Chongthammakun Vasutakarn, Fialho Andre, Fialho Andrea, Lopez Rocio, Shen Bo
Department of Internal Medicine, The Cleveland Clinic Foundation, Cleveland, OH, USA.
Department of Quantitative Health Sciences, The Cleveland Clinic Foundation, Cleveland, OH, USA.
Gastroenterol Rep (Oxf). 2017 Nov;5(4):271-276. doi: 10.1093/gastro/gow043. Epub 2016 Dec 30.
Recurrence of Crohn's disease (CD) can occur after surgery, including end ileostomy (EI). The Rutgeerts score (RS) was developed to predict postsurgical CD recurrence via ileocolonoscopy in patients having ileocolonic resection. The role of ileoscopic evaluation via stoma for assessing recurrence of CD has not been investigated. The aim of this study was to evaluate the role of ileoscopy for predicting disease recurrence in CD patients after EI with the use of RS.
A total of 73 eligible CD patients with at least two ileoscopies in our institution following EI were included. Mucosal inflammation of the neo-terminal ileum was graded based on the RS. The primary outcomes were the need for endoscopic stricture dilation and subsequent surgery due to recurrence of disease. The secondary outcomes were CD-related hospitalization and the need to escalate CD-associated medications.
The median duration of CD until EI was 9 years (interquartile range: 4-13 years), and the median duration from EI to the first ileoscopy was 28 months (interquartile range: 11-93 months). The RSs in the neo-terminal ileum close to EI were calculated, and subjects were divided into two groups: the normal RS group with the score being zero (n = 25) and the abnormal RS group with the RS score being ≥1 (n = 48). Patients in the abnormal RS group were more likely to have recurrence of CD (92% vs 27%) and need endoscopic dilation of stricture (40% vs 10%), subsequent bowel surgery (68% vs 15%), disease-related hospitalizations (80% vs 23%) and escalation of CD medications (64% vs 25%) than those in the normal RS group. Time-to-event analysis showed that patients in the abnormal RS group were at a higher risk of endoscopic dilation (odds ratio (OR) = 1.5; 95% CI: 1.09-1.9), need of second bowel surgery (OR = 1.5; 95%CI: 1.2-1.8) and disease-related hospitalizations (OR = 1.3; 95%CI: 1.1-1.6) after adjusting for factors such as duration from surgery to sensor, duration of disease and the patient's sex (all P < 0.001). Further multivariable analysis showed that patients in the abnormal RS group were more likely to need escalation of CD-related medications after adjusting for duration from surgery and age (OR = 5.3; 95% CI: 1.7-16.5; P = 0.004).
RS can be used to predict the recurrence of CD in patients with EI. A high RS score based on ileoscopy appeared to be associated with poor outcomes. This may be considered a useful decision-making tool for monitoring disease after ileostomy surgery.
克罗恩病（CD）术后可复发，包括末端回肠造口术（EI）后。鲁杰尔斯评分（RS）用于预测回结肠切除术后患者通过结肠镜检查的术后CD复发情况。通过造口进行的回肠镜评估在评估CD复发中的作用尚未得到研究。本研究的目的是利用RS评估回肠镜检查在预测EI术后CD患者疾病复发中的作用。
纳入在我院接受EI后至少进行过两次回肠镜检查的73例符合条件的CD患者。根据RS对新末端回肠的黏膜炎症进行分级。主要结局是因疾病复发而需要进行内镜下狭窄扩张和后续手术。次要结局是与CD相关的住院治疗以及增加CD相关药物治疗的必要性。
CD至EI的中位病程为9年（四分位间距：4 - 13年），从EI至首次回肠镜检查的中位病程为28个月（四分位间距：11 - 93个月）。计算靠近EI的新末端回肠的RS，将受试者分为两组：RS评分为零的正常RS组（n = 25）和RS评分≥1的异常RS组（n = 48）。与正常RS组相比，异常RS组的患者更有可能出现CD复发（92%对27%），需要内镜下扩张狭窄（40%对10%）、后续肠道手术（68%对15%）、与疾病相关的住院治疗（80%对23%）以及增加CD药物治疗（64%对25%）。生存分析表明，在调整手术至检查的时间、疾病病程和患者性别等因素后，异常RS组的患者进行内镜扩张（比值比（OR） = 1.5；95%置信区间：1.09 - 1.9）、需要二次肠道手术（OR = 1.5；95%置信区间：1.2 - 1.8）和与疾病相关的住院治疗（OR = 1.3；95%置信区间：1.1 - 1.6）的风险更高（均P < 0.001）。进一步的多变量分析表明，在调整手术时间和年龄后，异常RS组的患者更有可能需要增加CD相关药物治疗（OR = 5.3；95%置信区间：1.7 - 16.5；P = 0.004）。
RS可用于预测EI患者的CD复发。基于回肠镜检查的高RS评分似乎与不良结局相关。这可被视为回肠造口术后监测疾病的有用决策工具。
