Postop complications & anti-TNFs

June 21, 2022

Issue 12

Clinical Question

Does preoperative anti-TNF use increase the risk of postoperative complications?

Editor’s Bottom Line

These findings corroborate other evidence supporting the safety of peri-operative anti-TNF exposure and argue against routine peri-operative interruption of therapy.

Reference

Cohen BL, Fleshner P, Kane SV, et al. Prospective Cohort Study to Investigate the Safety of Preoperative Tumor Necrosis Factor Inhibitor Exposure in Patients With Inflammatory Bowel

Disease Undergoing Intra-abdominal Surgery. Gastroenterology. Epub ahead of print Apr 10, 2022; https://www.gastrojournal.org/article/S0016-5085(22)00359-

6/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F

Synopsis

Researchers at 17 academic centers in the United States prospectively enrolled 947 patients with Crohn’s disease or ulcerative colitis who were undergoing abdominal surgery between 2014 and 2017. They compared surgical site infections and other complications among 382 of the patients who were receiving an anti-tumor necrosis factor (TNF) agent within 12 weeks of surgery and the remaining participants, who had not received an anti-TNF drug during the 12-week preoperative period.

The most commonly administered anti-TNF agents were adalimumab (47.9%) and infliximab (43.2%). Roughly 24% of those not receiving anti-TNF agents at the time of surgery were also anti-TNF-naïve.

Patients receiving an anti-TNF at the time of surgery were significantly younger (39 vs. 43 years of age; p<0.001), had a shorter disease duration (11 vs. 14 years; p<0.001), were less likely to have had prior bowel resection (28% vs. 39%; p=0.001), and more likely to have been admitted to hospital within the previous 30 days (22% vs. 15%; p=0.09), compared to those not receiving an anti-TNF. Most patients were undergoing bowel resection, and 64% of these were performed laparoscopically.

The authors found that 18.1% of preoperative anti-TNF recipients developed a postoperative infection of any kind, compared to 20.2% of those not receiving an anti-TNF prior to surgery (p=0.469). Rates of surgical site infections specifically were similar, with 12% and 12.6% of anti-TNF recipients and anti-TNF unexposed individuals, respectively, developing a surgical site infection (p=0.889). Multivariable analyses controlling for the effects of age, sex, preoperative steroid use, and disease type confirmed that anti-TNF exposure prior to surgery was not associated with infections, including surgical site infections. Serum anti-TNF levels and specific anti-TNF agents were also not correlated with infection risk.

Other findings showed that 3.7% of anti-TNF recipients developed a postoperative venous thromboembolism, compared to 1.4% of anti-TNF-unexposed patients (p=0.024).

Details

Study Design: Prospective observational

Funding: The Crohn’s and Colitis Foundation

Allocation: Not applicable

Setting: Multicenter

Level of Evidence: 1b