O'Connor Anthony, Hamlin Peter J, Taylor Jennifer, Selinger Christian, Scott Nigel, Ford Alexander C
Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.
Frontline Gastroenterol. 2017 Jul;8(3):203-209. doi: 10.1136/flgastro-2016-100749. Epub 2016 Dec 1.
Up to 80% of patients with Crohn's disease (CD) may require surgery at some point in their lives, and it is estimated that as many as 40% may require several surgeries. It has been suggested that prophylactic medication decreases the rate of clinical and endoscopic recurrence following intestinal resection. This study aims to describe real-world clinical outcomes observed from a pragmatic, individualised strategy in postoperative CD.
All patients undergoing intestinal resection for CD between 2009 and 2013 were identified. The endpoint of the study, treatment success, was defined as glucocorticosteroid-free, resection-free survival, at the last point of follow-up, without requiring an escalation or change of therapy during this time. Clinical information was extracted from chart reviews, endoscopy and radiology reports, and from prescribing databases. Patients were followed from the date of surgery, and the last point of follow-up was 31 January 2015.
149 patients were analysed. Median duration of follow-up was 32 months (range 1-69 months). 101 patients received postoperative prophylactic therapy, and 48 did not. In 77 (51.7%) patients, thiopurines were used as first-line therapy, with treatment success occurring in 32 (41.6%) with a median follow-up of 25 months. 11 patients (7.4%) received anti-tumour necrosis factor (TNF)-α monotherapy, with treatment success occurring in 5 patients (45.5%) with a median follow-up of 35 months. 13 (8.7%) patients received first-line combination therapy, with 11 (84.6%) patients achieving treatment success with a median follow-up of 21 months.
In our study, combination therapy with anti-TNF-α and immunomodulator therapy was well tolerated, efficacious (efficacy appeared durable for patients with postoperative CD) and superior to monotherapy with either thiopurines or anti-TNF-α drugs. Several limitations notwithstanding, our data suggest that there may be merit in the use of combination therapy in carefully selected postoperative patients whose care has been individualised via a multidisciplinary team meeting format. Prospective, controlled studies are therefore required to further assess the efficacy and safety of combination therapy for postoperative prophylaxis in CD.
高达80%的克罗恩病（CD）患者在其生命中的某个阶段可能需要手术，据估计，多达40%的患者可能需要多次手术。有人提出预防性用药可降低肠道切除术后临床和内镜复发率。本研究旨在描述在术后CD患者中采用务实、个体化策略所观察到的实际临床结果。
确定2009年至2013年间所有因CD接受肠道切除的患者。研究终点为治疗成功，定义为在最后一次随访时无糖皮质激素、无再次切除的生存，且在此期间无需升级或改变治疗方案。临床信息从病历审查、内镜和放射学报告以及处方数据库中提取。患者从手术日期开始随访，最后一次随访时间为2015年1月31日。
分析了149例患者。中位随访时间为32个月（范围1 - 69个月）。101例患者接受了术后预防性治疗，48例未接受。77例（51.7%）患者使用硫唑嘌呤作为一线治疗，32例（41.6%）治疗成功，中位随访时间为25个月。11例（7.4%）患者接受抗肿瘤坏死因子（TNF）-α单药治疗，5例（45.5%）治疗成功，中位随访时间为35个月。13例（8.7%）患者接受一线联合治疗，11例（84.6%）患者治疗成功，中位随访时间为21个月。
在我们的研究中，抗TNF-α与免疫调节剂联合治疗耐受性良好、有效（对术后CD患者疗效持久）且优于硫唑嘌呤或抗TNF-α药物单药治疗。尽管存在一些局限性，但我们的数据表明，对于通过多学科团队会议形式进行个体化治疗的精心挑选的术后患者，联合治疗可能有益。因此，需要进行前瞻性对照研究，以进一步评估联合治疗在CD术后预防中的疗效和安全性。
