克罗恩病肛瘘二期根治性手术结局的影响因素分析

Factors influencing the outcomes of two-stage radical surgery for perianal fistulizing Crohn′s disease

目的探讨影响克罗恩病(CD)肛瘘根治性手术结局的因素。方法回顾性分析2016年3月至2018年6月于中山大学附属第六医院行二期根治性手术治疗的31例CD肛瘘患者的临床资料。所有患者在根治性手术前均接受一期挂线引流术及规范内科药物治疗并经术后MRI确认引流效果良好。根据根治性手术治疗结局分为手术治愈组(n=23)和手术失败组(n=8)。比较两组患者的临床特点,并使用Wilcoxon秩和检验分析每组患者C-反应蛋白(CRP)、红细胞沉降率(ESR)、血小板(PLT)、体质量指数(BMI)、血红蛋白(HB)、白蛋白(ALB)在一期挂线引流术前和二期根治性手术前的差异。结果CD肛瘘患者接受二期根治性手术的临床治愈率为74.2%(23/31)。手术治愈组一期挂线引流术前直肠炎比例(8.70%比50.00%,P=0.026)、一期挂线引流术前多个内口或多条独立瘘管的比例(21.74%比75.00%,P=0.012)、二期根治性手术前PLT[240.0(202.0,277.0)×10^(9)/L比319.5(247.3,385.5)×10^(9)/L,P=0.04]均低于手术失败组,差异具有统计学意义。手术治愈组二期根治性手术前PLT[240.0(202.0,277.0)×10^(9)/L比300.9(230.0,413.0)×10^(9)/L,P=0.004]、HB[136.0(114.0,144.0)g/L比127.0(107.0,137.0)g/L,P=0.004]、ALB[43.10(39.62,47.41)g/L比40.45(36.58,42.58)g/L,P=0.011]及BMI[19.93(17.99,21.22)kg/m2比18.22(16.61,19.38)kg/m2,P<0.001]较一期挂线引流手术前指标均明显改善,而CRP和ESR在2个时间点的差异均无统计学意义(均P>0.05)。手术失败组在二期根治性手术前所有上述指标较一期挂线引流术前的变化差异均无统计学意义(均P>0.05)。结论除初诊时存在直肠炎和多个内口或多条独立瘘管外,CD肛瘘二期根治性手术前PLT水平也是影响手术结局的因素,二期根治性手术前BMI、HB、ALB、PLT较一期挂线引流术前的改善情况可作为根治性手术的筛选指标。

Objective To explore the factors which influence the outcomes of two-stage radical surgery for the patients with perianal fistulizing Crohn′s disease(pfCD).Methods Clinical data of 31 pfCD patients who underwent two-stage radical surgery in the Sixth Affiliated Hospital of Sun Yat-sen University from March 2016 to June 2018 were analyzed retrospectively.All the patients got good drainage results comfirmed by MRI after the treatment of one-stage seton drainage and the following medical treatment.According to the outcome of two-stage radical surgery,the patients were divided into the healing group(n=23)and the failed group(n=8).The clinical characteristics between the two groups were analyzed statistically.Wilcoxon rank sum test was used to analyze the difference in C-reactive protein(CRP),erythrocyte sedimentation rate(ESR),platelet(PLT),body mass index(BMI),hemoglobin(HB)and albumin(ALB)between before the one-stage seton drainage and before the two-stage radical surgery in each group.Results The healing rate of pfCD after two-stage radical surgery was 74.2%(23/31).The ratio of proctitis before the one-stage seton drainage(8.70%vs.50.00%,P=0.026),the ratio of multiple internal openings or multiple independent fistulas before the one-stage seton drainage(21.74%vs.75.00%,P=0.012)and the PLT before the two-stage radical surgery[240.0(202.0,277.0)×10^(9)/L vs.319.5(247.3,385.5)×10^(9)/L,P=0.04]in the healing group were significantly lower than those in the failed group.The variations of PLT[240.0(202.0,277.0)×10^(9)/L vs.300.9(230.0,413.0)×10^(9)/L,P=0.004],HB[136.0(114.0,144.0)g/L vs.127.0(107.0,137.0)g/L,P=0.004],ALB[43.10(39.62,47.41)g/L vs.40.45(36.58,42.58)g/L,P=0.011]and BMI[19.93(17.99,21.22)kg/m2 vs.18.22(16.61,19.38)kg/m2,P<0.001]in the healing group before two-stage radical surgery showed better trends than those before one-stage seton drainage,while there was no significant variation trend of ESR and CRP between the two points in time(both P>0.05).There were no sigificant differences in all indexes in the failed group between before one-stage seton drainage and before the two-stage radical surgery(all P>0.05).Conclusions Beside the initial proctitis and multiple internal openings or multiple independent fistulas,PLT level before the two-stage radical surgery for pfCD is also an influencing factor of surgical outcome.The situations of BMI,HB,ALB,and PLT before the two-stage radical surgery are better than those before the one-stage seton drainage may be used as the screening indications of the radical surgery.