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Debate exists concerning the presumed risk of postoperative complications in patients with ulcerative colitis (UC) receiving preoperative infliximab (IFX). Meta-analyses are contrasting because of many confounders included into analysis. Our aim was to determine the impact of IFX on pouch-related postoperative complications in patients with UC undergoing surgery with primary ileal pouch–anal anastomosis.We performed a systematic review to identify studies comparing the outcomes of patients undergoing surgery for UC with or without previous IFX exposure. The primary end points were (1) early ileal pouch–anal anastomosis–related complications after surgery with primary pouch formation and (2) those occurring after ileostomy closure. Secondary end points were the effects of IFX on total, infectious, and noninfectious complications in patients with UC undergoing any type of surgery. Results are reported as pooled odds ratio (OR) with 95% confidence intervals (CIs).Seven papers, including 162 patients receiving biologics and 468 controls all undergoing primary pouch formation, were included for the primary aim. Patients receiving IFX were more likely developing early (OR = 4.12; 95% CI, 2.37–7.15; P < 0.001) and post-ileostomy closure (OR = 2.27; 95% CI, 1.27–4.05; P = 0.005) ileal pouch–anal anastomosis–related complications. Number needed to harm was calculated to be 5 and 4, respectively. Having received at least 3 IFX effusions increased the risk of early complications (OR = 9.59; 95% CI, 2.92–31.44; P = 0.0002), whereas an interval of <12 weeks since last effusion did not (OR = 2.35; 95% CI, 0.98–5.64; P = 0.06). Meta-analyses of 14 studies reporting on any type of surgery found that IFX showed a trend toward higher total and infectious complications, but no significant differences were observed. Biologics were associated with lower surgical site infection (OR = 0.67; 95% CI, 0.45–0.99; P = 0.04).IFX exposure increases early pouch-specific complications and complications after ileostomy closure in UC. Avoiding primary pouch formation could be a prudent approach.