflammatory bowel disease [IBD] undergoing abdominal surgery. A systematic search of multiple electronic databases from inception until May 2017 identified studies reporting rates of postoperative complications in vedolizumab-treated IBD patients compared to no biologic exposure or anti-tumor necrosis factor (anti-TNF) treated IBD patients. Outcomes of interest included postoperative infectious complications and overall postoperative complications. Pooled risk ratios and 95% confidence intervals were estimated using the random-effects model. Five studies comprising 307 vedolizumab-treated IBD patients, 490 anti-TNF-treated IBD patients and 535 IBD patients not exposed to preoperative biologic therapy were included. The risk of postoperative infectious complications (risk ratio [RR] 0.99, 95% confidence interval [CI] 0.37-2.65) and overall postoperative complications [RR 1.00, 95% CI 0.46-2.15] were not significantly different between vedolizumab-treated patients and those who received no preoperative biologic therapy. In addition, the risk of postoperative infectious complications [RR 0.99, 95% CI 0.34-2.90] and overall postoperative complications [RR 0.92, 95% CI 0.44-1.92] were not significantly different between vedolizumab-treated vs anti-TNF-treated patients. Preoperative vedolizumab treatment in IBD patients does not appear to be associated with an increased risk of postoperative infectious or overall postoperative complications compared to either preoperative anti-TNF therapy or no biologic therapy. Future prospective studies which include perioperative drug level monitoring are needed to confirm these findings.

Anti-TNF Therapy Is Associated With an Increased Risk of Postoperative Morbidity After Surgery for Ileocolonic Crohn Disease: Results of a Prospective Nationwide Cohort.

To determine the risk factors of morbidity after surgery for ileocolonic Crohn disease (CD). The risk factors of morbidity after surgery for CD, particularly the role of anti-TNF therapy, remain controversial and have not been evaluated in a large prospective cohort study. From 2013 to 2015, data on 592 consecutive patients who underwent surgery for CD in 19 French specialty centers were collected prospectively. Possible relationships between anti-TNF and postoperative overall morbidity were tested by univariate and multivariate analyses. Because treatment by anti-TNF is possibly dependent on the characteristics of the patients and disease, a propensity score was calculated and introduced in the analyses using adjustment of the inverse probability of treatment-weighted method. Postoperative mortality, overall and intra-abdominal septic morbidity rates in the entire cohort were 0%, 29.7%, and 8.4%, respectively; 143 (24.1%) patients had received anti-TNF <3 months prior to surgery. In the multivariate analysis, anti-TNF <3 months prior to surgery was identified as an independent risk factor of the overall postoperative morbidity (odds-ratio [OR] =1.99; confidence interval [CI] 95% = 1.17-3.39, P = 0.011), with preoperative hemoglobin <10 g/dL (OR = 4.77; CI 95% = 1.32-17.35, P = 0.017), operative time >180 min (OR = 2.71; CI 95% = 1.54-4.78, P < 0.001) and recurrent CD (OR = 1.99; CI 95% = 1.13-3.36, P = 0.017). After calculating the propensity score and adjustment according to the inverse probability of treatment-weighted method, anti-TNF <3 months prior to surgery remained associated with a higher risk of overall (OR = 2.98; CI 95% = 2.04-4.35, P <0.0001) and intra-abdominal septic postoperative morbidities (OR = 2.22; CI 95% = 1.22-4.04, P = 0.009). Preoperative anti-TNF therapy is associated with a higher risk of morbidity after surgery for ileocolonic CD. This information should be considered in the surgical management of these patients, particularly with regard to the preoperative preparation and indication of temporary defunctioning stoma.

Postoperative course of laparoscopic subtotal colectomy is affected by prolonged preoperative anti-TNF therapy in patients with acute colitis complicating inflammatory bowel disease

The aim of medical treatment of severe acute colitis (SAC) complicating inflammatory bowel disease (IBD) is to avoid surgery, but in 20 to 50% of the cases, colectomy remains necessary. This study aimed to determine the impact of the different lines of medical therapy (i.e., steroids, anti-TNF, or ciclosporin) on postoperative course after laparoscopic subtotal colectomy for SAC complicating IBD. All the patients who underwent laparoscopic subtotal colectomy for SAC were included and divided into two groups: those who presented with postoperative morbidity (group A) and those with an uneventful postoperative course (group B). Preoperative physical, endoscopic and radiological data, and medical treatments were compared between groups. From 2006 to 2015, 65 consecutive patients (32 males, median age=35 [17-87] years) operated for SAC were included. Postoperative morbidity occurred in 19 patients (29%, group A) and was mainly represented by surgical morbidity (n=15), including ileus (n=9), stoma-related complications (n=5), and intra-abdominal abscess (n=4). Lichtiger score, endoscopic and radiological evaluations were similar between groups. Patients with morbidity had more frequently presented two previous episodes of SAC (26%) than those without (7%, p=0.04). Duration of anti-TNF treatment was more frequently longer than 2months in group A (67%) than that in group B (14%, p=0.04). No significant differences between groups were noted regarding other preoperative medical treatments and number of lines therapy. This study suggests that postoperative course after laparoscopic subtotal colectomy for SAC is affected by prolonged preoperative anti-TNF therapy, and in the case of recurrent SAC.

Postoperative Complications after Ileocecal Resection in Crohn's Disease: A Prospective Study From the REMIND Group.

We sought to determine the frequency of and risk factors for early (30-day) postoperative complications after ileocecal resection in a well-characterized, prospective cohort of Crohn's disease patients. The REMIND group performed a nationwide study in 9 French university medical centers. Clinical-, biological-, surgical-, and treatment-related data on the 3 months before surgery were collected prospectively. Patients operated on between 1 September 2010 and 30 August 2014 were included. A total of 209 patients were included. The indication for ileocecal resection was stricturing disease in 109 (52%) cases, penetrating complications in 88 (42%), and medication-refractory inflammatory disease in 12 (6%). A two-stage procedure was performed in 33 (16%) patients. There were no postoperative deaths. Forty-three (21%) patients (23% of the patients with a one-stage procedure vs. 9% of those with a two-stage procedure, P=0.28) experienced a total of 54 early postoperative complications after a median time interval of 5 days (interquartile range, 4-12): intra-abdominal septic complications (n=38), extra-intestinal infections (n=10), and hemorrhage (n=6). Eighteen complications (33%) were severe (Dindo-Clavien III-IV). Reoperation was necessary in 14 (7%) patients, and secondary stomy was performed in 8 (4.5%). In a multivariate analysis, corticosteroid treatment in the 4 weeks before surgery was significantly associated with an elevated postoperative complication rate (odds ratio (95% confidence interval)=2.69 (1.15-6.29); P=0.022). Neither preoperative exposure to anti-tumor necrosis factor (TNF) agents (n=93, 44%) nor trough serum anti-TNF levels were significant risk factors for postoperative complications. In this large, nationwide, prospective cohort, postoperative complications were observed after 21% of the ileocecal resections. Corticosteroid treatment in the 4 weeks before surgery was significantly associated with an elevated postoperative complication rate. In contrast, preoperative anti-TNF therapy (regardless of the serum level or the time interval between last administration and surgery) was not associated with an elevated risk of postoperative complications.

Anti-tumor Necrosis Factor Therapy for Crohn Disease: Friend or Foe to the Surgeon?

Anti-tumor Necrosis Factor Therapy for Crohn Disease: Friend or Foe to the Surgeon?