Surgery and IBD Medications: What a 2026 Network Meta-Analysis Found About Complication Risks

For people living with ulcerative colitis (UC), biological therapies and small-molecule drugs have become cornerstones of disease management. But when surgery becomes necessary (for disease that cannot be controlled with medication, or for complications such as severe colitis, dysplasia, or cancer) a practical question arises: does the type of medication a person is taking in the weeks before the operation affect how the surgery goes?

A 2026 network meta-analysis published in the Journal of Crohn's & Colitis set out to examine exactly this. The analysis brought together data from 16 studies and more than 3,200 patients to compare short-term postoperative complication rates across different classes of UC therapy. Its findings vary by drug class, and the authors are clear about where the evidence is solid and where it remains limited.

Why Surgery Arises in Ulcerative Colitis

The Mayo Clinic describes ulcerative colitis as a chronic inflammatory bowel disease that causes inflammation and ulcers in the inner lining of the large intestine. Approximately one in five people with UC will require surgery at some point in their lifetime, most commonly a colectomy (removal of the colon). Surgery is considered when medication cannot adequately control the disease, during acute severe flares that do not respond to intensive medical treatment, or when changes in the lining of the bowel raise concern about cancer risk.

UC surgery is a major operation. Depending on the procedure and the individual's anatomy, it may result in a temporary or permanent stoma (an opening in the abdomen through which waste is collected in a pouch). For people living with UC on biological therapies, a question that matters greatly is whether the medication they are taking affects their surgical risk.

What the Network Meta-Analysis Did

The research team (pubmed:42570330) searched three large databases (PubMed, Web of Science, and the Cochrane Library) through September 15, 2025, looking for studies of adults with UC who received biologic or small-molecule therapy in the 12 weeks before colorectal surgery. This timeframe reflects clinical practice: decisions about whether to continue or stop a biologic near surgery are typically made in this window.

The therapies included:

• Anti-TNF agents (such as infliximab and adalimumab)
• Vedolizumab (a gut-selective biologic)
• Ustekinumab (an interleukin 12/23 inhibitor)
• Tofacitinib (a JAK inhibitor, a small-molecule therapy)
• Control (no biologic or small-molecule therapy)

The network meta-analysis design allows comparisons between treatments even when they were not directly tested head-to-head in the same study, by using shared comparison groups as bridges between separate trials. Sixteen retrospective cohort studies involving 3,235 patients met the inclusion criteria.

The primary outcome was overall postoperative complications at 30 and 90 days. Venous thromboembolism (blood clots) was assessed as a secondary outcome.

What the Evidence Found at 30 Days

At 30 days after surgery, the analysis found notable differences between drug classes.

Ustekinumab was associated with an overall complication rate substantially lower than the control group (risk ratio [RR] 0.29; 95% confidence interval [CI] 0.09-0.96). A risk ratio below 1.0 indicates a lower rate than the comparator. The confidence interval here is wide (0.09 to 0.96), which reflects statistical uncertainty: fewer ustekinumab-treated patients were included and the estimate carries more uncertainty than for some other comparisons.

Tofacitinib was associated with a lower 30-day complication rate than control (RR 0.66; 95% CI 0.46-0.96). The confidence interval is tighter here than for ustekinumab, suggesting a more stable estimate, though the upper boundary of 0.96 is just below 1.0, indicating a statistically meaningful but not wide margin.

Anti-TNF therapy showed a different pattern. Compared with vedolizumab, anti-TNF was associated with higher 30-day complication rates (RR 1.27; 95% CI 1.00-1.63). Compared with ustekinumab, the difference was larger (RR 3.67; 95% CI 1.12-12.03). Compared with tofacitinib, anti-TNF was again associated with higher complications (RR 1.61; 95% CI 1.14-2.27).

These are associations drawn from retrospective observational data, not randomised controlled trials. That distinction matters, and is addressed below.

What the Evidence Found at 90 Days

At 90 days, the analysis found that anti-TNF therapy was associated with higher overall postoperative complication rates compared with the control group (RR 1.20; 95% CI 1.03-1.40). The authors note explicitly that the 90-day analysis rested on far fewer studies than the 30-day analysis, and that findings at 90 days should be interpreted with greater caution.

Venous thromboembolism (VTE), a particular concern with some IBD medications including tofacitinib, showed similar rates across all treatment groups at both time points. This was a reassuring finding, though VTE events in these retrospective datasets may also be subject to reporting variation.

The Limitations the Authors Name Directly

The network meta-analysis is notable for the clarity with which its authors name the limits of its findings. All 16 included studies were retrospective cohort studies, meaning researchers looked backward at patient records rather than randomly assigning people to different treatments. Observational studies of this type are subject to a problem called confounding: patients on different therapies in real clinical practice differ in many ways beyond just their medication.

A patient failing anti-TNF therapy and switching to ustekinumab, for example, may have more severe or refractory disease than someone who started on ustekinumab initially. Severity of disease at the time of surgery is itself a predictor of complications. The choice of medication may reflect the clinical trajectory of the patient's IBD, and disentangling the medication's effect from the underlying disease course is methodologically difficult in retrospective data.

The authors state that findings "should be interpreted with caution and require confirmation in well-designed prospective studies with rigorous adjustment for confounding factors." This is standard and appropriate scientific language, and it reflects the genuine state of the evidence.

What This Means for People With UC Facing Surgery

The findings from this network meta-analysis are hypothesis-generating: they identify patterns that warrant further investigation and discussion, rather than definitively answering the question of whether to continue or switch a biologic before surgery.

What is clinically relevant is that the question itself is being investigated at a high methodological standard, with a large patient dataset and careful statistical comparison across drug classes. The variation the analysis identifies between anti-TNF agents and newer mechanisms such as vedolizumab, ustekinumab, and tofacitinib reflects a genuine area of scientific and clinical interest.

For someone with UC approaching surgery, the most important takeaway is that this is a conversation to have with your gastroenterologist and colorectal surgeon together, well before the planned procedure. Decisions about whether to continue, pause, or switch a biologic in the perioperative period depend on many factors: which medication you are on, how long you have been on it, how well controlled your disease is, what type of surgery is planned, your overall health, and the surgical team's assessment of your individual risk.

The network meta-analysis contributes evidence to inform that conversation. It does not replace it.

Understanding the Drug Classes

For readers less familiar with these medications:

Anti-TNF agents (infliximab, adalimumab, golimumab) work by blocking tumour necrosis factor-alpha, a protein involved in the inflammatory cascade that drives UC. They have been used in IBD since the early 2000s and remain widely prescribed.

Vedolizumab works selectively on the gut by blocking certain white blood cells from migrating into intestinal tissue. Because its mechanism is gut-selective, it has a different systemic immune profile than anti-TNF therapy.

Ustekinumab blocks the interleukin 12 and 23 pathways, which drive inflammation in IBD. It was first licensed for Crohn's disease and subsequently extended to UC.

Tofacitinib is a JAK (Janus kinase) inhibitor, a small-molecule therapy taken orally. It works differently from biologics because it is not a protein administered by injection or infusion, but rather a tablet that modulates immune signalling pathways inside cells. It is associated with a different risk profile from biologics, including considerations around infection and, at higher doses, cardiovascular safety, which clinicians weigh in prescribing decisions.