Immunomodulators and their impact on Surgery in IBD

Do immunomodulators increase risks of surgery?
- no good prospective studies on this topic
Appau etl al, J Gastrointest Surg 2008: Effects of infliximab on ileocolic resection
- use of steroids in non-infliximab group higher
- rate of sepsis and readmission higher in IFX group
- trend toward leak and reoperation in IFX group
Columbel et al, Mayo Clinic
- no difference in septic complications after use of IFX, AZA/6-MP/MTX, steroids
Kunitake, J Gastro surg 2008
- no significant difference in complication rate.
Therefore, conflicting data on whether they cause complications
- all retrospective and had methodological flaws
- One speaker suggested that pts of on combinations of IFX and steroids are at risk of anastamotic leak.

When should you stop immunomodulators?
- if attenuation to IFX, consider trying a 2nd biologic
- for fibrostenotic disease, will need surgery
- worsens obstruction as quick healing results in worsening of fibrostenotic disease
- stop if develop abscess
- failure of 2nd biologic
- always worry about possibility of malignancy
- stop 1 month prior to surgery: OK to continue AZA/6-MP/MTX until date of surgery