【摘要】：背景和目的克羅恩病(Crohn's disease,CD)是一種病因尚不清楚的慢性非特異性腸道炎性疾病。在生物制劑時(shí)代,手術(shù)方式在不斷進(jìn)展,CD相關(guān)的手術(shù)率明顯下降。然而,仍有46.6%的CD患者自診斷10年內(nèi)需行手術(shù)治療,且1年內(nèi)約20-40%出現(xiàn)術(shù)后復(fù)發(fā)(Postoperative recurrence,POR),而關(guān)于影響POR危險(xiǎn)因素的研究結(jié)論尚不統(tǒng)一。CD患者因長(zhǎng)期消耗和炎癥活動(dòng)等原因常常出現(xiàn)術(shù)后并發(fā)癥。本研究旨在分析CD的手術(shù)現(xiàn)狀、術(shù)后未用藥患者的長(zhǎng)期復(fù)發(fā)情況、POR相關(guān)的危險(xiǎn)因素及術(shù)后并發(fā)癥。方法:回顧性分析118例行腸切除術(shù)的CD患者,采用卡方檢驗(yàn)或Fisher精確概率法比較計(jì)數(shù)資料,Log-rank檢驗(yàn)和多元Cox回歸模型分別進(jìn)行單因素和多因素分析析。P0.05為有統(tǒng)計(jì)學(xué)意義。結(jié)果:1.一般情況1.1基本臨床資料共納入118例CD患者,28.8%(34/118)為女性患者,中位確診年齡為36.5(17.0)歲。49.2%(58/118)的患者為未用藥組。1.2手術(shù)現(xiàn)狀:(1)手術(shù)方式:2011-2016年,44.9%行腹腔鏡手術(shù),較2003-2010年顯著降低(79.3%),p==0.001。(2)吻合方式:2011-2016年,69.7%行吻合器-側(cè)側(cè)吻合術(shù),較2003-2010年顯著升高(0),p0.0001。2.POR2.1 POR 率118例CD患者中位隨訪時(shí)間為14.3(27.0)月,術(shù)后1年、3年、5年、9年累積復(fù)發(fā)率為 43.3%、63.7%、74.1%和 83.8%。58例未用藥組術(shù)后1年、3年、5年、9年累積復(fù)發(fā)率分別為48.1%、66.4%、77.1%和 87.7%。2.2單變量分析合并腸外表現(xiàn)、中性粒細(xì)胞百分比≥75%、C-反應(yīng)蛋白≥10mg/L和術(shù)前使用硫唑嘌呤(Azathioprine,AZA)對(duì)POR的影響有統(tǒng)計(jì)學(xué)差異(p0.05)。2.3多變量分析術(shù)后用藥顯著降低POR率(p0.05),中性粒細(xì)胞百分比≥75%和血紅蛋白90g/L 顯著增加 POR(p0.05)。3.術(shù)后并發(fā)癥14.4%的CD患者出現(xiàn)腹腔感染性并發(fā)癥。4.比較英夫利昔單抗(Infliximab,IFX)+AZA和單用AZA預(yù)防POR20例IFX+AZA組中位隨訪時(shí)間23.3(23.6)月,50%(10/20)的患者出現(xiàn)POR,術(shù)后1年、2年、3年累積復(fù)發(fā)率為20.5%、43.2%,58.4%;29例術(shù)后AZA組中位隨訪時(shí)間16.3(22.8)月,48.3%(14/29)的患者出現(xiàn)POR,術(shù)后1年、2年、3年累積復(fù)發(fā)率為42.3%、53.8%和53.8%。兩組術(shù)后累積復(fù)發(fā)率無(wú)明顯差異(p=0.969)。5.沙利度胺預(yù)防POR的初步探索術(shù)后3例患者使用沙利度胺50-150mg/d預(yù)防CD復(fù)發(fā),其中1例患者在用藥3個(gè)月后出現(xiàn)臨床復(fù)發(fā),另2例患者則至隨訪終點(diǎn)仍處于術(shù)后緩解期。結(jié)論吻合器-側(cè)側(cè)吻合術(shù)是目前外科治療CD的主要吻合方式。CD患者術(shù)后長(zhǎng)期病程預(yù)后不佳,需及時(shí)有效的干預(yù)措施。術(shù)前中性粒細(xì)胞百分比升高、血紅蛋白降低和術(shù)后未預(yù)防用藥POR的獨(dú)立危險(xiǎn)因素。IFX+AZA預(yù)防POR的效果與單用AZA相近。沙利度胺在預(yù)防POR中有一定的應(yīng)用價(jià)值,需進(jìn)一步的研究證實(shí)。CD術(shù)后腹腔感染性并發(fā)癥發(fā)生率高。
[Abstract]:Background and objective Crohn's disease (CD) is a chronic nonspecific inflammatory disease with unknown etiology. In the age of biological agents, the rate of CD-related surgery has decreased significantly. However, 46.6% of patients with CD have been diagnosed for 10 years and need to be treated surgically. Within one year, Postoperative recurrence occurred in about 20-40% of the patients. However, the results of the study on the risk factors affecting POR were not uniform. The postoperative complications were often found in patients with CD due to long-term consumption and inflammatory activity. The purpose of this study was to analyze the surgical status of CD, the long term recurrence of untreated patients and the risk factors associated with POR and postoperative complications. Methods: the data of 118 CD patients undergoing enterectomy were analyzed retrospectively. The count data were compared by chi-square test or Fisher accurate probability method. Single factor analysis and multivariate Cox regression model were used to analyze the single factor and the multivariate Cox regression model respectively. The result is 1: 1. General situation 1.1 basic clinical data included 118 cases of CD patients with 28.8% (34 / 118) of female patients. The median age of diagnosis was 36.5 (17.0) years old. 49.2% (58 / 118) of the patients was the non-medication group. 1.2 operation status: (1) the operation mode: 2011-2016, 44.9% of the patients underwent laparoscopic surgery. Compared with 2003-2010, it was significantly lower (79.3%) than that of 2003-2010 (79.3%). (2) the anastomosis mode: from 2011-2016 to 2016 was 69.7%, which was significantly higher than that in 2003-2010 (0) p 0.0001.2.POR2.1 POR rate was 14.3 (27.0) months in 118 patients with CD. The cumulative recurrence rates of 43.3%, 63.7% and 83.8% in the group of 1, 3, 5 and 9 years after operation were 48.1% and 83.8%, respectively. The accumulative recurrence rates were 48.1%, 66.4% and 77.1%, respectively, and 87.7%, respectively, in the group of untreated drugs for 1 year, 3 years, 5 years and 9 years, respectively. The percentage of neutrophilic granulocytes 鈮，

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