Patient characteristics
Of the 155 patients who underwent surgery for intestinal lesions caused by CD for indications other than malignant tumors, 65 who had no endoscopic follow-up within 18 months after surgery were excluded from the analysis, and the remaining 90 people became the object of analysis. Table 1 summarizes the patient characteristics. The median age at the time of surgery was 39.5 years (67 men and 23 women). The median age at the time of diagnosis was 27.5 years. The age group at diagnosis according to the Montreal classification was as follows: A1 was 73 (81.1%), A2 was 16 (17.8%), and A3 was 1 (1.1%). For disease location classification, L1 was 45 (50.0%), L2 was 9 (10.0%), L3 was 34 (37.8%), and L4 was 2 (2.2%). In the disease behavior classification of lesions, B1 was 2 (2.2%), B2 was 35 (38.9%), and B3 was 53 (58.9%). 32 people (35.6%) were given immunomodulators, such as azathioprine and 6-mercaptopurine, before surgery. Nine patients (10.0%) received corticosteroids.
Table 1
Baseline characteristics of Crohn’s disease patients.
Total
|
90
|
Age, years
|
39.5 (14–72)
|
Male/female, n
|
67/23 (74.4%/25.6%)
|
Body mass index, kg/m2
|
19.4 ± 2.8
|
Age at diagnosis of Crohn’s disease, years
|
27.5 (12–66)
|
Surgical history, primary/repeated
|
74/16 (82.2%/17.8%)
|
Age at diagnosis
|
|
A1
|
73 (81.1%)
|
A2
|
16 (17.8%)
|
A3
|
1 (1.1%)
|
Preoperative albumin, mg/dL
|
3.4 ± 0.6
|
Preoperative CRP, mg/dL
|
1.4 ± 2.7
|
Preoperative CDAI
|
188.1 ± 109.3
|
Lesion location
|
|
L1
|
45 (50.0%)
|
L2
|
9 (10.0%)
|
L3
|
34 (37.8%)
|
L4
|
2 (2.2%)
|
Disease behavior
|
|
B1
|
2 (2.2%)
|
B2
|
35 (38.9%)
|
B3
|
53 (58.9%)
|
Preoperative medication
|
|
AZAཥ6MP +/-, n
|
32/58 (35.6%/64.4%)
|
Steroid +/-, n
|
9/81 (10.0%/90.0%)
|
Anti-TNFα agent +/-, n
|
57/33 (63.3%/36.7%)
|
Data are given as median (range), mean ± SD, or n (%)
|
CRP, C-reactive protein; CDAI, Crohn’s Disease Activity Index; AZA, azathioprine; 6MP, 6-mercaptopurine; Anti-TNFα, anti-tumor necrosis factor α |
Clinical features of the TNF groups
57 patients were assigned to the TNFα group and 33 to the non-TNFα group. No differences were found between the groups in regards to the age at the time of surgery, gender, BMI, age at diagnosis, surgery history, preoperative CRP values, preoperative CDAI, or use of corticosteroids. However, preoperative albumin levels were significantly lower (3.3 vs. 3.6, p = 0.0130) and the number of the patients using azathioprine was significantly higher (25(43.4%) vs. 7(21.2%), p = 0.0400) in the TNFα group than in the non-TNFα group (Table 2).
Table 2
Patient characteristics according to TNFα treatment group.
Characteristic
|
TNFα
n = 57
|
Non-TNFα
n = 33
|
P-value
|
Age, years
|
39 (14–68)
|
42 (19–72)
|
0.4586
|
Male/female, n
|
41/16
|
26/7
|
0.6173
|
Body mass index, kg/m2
|
19.2 ± 2.7
|
19.6 ± 3.0
|
0.5763
|
Age at diagnosis of Crohn’s disease, years
|
25 (12–66)
|
29 (12–52)
|
0.0516
|
Surgical history, primary/repeated
|
45/12
|
29/4
|
0.3942
|
Preoperative Albumin, mg/dL
|
3.3 ± 0.7
|
3.6 ± 0.5
|
0.0130*
|
Preoperative CRP, mg/dL
|
1.3 ± 2.7
|
1.5 ± 2.8
|
0.8179
|
Preoperative CDAI
|
185.8 ± 107.8
|
192.2 ± 113.6
|
0.7958
|
Preoperative medication
|
|
|
|
AZAཥ6MP +/-, n
|
25/32
|
7/26
|
0.0400*
|
Steroid +/-, n
|
7/50
|
2/31
|
0.4771
|
Data are presented as median (range), mean ± SD unless otherwise noted.
|
Clinical features of the LOR and non-LOR groups
31 patients were assigned to the LOR group and 26 to the non-LOR group. No differences were found between the groups in regards to the age at the time of surgery, gender, BMI, age at diagnosis, surgery history, preoperative albumin levels, preoperative CRP values, preoperative CDAI, presence or absence of immunomodulators, or use of corticosteroids (Table 3).
Table 3
Patient characteristics according to LOR and non-LOR.
Characteristic
|
LOR
n = 31
|
Non-LOR
n = 26
|
P-value
|
Age, years
|
38 (19–61)
|
40 (14–68)
|
0.8670
|
Male/female, n
|
21/10
|
20/6
|
0.5581
|
Body mass index, kg/m2
|
19.5 ± 2.8
|
19.0 ± 2.7
|
0.4930
|
Age at diagnosis of Crohn’s disease, years
|
25 (12–40)
|
25.5 (14–66)
|
0.1395
|
Surgical history, primary/repeated
|
26/5
|
19/7
|
0.3490
|
Preoperative Albumin, mg/dL
|
3.3 ± 0.6
|
3.3 ± 0.7
|
0.9967
|
Preoperative CRP, mg/dL
|
1.4 ± 2.6
|
1.3 ± 2.9
|
0.8397
|
Preoperative CDAI
|
175.0 ± 100.0
|
198.7 ± 117.1
|
0.4201
|
Preoperative medication
|
|
|
|
AZAཥ6MP +/-, n
|
15/16
|
10/16
|
0.5931
|
Steroid +/-, n
|
6/25
|
1/25
|
0.1118
|
Data are presented as median (range), mean ± SD unless otherwise noted.
|
Symptomatic and endoscopic recurrence-free duration
Figure 2 shows the symptomatic and endoscopic recurrence-free period. The median symptomatic recurrence duration was 19 months, and the median endoscopic recurrence duration was 54 months.
Rate of endoscopic recurrence at first postoperative endoscopy
Figure 3 shows the rate of endoscopic recurrence observed during the first postoperative endoscopy. The first postoperative endoscopy was performed a median 6 months (range; 1–18 months) after surgery. Of all 90 patients, 25 (27.8%) had endoscopic recurrence. Endoscopic recurrence was observed in 20 patients (35.1%) from the TNFα group and 5 (15.2%) from the non-TNFα group. In the TNFα group, 9 patients (29.0%) from the LOR group and 11 patients (42.3%) from the non-LOR group had endoscopic recurrence.
Relationship between preoperative anti-TNFα antibody treatment history and postoperative recurrence
The median duration of symptomatic recurrence was 11 months for the TNFα group and 40 months for the non-TNFα group (p = 0.1749). The median endoscopic recurrence-free duration was 21 months for the TNFα group and 60 months for the non-TNFα group (p = 0.1311; Fig. 4).
Relationship between LOR and recurrence after surgery
The median duration of symptomatic recurrence was 8 months for the LOR group and 44 months for the non-LOR group (p = 0.0108). The median endoscopic recurrence-free duration was 10 months for the LOR group and 60 months for the non-LOR group (p = 0.0277; Fig. 5).