RESUMO
BACKGROUND/AIMS: The use of anti-tumor necrosis factor (anti-TNF) agents seems to reduce surgical rates and delay surgical procedures in prospective trials and population-based studies in the management of Crohn's disease (CD). This study aimed to identify whether preoperative anti-TNF agents influence the time from diagnosis to surgery. METHODS: An observational retrospective cohort study was conducted on patients with CD submitted to intestinal resections due to complications or medical therapy failure in a period of 7 years. The patients were allocated into 2 groups according to their previous exposure to anti-TNF agents in the preoperative period. Epidemiological aspects regarding age at diagnosis, smoking, perianal disease, and preoperative conventional therapy were considered. A Kaplan-Meier survival analysis was used to outline possible differences between the groups regarding the time to surgery. RESULTS: A total of 123 patients were included (71 and 52 with and without previous exposure to biologics, respectively). The overall time to surgery was 108±6.9 months (maximum, 276 months). The survival estimation revealed no difference in the mean time to intestinal resection between the groups (99.78±10.62 months in the patients without and 114.01±9.07 months in those with previous anti-TNF use) (log-rank P=0.35). There was no significant difference in the time to surgery regarding perianal CD (P=0.49), smoking (P=0.63), preoperative azathioprine (P=0.073) and steroid use (P=0.58). CONCLUSIONS: The time from diagnosis to surgery was not influenced by the preoperative use of anti-TNF therapy in this cohort of patients.
RESUMO
BACKGROUND: data are scarce regarding the effect of preoperative Adalimumab (ADA) in postoperative complications in Crohn's disease (CD) patients. AIM: to compare the rates of postoperative complications after intestinal resections in CD, with and without previous exposure to ADA. METHOD: case-matched retrospective observational study of patients submitted to intestinal resections for CD. The patients were allocated to 2 groups, according to their previous exposure to ADA before surgery. The patients under ADA therapy were matched with controls (patients without previous biologics) with the propensity score method (PSM), according to age at surgery, CD location (Montreal L) and phenotype (Montreal B). Medical and surgical complications were compared. RESULTS: 123 patients were initially considered, 71 with previous biologics (32 under ADA therapy) and 52 without. The PSM selected 25 ADA patients to be matched with 25 controls from the non-biologics group. There was no difference regarding overall surgical complications (40% in the control vs 36% in the ADA group; p = 1.0000) or medical complications (36% vs 12% in the control and ADA groups, respectively; p = 0.095). In univariate analysis, previous ADA was not considered a risk factor for higher postoperative complication rates. Stomas were considered a risk factor for surgical complications, and previous steroids were associated to higher medical complication rates. CONCLUSIONS: preoperative ADA did not influence the rates of medical and surgical complications after elective intestinal resections for CD. This was the first study to include exclusively patients under ADA therapy. This article is protected by copyright. All rights reserved.
RESUMO
BACKGROUND: The real impact of anti-tumor necrosis alpha (TNF) therapy in postoperative complications after intestinal resections in Crohn's disease (CD) still needs to be determined. AIMS: To compare the postoperative complication rates after elective intestinal resections in CD patients, with or without previous exposure to anti-TNF therapy. METHODS: This was a retrospective and observational study, with elective intestinal resections for CD (emergency procedures were excluded). Patients were allocated in two groups according to preoperative anti-TNF status. Surgical and medical complications were analyzed and subsequently compared between the groups. RESULTS: A total of 123 patients were included (71 with and 52 without preoperative anti-TNF). The groups were considered homogeneous, except for perianal CD, previous azathioprine, and stomas. There was no significant difference between the groups regarding overall surgical complications (32.69% in anti-TNF- vs. 39.44% in anti-TNF+ patients, p = 0.457) or overall medical complications (21.15 vs. 21.13%, respectively, p = 1.000). In univariate analysis, previous steroids, perianal CD, and stomas were considered risk factors for surgical complications, and previous steroids and hypoalbuminemia for medical complications. In multivariate analysis, previous steroids were associated with higher rates of surgical and medical complications, while hypoalbuminemia was associated with higher medical complication rates. CONCLUSIONS: There was no influence of the previous use of anti-TNF agents in postoperative surgical and medical complication rates in elective intestinal resections for CD. Previous steroids and hypoalbuminemia were associated with higher complication rates. This was the first case series of the literature describing outcomes in exclusively elective operations.
Assuntos
Adalimumab/uso terapêutico , Antirreumáticos/uso terapêutico , Colectomia , Doença de Crohn/terapia , Infliximab/uso terapêutico , Complicações Pós-Operatórias/epidemiologia , Abscesso Abdominal/epidemiologia , Adulto , Ceco/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório , Procedimentos Cirúrgicos Eletivos , Enterostomia , Feminino , Humanos , Íleo/cirurgia , Obstrução Intestinal/epidemiologia , Intestino Delgado/cirurgia , Masculino , Pessoa de Meia-Idade , Pneumonia/epidemiologia , Modelos de Riscos Proporcionais , Reoperação , Estudos Retrospectivos , Fatores de Risco , Deiscência da Ferida Operatória/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Infecções Urinárias/epidemiologia , Adulto JovemRESUMO
The real impact of biological therapy (anti-TNF agents) in abdominal operations secondary to Crohn's disease is a matter of debate in the international literature. Several studies demonstrated that there can be an increase in postoperative complications in patients previously treated with these agents. On the other hand, the majority of studies published over the last years question this effect, and did not demonstrate any relationship between biologics and outcomes related to surgical postoperative complications. Some meta-analyses were published, with different outcomes and different conclusions. Experimental studies in animals were also recently published, with opposite results, despite similar methodology. In this review, the authors resume all the relevant papers in the international literature with respect to the theme, and demonstrate the heterogeneity of the studies, as well as the disparity of their results and outcomes. The real impact of anti-TNF agents on postoperative complications in Crohn's disease is still controversial, and needs to be better elucidated. Controlled trials must be performed to better address this issue. (AU)
O real e verdadeiro impacto da terapia biológica, constituída por inibidores do fator de necrose tumoral (TNF) alfa, em operações abdominais na doença de Crohn, ainda é extensamente debatido na literatura. Há muitos estudos que referem aumento da possibilidade de complicações em pacientes tratados previamente com esses agentes. Por outro lado, há uma série maior de trabalhos que questionam esse aumento, não demonstrando qualquer impacto dessas drogas nos desfechos pós-operatórios. Algumas metanálises foram publicadas, com resultados ligeiramente diversos. Trabalhos experimentais em animais foram recentemente realizados, igualmente com resultados opostos, apesar de metodologia semelhante. Nessa revisão, os autores discorrem sobre todos os trabalhos relevantes na literatura nacional e internacional sobre o tema, e demonstram a heterogenicidade dos mesmos, bem como a disparidade dos resultados e desfechos. O real impacto dos agentes anti-TNF sobre operações abdominais na doença de Crohn ainda é controverso, e precisa ser melhor elucidado. Estudos controlados devem ser realizados para melhor elucidação dessa questão. (AU)