Systematic review of perioperative use of immunosuppressive agents in patients undergoing bariatric surgery

Background: Patients who qualify for bariatric surgery are increasingly experiencing co-morbid conditions, which often require management through the use of immunosuppressive agents, such as corticosteroids, tumor necrosis factor-alpha inhibitors, or other immunomodulators, which may increase the risk of infection or wound healing complications. Perioperative management of these agents in bariatric surgery is challenging because of the lack of research in this patient population. With the use of immunosuppressive agents on the rise, the effects of these medications must be understood, both the risks posed in the perioperative period, and the benefit their sustained use may have for co-morbidity management. Objectives: To describe the safety of immunosuppressive agents prior to bariatric surgery. Setting: United States of America. Methods: A systematic review was conducted to answer these questions about commonly encountered immunosuppressive agents. This review includes information from 37 studies to present recommendations and reasoning for the discontinuation and postoperative reinitiation of immunosuppressive agents including, tumor necrosis alpha factor-a inhibitors, methotrexate, and more. Results: Research addressing complications of these medications in patients undergoing bariatric surgery is sparse. Information from abdominal or general surgical complications may serve as a basis for conservative recommendations. Data specific to each agent or class are presented below. Conclusions: The use of these agents may be critical for patients' chronic disease management, and the consequences of their impact should be considered by bariatric surgeons. While their immune system effects ultimately lead to disease management, each agent must be handled individually due to the varying effects and the potential for perioperative untoward effects. (C) 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.