Operative Strategy Modifies Risk of Pouch-related Outcomes in Patients With Ulcerative Colitis on Preoperative Anti-Tumor Necrosis Factor-α Therapy

BACKGROUND: Whether preoperative biological therapy increases postoperative complications after restorative proctocolectomy remains controversial. OBJECTIVE: This study aims to evaluate the influence of preoperative use of biologics on outcomes after restorative proctocolectomy and to assess whether a staged approach modifies any negative influence of these medications. SETTING: The study was conducted at a single tertiary institution. DESIGN AND PATIENTS: Patients who were operated on for medically refractory ulcerative or indeterminate colitis were identified and classified by initial surgery, whether subtotal colectomy or total proctocolectomy, then categorized into biologics user and nonuser groups. Demographics, perioperative data, postoperative complications, pouch function, and quality of life were collected. OUTCOME MEASURE: Cumulative 1-year complication rates were estimated by using the Kaplan-Meier curve, and independent predictors for infectious complications were identified by using Cox proportional hazards regression models. RESULTS: From 2006 to 2010, 407 and 181 patients underwent initial subtotal colectomy with end ileostomy or total proctocolectomy with IPAA. For the 181 patients who underwent total proctocolectomy straightaway, pre- and perioperative data were comparable for biologics users (n = 25) and nonusers (n = 156). Cumulative 1-year pelvic sepsis rate was significantly greater in patients on biologics (32% vs 16%, p = 0.012). Multivariate analysis demonstrated that preoperative anti-tumor necrosis factor therapy (HR, 2.62; p = 0.027) was an independent risk factor for postoperative pelvic sepsis after total proctocolectomy. After subtotal colectomy, no differences occurred in both 30-day and cumulative 1-year postoperative complications between biologics users (n = 142) and nonusers (n = 265). Outcomes were also similar when biologics users (n = 88) and nonusers (n = 164) underwent subsequent completion proctectomy with ileal pouch creation after initial colectomy. LIMITATIONS: The retrospective nature of this study and physician's preference were limitations. CONCLUSIONS: Preoperative exposure to biologics is associated with an increased risk of pelvic sepsis after total proctocolectomy with IPAA. This risk is mitigated by the performance of an initial subtotal colectomy.