Fumery M, Dulai P S, Meirick P, Farrell A M, Ramamoorthy S, Sandborn W J, Singh S
Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA.
Gastroenterology Unit, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France.
Aliment Pharmacol Ther. 2017 Feb;45(3):381-390. doi: 10.1111/apt.13886. Epub 2016 Dec 8.
Subtotal or total colectomy or proctocolectomy with permanent ileostomy (TC-PI) may be a treatment option for medically refractory colonic Crohn's disease (CD).
To perform a systematic review and meta-analysis to evaluate the rate, risk factors and outcomes of CD recurrence after TC-PI.
In a systematic review ending 31 March 2016, we identified 18 cohort studies (1438 adults) who underwent TC-PI for colonic CD (median follow-up, 7.4 years; interquartile range, 5.3-9.0). We estimated pooled rates [with 95% confidence interval (CI)] of clinical and surgical recurrence, and risk factors for disease recurrence.
On meta-analysis, the risk of clinical recurrence after TC-PI was 28.0% (95% CI, 21.7-35.3; 14 studies, 260/1004 patients), with a 5 and 10-year median cumulative rate of 23.5% (range, 7-35) and 40% (range, 11-60) respectively. The risk of surgical recurrence was 16.0% (95% CI, 11.1-22.7; 10 studies; 183/1092 patients), with a 5 and 10-year median cumulative rate of 10% (range, 3-29) and 18.5% (range, 14-34) respectively. The risk of clinical and surgical recurrence in patients without ileal disease at baseline was 11.5% (95% CI, 7.7-16.8) and 10.4% (95% CI, 4.5-22.5) respectively. History of ileal disease was associated with 3.2 times higher risk of disease recurrence (RR, 3.2; 95% CI, 1.8-5.6). Other inconsistent risk factors for disease recurrence were penetrating disease and young age at disease onset.
Small bowel clinical recurrence occurs in about 28% of patients after total colectomy with permanent ileostomy for colonic Crohn's disease. Disease recurrence risk is 3.2 times higher in patients with history of ileal disease, and continued medical therapy may be advisable in this population. In patients without ileal inflammation at surgery, continued endoscopic surveillance may identify asymptomatic disease recurrence to guide therapy.
结肠次全切除术或全切除术或永久性回肠造口术的直肠结肠切除术（TC-PI）可能是药物难治性结肠克罗恩病（CD）的一种治疗选择。
进行一项系统评价和荟萃分析，以评估TC-PI术后CD复发率、危险因素及结局。
在一项截至2016年3月31日的系统评价中，我们确定了18项队列研究（1438例成年人），这些患者因结肠CD接受了TC-PI（中位随访时间7.4年；四分位间距5.3 - 9.0）。我们估计了临床复发和手术复发的合并率[及95%置信区间（CI）]，以及疾病复发的危险因素。
荟萃分析显示，TC-PI术后临床复发风险为28.0%（95%CI，21.7 - 35.3；14项研究，260/1004例患者），5年和10年的中位累积复发率分别为23.5%（范围7 - 35）和40%（范围11 - 60）。手术复发风险为16.0%（95%CI，11.1 - 22.7；10项研究；183/1092例患者），5年和10年的中位累积复发率分别为10%（范围3 - 29）和18.5%（范围14 - 34）。基线时无回肠疾病患者的临床和手术复发风险分别为11.5%（95%CI，7.7 - 16.8）和10.4%（95%CI，4.5 - 22.5）。回肠疾病史与疾病复发风险高3.2倍相关（RR，3.2；95%CI，1.8 - 缺5.6）。其他不一致的疾病复发危险因素为穿透性疾病和发病时年龄较小。
对于结肠克罗恩病行永久性回肠造口术的全结肠切除术后，约28%的患者会发生小肠临床复发。有回肠疾病史的患者疾病复发风险高3.2倍，该人群可能建议继续药物治疗。对于手术时无回肠炎症的患者，持续的内镜监测可能发现无症状的疾病复发以指导治疗。
