外科治疗123例克罗恩病的疗效分析

Curative effect of surgical treatment for 123 cases of Crohn′s disease

目的探讨外科治疗克罗恩病的疗效,以及外科手术干预的时机和手术方式的选择。方法回顾性分析2016年1月1日至2020年8月31日于上海交通大学医学院附属瑞金医院接受外科手术治疗的123例克罗恩病患者的临床资料,包括病变类型、病变部位、临床表现、手术方式、术前炎症和营养指标、术后消化道功能恢复,以及术后并发症发生和处理情况。依据《炎症性肠病诊断与治疗的共识意见(2018,北京)》中克罗恩病的诊断标准进行诊断,根据蒙特利尔分型进行克罗恩病分型,采用Clavien-Dindo标准对术后并发症进行分级。采用Mann-Whitney U检验进行统计学分析。结果123例患者中,蒙特利尔分型为确诊年龄≤16岁(A1型)2例(1.6%),确诊年龄为17~40岁(A2型)66例(53.7%),确诊年龄>40岁(A3型)55例(44.7%);病变部位为回肠末端(L1)型52例(42.3%),结肠(L2)型20例(16.3%),回结肠(L3)型51例(41.5%);疾病行为为非狭窄非穿透(B1)型4例(3.3%),狭窄(B2)型87例(70.7%),穿透(B3)型32例(26.0%)。18例(14.6%)患者因完全性肠梗阻(10例)、消化道穿孔(5例)、消化道出血(2例)和直肠膀胱瘘合并感染性休克(1例)接受急诊手术,105例(85.4%)患者因保守治疗效果不佳接受择期手术治疗;行传统开腹手术51例(41.5%),腹腔镜手术72例(58.5%);19例(15.4%)患者接受临时性或永久性消化道造口手术。急诊手术患者术前的C反应蛋白水平高于择期手术患者[(39.23±24.13)mg/L比(11.48±2.68)mg/L],血清白蛋白、前白蛋白水平均低于择期手术患者[(29.90±10.60)g/L比(38.38±8.30)g/L、(146.00±125.49)mg/L比(209.06±61.19)mg/L],差异均有统计学意义(Z=9.603、8.754、7.111,P均<0.01)。共23例(18.7%)患者在随访过程中发生术后并发症,其中术后腹腔内出血1例,接受再次手术探查,评估为Clavien-DindoⅢ级并发症;术后吻合口漏4例;术后麻痹性肠梗阻6例;手术部位感染11例,均评估为Clavien-DindoⅡ级并发症;下肢深静脉血栓1例。未观察到术中严重并发症,以及术中死亡或住院期间死亡病例,患者术后排气时间为(3.2±1.4)d,开放流质饮食时间为(5.8±0.8)d,住院天数为(18.0±14.1)d,术后住院天数为(11.2±8.8)d。结论克罗恩病的治疗应强调多学科协作的概念,外科手术治疗能够有效地控制并发症发生并改善患者生活质量,但应在围手术期全程治疗、多学科参与、积极调节内环境的前提下审慎地把握手术时机,选择合理的手术入路和方式,并针对炎症性肠病的手术难点进行规范化、针对性的处理。

Objective To explore the curative effect of surgical treatment for Crohn′s disease(CD),to investigate the timing of surgical intervention and the choice of surgical methods.Methods From January 1,2016 to August 31,2020,at Ruijin Hospital,Shanghai Jiao Tong University School of Medicine,the clinical data of 123 patients with CD and receiving surgical treatment were retrospectively analyzed,which included the type of lesion,the location of lesion,clinical manifestation,surgical method,preoperative inflammatory and nutritional indicators,postoperative recovery of digestive tract function,and the development and treatment of postoperative complications.CD was diagnosed according to Consensus opinion on diagnosis and treatment of inflammatory bowel disease(Beijing 2018).Patient was classitied according to the Montreal Classification.Postoperative complications were graded according to the Clavien-Dindo Criteria.Mann-Whitney U test was used for statistical analysis.Results Among 123 patients,according to the Montreal classification,two cases(1.6%)were diagnosed at≤16 years old(type A1),66 cases(53.7%)were diagnosed at 17 to 40 years old(type A2),and 55 cases(44.7%)were diagnosed at>40 years old(type A3).The lesions were 52 cases(42.3%)of terminal ileum(L1)type,20 cases(16.3%)of colon(L2)type,and 51 cases(41.5%)of ileocolon(L3)type.Four cases(3.2%)were non-stenosis and non-penetrating(B1)type,87 cases(70.7%)were stenosis(B2)type,and 32 cases(26.0%)were penetrating(B3)type.Eighteen patients(14.6%)underwent emergency surgery due to complete intestinal obstruction(10 cases),gastrointestinal perforation(five cases),gastrointestinal bleeding(two cases),and rectovesical fistula complicated with septic shock(one case).One hundred and five patients(85.4%)received selective surgery due to poor conservative treatment effects.51 cases(41.5%)underwent traditional open surgery and 72 cases(58.5%)underwent laparoscopic surgery.Nineteen patients(15.4%)received temporary or permanent ostomy.The preoperative C reactive protein level of patients with emergency surgery was higher than that of patients undergoing selective surgery((39.23±24.13)mg/L vs.(11.48±2.68)mg/L),while the levels of plasma albumin(ALB)and pre-ALB were lower than those of patients receiving selective surgery((29.90±10.60)g/L vs.(38.38±8.30)g/L,(146.00±125.49)mg/L vs.(209.06±61.19)mg/L),and the differences were statistically significant(Z=9.603,8.754 and 7.111,all P<0.01).During the follow-up,a total of 23 cases(18.7%)developed postoperative complications,including one case of postoperative intra-abdominal hemorrhage and underwent re-operation(Clavien-Dindo gradeⅢcomplication);four cases of anastomotic leakage after operation;six cases of postoperative paralytic ileus;11 cases of surgical site infection,all of which were Clavien-Dindo gradeⅡcomplications,and one case of deep venous thrombosis of lower extremity.No patient with severe intraoperative complication was observed,and no patients died during the operation or hospitalization.The postoperative exhaust time of patients was(3.2±1.4)d,the time of open fluid diet was(5.8±0.8)d,the length of hospital stay was(18.0±14.1)d,and the length of postoperative hospital stay was(11.2±8.8)d.Conclusions The concept of multidisciplinary collaboration should be emphasized in the treatment of CD.Surgical treatment can effectively control the complications and improve the quality of life of patients,but the timing of operation and the choice of surgical methods should be decided prudently after perioperative treatment,multi-disciplinary participated and regulation of the internal environment.The standardized and targeted treatments for the surgical difficulties of inflammatory bowel disease should be conducted.