Risk and management of post-operative infectious complications in inflammatory bowel disease: A systematic review

ARTICLE HIGHLIGHTS

Research background

Inflammatory bowel disease (IBD), including ulcerative colitis and Crohn’s disease, are chronic auto-inflammatory conditions marked by relapses and remissions, with increasing prevalence due to dietary changes. These diseases bring substantial physical, psychosocial, and economic burdens. Despite various available treatments, a significant proportion of patients require surgery within a decade of diagnosis. Surgical intervention poses challenges, particularly in emergency cases, with infectious complications being a major concern. Surgical approaches range from open procedures for emergencies to laparoscopic techniques for stable patients, aiming to minimize complications and hospital stays.

Research motivation

The study’s focus stems from the escalating IBD prevalence, the inadequacies of current treatments leading to surgeries, and the associated risk of post-operative infections. Addressing these issues is vital to enhance patient outcomes and reduce healthcare costs. Identifying risk factors linked to infections post-surgery, such as patient general status, preoperative abscess presence, obesity, and perioperative blood transfusions, is pivotal for preemptive measures. Understanding the impact of medications, such as steroids and anti-tumor necrosis factor (TNF), on post-operative complications is essential for informed treatment decisions. The significance lies in improving surgical practices and patient management, subsequently curbing infection-related morbidity and mortality.

Research objectives

This study primarily aims to investigate risk factors contributing to heightened post-operative infectious complications in IBD patients undergoing surgery. By systematically analyzing patient factors such as serum albumin levels, preoperative abscess presence, obesity, and perioperative blood transfusion requirements, the study aims to elucidate their role in infection susceptibility. Furthermore, the research delves into the impact of medications, specifically steroids and anti-TNF-α, on post-operative infection rates. Achieving these objectives will furnish insights into preoperative assessment and optimization strategies, influencing surgical decisions and post-operative care. Ultimately, the study’s significance lies in refining surgical practices and patient care to ameliorate post-operative morbidity, mortality, and overall quality of life in IBD patients undergoing surgery.

Research methods

The systematic review adhered to PRISMA-P guidelines and aimed to explore existing literature related to post-operative infectious complications in IBD surgery. Searches were conducted in MEDLINE (PubMed) and Cochrane Library using keywords related to IBD, surgery, and infection. The retrieved data were categorized into complications, medications, and risk factors. Inclusion criteria encompassed patients aged over 18, diagnosed with IBD, undergoing abdominal surgery, and experiencing infectious complications within 30 d post-surgery. Exclusions included patients under 18, pregnant women, and complications occurring after 30 d. Selected studies included systematic reviews, retrospective/prospective cohort studies, and case-control studies in English and French. The chosen papers were analyzed to address questions about infectious complications, medication impact, and contributing factors. The results underwent narrative analysis to derive evidence-based factors leading to increased complications and offer management recommendations.

Research results

The research outcomes contribute significant insights into post-operative complications in patients with IBD. The study encompassed a rigorous selection process, yielding 70 articles for analysis. Categorizing results into distinct domains highlighted the critical aspects of risk factors and medication effects on post-operative outcomes. The investigation identified several noteworthy risk factors, including hypoalbuminemia, malnutrition, preoperative abscess, obesity, and perioperative blood transfusion. Hypoalbuminemia consistently emerged as a predictor of infectious complications, emphasizing its clinical relevance. Malnutrition, determined by weight loss and serum albumin, consistently heightened the risk of complications, highlighting its importance in patient management. Further analysis revealed the impact of medications. 5-aminosalicylates demonstrated no overall increase in infectious complications. Immunomodulators, corticosteroids, and anti-interleukin antibodies displayed varying associations with post-operative outcomes. While some studies suggested increased infectious risks, others contradicted these findings. Additionally, anti-TNF therapy’s impact showed conflicting results, possibly influenced by timing and patient population. The inclusion of large prospective trials such as Patients Undergoing Surgery to Identify Risk Factors for Postoperative Infection contributed valuable evidence regarding the safety of anti-TNF therapy. Comparing minimally invasive (laparoscopic and robotic) open surgery yielded mixed findings. While some studies reported reduced complications with minimally invasive approaches, others showed no significant differences. The field benefits from these insights, although further research is needed to clarify the optimal surgical approach. Overall, this research advances the understanding of post-operative complications in IBD patients. By comprehensively addressing risk factors and medication effects, the study guides clinical decision-making and highlights areas for future investigation.

Research conclusions

This study contributes significant insights into the management of post-operative complications in patients with IBD. The findings underscore the importance of addressing risk factors such as hypoalbuminemia and malnutrition, which have been consistently associated with increased infectious complications following surgery. The study highlights the critical role of optimizing nutritional status, utilizing tools like Onodera’s Prognostic Nutritional Index, and considering interventions such as percutaneous drainage for managing intra-abdominal abscesses. Obesity’s impact on immune function and altered pharmacokinetics of IBD medications emphasize its association with post-operative infectious complications. The research also provides clarity regarding the use of various medications, including corticosteroids, immunomodulators, and biologics, in the preoperative period, offering valuable guidance for clinical practice.

Research perspectives

Future research should delve deeper into the dynamics of nutritional interventions to mitigate infectious complications in IBD patients undergoing surgery. Longitudinal studies exploring the influence of personalized nutritional strategies on surgical outcomes are warranted. Additionally, further investigation into the role of emerging therapies such as ustekinumab, vedolizumab, and tofacitinib in the perioperative setting is essential. Prospective studies with larger cohorts are needed to definitively determine the impact of anti-TNF agents on post-operative infections in IBD patients. The ongoing evolution of IBD management, including the emergence of new medications like ozanimod, risankizumab, and upadacitinib, necessitates comprehensive studies to ascertain their effects on surgical outcomes. Future research directions should aim to refine treatment algorithms, considering individual patient characteristics and disease severity, ultimately enhancing patient care and minimizing post-operative complications.