Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands.
BJS Open. 2023 Sep 5;7(5). doi: 10.1093/bjsopen/zrad097.
The advantage of early ileocecal resection after Crohn's disease diagnosis is a matter of debate. This study aims to assess the timing of ileocecal resection on prognosis, after correction for possible confounders.
Patients with Crohn's disease with primary ileocecal resection between 2000 and 2019 were included in a retrospective multicentre cohort. The primary endpoint was endoscopic recurrence (Rutgeerts score ≥i2b) within 18 months. Secondary endpoints were escalation of inflammatory bowel disease medication within 18 months and re-resection during follow-up. The association between timing of ileocecal resection and these endpoints was investigated using multivariable proportional hazard models, corrected for covariates including Montreal classification, postoperative prophylaxis, smoking, indication for surgery, medication before ileocecal resection, perianal fistulas, surgical approach, histology, length of resected segment and calendar year.
In 822 patients ileocecal resection was performed after a median of 3.1 years (i.q.r. 0.7-8.0) after Crohn's disease diagnosis. The lowest incidence of endoscopic recurrence, escalation of inflammatory bowel disease medication and re-resection was observed for patients undergoing ileocecal resection shortly after diagnosis (0-1 months). After correction for covariates, patients with ileocecal resection at 0, 4 and 12 months after diagnosis had a cumulative incidence of 35 per cent, 48 per cent and 39 per cent for endoscopic recurrence, 20 per cent, 29 per cent and 28 per cent for escalation of inflammatory bowel disease medication and 20 per cent, 30 per cent and 34 per cent for re-resection, respectively. In the multivariable model ileocolonic disease (HR 1.39 (95 per cent c.i. 1.05 to 1.86)), microscopic inflammation of proximal and distal resection margins (HR 2.20 (95 per cent c.i. 1.21 to 3.87)) and postoperative prophylactic biological and immunomodulator (HR 0.16 (95 per cent c.i. 0.05 to 0.43)) were associated with endoscopic recurrence.
The timing of ileocecal resection was not associated with a change of disease course; in the multivariable model, the postoperative recurrence was not affected by timing of ileocecal resection.
在克罗恩病诊断后尽早行回盲部切除术的优势尚存争议。本研究旨在校正可能的混杂因素后，评估回盲部切除的时机对预后的影响。
本研究为回顾性多中心队列研究，纳入了 2000 年至 2019 年间行原发性回盲部切除术的克罗恩病患者。主要终点为术后 18 个月内内镜下复发（Rutgeerts 评分≥i2b）。次要终点为术后 18 个月内炎症性肠病药物升级和随访期间再次手术。使用多变量比例风险模型，校正蒙特利尔分类、术后预防、吸烟、手术适应证、回盲部切除前药物治疗、肛周瘘管、手术入路、组织学、切除肠段长度和日历年后，评估回盲部切除时机与这些终点的关系。
在 822 例患者中，回盲部切除的中位时间为克罗恩病诊断后 3.1 年（IQR 0.7-8.0）。在诊断后 0-1 个月行回盲部切除的患者，内镜下复发、炎症性肠病药物升级和再次手术的发生率最低。校正混杂因素后，诊断后 0、4 和 12 个月行回盲部切除术的患者，内镜下复发的累积发生率分别为 35%、48%和 39%，炎症性肠病药物升级的累积发生率分别为 20%、29%和 28%，再次手术的累积发生率分别为 20%、30%和 34%。多变量模型显示，回结肠疾病（HR 1.39（95%可信区间 1.05 至 1.86））、近端和远端切除边缘的显微镜下炎症（HR 2.20（95%可信区间 1.21 至 3.87））和术后预防性使用生物制剂和免疫调节剂（HR 0.16（95%可信区间 0.05 至 0.43））与内镜下复发相关。
回盲部切除术的时机与疾病进程的变化无关；在多变量模型中，术后复发不受回盲部切除术时机的影响。
