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P333 Associations between multiple immunosuppressive treatments before surgery and surgical morbidity in patients with ulcerative colitis during the era of biologics

M. Uchino*1, H. Ikeuchi1, T. Bando1, T. Chohno1, H. Sasaki1, Y. Horio1, R. Kuwahara1, T. Minagawa1, Y. Goto1

1Hyogo College of Medicine, Inflammatory Bowel Disease, Nishinomiya, Japan

Background

Immunomodulators or biologics, with the exception of corticosteroids, do not appear to be risk factors for postoperative infectious complications of ulcerative colitis (UC). Recently, many immunosuppressive therapies including some biologics are used mainly to treat UC, and many patients are on multi-agent immunosuppressive therapy at the time of surgery. Therefore, we evaluated the influence of preoperative multiple immunosuppressive agents on the occurrence of surgical site infection (SSI) in UC during the era of biologics.

Methods

We reviewed surveillance data from 301 patients who underwent restorative proctocolectomy between January 2015 and April 2018. The incidences of SSI and possible risk factors among patients receiving different immunosuppressive therapies were compared and analysed.

Results

The incidence of incisional SSI (wound infection) was 6.6%, and that of organ/space SSI (abdominal/pelvic sepsis) was 7.0%. Prednisolone (PSL), carcineurin inhibitors (CNIs), and anti-TNF-α antibodies were administered to 117/301 (38.9%), 119/301 (39.5%), and 146/301 (48.5%) patients, respectively. Doses of PSL were significantly decreased because of the recent shift towards the use of biologics. The median total amount of PSL administered and preoperative PSL dose were 3,000 mg and 10 mg, respectively. Numbers of patients who are treated with none agents or thiopurine alone, with one agent, with two agents, and with three agents were 66(21.9%), 107(35.5%), 111(36.9%), and 17(5.6%), respectively. Age at initial surgery was significantly lower in patients with three agents, including PSL, CNIs, and anti-TNF-α antibody (p < 0.01). Urgent/emergent surgery was significantly less common in patients with no or one agent(s) (p = 0.04). Patients with no agents or AZA/6-MP administration alone had many more surgical indications of cancer/dysplasia (p < 0.01). Severe or fulminant disease was significantly lower in patients with no agents or thiopurine alone than in other groups (p < 0.01). The kinds and numbers of immunosuppressive agents did not significantly correlate with each incidence. Preoperative serum albumin <3.4 g/dl (odds ratio: OR, 5.0), surgical indication of cancer/dysplasia (OR, 8.4), and perioperative blood transfusion (OR, 4.6) were shown to be independent risk factors for incisional SSI, whereas only perioperative blood transfusion (OR, 3.4) was identified as an independent risk factor for organ/space SSI.

Conclusion

Although no correlation between preoperative immunosuppressive therapies was found, we should mention selection bias for treatment before surgery. However, biologics, calcineurin inhibitors, and thiopurines did not affect surgical morbidity in UC.