溃疡性结肠炎的外科治疗：一家外科转诊中心的10年回顾性分析。

Q3 Medicine

中华胃肠外科杂志 Pub Date : 2025-04-25 DOI:10.3760/cma.j.cn441530-20240928-00330

S Li, F Zhu, Abudourexiti Waresi, Z Y Wang, M F Chen, Y Z Guo, Z R Yang, Y Zhou, J F Gong

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Clinical characteristics and surgical complications were analyzed and compared between the 2014-2019 and 2020-2024 groups. Multivariable logistic regression was performed to identify the risk factors associated with pouchitis in UC patients undergoing total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA). Results: The study cohort comprised 336 UC patients, 193 (57.4%) of whom were men. The median preoperative disease course was 48.0 months and the mean age at colectomy was 46.4±15.4 years. TPC-IPAA had been performed on 275 patients (81.8%), 129 in the 2014-2019 group and 146 in the 2020-2024 group. Sixty-one patients had undergone total or subtotal colectomy, 29 in the 2014-2019 group and 32 in the 2020-2024 group. 262 (78.0%) UC patients underwent surgery due to medical refractory. Ninety-nine (29.5%) had used biopharmaceuticals within 2 months prior to surgery, 63 (18.8%) of them having received infliximab. A smaller proportion of patients had undergone surgery for UC that was refractory to medications in the 2020-2024 group than in the 2014-2019 group (73.0% [130/178] vs. 83.5% [132/158], χ2=5.384, P=0.020), the patients were older at colectomy (48.0±15.4 years vs. 44.6±15.2 years, t=-2.008, P=0.045), the body mass index was higher (20.2±3.1 kg/m2 vs. 19.4±3.2 kg/m2, t=-2.201, P=0.028), the Mayo score prior to surgery was lower (M[Q1, Q3]: 11.0 [9.2, 12.0 points] vs. 12.0 [11.0, 12.0) points, Z=-4.242, P=0.001), the rate of Charlson Comorbidity Index ≥ 3 scores was higher (27.0% [48/178] vs. 17.1% [27/158], χ2=5.384, P=0.020), a greater percentage of patients had received biologics prior to surgery (41.0% [73/178) vs. 16.5% [26/158], χ2=24.285, P<0.001), and intraoperative blood loss was greater (M[Q1, Q3]: 100.0 [100.0, 150.0] ml vs. 50.0 [30.0, 100.0] ml, Z=-7.054, P<0.001) despite the operation time being shorter (253.8±74.6 minutes vs. 315.2±96.8 minutes, t=6.265, P<0.001). Among the 275 patients undergoing TPC-IPAA, 95 (34.6%) had early complications (within 30 days after surgery), 20 (7.3%) of which were Clavien-Dindo Grade III-IV complications. Among these patients, 50 (18.2%) had ileus or small bowel obstruction, 11 in the 2014-2019 group and 39 in the 2020-2024 group; this difference is statistically significant (χ2=15.225, P<0.001). Ninety-one patients (33.1%) had late complications (more than 30 days after surgery), 75 (27.3%) being pouchitis (36 in the 2014-2019 group and 39 in the 2020-2024 group); this difference is not statistically significant (χ2=0.049, P=0.824). Five patients (1.8%) had undergone pouch excision with permanent ileostomy. Among the 61 patients who had undergone total or subtotal colectomy, 26 (42.6%) developed early postoperative complications, including 10 (16.4%) Clavien-Dindo Grade III-IV complications and one death (1.6%), the last being attributable to multiorgan dysfunction. Three patients (4.9%) had late complications; the difference in incidence of postoperative complications between the 2014-2019 and 2020-2024 groups is not statistically significant (both P>0.05). Multivariable analysis identified intraoperative blood transfusion (OR: 2.12, 95% CI: 1.19-3.75, P=0.010) and interval to stoma closure > 120 days (OR: 2.05, 95%CI: 1.16-3.62, P = 0.013) as independent risk factors for development of pouchitis in UC patients undergoing TPC-IPAA. Conclusion: Surgical treatment of UC remains safe in the biologics era. 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Three patients (4.9%) had late complications; the difference in incidence of postoperative complications between the 2014-2019 and 2020-2024 groups is not statistically significant (both P>0.05). Multivariable analysis identified intraoperative blood transfusion (OR: 2.12, 95% CI: 1.19-3.75, P=0.010) and interval to stoma closure > 120 days (OR: 2.05, 95%CI: 1.16-3.62, P = 0.013) as independent risk factors for development of pouchitis in UC patients undergoing TPC-IPAA. Conclusion: Surgical treatment of UC remains safe in the biologics era. 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引用次数: 0

