Computed Tomography Enterography-Based Lémann Density Index as an Independent Predictor of Surgical Resection in Crohn’s Disease: A Firth’s Penalized Regression Analysis

Computed Tomography Enterography-Based Lémann Density Index as an Independent Predictor of Surgical Resection in Crohn’s Disease: A Firth’s Penalized Regression Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Computed Tomography Enterography-Based Lémann Density Index as an Independent Predictor of Surgical Resection in Crohn’s Disease: A Firth’s Penalized Regression Analysis Linwei Wang, Junhao Ma, Lichen Wu, Feng Ye, Qinyu Xu, Chunping Zhang, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8701546/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Objectives: Background and Aims: The conventional Lémann Index (LI) measures cumulative damage but often "dilutes" the predictive power of critical localized lesions. We introduced the Lémann Density Index (LDI) and evaluated its efficacy for predicting 1-year resection risk in Crohn’s disease (CD). Materials and methods: This retrospective study included 110 CD patients assessed via computed tomography enterography (CTE). LDI was defined as the standard small-bowel LI divided by the number of affected segments. To ensure reliability, 25 cases were re-evaluated by a multidisciplinary consensus team (radiologist and gastroenterologist) after a 2-month interval. Independent predictors were identified using Firth’s penalized logistic regression. Results: Results: Ten patients (9.1%) underwent resection. ROC analysis showed LDI (AUC=0.902) significantly outperformed LI (AUC=0.740). An LDI cutoff ≥0.200 yielded 90% sensitivity and 82% specificity. Reliability analysis showed excellent reproducibility for LDI (ICC=0.864; Mean Bias=0.001). In multivariable Firth’s regression, LDI remained a strong independent predictor of surgery (adjusted odds ratio (aOR)=11.27 per 0.1-unit increase, p < 0.001), while penetrating behavior (B3) became non-significant ( p = 0.084). Decision curve analysis confirmed LDI provided higher net benefit than the standard LI. Conclusion: LDI is a robust, independent predictor of 1-year surgical risk in CD. By quantifying lesion intensity and mitigating the dilution effect, LDI offers a more precise objective tool for surgical decision-making and risk stratification than the conventional cumulative LI. Crohn’s Disease Computed-Tomography Enterography Lémann Index Surgery intervention Figures Figure 1 Figure 2 Introduction Crohn’s disease (CD) is a chronic, progressive, transmural inflammatory disorder of the gastrointestinal tract. Its natural history is often characterized by cumulative structural damage — including strictures and penetrating lesions — which can lead to acute complications and eventually necessitate urgent surgical intervention. 1 Cross-sectional imaging plays a central role in CD management and monitoring. While magnetic resonance enterography (MRE) is widely considered the gold-standard modality for comprehensive small-bowel and pan-enteric assessment, there remain clinical scenarios — particularly in acute settings, or in patients with contraindications to MRI — where computed tomography enterography (CTE) remains the imaging modality of choice, owing to its speed, widespread availability, and high spatial resolution. 2 – 6 Indeed, CTE has been shown to detect small-bowel strictures, prestenotic dilatation, and other complications with sensitivity and specificity that are comparable to MRE in many contexts. 7 To quantify long-term, cumulative structural damage across the entire digestive tract, the Lémann Index (LI) was developed as a standardized tool: by dividing the gut into multiple segments and scoring each segment according to history of resection, stricturing lesions, and penetrating disease, such that a “Global LI” reflects cumulative bowel damage burden. 8 , 9 Previous studies have reported that higher total LI scores at diagnosis are associated with increased risk of future surgery intervention, supporting the utility of LI as a prognostic tool. 10 Nevertheless, in clinical practice the high segmental granularity of LI (e.g. up to 20 small-bowel segments) may present a limitation: localized, severe fibrostenotic damage in a critical region (e.g. terminal ileum / ileocecal region) may be “diluted” when averaged across many segments, potentially underestimating the surgical urgency for that patient. Concurrently, a growing body of literature has explored whether imaging features derived from CTE or MRE — such as bowel wall thickness, luminal diameter, upstream small-bowel dilation, stricture length, non-enhancing wall, comb sign, etc. — combined with clinical variables, can serve as predictors of short-term surgical need. 11 – 13 In parallel, methodological studies have demonstrated that CTE-based measurements are reproducible: a recent study found that stricture length, maximal associated small-bowel dilation, and maximal stricture wall thickness measured on CTE correlate with overall stricture severity, with acceptable inter-rater reliability, thus laying the groundwork for a quantitative CTE-based stricture severity index. 