Association of Preoperative Anti-Tumor Necrosis Factor Therapy With Adverse Postoperative Outcomes in Patients Undergoing Abdominal Surgery for Ulcerative Colitis
Association of Preoperative Anti-Tumor Necrosis Factor Therapy With Adverse Postoperative Outcomes in Patients Undergoing Abdominal Surgery for Ulcerative Colitis
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DOI：
10.1001/jamasurg.2017.1538
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发表时间：
2017-08-01
期刊：
影响因子：
16.9
通讯作者：
Messaris, Evangelos
中科院分区：
文献类型：
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作者：
Kulaylat, Audrey S.;Kulaylat, Afif N.;Messaris, Evangelos
重要性 尽管抗肿瘤坏死因子 (TNF) 治疗在溃疡性结肠炎中的使用越来越多，但其对术后结果的影响仍不清楚，尽管有最佳的医疗管理，许多患者仍需要手术干预。 目的 评估术前使用抗 TNF 药物与不良术后结果的关联。 设计、设置和参与者 这项分析使用来自大型国家数据库的保险索赔数据来识别 18 岁或以上的溃疡性结肠炎患者。这些受保患者在2005年1月1日至2013年12月31日期间进行了住院和/或门诊索赔，当前程序术语代码为结肠次全切除术或全腹部结肠切除术、全直肠结肠切除术加回肠末端造口术、或联合全直肠结肠切除术和回肠贮袋肛门吻合术。仅提取有关时间范围内第一次或第二次手术入院的数据。使用医疗保健通用程序编码系统代码确定手术后 90 天内使用抗 TNF 药物、皮质类固醇和免疫调节剂。纳入研究要求患者具有溃疡性结肠炎的国际疾病分类第九版临床修订版 (ICD-9-CM) 诊断代码。如果患者具有克罗恩病的二级 ICD-9-CM 诊断代码，或者患者在指数手术前后至少 180 天没有连续加入保险计划，则被排除。数据收集和分析时间为 2015 年 2 月 1 日至 2016 年 6 月 2 日。 主要结果和措施 结果包括 90 天并发症、急诊科就诊和再入院。使用多变量逻辑回归对结果发生的协变量（包括抗 TNF 药物的使用）进行建模。 结果 在确定的 2476 名患者中，1379 名 (55.7%) 为男性，平均 (SD) 年龄为 42.1 (12.9) 岁。其中，950例（38.4%）接受结肠次全切除或全腹结肠切除术，354例（14.3%）接受全直肠结肠切除加回肠末端造口术，1172例（47.3%）接受回肠贮袋肛管吻合术。在单变量分析中，术前接受抗 TNF 药物治疗的回肠贮袋队列患者与未接受抗 TNF 药物治疗的患者相比，术后并发症增加（137 例 [45.2%] vs 327 例 [37.6%]；P = 0.02），但结肠切除术或直肠结肠切除术队列中的患者则没有这种情况。多变量分析还发现回肠储袋队列患者的并发症有所增加（比值比，1.38；95% CI，1.05-1.82）。结论和相关性与接受结肠切除术或全直肠结肠切除术的患者术前使用抗 TNF 药物且术后并发症没有显着增加不同，接受回肠储袋肛门的患者在手术后 90 天内使用抗 TNF 药物吻合术与较高的术后 90 天并发症发生率相关。
IMPORTANCE Despite the increasing use of anti-tumor necrosis factor (TNF) therapy in ulcerative colitis, its effects on postoperative outcomes remain unclear, with many patients requiring surgical intervention despite optimal medical management.OBJECTIVE To assess the association of preoperative use of anti-TNF agents with adverse postoperative outcomes.DESIGN, SETTING, AND PARTICIPANTS This analysis used insurance claims data from a large national database to identify patients 18 years or older with ulcerative colitis. These insured patients had inpatient and/or outpatient claims between January 1, 2005, and December 31, 2013, with Current Procedural Terminology codes for a subtotal colectomy or total abdominal colectomy, a total proctocolectomy with end ileostomy, or a combined total proctocolectomy and ileal pouch-anal anastomosis. Only data regarding the first or index surgical admission within the time frame were abstracted. Use of anti-TNF agents, corticosteroids, and immunomodulators within 90 days of surgery was identified using Healthcare Common Procedure Coding System codes. Inclusion in the study required the patient to have an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for ulcerative colitis. Exclusion occurred if the patient had a secondary ICD-9-CM diagnosis code for Crohn disease or if the patient was not continuously enrolled in an insurance plan for at least 180 days before and after the index surgery. Data were collected and analyzed from February 1, 2015, to June 2, 2016.MAIN OUTCOMES AND MEASURES Outcomes included 90-day complications, emergency department visits, and readmissions. Multivariable logistic regression was used to model covariates, including anti-TNF agent use, on the occurrence of outcomes.RESULTS Of the 2476 patients identified, 1379 (55.7%) were men, and the mean (SD) age was 42.1 (12.9) years. Among these, 950 (38.4%) underwent subtotal colectomy or total abdominal colectomy, 354 (14.3%) underwent total proctocolectomy with end ileostomy, and 1172 (47.3%) received ileal pouch-anal anastomoses. In univariate analyses, increased postoperative complications were observed among patients in the ileal pouch cohort who received anti-TNF agents preoperatively vs those who did not (137 [45.2%] vs 327 [37.6%]; P =.02) but not among those in the colectomy or proctocolectomy cohorts. An increase in complications was also observed on multivariable analyses among patients in the ileal pouch cohort (odds ratio, 1.38; 95% CI, 1.05-1.82).CONCLUSIONS AND RELEVANCE Unlike preoperative anti-TNF agent use among patients who underwent colectomy or total proctocolectomy and experienced no significant increase in postoperative complications, anti-TNF agent use within 90 days of surgery among patients who underwent ileal pouch-anal anastomosis was associated with higher 90-day postoperative complication rates.