背景:对于肛周克罗恩病,建议采用麻醉下检查(EUA)和肿瘤坏死因子(TNF)抑制剂的多学科治疗。然而,这种综合方法的影响还没有得到很好的证实。
方法:我们在2009年至2019年之间进行了一项比较队列研究。将在抗TNF治疗(联合治疗)之前接受EUA治疗的肛周克罗恩病患者与单独使用抗TNF进行比较。主要结果是临床评估瘘管闭合。次要结果包括随后的局部手术和粪便转移。针对脓肿调整后的多变量分析,伴随的免疫调节剂,和开始抗TNF的时间。
结果:在155名不同的患者中开始了188次抗TNF治疗:EUA后66(35%)。脓肿(50%vs15%;P<.001)和伴随免疫调节剂(64%vs50%;P=.07)在联合模式组中更常见,而年龄,吸烟状况,疾病持续时间,与肠道疾病部位无显著差异。综合治疗与3岁时的瘘管闭合率无关(调整后比值比[aOR],0.7;95%置信区间[CI],0.3-1.8),6(AOR,0.8;95%CI,0.4-2.0)和12(aOR,1.0;95%CI,0.4-2.2)个月。在中位随访4.6(四分位距,5.95;2.23-8.18)年,联合治疗与随后的局部手术干预相关(调整后的风险比,2.2;95%CI,1.3-3.6),但不包括粪便转移(调整后的危险比,1.3;95%CI,0.45-3.9)。当排除脓肿和先前的生物失败患者时,结果保持一致。
结论:与单独使用抗TNF治疗相比,抗TNF治疗前的EUA与改善的临床结局无关。这表明EUA可能不是普遍需要的。未来有必要进行控制瘘管严重程度的前瞻性研究。
这项比较队列研究发现,肛周克罗恩病开始抗肿瘤坏死因子治疗前的麻醉检查与更高的瘘管闭合率无关。这表明肛周克罗恩病患者可能不需要在麻醉下进行检查。
Multidisciplinary care involving exam under anesthesia (EUA) and tumor necrosis factor (TNF) inhibitors is recommended for
perianal Crohn\'s disease. However, the impact of this combined approach is not well established.
We performed a comparative cohort
study between 2009 and 2019. Patients with
perianal Crohn\'s disease treated with EUA before anti-TNF therapy (combined modality therapy) were compared with anti-TNF alone. The primary outcome was fistula closure assessed clinically. Secondary outcomes included subsequent local surgery and fecal diversion. Multivariable analysis adjusted for abscesses, concomitant immunomodulators, and time to anti-TNF initiation was performed.
Anti-TNF treatment was initiated 188 times in 155 distinct patients: 66 (35%) after EUA. Abscesses (50% vs 15%; P < .001) and concomitant immunomodulators (64% vs 50%; P = .07) were more common in the combined modality group, while age, smoking status, disease duration, and intestinal disease location were not significantly different. Combined modality therapy was not associated with higher rates of fistula closure at 3 (adjusted odds ratio [aOR], 0.7; 95% confidence interval [CI], 0.3-1.8), 6 (aOR, 0.8; 95% CI, 0.4-2.0) and 12 (aOR, 1.0; 95% CI, 0.4-2.2) months. After a median follow-up of 4.6 (interquartile range, 5.95; 2.23-8.18) years, combined therapy was associated with subsequent local surgical intervention (adjusted hazard ratio, 2.2; 95% CI, 1.3-3.6) but not with fecal diversion (adjusted hazard ratio, 1.3; 95% CI, 0.45-3.9). Results remained consistent when excluding patients with abscesses and prior biologic failure.
EUA before anti-TNF therapy was not associated with improved clinical outcomes compared with anti-TNF therapy alone, suggesting that EUA may not be universally required. Future prospective studies controlling for fistula severity are warranted.
This comparative cohort
study found that an exam under anesthesia before initiation of anti-tumor necrosis factor therapy in
perianal Crohn’s disease was not associated with higher rates of fistula closure, suggesting that an exam under anesthesia may not be universally required in patients with perianal Crohn’s disease.