Caprilli R, Taddei G, Viscido A
Gastroenterology Unit, University of Rome La Sapienza, Rome, Italy.
Ital J Gastroenterol Hepatol. 1998 Apr;30(2):219-25.
Endoscopic follow-up of patients resected for ileal Crohn's disease have shown that, in the absence of treatment, the post-operative recurrence rate is 70-90% within one year of the operation and 83-100% within 3 years. Post-operative recurrence requires further operation in approximately half the patients in a 10-year period of follow-up. Therapeutic strategies aimed to prevent recurrence are, therefore, needed. Evidence supporting the administration of drugs early after surgery are listed below. Evidence from morphological and immunological studies: minimal mucosal lesions have been found using scanning electron microscopy in unaffected specimens of ileum and colon from 2/3 of patients resected for Crohn's disease. An increased production of TNF alpha, IL-1 beta, IL-6 and phospholipase A2 has also been found in the unaffected mucosa of patients with Crohn's disease providing evidence for a sustained immune stimulation in Crohn's disease even in the absence of patent inflammation. These inflammatory mediators are inhibited "in vitro" by aminosalicylates and, therefore, their use early after surgery is justified. Evidence from randomised controlled trials: several randomised controlled clinical trials have shown that aminosalicylates are able to prevent post-operative recurrence. In particular, an Italian study demonstrated that the cumulative proportion of endoscopic recurrence at 36 months was significantly lower in patients treated with Asacol compared to controls (0.57 +/- 0.12 vs 0.83 +/- 0.07, p = 0.003). A less frequent occurrence of severe complications and reoperations was also observed in the Asacol group. A North American study confirmed these results at 3 years' follow-up using Salofalk. Additional evidence for effectiveness of aminosalicylates in the prevention of post-operative recurrence was provided by two more studies in which Pentasa was used. Further evidence in favour of 5-ASA treatment comes from a recent metanalysis which showed that 5-ASA is effective as maintenance treatment in Crohn's disease, in particular in patients with resection. Metronidazole and fish-oil have also been found to be useful in the prevention of post-operative recurrence in isolated reports but need further investigation. Finally, cigarette smoking and end-to-end anastomosis are considered to be associated with an increased risk of recurrence. Overall, these data suggest that to stop smoking, avoiding end-to-end anastomosis and early administration of admino-salicylates after surgery should be recommended for all patients resected for Crohn's disease.
对因回肠克罗恩病接受手术切除的患者进行内镜随访发现，在未进行治疗的情况下，术后1年内复发率为70 - 90%，3年内为83 - 100%。在10年的随访期内，约半数患者术后复发需要再次手术。因此，需要旨在预防复发的治疗策略。支持术后早期给药的证据如下。形态学和免疫学研究证据：在2/3因克罗恩病接受手术切除患者的未受影响的回肠和结肠标本中，通过扫描电子显微镜发现了微小的黏膜病变。在克罗恩病患者未受影响的黏膜中还发现肿瘤坏死因子α、白细胞介素-1β、白细胞介素-6和磷脂酶A2的产生增加，这为即使在无明显炎症的情况下克罗恩病中持续的免疫刺激提供了证据。这些炎症介质在“体外”被氨基水杨酸盐抑制，因此术后早期使用氨基水杨酸盐是合理的。随机对照试验证据：多项随机对照临床试验表明，氨基水杨酸盐能够预防术后复发。特别是一项意大利研究表明，与对照组相比，使用艾克沙（Asacol）治疗的患者在36个月时内镜复发的累积比例显著更低（0.57±0.12对0.83±0.07，p = 0.003）。在艾克沙组中还观察到严重并发症和再次手术的发生率更低。一项北美研究在3年随访期使用莎尔福（Salofalk）证实了这些结果。另外两项使用颇得斯安（Pentasa）的研究为氨基水杨酸盐预防术后复发的有效性提供了更多证据。支持5-氨基水杨酸（5-ASA）治疗的进一步证据来自最近的一项荟萃分析，该分析表明5-ASA作为克罗恩病的维持治疗是有效的，特别是在接受切除术的患者中。在个别报道中还发现甲硝唑和鱼油对预防术后复发有用，但需要进一步研究。最后，吸烟和端端吻合被认为与复发风险增加有关。总体而言，这些数据表明，对于所有因克罗恩病接受手术切除的患者，应建议戒烟、避免端端吻合以及术后早期给予氨基水杨酸盐。
