The effect of anti-tumor necrosis factor alpha agents on postoperative anastomotic complications in Crohn's disease: a systematic review.

BACKGROUND

Patients with Crohn's disease treated with anti-tumor necrosis factor alpha agents may have an increased risk of surgical complications.

OBJECTIVE

We assessed the effect of anti-tumor necrosis factor alpha on postoperative complications in patients with Crohn's disease undergoing abdominal surgery.

DATA SOURCES

Studies were identified through electronic and manual searches.

STUDY SELECTION

Observational studies on patients with Crohn's disease undergoing laparoscopic or open abdominal surgery were included.

INTERVENTIONS

Anti-tumor necrosis factor alpha agents were administered within 3 months before surgery.

MAIN OUTCOME MEASURES

The primary outcome was anastomotic complications including overt dehiscence, intra-abdominal abscess, and enteric fistulas.

RESULTS

Fourteen studies on 679 patients in the intervention (anti-tumor necrosis factor alpha) group and 2363 controls were included. Random-effects meta-analysis found no difference in anastomotic complications between the 2 groups (7.6% versus 8.2%; risk ratio, 0.91; 95% CI, 0.56-1.48). There was clear heterogeneity between studies. In subgroup analyses, the anti-tumor necrosis factor alpha increased anastomotic complications in trials with a lower risk of bias, but not in the studies with a higher bias risk (risk ratio, 1.63; 95% CI, 1.03-2.60 and risk ratio, 0.17; 95% CI, 0.05-0.60). In the overall analysis and in studies with a lower bias risk, anti-tumor necrosis factor alpha agents increased the risk of nonanastomotic surgical complications, major medical complications, and minor medical complications.

LIMITATIONS

Limitations of observations studies.

CONCLUSIONS

In studies with a low risk of bias, anti-tumor necrosis factor alpha agents increased the risk of anastomotic complications. Inadequate bias control may lead to an underestimated risk of anastomotic complications.