We read with interest the article by Nørgård et al. The authors examined the impact of pre-operative use of anti-tumour necrosis factor-alpha (TNF-α) agents on post-operative complications after colectomy for ulcerative colitis (UC). Patients (n = 1226) were classified according to use of anti-TNF-α agents within the 12 weeks prior to surgery. They found that pre-operative use of anti-TNF-α agents did not increase the risk of post-operative complications (within 30 and 60 days after surgery).
A meta-analysis has reported that pre-operative infliximab use increases short-term post-operative complications in UC. In the studies included in this meta-analysis, most patients received combined therapy (glucocorticosteroids, ciclosporin A or other immunomodulators) with infliximab prior to surgery.
In addition, not all the studies clarified the duration between last infliximab infusion and surgery. Some patients had received their last infusion more than 12 weeks before. A sustained biological effect of infliximab beyond 12 weeks seems unlikely. Furthermore, the number of patients in each study was relatively small. The nationwide study by Nørgård et al. provides reassuring results after pre-operative use of anti-TNF-α agents in UC patients.
In this study, the majority of patients underwent colectomy and ileostomy. Few patients had construction of ileal pouch-anal anastomosis (IPAA). From the results in this study, we conclude that anti-TNF-α agents do not increase the risk of complications after colectomy without IPAA.
However, most surgeons would like to know whether anti-TNF-α agents increase the risk of pouch-related complications after IPAA. If the risk is significantly increased, surgeons should avoid construction of IPAA at the first colectomy for UC. Further studies evaluating the impact of anti-TNF-α agents on the risk of pouch-related complication after IPAA are warranted.