摘要

目的：探讨溃疡性结肠炎（UC）手术患者囊炎的临床特点、术后并发症及危险因素。方法：回顾性观察性研究。纳入2014年2月至2024年2月在南京大学医学院附属金陵医院普通外科炎症性肠病中心接受手术治疗的336例UC患者的临床资料。研究患者被分为2014-2019年组（n = 158）和2020-2024年组（n = 178），这是2020年中国国民保险覆盖生物制剂治疗UC之前和之后的时期。分析比较2014-2019年组和2020-2024年组的临床特点和手术并发症。采用多变量logistic回归分析UC患者行全直结肠切除术并回肠袋-肛门吻合术（TPC-IPAA）后发生袋炎的相关危险因素。结果：研究队列包括336例UC患者，其中193例（57.4%）为男性。术前病程中位数为48.0个月，结肠切除术时平均年龄为46.4±15.4岁。TPC-IPAA治疗275例（81.8%），其中2014-2019年组129例，2020-2024年组146例。61例患者接受了全结肠或次全结肠切除术，其中29例在2014-2019年组，32例在2020-2024年组。262例（78.0%）UC患者因内科难治性手术。99例（29.5%）患者在手术前2个月内使用过生物药物，其中63例（18.8%）患者使用过英夫利昔单抗。2020-2024年组接受难治性UC手术的患者比例低于2014-2019年组（73.0%[130/178]比83.5% [132/158],χ2=5.384， P=0.020），患者在结肠切除术时年龄较大（48.0±15.4岁比44.6±15.2岁，t=-2.008， P=0.045），体重指数较高（20.2±3.1 kg/m2比19.4±3.2 kg/m2, t=-2.201， P=0.028），术前Mayo评分较低(M[Q1, Q3]：11.0[9.2, 12.0分]比12.0[11.0,12.0分]比12.0[11.0,12.0)分，Z=-4.242， P=0.001)， Charlson共病指数≥3分的比例较高（27.0%[48/178]比17.1% [27/158],χ2=5.384， P=0.020），术前接受生物制剂的患者比例较高（41.0%[73/178]比16.5% [26/158],χ2=24.285, PM[Q1, Q3]: 100.0 [100.0, 150.0] ml比50.0 [30.0,100.0]ml， Z=-7.054, Pt=6.265, P2=15.225, P2=0.049， P=0.824）。5例患者（1.8%）行永久性回肠造口术。61例全结肠或次全结肠切除术患者中，26例（42.6%）出现术后早期并发症，其中Clavien-Dindo III-IV级并发症10例（16.4%），1例死亡（1.6%），最后一例死亡归因于多器官功能障碍。晚期并发症3例（4.9%）；2014-2019年组与2020-2024年组术后并发症发生率比较，差异无统计学意义（P < 0.05）。多变量分析发现术中输血（OR: 2.12, 95%CI: 1.19-3.75， P=0.010）和闭合造口间隔时间（OR: 2.05, 95%CI: 1.16-3.62， P= 0.013）是UC患者行TPC-IPAA后发生袋炎的独立危险因素。结论：在生物制剂时代，UC的手术治疗仍然是安全的。主动减少术中输血和及时关闭造口可以降低UC患者接受TPC-IPAA后发生袋炎的风险。

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[Surgical treatment of ulcerative colitis: a 10-year retrospective analysis at a surgical referral center].

