Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio.
Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Clin Gastroenterol Hepatol. 2024 Apr;22(4):847-857.e12. doi: 10.1016/j.cgh.2023.10.009. Epub 2023 Oct 23.
BACKGROUND & AIMS: Preoperative risk stratification may help guide prophylactic biologic utilization for the prevention of postoperative Crohn's disease (CD) recurrence; however, there are limited data exploring and validating proposed clinical risk factors. We aimed to explore the preoperative clinical risk profiles, quantify individual risk factors, and assess the impact of biologic prophylaxis on postoperative recurrence risk in a real-world cohort.
In this multicenter retrospective analysis, patients with CD who underwent ileocolonic resection (ICR) from 2009 to 2020 were identified. High-risk (active smoking, ≥2 prior surgeries, penetrating disease, and/or perianal disease) and low-risk (nonsmokers and age >50 y) features were used to stratify patients. We assessed the risk of endoscopic (Rutgeert score, ≥i2b) and surgical recurrence by risk strata and biologic prophylaxis (≤90 days postoperatively) with logistic and time-to-event analyses.
A total of 1404 adult CD patients who underwent ICR were included. Of the high-risk factors, 2 or more ICRs (odds ratio [OR], 1.71; 95% CI, 1.13-2.57), active smoking (OR, 1.73; 95% CI, 1.17-2.53), penetrating disease (OR, 1.41; 95% CI, 1.02-1.94), and history of perianal disease alone (OR, 1.99; 95% CI, 1.42-2.79) were associated with surgical but not endoscopic recurrence. Surgical recurrence was lower in high-risk patients receiving prophylaxis vs not (10.2% vs 16.7%; P = .02), and endoscopic recurrence was lower in those receiving prophylaxis irrespective of risk strata (high-risk, 28.1% vs 37.4%; P = .03; and low-risk, 21.1% vs 38.3%; P = .002).
Clinical risk factors accurately illustrate patients at risk for surgical recurrence, but have limited utility in predicting endoscopic recurrence. Biologic prophylaxis may be of benefit irrespective of risk stratification and future studies should assess this.
术前风险分层有助于指导预防生物制剂的使用，以防止术后克罗恩病（CD）复发；然而，目前用于探索和验证拟议的临床风险因素的数据有限。本研究旨在探索真实世界队列中术前临床风险特征，量化个体风险因素，并评估生物预防对术后复发风险的影响。
本多中心回顾性分析纳入了 2009 年至 2020 年间接受回肠结肠切除术（ICR）的 CD 患者。采用高危（吸烟、≥2 次手术、穿透性疾病和/或肛周疾病）和低危（不吸烟和年龄＞50 岁）特征对患者进行分层。我们通过逻辑和时间事件分析，根据风险分层和生物预防（术后≤90 天）评估内镜（Rutgeert 评分，≥i2b）和手术复发的风险。
共纳入 1404 例接受 ICR 的成年 CD 患者。在高危因素中，2 次或以上 ICR（比值比[OR]，1.71；95%置信区间[CI]，1.13-2.57）、吸烟（OR，1.73；95%CI，1.17-2.53）、穿透性疾病（OR，1.41；95%CI，1.02-1.94）和单纯肛周疾病史（OR，1.99；95%CI，1.42-2.79）与手术而非内镜复发相关。与未接受预防治疗的患者相比，高危患者接受预防治疗后手术复发率较低（10.2%比 16.7%；P=0.02），无论风险分层如何，接受预防治疗的患者内镜复发率均较低（高危，28.1%比 37.4%；P=0.03；低危，21.1%比 38.3%；P=0.002）。
临床风险因素准确地说明了手术复发风险较高的患者，但在预测内镜复发方面的作用有限。生物预防可能对分层风险无益处，未来的研究应评估这一点。
