术中意外发现克罗恩病的外科治疗及预后

Surgical treatment and prognosis of incidental Crohn＇s disease during operation

目的探讨术中意外发现克罗恩病的外科治疗及预后。方法采用回顾性队列研究方法。收集2012年1月至2016年6月浙江大学医学院附属邵逸夫医院收治的81例术中意外发现克罗恩病并首次确诊的患者的临床资料。31例我院手术患者根据其临床表现完善相关检查后行相关手术治疗，50例术后转诊患者根据其具体情况行相关治疗。观察指标：（1）总体手术情况：手术指征、手术方式、术后并发症。（2）后续治疗：术后用药。（3）随访情况：克罗恩病相关再次手术（排除因首次手术并发症再手术、造口还纳和肛瘘手术等）。采用门诊及电话方式进行随访，了解患者克罗恩病相关再次手术情况，随访时间截至2016年8月。正态分布的计量资料采用面±s表示，偏态分布计量资料采用M（范围）表示。计数资料采用Fisher确切概率法。采用Kaplan—Meier法计算再次手术率。结果（1）总体手术情况：①手术指征：81例患者中，手术指征包括“急性阑尾炎”23例，消化道梗阻22例，消化道穿孔17例，腹腔脓肿或包块7例，消化道出血5例，可疑肠道肿瘤4例，肠皮肤瘘1例，肠道异物1例，肠膀胱瘘1例。其中急诊手术63例，择期手术18例。②手术方式：81例患者中，单纯阑尾切除17例，回盲部切除14例，结肠节段切除9例，小肠节段切除36例，单纯穿孔修补3例，远端胃大部切除术1例，肠道异物取出＋修补术1例。③术后并发症：81例患者中术后出现Clavien—Dindo GradeⅡ级以上术后并发症15例，其中肠瘘或腹腔脓肿12例，肠梗阻3例。（2）后续治疗：81例患者中66例接受克罗恩病药物治疗（部分患者采用多种方式进行治疗），其中40例采用免疫抑制剂治疗，34例采用美沙拉嗪治疗，22例采用生物制剂治疗，18例采用激素治疗。（3）随访情况：81例患者均获得随访，随访时间为6个月至23年，中位随访时间为3年。24例患者随访期间出现复发，接受再次手术。3年内再次手术率为12．3％，5年内再次手术率为17．3％，10年内再次手术率为24．7％。结论外科医师需提高对克罗恩病的认识，术中意外发现克罗恩病施行合适手术治疗，患者预后良好。

Objective To explore the surgical treatment and prognosis of incidental Crohn＇s disease （CD） during operation. Methods The retrospective cohort study was conducted. The clinical data of 81 patients who were originally diagnosed with incidental CD during operation and admitted to the Sir Run Run Shaw Hospital of Zhejiang University School of Medicine between January 2012 to June 2015 were collected. Thirty-one patients underwent surgical treatment after relative examinations according to the clinical manifestation and 50 referrals after the operation underwent relative treatment. Observation indicators included （ 1 ） overall surgical situations ： surgical indications, surgical procedures and postoperative complications. （2） Subsequent treatment： postoperative medication. （3） Fallow-up： CD-related reoperation （excluding reoperation due to initial surgery-related complication, ostomy reversal and anal fistula operation）. Follow-up using outpatient examination and telephone interview was performed to detect the CD-related reoperation up to August 2016. SPSS software was used for all statistical analyses. Measurement data with normal distribution were represented as x ± s, and measurement data with skewed distribution were described as M （range）. Count data were analyzed using the Fisher exact probability. The reoperation curve was drawn by the Kaplan-Meier method. Results （ 1 ） Overall surgical situations ： ① surgical indications： of 81 patients, 23, 22, 17, 7, 5, 4, 1, 1, and 1 patients had respectively acute appendicitis,gastrointestinal tract obstruction, gastrointestinal perforation, intra-abdominal abscess or gastrointestinal hemorrhage, suspected intestinal tumor, intestinal fistula, foreign bodies in intestinal tract and enterovesical fistula. Sixty-three patients underwent emergency operations and 18 underwent selective operations. ② Surgical procedures： single appendectomy, ileocecal resection, segmental resection of colon, segmental resection of small intestine, simple repair of perforation, distal subtotal gastrectomy and foreign bodies removal in intestine tract ＋ repair were performed in 17, 14, 9, 36, 3, 1 and 1 patients, respectively. ③ Postoperative complications ： of 81 patients, 15 had postoperative complications in Clavien-Dindo Grade Ⅱ and above, including 12 with intestinal fistula or abdominal abscess and 3 with intestinal obstruction. （2） Subsequent treatment： 66 of 81 patients received postoperative medication for CD （some patients received multiple treatments ）, including 40 using immuno- suppressive agents, 34 using mesalamine, 22 using biologics and 18 using steroids therapy. （3） Follow-up： all the 81 patients were followed up for 6 months to 23 years, with a median time of 3 years. Twenty-four patients underwent reoperations due to the surgical recurrence during the follow-up. The 3-, 5-, 10-year reoperation rates were 12.3%, 17.3% and 24.7%, respectively. Conclusion Surgeons should enhance the recognition to select the proper surgical treatment for incidental CD during operation and improve the prognosis of patients.