Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands.
Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
J Crohns Colitis. 2023 Mar 18;17(2):221-230. doi: 10.1093/ecco-jcc/jjac128.
To prevent recurrence after ileocolonic resection [ICR] in Crohn's disease [CD], postoperative prophylaxis based on risk stratification is recommended in international guidelines. This study aimed to evaluate postoperative CD recurrence after implementation of a clinical management algorithm and to determine the predictive value of clinical and histological risk factors [RFs].
In this multicentre, prospective cohort study, CD patients [≥16 years] scheduled for ICR were included. The algorithm advised no postoperative medication for low-risk patients, and treatment with prophylaxis [immunosuppressant/biological] for high-risk patients [≥1 RF: active smoking, penetrating disease, prior ICR]. Clinical and histological RFs [active inflammation, granulomas, plexitis in resection margins] for endoscopic recurrence [Rutgeerts' score ≥i2b at 6 months] were assessed using logistic regression and ROC curves based on predicted probabilities.
In total, 213 CD patients after ICR were included [age 34.5 years; 65% women] (93 [44%] low-risk; 120 [56%] high-risk: 45 [38%] smoking; 51 [43%] penetrating disease; 51 [43%] prior ICR). Adherence to the algorithm was 82% in low-risk [no prophylaxis] and 51% in high-risk patients [prophylaxis]. Endoscopic recurrence was higher in patients treated without prophylaxis than with prophylaxis in both low [45% vs 16%, p = 0.012] and high-risk patients [49% vs 26%, p = 0.019]. Clinical risk stratification including the prescription of prophylaxis corresponded to an area under the curve [AUC] of 0.70 (95% confidence interval [CI] 0.61-0.79). Clinical RFs combined with histological RFs increased the AUC to 0.73 [95% CI 0.64-0.81].
Adherence to this management algorithm is 65%. Prophylactic medication after ICR prevents endoscopic recurrence in low- and high-risk patients. Clinical risk stratification has an acceptable predictive value, but further refinement is needed.
为了预防克罗恩病（CD）患者在接受回肠结肠切除术（ICR）后的复发，国际指南推荐基于风险分层的术后预防措施。本研究旨在评估实施临床管理算法后 CD 复发的情况，并确定临床和组织学风险因素（RFs）的预测价值。
这是一项多中心前瞻性队列研究，纳入了计划接受 ICR 的 CD 患者（≥16 岁）。该算法建议低风险患者术后无需用药，高风险患者（≥1 个 RF：吸烟、穿透性疾病、既往 ICR）则采用预防治疗（免疫抑制剂/生物制剂）。使用逻辑回归和基于预测概率的 ROC 曲线评估内镜复发（6 个月时 Rutgeerts 评分≥i2b）的临床和组织学 RFs（活动炎症、肉芽肿、切缘神经丛炎）。
共纳入 213 例 ICR 后的 CD 患者（年龄 34.5 岁；65%为女性）（93 例[44%]为低风险；120 例[56%]为高风险：45 例[38%]为吸烟；51 例[43%]为穿透性疾病；51 例[43%]为既往 ICR）。低风险患者（无预防）和高风险患者（预防）中，分别有 82%和 51%的患者遵循了该算法。无预防治疗的患者内镜复发率高于预防治疗的患者，无论低风险[45% vs 16%，p=0.012]还是高风险[49% vs 26%，p=0.019]。包括预防治疗处方的临床风险分层对应曲线下面积（AUC）为 0.70（95%置信区间[CI] 0.61-0.79）。将临床 RFs 与组织学 RFs 相结合可提高 AUC 至 0.73（95% CI 0.64-0.81）。
该管理算法的依从性为 65%。ICR 后预防性用药可预防低风险和高风险患者的内镜复发。临床风险分层具有可接受的预测价值，但需要进一步改进。
