Issue 17

Clinical Question

What is the postoperative risk of high preoperative anti-TNF-α levels?

Editor’s Bottom Line

Crohn’s disease (CD) patients with preoperative anti-TNFα levels >3 µg/mL have an increased postoperative infection risk. This risk increases with increasing preoperative levels.

Editorial Note

This is the first study of its kind to demonstrate the correlation between pre-operative anti-TNF-α levels and postoperative morbitity. The study needs validation, however, for now we should all aim for lower preoperative levels prior to surgery.

Reference

Lau C, Dubinsky M, Melmed G, et al. The impact of preoperative serum anti-TNFα therapy levels on early postoperative outcomes in inflammatory bowel disease surgery. Ann Surg. 2015 Mar;261(3):487–96.
https://www.ncbi.nlm.nih.gov/pubmed/24950263

Synopsis

Between 1999 and 2012, patients undergoing IBD-related abdominal surgery and a serum anti-TNF level within 7 days of surgery were included in this study. Postoperative adverse events, length of hospitalization and readmission rates were followed for 30 days. Patients who had ≥0.98 µg/mL of a biologic (infliximab, adalimumab, or certolizumab) in their serum were categorized as “detected” compared to “undetected.” The detected group was further organized into low (<3 µg/mL), medium, and high levels (≥8 µg/mL).

In the study cohort (n=217; CD=123; ulcerative colitis [UC]=94), 65% had preoperative treatment with biologics (mainly infliximab) while 20% had received multiple biologics. More CD than UC patients had detectable preoperative levels of biologics (75% vs. 25%, P=0.0005). Patients receiving steroids also had a significantly higher detection rate (70% vs. 46%, P=0.001).

UC patients had similar postoperative outcomes irrespective of anti-TNF level.

Conversely, CD patients who had anti-TNF-α levels ≥3 µg/mL had significant increase in infectious complications (OR: 3.0). CD patients with “high” (> 8ug/mL) levels demonstrated even higher rates of infection-related complications than the “low” and “medium” groups.

Details

Study Design: Retrospective observational study
Funding: None
Allocation: N/A
Setting: Cedars-Sinai Medical Center, CA
Level of Evidence: 2b (Oxford Levels of Evidence)

The summary and conclusion in this issue of E-mentoring in IBD pertains to the manuscript(s) being reviewed, and should be considered in the context of what is already known surrounding the topic and incorporated into practice as deemed appropriate by the individual learner.