Objective: To investigate the clinical characteristics, postoperative complications, and risk factors for pouchitis in surgical patients with ulcerative colitis (UC). Methods: This was a retrospective observational study. The clinical data of 336 UC patients who had undergone surgical treatment at the Inflammatory Bowel Disease Center of the Department of General Surgery, Jinling Hospital Affiliated to Nanjing University Medical School from February 2014 to February 2024 were enrolled. The study patients were stratified into 2014-2019 (n = 158) and 2020-2024 groups (n = 178), these being the periods before and after biologics were covered for treatment of UC by national insurance in China in 2020. Clinical characteristics and surgical complications were analyzed and compared between the 2014-2019 and 2020-2024 groups. Multivariable logistic regression was performed to identify the risk factors associated with pouchitis in UC patients undergoing total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA). Results: The study cohort comprised 336 UC patients, 193 (57.4%) of whom were men. The median preoperative disease course was 48.0 months and the mean age at colectomy was 46.4±15.4 years. TPC-IPAA had been performed on 275 patients (81.8%), 129 in the 2014-2019 group and 146 in the 2020-2024 group. Sixty-one patients had undergone total or subtotal colectomy, 29 in the 2014-2019 group and 32 in the 2020-2024 group. 262 (78.0%) UC patients underwent surgery due to medical refractory. Ninety-nine (29.5%) had used biopharmaceuticals within 2 months prior to surgery, 63 (18.8%) of them having received infliximab. A smaller proportion of patients had undergone surgery for UC that was refractory to medications in the 2020-2024 group than in the 2014-2019 group (73.0% [130/178] vs. 83.5% [132/158], χ²=5.384, P=0.020), the patients were older at colectomy (48.0±15.4 years vs. 44.6±15.2 years, t=-2.008, P=0.045), the body mass index was higher (20.2±3.1 kg/m² vs. 19.4±3.2 kg/m², t=-2.201, P=0.028), the Mayo score prior to surgery was lower (M[Q₁, Q₃]: 11.0 [9.2, 12.0 points] vs. 12.0 [11.0, 12.0) points, Z=-4.242, P=0.001), the rate of Charlson Comorbidity Index ≥ 3 scores was higher (27.0% [48/178] vs. 17.1% [27/158], χ²=5.384, P=0.020), a greater percentage of patients had received biologics prior to surgery (41.0% [73/178) vs. 16.5% [26/158], χ²=24.285, P<0.001), and intraoperative blood loss was greater (M[Q₁, Q₃]: 100.0 [100.0, 150.0] ml vs. 50.0 [30.0, 100.0] ml, Z=-7.054, P<0.001) despite the operation time being shorter (253.8±74.6 minutes vs. 315.2±96.8 minutes, t=6.265, P<0.001). Among the 275 patients undergoing TPC-IPAA, 95 (34.6%) had early complications (within 30 days after surgery), 20 (7.3%) of which were Clavien-Dindo Grade III-IV complications. Among these patients, 50 (18.2%) had ileus or small bowel obstruction, 11 in the 2014-2019 group and 39 in the 2020-2024 group; this difference is statistically significant (χ²=15.225, P<0.001). Ninety-one patients (33.1%) had late complications (more than 30 days after surgery), 75 (27.3%) being pouchitis (36 in the 2014-2019 group and 39 in the 2020-2024 group); this difference is not statistically significant (χ²=0.049, P=0.824). Five patients (1.8%) had undergone pouch excision with permanent ileostomy. Among the 61 patients who had undergone total or subtotal colectomy, 26 (42.6%) developed early postoperative complications, including 10 (16.4%) Clavien-Dindo Grade III-IV complications and one death (1.6%), the last being attributable to multiorgan dysfunction. Three patients (4.9%) had late complications; the difference in incidence of postoperative complications between the 2014-2019 and 2020-2024 groups is not statistically significant (both P>0.05). Multivariable analysis identified intraoperative blood transfusion (OR: 2.12, 95% CI: 1.19-3.75, P=0.010) and interval to stoma closure > 120 days (OR: 2.05, 95%CI: 1.16-3.62, P = 0.013) as independent risk factors for development of pouchitis in UC patients undergoing TPC-IPAA. Conclusion: Surgical treatment of UC remains safe in the biologics era. Proactive strategies to reduce intraoperative blood transfusion and achieve timely stoma closure may reduce the risk of pouchitis in UC patients undergoing TPC-IPAA.

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中华胃肠外科杂志 Medicine-Medicine (all)

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1.00

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6776

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