Since the approval in 2005 of anti-TNF drugs for the treatment of ulcerative colitis, concerns
have been raised about the potential detrimental effect of these agents on postoperative infectious
complications related to pouch surgery. Data on this topic are controversial and mostly derived
from retrospective underpowered cohort studies largely affected by relevant bias. Three meta-analyses
have been published with contradictory results. Moreover, the correlation between serum levels of infliximab
at the time of surgery and the occurrence of septic postoperative complication is far to be
proven and remains an answered research question. The construction of an ileal pouch-anal anastomosis
(IPAA) as first surgical step in patients with ulcerative colitis (UC) refractory to medical treatment
seems to be associated with an increased risk of septic complications. Population-based data from the
United States show a shift towards stage surgery for patients with refractory UC as a consequence of
the widespread use of biological agents and the increased tendency to consider surgery as ultimate resort
(step-up approach). In this setting, the classic 3-stage procedure (ileoanal pouch and diversion
ileostomy after initial total colectomy) together with the modified 2-stage approach (ileoanal pouch
without diversion ileostomy after initial total colectomy) are both effective options. Whether or not a
diversion ileostomy could prevent pouch complications at the time of the pouch construction during
the second stage of surgery is still a matter of debate. Emerging data seem to claim for increased risk
of small bowel obstructions related to the presence of a stoma without proven effect on the prevention
of anastomotic leak.
Anti-TNF and Pouch Surgery for Ulcerative Colitis: The Ones who Blame for More Complications?
