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Original Investigation
August 16, 2017

Association of Preoperative Anti–Tumor Necrosis Factor Therapy With Adverse Postoperative Outcomes in Patients Undergoing Abdominal Surgery for Ulcerative Colitis

Author Affiliations
  • 1Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey
  • 2Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey
  • 3Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Pennsylvania State University, Hershey
JAMA Surg. 2017;152(8):e171538. doi:10.1001/jamasurg.2017.1538
Key Points

Question  Are adverse postoperative events higher among patients with ulcerative colitis who require anti–tumor necrosis factor (TNF) therapy?

Findings  In this analysis involving the insurance claims records of 2476 patients who underwent colectomy or total proctocolectomy for ulcerative colitis, preoperative anti-TNF agent use was not associated with a significant increase in postoperative complications. However, anti-TNF agent use within 90 days of surgery among patients who underwent ileal pouch-anal anastomosis was associated with higher complication rates.

Meaning  For patients using anti-TNF therapy for ulcerative colitis, avoidance of ileal pouch-anal anastomosis during the initial ulcerative colitis–associated procedure may be warranted.

Abstract

Importance  Despite the increasing use of anti–tumor necrosis factor (TNF) therapy in ulcerative colitis, its effects on postoperative outcomes remain unclear, with many patients requiring surgical intervention despite optimal medical management.

Objective  To assess the association of preoperative use of anti-TNF agents with adverse postoperative outcomes.

Design, Setting, and Participants  This analysis used insurance claims data from a large national database to identify patients 18 years or older with ulcerative colitis. These insured patients had inpatient and/or outpatient claims between January 1, 2005, and December 31, 2013, with Current Procedural Terminology codes for a subtotal colectomy or total abdominal colectomy, a total proctocolectomy with end ileostomy, or a combined total proctocolectomy and ileal pouch-anal anastomosis. Only data regarding the first or index surgical admission within the time frame were abstracted. Use of anti-TNF agents, corticosteroids, and immunomodulators within 90 days of surgery was identified using Healthcare Common Procedure Coding System codes. Inclusion in the study required the patient to have an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for ulcerative colitis. Exclusion occurred if the patient had a secondary ICD-9-CM diagnosis code for Crohn disease or if the patient was not continuously enrolled in an insurance plan for at least 180 days before and after the index surgery. Data were collected and analyzed from February 1, 2015, to June 2, 2016.

Main Outcomes and Measures  Outcomes included 90-day complications, emergency department visits, and readmissions. Multivariable logistic regression was used to model covariates, including anti-TNF agent use, on the occurrence of outcomes.

Results  Of the 2476 patients identified, 1379 (55.7%) were men, and the mean (SD) age was 42.1 (12.9) years. Among these, 950 (38.4%) underwent subtotal colectomy or total abdominal colectomy, 354 (14.3%) underwent total proctocolectomy with end ileostomy, and 1172 (47.3%) received ileal pouch-anal anastomoses. In univariate analyses, increased postoperative complications were observed among patients in the ileal pouch cohort who received anti-TNF agents preoperatively vs those who did not (137 [45.2%] vs 327 [37.6%]; P = .02) but not among those in the colectomy or proctocolectomy cohorts. An increase in complications was also observed on multivariable analyses among patients in the ileal pouch cohort (odds ratio, 1.38; 95% CI, 1.05-1.82).

Conclusions and Relevance  Unlike preoperative anti-TNF agent use among patients who underwent colectomy or total proctocolectomy and experienced no significant increase in postoperative complications, anti-TNF agent use within 90 days of surgery among patients who underwent ileal pouch-anal anastomosis was associated with higher 90-day postoperative complication rates.

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