Associations between multiple immunosuppressive treatments before surgery and surgical morbidity in patients with ulcerative colitis during the era of biologics
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.
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.
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.
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.
KeywordsUlcerative colitis Surgical site infection Anti-tumor necrosis factor-α Immunosuppressive therapy
Compliance with ethical standards
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.
Conflict of interest
The authors declare that they have no conflict of interest.
- 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 20:14–20CrossRefPubMedPubMedCentralGoogle 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 46:930–938CrossRefPubMedGoogle 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 962-963CrossRefGoogle 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 92:121–129CrossRefPubMedGoogle 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–158SCrossRefPubMedPubMedCentralGoogle Scholar
- 18.Isik O, Kaya E, Dundar HZ, Sarkut P (2015) Surgical site infection: re-assessment of the risk factors. Chirurgia (Bucur) 110:457–461Google 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 216:23–33CrossRefPubMedGoogle 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 15:463–473CrossRefPubMedGoogle Scholar