Pro: Perioperative anti-TNF Biologics are safe and do not increase complications associated with surgery. Miguel Regueiro, M.D. Professor of Medicine Associate Chief for Education Clinical Head and Co-Director, IBD Center University of Pittsburgh School of Medicine
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Pro: Perioperative anti-TNF Biologics are safe and do not increase complications associated with surgery. Miguel Regueiro, M.D. Professor of Medicine Associate.
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Pro: Perioperative anti-TNF Biologics are safe and do not increase
complications associated with surgery.
Pro: Perioperative anti-TNF Biologics are safe and do not increase
complications associated with surgery.
Miguel Regueiro, M.D.Professor of MedicineAssociate Chief for EducationClinical Head and Co-Director, IBD CenterUniversity of Pittsburgh School of Medicine
Peyrin-Biroulet L et al. Gut 2011
Probability of using IMM before 1st abd surgery (n=296)
Probability of using IMM before 1st abd surgery (n=296)
Peyrin-Biroulet L et al. Gut 2011
Probability of receiving at least 1 antiTNF before 1st surgery (296)
Probability of receiving at least 1 antiTNF before 1st surgery (296)
This means that most IBD patients undergoing surgery are taking an
IMM and/or antiTNF
This means that most IBD patients undergoing surgery are taking an
IMM and/or antiTNF
-If it’s an emergent surgery, we don’t have much choice on altering pre-op meds.
-Should the type of operation be altered?
-If the surgery is elective:-Should we alter pre-op meds?
Is starting an antiTNF in the postop setting safe?
Dr Remzi will argue that peri-operative antiTNF is unsafe
Dr Remzi will argue that peri-operative antiTNF is unsafe
As you may know, there’s a bit of a rivalry between Pittsburgh and
Cleveland
Pittsburgh vs ClevelandPittsburgh vs Cleveland
Despite the intercity rivalry, I have the utmost respect for Dr Remzi
and the Cleveland Clinic
Despite the intercity rivalry, I have the utmost respect for Dr Remzi
and the Cleveland Clinic
In reality, our hospitals and cities are quite similar
UPMC and Pittsburgh on a typical summer morning
Cleveland Clinic on that same, bright summer morning
A Tale of Two Cities – a surgeon’s perspective on postop outcome
A Tale of Two Cities – a surgeon’s perspective on postop outcome
• 27 yo CD from Youngstown OH sees Dr Regueiro in Pittsburgh on AZA/ADA
• Develops SBO while in Cleveland and requires emergent surgery w Dr Remzi
• Scenario 1: dc’d 4 days later, “great!” – Dr Remzi – “I am a brilliant surgeon!!”
• Scenario 2: POD 2 develops an anast leak – Dr Remzi – “it’s all because of those poisons Dr Regueiro was giving you!”
Three Scenarios to ConsiderThree Scenarios to Consider
• PRE-operative antiTNF for CROHN’S disease and POST-op complications
• PRE-operative antiTNF for ULCERATIVE COLITIS disease and POST-op complications
• POST-operative antiTNF for CROHN’S disease and POST-op complications
PRE-operative antiTNF for CROHN’S disease and POST-op complications
PRE-operative antiTNF for CROHN’S disease and POST-op complications
What are the data?
9 Crohn’s ds Postop References9 Crohn’s ds Postop References• Tay et al. Surgery 2003• Marchal et al. Aliment Pharmacol Ther 2004
• Colombel et al. Am J Gastroenterol 2004
• Appau et al. J Gastrointest Surg 2008
• Indar et al. World J Surg 2009
• Canedo et al. Colorectal Dis 2011
• Nasir et al. J Gastrointest Surg 2012
• Kasparek et al. Inflamm Bowel Dis 2012
• Kopylov et al. Inflamm Bowel Dis 2012
Tay – Multivariate analysis suggests improved perioperative outcome in CD
pts receiving IMMs before resection
Tay – Multivariate analysis suggests improved perioperative outcome in CD
pts receiving IMMs before resection
• Overall, 11% Postop complications (5.6% on IMM, 25% not on IMM)
resection with primary anastomosis or strictureplasty
100 11% No
Marchal Intestinal resection (symptomatic stenosis or
refractory fistulas and/orabscesses, or intractable disease)
79 24% No
Colombel Abdominal surgery 270 23% No
Appau ileocolonic resection 389 71.7% Yes
Indar Intestinal surgey (Ileocecal resection and small
intestine resection++) 112 33% No
Nasir surgery which included a suture or staple line 370 29% No
Canedo Abdominal surgery 225 ND No
Kasparek Abdominal surgery 96 59% No
Kopylov et al. IBD 2012
Risk of postop complications in CD – only one “Yes”
PRE-operative antiTNF for ULCERATIVE COLITIS disease
and POST-op complications
PRE-operative antiTNF for ULCERATIVE COLITIS disease
and POST-op complications
What’s the data?
UC Postop ReferencesUC Postop References• Selvasekar et al J Am Coll Surg 2007• Schluender et al Dis Colon Rectum 2007• Mor et al Dis Colon Rectum 2008• Ferrante et al Inflamm Bowel Dis 2009• Norgard et Aliment Pharmacol Ther 2012• Yang et al Aliment Pharmacol Ther 2010
UC and CD Studies combined:• Kunitake et al J Gastrointest Surg 2008• Waterman et al Gut 2012
Selvasekar – Effect of IFX on short-term complications in pts undergoins operation for
chronic UC – 62% complicaiton with IFX
Selvasekar – Effect of IFX on short-term complications in pts undergoins operation for
chronic UC – 62% complicaiton with IFX
Mor – IFX in UC is associated with an increased risk of postop complications
after restorative proctocolectomy
Mor – IFX in UC is associated with an increased risk of postop complications
after restorative proctocolectomy
• OR early complication IFX 3.54 (P = 0.004; 95% CI1.51-8.31).