PALM DESERT, CALIF. – Children treated with infliximab prior to ileal pouch anal anastomosis for chronic ulcerative colitis experienced nearly twice as many postoperative complications, compared with controls, but the long-term outcomes were similar between the two groups, results from a single-center study showed.
Infliximab, an anti–tumor necrosis factor–alpha antibody, has become increasingly popular for the treatment of ulcerative colitis and was approved by the Food and Drug Administration for use in moderate and severe disease in 2005. "Since that time, there have been a multitude of conflicting reports regarding infliximab’s potential to cause postoperative infections," Dr. Raelene Kennedy said at the annual meeting of the American Pediatric Surgical Association. "However, there has been a lack of data specific to the pediatric population."
Dr. Raelene D. Kennedy
Dr. Kennedy of the Mayo Clinic, Rochester, Minn., and her pediatric surgery associates retrospectively studied 38 patients aged 18 years and younger who underwent ileal pouch anal anastomosis (IPAA) for chronic ulcerative colitis at the Mayo Clinic in 2003-2008. Of these, 11 patients received infliximab within 8 weeks prior to surgery. The control group included 27 patients who were well matched in terms of age and sex. "However, preoperative albumin levels were slightly lower in the infliximab group (3.4 vs. 4 g/dL)," she said. "This may suggest that our infliximab group had more severe disease."
Use of other medications was similar between the two groups, except that a significantly greater proportion of patients in the infliximab group vs. the control group used thiopurines (91% vs. 41%, respectively).
Operative technique for the groups varied. Overall, most patients underwent a two-stage procedure, but 33% of control group patients underwent three-stage procedures, whereas none in the infliximab group did. Additionally, a laparoscopic approach was used for all patients in the infliximab group, compared with 63% of the control group.
Overall complications following IPAA were more frequent in the infliximab group than in the control group (55% vs. 26%, respectively), but this did not reach statistical significance. Small-bowel obstruction was significantly higher in the infliximab group, compared with the control group (55% vs. 7%), as was the rate of wound infections (18% vs. 7%). The rate of postoperative leaks between the two groups was similar (9% vs. 7%, respectively).
Compared with controls, a greater proportion of patients in the infliximab group had leak/abscess, small-bowel obstruction, wound infection, or pouchitis 30 days after ileostomy closure (36% vs. 19%), but there were no differences in the rates of complications between the two groups at postoperative year 1 (64% in the infliximab group vs. 62% in the control group). Pouchitis accounted for nearly all of the late complications in both groups.
"From this, we can conclude that children treated with infliximab prior to surgery are at increased risk for postoperative complications following their pouch procedures," Dr. Kennedy said. "Specifically, these children are at increased risk for small-bowel obstruction and wound infection. However, long-term outcomes remain similar to [those of] children who were not treated with infliximab."
She acknowledged certain limitations of the study, including its small sample size. "Larger pediatric studies are required to further evaluate these findings," she said.
Currently, Dr. Kennedy and her associates recommend discontinuing infliximab at least 8 weeks prior to IPAA when possible. "For patients who are currently being treated with infliximab, we recommend total abdominal colectomy with temporary end ileostomy followed by IPAA at a later date," she said.
Dr. Kennedy said that she had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.