A Multicenter Case-control Study Of Postoperative Intestinal Fistula In Chinese Patients With Crohn’s Disease

Objective: By analyzing the preoperative clinical data of patients with Crohn’s disease,the independent influencing factors of postoperative intestinal fistula were screened.The Nomogram prediction model of postoperative intestinal fistula in patients with Crohn’s disease was established on the basis of the independent influencing factors,and then verified the prediction model to evaluate the accuracy.We were expected to intervene the relevant factors in advance to reduce the risk of postoperative intestinal fistula in patients.Methods: The retrospective multi-center case-control study was conducted.The complete clinical data and postoperative follow-up information of 240 patients with Crohn’s disease at the Third Xiangya Hospital of Central South University,Xiangya Hospital of Central South University and the Sixth Affiliated Hospital of Sun Yat-sen University from September 2017 to September 2019 were collected.They were divided into modeling group(168 cases,70%)and validation group(72cases,30%)randomly.According to postoperative follow-up information,patients with postoperative intestinal fistula were included in the case group and patients without postoperative intestinal fistula were included in the control group.Observation indicators:(1)Preoperative information:gender,age at onset,body mass index,disease course,disease behavior,disease location,extraintestinal manifestations,perianal disease and complications,disease activity score,appendectomy surgery,drug use,white blood cell,hemoglobin,platelets,hematocrit,neutrophil,lymphocyte,eosinophil,basophil,C-reactive protein,erythrocyte sedimentation rate,albumin,globulin,D-dimer,neutrophil to lymphocyte count ratio(NLR),platelet to lymphocyte count ratio(PLR),CRP to albumin ratio(CAR),systemic immune inflammatory index,prognostic nutritional index,emergency or elective surgery,open or laparoscopic surgery,and anastomosis methods,Epstein-Barr virus DNA or Epstein-Barr virus-Ig M,cytomegalovirus DNA,Clostridium difficile.(2)90-day follow-up after operation.The univariate analysis was performed on relevant factors,and potential independent influencing factors of postoperative intestinal fistula in patients with Crohn’s disease were evaluated by multivariate Logistic regression analysis.The risk equation for postoperative intestinal fistula was established according to the screened independent influencing factors,R software was used to construct a Nomogram model for predicting postoperative intestinal fistula in patients with Crohn’s disease,and the calibration curve was used to evaluate the accuracy of the model.Subsequently,the predictive ability of the model was verified in the validation group.Results:(1)The univariate analysis showed: disease site,disease behavior,disease activity,abdominal abscess,intestinal perforation,intestinal obstruction,hormone therapy,infliximab therapy,BMI,WBC,PLT,NEU,LYM,CRP,ESR,Alb,NLR,PLR,CAR,SII and PNI were associated with the factors affecting postoperative intestinal fistula in CD patients(p<0.05).While gender,age of onset,course of disease,history of appendectomy,perianal lesions,5-ASA drugs,immunosuppressants,HB,HCT,eosinophil,basophil,globulin,D-dimer,emergency or elective surgery,open or laparoscopic surgery,anastomosis method,EBV infection,CMV infection,and Clostridium difficile were not the factors affecting the occurrence of postoperative intestinal fistula in CD patients(p>0.05).(2)The multivariate Logistic regression analysis showed that NLR,PNI,disease behavior(B2),and CDAI score were independent influencing factors for postoperative intestinal fistula in patients with Crohn’s disease.(3)The AUC obtained after the evaluation of the validation group was 0.899(95% CI 0.830～0.968,p<0.001),which had showing good prediction accuracy.It indicates that the Nomogram prediction model has better prediction performance.Conclusion: NLR,PNI,disease behavior(B2),and CDAI score are independent influencing factors for postoperative intestinal fistul a in patients with Crohn’s disease.Actively controlling inflammatory response before surgery and supplementing nutrition can help to re duce the incidence of postoperative intestinal fistula in patients with Crohn’s disease,so that the patient derives greater benefit from the treatment.Prediction model Logit(P)=-0.301+0.078*NLR-0.108*PNI+1.841(B2)+2.122(light activity period)+2.434(moderate activity perio d)+3.522(Severe activity period)can predict the risk of postoperativ e intestinal fistula in individuals effectively.