经肛门直肠病变旷置术治疗难治性肛直肠型克罗恩病：在抗 TNF 时代真的有用吗？74 例连续患者的多因素分析。

Diverting Stoma for Refractory Ano-perineal Crohn's Disease: Is It Really Useful in the Anti-TNF Era? A Multivariate Analysis in 74 Consecutive Patients.

机构信息

Department of Colorectal Surgery, Beaujon Hospital, University Denis Diderot [Paris VII], Clichy, France.

Department of Gastroenterology, Inflammatory Bowel Disease, and Nutritive Assistance, Beaujon Hospital, University Denis Diderot [Paris VII], Clichy, France.

出版信息

J Crohns Colitis. 2019 Apr 26;13(5):572-577. doi: 10.1093/ecco-jcc/jjy195.

DOI:10.1093/ecco-jcc/jjy195

PMID:30452620

Abstract

BACKGROUND AND AIMS

Faecal diversion [FD] can be proposed in patients with refractory anoperineal Crohn's disease [APCD]. This study aimed to assess long-term results of this strategy, following the advent of the anti-tumour necrosis factor [TNF] era.

METHODS

All patients who underwent FD for refractory APCD between 2005 and 2017 were included, excluding patients with a history of ileal pouch-anal anastomosis. A multivariate analysis regarding absence of stoma reversal [SR] was performed.

RESULTS

A total of 65 consecutive patients who underwent FD for APCD (comprising anoperineal fistula [n = 40, 62%], rectovaginal fistula [n = 21, 32%], fissures and/or ulceration [n = 9, 14%], and/or anal stricture [n = 5, 8%]) were included. At the time of FD, 34 patients [52%] presented with small bowel Crohn's disease [CD] involvement, 29 [45%] with colonic involvement, and 19 [29%] with rectal involvement. Following FD, 54 patients [83%] were treated with anti-TNF therapy, prescribed for isolated APCD [n = 10, 15%] or luminal CD with APCD [n = 44, 68%]. After a mean follow-up of 49 ± 29 [7-120] months, SR was not possible in 32 patients [49%], including 17 patients [26%] requiring a subsequent proctectomy with abdominoperineal excision. In multivariate analysis, rectal CD involvement was the only independent factor associated with a reduced rate of SR (odds ratio: 4.0 [1.153-14.000]; p = 0.029), and anti-TNF therapy had no impact on SR rate.

CONCLUSIONS

FD can be performed in selected patients with refractory APCD, to avoid abdominoperineal resection. However, this strategy should be proposed with caution in patients presenting with rectal CD involvement. Anti-TNF therapy has no impact on SR rate.

摘要

背景与目的

粪便转流术（FD）可用于治疗难治性肛直肠克罗恩病（APCD）。本研究旨在评估抗 TNF 时代到来后，该策略的长期结果。

方法

纳入 2005 年至 2017 年间因难治性 APCD 而行 FD 的所有患者，排除有回肠储袋肛门吻合术病史的患者。对无造口反转（SR）进行多因素分析。

结果

共纳入 65 例因 APCD 而行 FD 的连续患者（其中肛直肠瘘 40 例，占 62%；直肠阴道瘘 21 例，占 32%；肛裂和/或溃疡 9 例，占 14%；和/或肛门狭窄 5 例，占 8%）。行 FD 时，34 例（52%）患者合并小肠克罗恩病（CD），29 例（45%）患者合并结肠 CD，19 例（29%）患者合并直肠 CD。FD 后，54 例（83%）患者接受抗 TNF 治疗，单独治疗 APCD 10 例（15%），联合治疗伴有 APCD 的腔 CD 44 例（68%）。平均随访 49 ± 29 个月（7-120 个月）后，32 例（49%）患者无法进行 SR，其中 17 例（26%）需要后续行腹会阴切除的直肠切除术。多因素分析显示，直肠 CD 受累是 SR 率降低的唯一独立因素（比值比：4.0[1.153-14.000]；p = 0.029），抗 TNF 治疗对 SR 率无影响。