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The Impact of Preoperative Serum Anti-TNFa Therapy Levels on Early Postoperative Outcomes in Inflammatory Bowel Disease Surgery

Lau, Cheryl MD*; Dubinsky, Marla MD; Melmed, Gil MD; Vasiliauskas, Eric MD; Berel, Dror MS; McGovern, Dermot MD, PhD; Ippoliti, Andrew MD; Shih, David MD, PhD; Targan, Stephan MD; Fleshner, Phillip MD*

doi: 10.1097/SLA.0000000000000757
Original Articles

Objective: Assess the impact of preoperative serum antitumor necrosis factor-α (anti-TNFα) drug levels on 30-day postoperative morbidity in inflammatory bowel disease (IBD) patients.

Background: Studies on the association of anti-TNFα drugs and postoperative outcomes in IBD are conflicting due to variable pharmacokinetics of anti-TNFα drugs. It remains to be seen whether preoperative serum anti-TNFα drug levels correlate with postoperative morbidity.

Methods: Thirty-day postoperative outcomes of consecutive IBD surgical patients with serum drawn within 7 days preoperatively were studied. The total serum level of 3 anti-TNFα drugs (infliximab, adalimumab, and certolizumab) was measured, with ≥0.98 μg/mL considered as detected. Data were also reviewed according to a clinical cutoff value of 3 μg/mL.

Results: A total of 217 patients [123 with Crohn disease (CD) and 94 with ulcerative colitis (UC)] were analyzed; 75 of 150 (50%) treated with anti-TNFα therapy did not have detected levels at the time of surgery. In the UC cohort, adverse postoperative outcome rates between the undetectable and detectable groups were similar when stratified according to type of UC surgery. In the CD cohort, there was a higher but statistically insignificant rate of adverse outcomes in the detectable versus undetectable groups. Using a cut off level of 3 μg/mL, postoperative morbidity (odds ratio [OR] = 2.5, P = 0.03) and infectious complications (OR = 3.0, P = 0.03) were significantly higher in the ≥3 μg/mL group. There were higher rates of postoperative morbidity (P = 0.047) and hospital readmissions (P = 0.04) in the ≥8 μg/mL compared with <3 μg/mL group.

Conclusions: Increasing preoperative serum anti-TNFα drug levels are associated with adverse postoperative outcomes in CD but not UC patients.

The impact of antitumor necrosis factor-α (anti-TNFα) therapy on the postoperative course of inflammatory bowel disease (IBD) is controversial, and many studies' results are conflicting. This study evaluates the association of serum anti-TNFα drug levels with the risk of early postoperative complications in a cohort of patients with IBD.

*Division of Colorectal Surgery, Department of General Surgery

Department of Pediatrics

F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA.

Reprints: Phillip Fleshner, MD, 8737 Beverly Boulevard, Suite 101, Los Angeles, CA 90048. E-mail:

Disclosure: The authors have no conflict of interest.

Podium presentation at Digestive Disease Week, May 21, 2013, Orlando, FL.

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