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Associations between multiple immunosuppressive treatments before surgery and surgical morbidity in patients with ulcerative colitis during the era of biologics

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Abstract

Purpose

It is unclear whether immunomodulators or biologics, with the exception of corticosteroids, can be risk factors for postoperative infectious complications of ulcerative colitis (UC). Moreover, many immunosuppressive therapies including some biologics are used mainly to treat UC, and many patients are on multi-agent immunosuppressive therapy at the time of surgery. Therefore, we evaluated the influence of pre-operative multiple immunosuppressive agents on the occurrence of surgical site infection (SSI) in UC during the era of biologics.

Methods

We reviewed surveillance data from 301 patients who underwent surgery between January 2015 and April 2018. The incidences of SSI and possible risk factors among patients receiving different immunosuppressive therapies were compared and analyzed.

Results

The incidence of incisional SSI was 6.6%, and that of organ/space SSI was 7.0%. Doses of corticosteroids were significantly decreased because of the recent shift toward the use of biologics. The types and numbers of immunosuppressive agents did not significantly correlate with each incidence. Age ≥ 65 years (odds ratio (OR) 3.0), total prednisolone dose ≥ 9000 mg (OR 2.7), and perioperative blood transfusion (OR 3.6) were shown to be independent risk factors for incisional SSI, whereas duration of surgery ≥ 252 min (OR 3.8), urgent/emergent surgery (OR 2.9), and perioperative blood transfusion (OR 2.6) were identified as independent risk factors for organ/space SSI.

Conclusions

Although no correlation between pre-operative immunosuppressive therapies, except for corticosteroids, was found, selection bias may have occurred due to treatment before surgery. However, biologics, calcineurin inhibitors, and thiopurines did not affect surgical morbidity in UC.

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References

  1. Nelson R, Liao C, Fichera A, Rubin DT, Pekow J (2014) Rescue therapy with cyclosporine or infliximab is not associated with an increased risk for postoperative complications in patients hospitalized for severe steroid-refractory ulcerative colitis. Inflamm Bowel Dis 20:14–20

    Article  PubMed  Google Scholar 

  2. Kimura H, Takahashi K, Futami K, Ikeuchi H, Tatsumi K, Watanabe K, Maeda K, Watadani Y, Nezu R, Kameyama H, Nakao S, Kurachi K, Hotokezaka M, Otsuka K, Watanabe T, Ozawa H (2016) Has widespread use of biologic and immunosuppressant therapy for ulcerative colitis affected surgical trends? Results of a questionnaire survey of surgical institutions in Japan. Surg Today 46:930–938

    Article  CAS  PubMed  Google Scholar 

  3. Selvasekar CR, Cima RR, Larson DW, Dozois EJ, Harrington JR, Harmsen WS, Loftus EV Jr, Sandborn WJ, Wolff BG, Pemberton JH (2007) Effect of infliximab on short-term complications in patients undergoing operation for chronic ulcerative colitis. J Am Coll Surg 204:956–962 discussion 962-963

    Article  PubMed  Google Scholar 

  4. Mor IJ, Vogel JD, da Luz MA et al (2008) Infliximab in ulcerative colitis is associated with an increased risk of postoperative complications after restorative proctocolectomy. Dis Colon Rectum 51:1202–1207 discussion 1207-1210

    Article  CAS  PubMed  Google Scholar 

  5. Yang Z, Wu Q, Wu K et al (2010) Meta-analysis: pre-operative infliximab treatment and short-term post-operative complications in patients with ulcerative colitis. Aliment Pharmacol Ther 31:486–492

    Article  CAS  PubMed  Google Scholar 

  6. Uchino M, Ikeuchi H, Matsuoka H, Tsuchida T, Tomita N, Takesue Y (2010) Risk factors associated with surgical site infection after ileal pouch-anal anastomosis in ulcerative colitis. Dis Colon Rectum 53:143–149

    Article  PubMed  Google Scholar 

  7. Uchino M, Ikeuchi H, Bando T, Hirose K, Hirata A, Chohno T, Sasaki H, Takahashi Y, Takesue Y, Hida N, Hori K, Nakamura S (2015) Does pre-operative multiple immunosuppressive therapy associate with surgical site infection in surgery for ulcerative colitis. Digestion 92:121–129

    Article  CAS  PubMed  Google Scholar 

  8. Chohno T, Uchino M, Sasaki H, Bando T, Takesue Y, Ikeuchi H (2018) Associations between the prognostic nutritional index and morbidity/mortality during intestinal resection in patients with ulcerative colitis. World J Surg 42:1949–1959

    Article  PubMed  Google Scholar 

  9. Heuschen UA, Hinz U, Allemeyer EH, Autschbach F, Stern J, Lucas M, Herfarth C, Heuschen G (2002) Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis. Ann Surg 235:207–216

    Article  PubMed  PubMed Central  Google Scholar 

  10. Smith RL, Bohl JK, McElearney ST et al (2004) Wound infection after elective colorectal resection. Ann Surg 239:599–607

    Article  PubMed  PubMed Central  Google Scholar 

  11. Truelove S, Jewell D (1974) Intensive intravenous regimen for severe attacks of ulcerative colitis. Lancet 1:1067–1070

