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Impact of Preoperative Immunosuppressive Agents on Postoperative Outcomes in Crohns Disease

Ali, Usama Ahmed M.Sc., M.D.1; Martin, Sean T. M.D.2; Rao, Abhishek D. B.A.3; Kiran, Ravi P. M.Sc., M.D.3

Diseases of the Colon & Rectum: May 2014 - Volume 57 - Issue 5 - p 663–674
doi: 10.1097/DCR.0000000000000099
Current Status

BACKGROUND: Immunosuppressive agents are essential in the management of Crohn’s disease. Their safety before surgery, however, is still controversial.

OBJECTIVE: The aim of this study is to evaluate whether the preoperative use of immunosuppressive agents is associated with increased postoperative complications in Crohn’s disease.

DATA SOURCES: A literature search of PubMed, EMBASE, and The Cochrane Library was undertaken in February 2013.

STUDY SELECTION: All studies describing postoperative outcomes of patients undergoing bowel resections for Crohn’s disease were included if they reported data comparing patients on preoperative immunosuppressive agents with an appropriate control group.

INTERVENTIONS: All immunosuppressive agents used to manage Crohn's disease were studied.

MAIN OUTCOME MEASURES: The main outcomes measured were total overall complications and total infectious complications.

RESULTS: Twenty-one eligible studies (20 retrospective and 1 prospective) with 6899 patients were included. When individual studies were examined, only 2/14 (14%), 4/13 (31%), and 1/8 (13%) studies found an association between postoperative complications and preoperative anti-tumor necrosis factor agents, corticosteroids, and thiopurines. In meta-analyses, patients on anti-tumor necrosis factor agents (risk ratio, 1.29; 95% CI, 1.07-1.55), and corticosteroids (risk ratio, 1.55; 95% CI, 1.23-1.95) were found to have a higher risk of postoperative infectious complications. The use of anti-tumor necrosis factor agents was also significantly associated with wound infection (risk ratio, 1.62; 95% CI, 1.12-2.34) and septic shock (risk ratio, 1.81; 95% CI, 1.03-3.17). There was no association between the use of thiopurines or combined immunomodulator drugs and postoperative complications.

LIMITATIONS: Most studies were retrospectively designed, and there were large variations in the patient populations and outcome definitions.

CONCLUSIONS: Patients with Crohn’s disease on preoperative immunosuppressive agents are at higher risk for complications. Both corticosteroids and anti-tumor necrosis factor agents may increase the risk of infections and septic shock. A preoperative drug-free interval, when feasible, might be considered to reduce the risk of infections. The adoption of any operative strategies that modify these outcomes may additionally counter these risks.

1Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands

2Department of Colorectal Surgery, St. Vincent’s University Hospital, Dublin, Ireland

3Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York

Financial Disclosure: None reported.

Correspondence: Ravi P. Kiran, M.D., Division of Colorectal Surgery, Department of Surgery, Columbia University, 161 Fort Washington Ave, New York, NY 10032. E-mail: rpk2118@columbia.edu

© 2014 The American Society of Colon and Rectal Surgeons