Shinagawa Takahide, Hata Keisuke, Ikeuchi Hiroki, Fukushima Kouhei, Futami Kitaro, Sugita Akira, Uchino Motoi, Watanabe Kazuhiro, Higashi Daijiro, Kimura Hideaki, Araki Toshimitsu, Mizushima Tsunekazu, Itabashi Michio, Ueda Takeshi, Koganei Kazutaka, Oba Koji, Ishihara Soichiro, Suzuki Yasuo
Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan.
Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan.
Clin Gastroenterol Hepatol. 2020 Apr;18(4):898-907.e5. doi: 10.1016/j.cgh.2019.07.025. Epub 2019 Jul 20.
BACKGROUND & AIMS: Patients with Crohn's disease (CD) can require multiple intestinal surgeries. We examined time trends and risk factors for reoperation in patients with CD who underwent intestinal surgery, focusing on the effects of postoperative medical treatments.
We performed a retrospective analysis of 1871 patients with CD who underwent initial intestinal resection at 10 tertiary care institutions in Japan, with an initial surgical date after May 1982. We collected data on the background characteristics of all patients, including Montreal Classification, smoking status, and medical therapy after surgery (tumor necrosis factor antagonists [anti-TNF] agents or immunomodulators). The primary outcome was requirement for first reoperation. Rate of reoperation was estimated using the Kaplan-Meier method, and risk factors for reoperation were identified using the Cox regression model.
The overall cumulative 5- and 10-year reoperation rates were 23.4% and 48.0%, respectively. Multivariable analysis showed that patients who underwent the initial surgery after May 2002 had a significantly lower rate of reoperation than patients who underwent surgery before April 2002 (hazard ratio [HR], 0.72; 95% CI, 0.61-0.86). Preoperative smoking (HR, 1.40; 95% CI, 1.18-1.68), perianal disease (HR, 1.50; 95% CI, 1.27-1.77), and ileocolic type of CD (HR, 1.42; 95% CI, 1.20-1.69) were significant risk factors for reoperation. Postoperative use of immunomodulators (HR, 0.60; 95% CI, 0.44-0.81) and anti-TNF therapy (HR, 0.71; 95% CI, 0.57-0.88) significantly reduced the risk. Anti-TNF was effective in the bionaive subgroup.
The rate of reoperation in patients with CD significantly decreased after May 2002. Postoperative use of anti-TNF agents might reduce the reoperation rate for bionaive patients with CD.
克罗恩病（CD）患者可能需要多次肠道手术。我们研究了接受肠道手术的CD患者再次手术的时间趋势和风险因素，重点关注术后药物治疗的影响。
我们对日本10家三级医疗机构中1871例于1982年5月之后进行初次肠道切除的CD患者进行了回顾性分析。我们收集了所有患者的背景特征数据，包括蒙特利尔分类、吸烟状况以及术后药物治疗情况（肿瘤坏死因子拮抗剂[抗TNF]或免疫调节剂）。主要结局是首次再次手术的需求。采用Kaplan-Meier法估计再次手术率，并使用Cox回归模型确定再次手术的风险因素。
总体累积5年和10年再次手术率分别为23.4%和48.0%。多变量分析显示，2002年5月之后接受初次手术的患者再次手术率显著低于2002年4月之前接受手术的患者（风险比[HR]，0.72；95%置信区间[CI]，0.61 - 0.86）。术前吸烟（HR，1.40；95% CI，1.18 - 1.68）、肛周疾病（HR，1.50；95% CI，1.27 - 1.77）以及回结肠型CD（HR，1.42；95% CI，1.20 - 1.69）是再次手术的显著风险因素。术后使用免疫调节剂（HR，0.60；95% CI，0.44 - 0.81）和抗TNF治疗（HR，0.71；95% CI，0.57 - 0.88）显著降低了风险。抗TNF在未使用过生物制剂的亚组中有效。
2起2年5月之后，CD患者的再次手术率显著下降。术后使用抗TNF药物可能会降低未使用过生物制剂的CD患者的再次手术率。