    Article  CAS  PubMed  Google Scholar 

  12. Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG, Banerjee SN, Edwards JR, Tolson JS, Henderson TS, Hughes JM, National Nosocomial Infections Surveillance System (1991) Surgical wound infection rates by wound class, operative procedure, and patient risk index. National nosocomial infections surveillance system. Am J Med 91:152S–158S

    Article  CAS  PubMed  Google Scholar 

  13. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG (1992) CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 13:606–608

    Article  CAS  PubMed  Google Scholar 

  14. Gu J, Remsi FH, Shen B et al (2013) Operative strategy modifies risk if pouch-related outcomes in patients with ulcerative colitis on preoperative anti-tumor necrosis factor-α therapy. Dis Colon Rectum 56:1243–1252

    Article  PubMed  Google Scholar 

  15. Eshuis EJ, Al Saady RL, Stokkers PCF et al (2013) Previous infliximab therapy and postoperative complications after proctocolectomy with ileum pouch anal anastomosis. J Crohns Colitis 7:142–149

    Article  PubMed  Google Scholar 

  16. Uchino M, Ikeuchi H, Matsuoka H, Bando T, Ichiki K, Nakajima K, Tomita N, Takesue Y (2013) Infliximab administration prior to surgery does not increase surgical site infections in patients with ulcerative colitis. Int J Color Dis 28:1295–1306

    Article  Google Scholar 

  17. Kwag SJ, Kim JG, Kang WK, Lee JK, Oh ST (2014) The nutritional risk is an independent factor for postoperative morbidity in surgery for colorectal cancer. Ann Surg Treat Res 86:206–211

    Article  PubMed  PubMed Central  Google Scholar 

  18. Isik O, Kaya E, Dundar HZ, Sarkut P (2015) Surgical site infection: re-assessment of the risk factors. Chirurgia (Bucur) 110:457–461

    CAS  Google Scholar 

  19. Kolbe L, Kligman AM, Schreiner V, Stoudemayer T (2001) Corticosteroid-induced atrophy and barrier impairment measured by non-invasive methods in human skin. Skin Res Technol 7:73–77

    Article  CAS  PubMed  Google Scholar 

  20. Keenan JE, Speicher PJ, Thacker JK et al (2014) The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings. JAMA Surg 149:1045–1052

    Article  CAS  PubMed  Google Scholar 

  21. Lutfiyya W, Parsons D, Breen J (2012) A colorectal “care bundle” to reduce surgical site infections in colorectal surgeries: a single center experience. Perm J 16:10–16

    PubMed  PubMed Central  Google Scholar 

  22. Waits SA, Fritze D, Banerjee M, Zhang W, Kubus J, Englesbe MJ, Campbell DA Jr, Hendren S (2014) Developing an argument for bundled interventions to reduce surgical site infection in colorectal surgery. Surgery 155:602–606

    Article  PubMed  Google Scholar 

  23. Cima R, Dankbar E, Lovely J, Pendlimari R, Aronhalt K, Nehring S, Hyke R, Tyndale D, Rogers J, Quast L, Colorectal Surgical Site Infection Reduction Team (2013) Colorectal surgery surgical site infection reduction program: a national surgical quality improvement program–driven multidisciplinary single-institution experience. J Am Coll Surg 216:23–33

    Article  PubMed  Google Scholar 

  24. Rogler G (2014) Chronic ulcerative colitis and colorectal cancer. Cancer Lett 345:235–241

    Article  CAS  PubMed  Google Scholar 

  25. Cornillie F, Shealy D, D'Haens G, Geboes K, van Assche G, Ceuppens J, Wagner C, Schaible T, Plevy SE, Targan SR, Rutgeerts P (2001) Infliximab induces potent anti-inflammatory and local immunomodulatory activity but no systemic immune suppression in patients with Crohn’s disease. Aliment Pharmacol Ther 15:463–473

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Inflammatory Bowel Disease, Division of Surgery, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo, Japan

    Motoi Uchino, Hiroki Ikeuchi, Toshihiro Bando, Teruhiro Chohno, Hirofumi Sasaki, Yuki Horio, Ryuichi Kuwahara, Tomohiro Minagawa & Yoshiko Goto

  2. Division of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan

    Kaoru Ichiki, Kazuhiko Nakajima, Yoshiko Takahashi, Takashi Ueda & Yoshio Takesue

Authors
  1. Motoi Uchino
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  2. Hiroki Ikeuchi
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  3. Toshihiro Bando
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  4. Teruhiro Chohno
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  5. Hirofumi Sasaki
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  6. Yuki Horio
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  7. Ryuichi Kuwahara
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  8. Tomohiro Minagawa
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  9. Yoshiko Goto
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  10. Kaoru Ichiki
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  11. Kazuhiko Nakajima
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  12. Yoshiko Takahashi
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  13. Takashi Ueda
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  14. Yoshio Takesue
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Corresponding author

Correspondence to Motoi Uchino.

Ethics declarations

All study protocols were approved by the institutional review board at Hyogo College of Medicine, and informed consent for permission to use patient data was required prior to admission.

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The authors declare that they have no conflict of interest.

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Uchino, M., Ikeuchi, H., Bando, T. et al. Associations between multiple immunosuppressive treatments before surgery and surgical morbidity in patients with ulcerative colitis during the era of biologics. Int J Colorectal Dis 34, 699–710 (2019). https://doi.org/10.1007/s00384-019-03253-x

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  • DOI: https://doi.org/10.1007/s00384-019-03253-x

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