Postoperative Crohn's disease recurrence:: A practical approach
Postoperative Crohn's disease recurrence:: A practical approach
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DOI：
10.3748/wjg.14.5540
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发表时间：
2008-09-28
影响因子：
4.3
通讯作者：
Domenech, Eugeni
中科院分区：
文献类型：
--
作者：
Nos, Pilar;Domenech, Eugeni
克罗恩病是一种慢性炎症性疾病，可累及胃肠道的任何部分。虽然一些药物已被证明在诱导和维持疾病缓解方面有效，但切除手术仍然是治疗该疾病的基石，主要用于治疗其狭窄和穿透性并发症。然而，术后早期新末端回肠出现新的粘膜（内镜下）病变几乎是不变的，中期出现临床症状，一部分患者需要重复肠切除术。术后复发（POR）的发病机制尚不完全清楚，但腔内因素（共生微生物、膳食抗原）似乎起重要作用，环境和遗传因素也可能有相关影响。许多研究试图确定POR的临床预测因素，但结果不一致，只有吸烟一再与POR的高风险相关。回肠结肠镜检查仍然是评估POR外观和严重程度的金标准，尽管现有的内窥镜评分的真正用途需要重新审视，替代技术正在出现。已经评估了几种预防POR的药物，但效果有限。戒烟似乎是比较有益的治疗措施之一。氨基水杨酸仅被证明具有边际效益，且仅用于低风险患者。硝基咪唑类抗生素虽然有效，但耐受性高，长期使用可能产生不可逆转的副作用。硫嘌呤类药物在回盲切除术后并未广泛应用，可能是因为对无症状患者给予免疫调节剂仍存在一些顾虑。在生物制剂和基因检测的时代，仍然缺乏完善的POR预防策略，需要更大规模的研究来确定早期POR的良好临床、血清学和遗传预测因素以及更有效的药物（或药物组合）。(C) 2008 WJG出版社。版权所有。
Crohn's disease is a chronic inflammatory condition that may involve any segment of the gastrointestinal tract. Although several drugs have proven efficacy in inducing and maintaining disease in remission, resectional surgery remains as a cornerstone in the management of the disease, mainly for the treatment of its stenosing and penetrating complications. However, the occurrence of new mucosal (endoscopic) lesions in the neoterminal ileum early after surgery is almost constant, it is followed in the mid-term by clinical symptoms and, in a proportion of patients, repeated intestinal resections are required. Pathogenesis of postoperative recurrence (POR) is not fully understood, but luminal factors (commensal microbes, dietary antigens) seem to play an important role, and environmental and genetic factors may also have a relevant influence. Many studies tried to identify clinical predictors for POR with heterogeneous results, and only smoking has repeatedly been associated with a higher risk of POR. Ileocolonoscopy remains as the gold standard for the assessment of appearance and severity of POR, although the real usefulness of the available endoscopic score needs to be revisited and alternative techniques are emerging. Several drugs have been evaluated to prevent POR with limited success. Smoking cessation seems to be one of the more beneficial therapeutic measures. Aminosalicylates have only proved to be of marginal benefit, and they are only used in low-risk patients. Nitroimidazolic antibiotics, although efficient, are associated with a high rate of intolerance and might induce irreversible side effects when used for a long-term. Thiopurines are not widely used after ileocecal resection, maybe because some concerns in giving immunomodulators in asymptomatic patients still remain. In the era of biological agents and genetic testing, a well-established preventive strategy for POR is still lacking, and larger studies to identify good clinical, serological, and genetic predictors of early POR as well as more effective drugs (or drug combinations) are needed. (C) 2008 The WJG Press. All rights reserved.