Gout stones are the main manifestation of advanced gout, and surgical removal of gout stones can reduce the total amount of uric acid in the body, slow down the progression of the lesion, and prevent irreversible damage to bones, joints, tendons, and nerves[19]. With the help of three-dimensional CT image surgery, the surgical scope can be clearer, and deeply hidden urate crystals can be completely removed to reduce uric acid residue. There are fewer studies on the efficacy of gout stone surgery and the efficacy of gout stone surgery under multidisciplinary integration (MDT). In this study, by comparing patients treated with MDT gout stone surgery, the results show that 3D reconstruction technology multidisciplinary fusion treatment has better efficacy for gout stone patients.
By comparing the baseline data of patients in the MDT surgery group and the drug group, the two groups were comparable. Gout is often combined with diabetes mellitus, hyperlipidemia, kidney stones, coronary artery disease, and hypertension[20]; with the prolonged course of gout, gout stones will gradually appear, involving multiple joints, and the frequency of attacks is elevated in patients with poorly controlled gout.The patients in the MDT surgery group had more co-morbidities and a longer course of gout, with a greater proportion of multi-joint gout stones and more frequent gouty attacks. The baseline blood uric acid was higher in the drug group than in the MDT surgery group in this study, and we hypothesized that this was related to the patients in the MDT surgery group undergoing stricter dietary management and application of medication due to more severe gouty conditions; however, the dietary habits and previous medication history were not investigated and analyzed in the present study, and studies are still needed to further substantiate the reasons for the difference in blood uric acid between the two groups.
During follow-up, uric acid levels decreased and SF-36 scores increased in both groups. After adjusting for confounding factors, multivariate logistic regression analysis showed that the rate of uric acid compliance and the increase of SF-36 were higher in the MDT surgery group. In the MDT group, the proportion of patients receiving high-dose drug therapy, the proportion of patients developing frequent gout, and the proportion of patients with abnormal liver function were lower.
Our study found a gradual decrease in blood uric acid levels over time after patient treatment, with a greater decrease in the drug group of patients. This may be related to the differences in blood uric acid levels at the time of enrollment as well as drug dosage between the two groups of patients. Surgery can remove subcutaneous gout stones and reduce the urate load in the body, but the current study did not find that surgery can directly reduce blood uric acid. The uric acid-lowering drug applied in this study was febuxostat, and previous studies have shown that the uric acid-lowering effect of febuxostat is dose-dependent, and the magnitude of uric acid-lowering is greater as the dose of the drug used increases[21; 22; 23]. In patients with comorbid gouty stones, dissolution of urate crystals deposited in the subcutis, tendons, and bones is possible when blood uric acid is < 300 µmol/l[11; 12; 24]. Using the blood uric acid level of < 300 µmol/l at 6 months of follow-up as the criterion for uric acid compliance, and logistic regression with whether or not uric acid compliance was the dependent variable, patients in the MDT surgery group had a higher rate of uric acid compliance, and after adjusting for confounding variables, the rate of uric acid compliance for patients in the MDT surgery group was approximately four times higher than that in the drug group (OR: 4.011). Previous studies also support this finding that patients with gout stones removed after surgical intervention have better control of blood uric acid[19]. During uric acid reduction, urate crystals dissolve and enter the bloodstream, causing an increase in blood uric acid levels; surgery reduces the urate load, resulting in a smooth decrease in blood uric acid during uric acid reduction.
In addition, we followed up the frequency of gouty attacks with medication use. Using more than 40 mg of medication as the delineation criterion and regression analysis after adjusting for confounders, the proportion of patients using larger doses of medication in the MDT surgical group was 1.8% of that in the medication group (OR: 0.018); using more than one gouty attack as the delineation criterion and regression analysis after adjusting for confounders, the proportion of patients experiencing frequent gouty attacks was significantly smaller in the MDT The proportion of patients with frequent gout attacks in the surgery group was significantly smaller than that in the drug group (OR: 0.028). Patients treated with MDT surgery had a lower degree of re-precipitation of uric acid from tissues after blood uric acid decreased than patients without surgery to reduce the urate load. The application of a conventional dose (40 mg once daily) resulted in a smooth decrease in uric acid. Previous studies have found that recurrent gout attacks are associated with gout stones, and serum urate levels correlate with the number of gout stones[25]. The high urate burden associated with gout stones is more likely to lead to recurrent acute gout attacks.
In our study, the collection of SF-36 scores was performed at baseline and follow-up nodes, containing relevant psychosomatic aspects[26]. At the initial quality of life related evaluation, SF-36 scores of patients in the MDT surgery group were lower than those of the drug group, and patients in the MDT surgery group suffered from recurrent episodes of pain, which interfered with activity, sleep, and a decrease in SF-36 scores .The improvement in SF-36 scores was greater in the MDT surgery group during follow-up, and after adjusting for confounders and performing regression analyses, the patients in the MDT surgery group SF-36 score improvement was approximately five times higher than that of the drug group (OR: 4.976), and the results showed that MDT surgery to remove gout stones significantly improved patients' quality of life.
Hepatic impairment is the most common digestive injury associated with the use of uric acid-lowering drugs (ULTs)[27; 28; 29; 30; 31; 32], manifested by an increase in alanine aminotransferase and glutamine aminotransferase[33; 34; 35]. The hepatic injury that occurs after the application of febuxostat is considered to be pharmacologic, and the degree of hepatic injury is dose-dependent to some extent. In this study, the effect of different treatment modalities on liver impairment was analyzed after adjusting for confounding variables, and the results showed that patients in the MDT surgery group were 68.3% less likely to develop liver impairment after treatment than those in the drug group (OR: 0.317). The larger proportion of patients in the drug group who used high doses of drugs was one of the reasons for this result.
Limitations of this study: the number of people included in this study was small, influenced by retrospective studies, non-randomized enrollment, no three-group comparisons of concurrent medications, MDT surgery, and conventional surgery were performed, and multicenter and randomized controlled studies are needed next to further validate the results.