Surgery for Crohn’s disease and anti-TNF agents: the changing scenario

Abstract

Surgery has been a mainstay of therapy for Crohn’s disease for a long time, essentially as a consequence of the fairly modest efficacy of traditional medications such as immunomodulators, antibiotics and 5-ASA, especially in severe cases. However, in the past decade and half, the advent of anti-TNF agents has greatly changed the medical approach to this disease and may modify its general management as well. Here, we have reviewed the current literature on incidence of surgery, timing of surgery and postoperative recurrence of Crohn’s disease before and after the advent of anti-TNF agents. In addition, we have reviewed the risk of perioperative complications in patients on anti-TNF agents before surgery. The data show that the use of these medications is changing or expecting to change shortly a number of surgical aspects of Crohn’s disease management.

Keywords::

• anti-TNF agents
• Crohn’s disease
• infliximab
• incidence of surgery
• perioperative complications
• postoperative recurrence
• timing of surgery

Financial & competing interests disclosure

D Sorrentino has acted as a consultant and received fees from Schering-Plough, Centocor, Abbott, Janssen, MSD, Hoffmann-LaRoche, Ferring, Giuliani. This study was not supported by the pharmaceutical industry. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Surgery has traditionally being a mainstay of Crohn’s disease (CD) management for a long time, essentially as a consequence of the modest efficacy of traditional medications (immunomodulators, 5-ASA, antibiotics) especially in severe cases.

• • In the past 15 years, the advent of the highly effective anti-TNF agents has profoundly affected CD management. This, in turn, is expected to change the role of surgery for this disease.

• • Many epidemiological studies have failed to show a decreased incidence of surgery for CD since the introduction of anti-TNF agents. However, incidence and prevalence rates of CD are increasing worldwide. More importantly, it is only in recent times that anti-TNF agents are being used widely and early during the course of the disease, when they are mostly effective and might change CD natural history.

• • Recurrence of CD after surgery has long been deemed inescapable. However since 2006, many studies have shown that anti-TNF agents appear capable of preventing relapse in the large majority of patients.

• • Effective prevention of postoperative recurrence of CD might in turn anticipate timing for surgery in patients with irreversible disease, who might then be treated immediately after surgery if at high risk of recurrence.

• • Some studies suggest that anti-TNF agents given perioperatively to CD patients might increase the risk of postsurgical complications. However, the large majority of studies do not show an increased risk.

Notes