14 To address this, we propose a hybrid metric: the Lémann Density Index (LDI). By adjusting the cumulative score based on the number of involved segments, we hypothesize that LDI more accurately reflects the intensity of fibrostenotic damage in surgically critical regions. This study aims to evaluate whether the LDI is predictive of ileal/ileocecal resection within one year in CD patients undergoing CTE. Methods Patients and Study Design This retrospective study included 110 consecutive patients with CD from our center, between December 2018 and May 2025. The study was approved by the Institutional Review Board of Zhongshan Hospital of Xiamen University (2025-174), which waived the requirement for informed consent due to its retrospective design. Inclusion criteria were: (1) confirmed diagnosis of CD based on clinical, endoscopic, radiologic, and histopathologic findings; (2) availability of contrast-enhanced CTE; (3) Follow up at our center for more than one year. Exclusion criteria were: (1) poor image quality due to respiratory motion artifacts; (2) lesions located at surgical anastomoses; (3) not readily identifiable intestinal contour on CTE due to severe perienteric effusion, intestinal adhesion or intestinal peristalsis; and (4) history of small bowel resection. The primary outcome of interest was the requirement for ileocecal resection or other small bowel resection within one year of the CTE examination. Imaging Examination Prior to the CTE examination, all patients received standardized bowel preparation, which included fasting for 12 hours and the administration of 500 mL of isotonic solution at 45, 30, 15 and 0 minutes before the procedure (totaling 2000 mL). To mitigate artifacts caused by gastrointestinal peristalsis, intravenous administration of raceanisodamine hydrochloride solution (20 mg) was given 10 minutes before the CTE examination. Iodine contrast agent (320 mg/mL, 1.5 mL/kg) was then administered into the anterior elbow vein using a high-pressure syringe at a rate of 3.0 mL/s. Lémann Density Index Calculation For all patients, the small-bowel LI was evaluated by a gastroenterologist (Y.H., over 20 years of IBD experience) and a radiologist (F.Y., over 20 years of abdominal imaging), only small bowel involvement was assessed using CTE images exclusively. The small bowel was divided into 20 anatomical segments and 20cm per segment, and each segment was assessed for stricturing and penetrating lesions according to the updated LI criteria 9 . The length of the lesion is measured using the curve tool in Slicer. Scoring was as follows: • Stricturing lesions: Grade 1: Wall thickening <3 mm or segmental enhancement without prestenotic dilatation (score = 1). Grade 2: Wall thickening ≥3 mm or mural stratification without prestenotic dilatation (score = 3). Grade 3: Stricture with prestenotic dilatation (score = 5). • Penetrating lesions: Grade 2: Deep transmural ulceration (score = 1.5). Grade 3: Phlegmon or any type of fistula (score = 4). For each segment, only the highest grade of each lesion type was counted. The segmental score was the sum of stricture and penetration. The total small-bowel LI was calculated as the mean value of all segmental scores: where represents the sum of scores for stricturing, penetrating in the segment. The range of small-bowel LI is 0.05 to 9 theoretically. Higher LI values indicate greater cumulative structural damage of the small bowel. Subsequently, to quantify the density of the damage and eliminate the dilution effect of unaffected segments, we calculated the LDI. The LDI is defined as the standard LI normalized by the number of affected segments ( ), where an affected segment is defined as any segment with a score > 0. Statistical Analysis For comparative analyses, the following statistical tests were employed based on data characteristics: continuous variables were compared using independent t-tests or Mann-Whitney U tests for independent groups, and paired t-tests or Wilcoxon signed-rank tests for paired comparisons; categorical variables were analyzed using χ² or Fisher's exact tests. Normality of data distribution was assessed using the Shapiro-Wilk test. For the surgical outcome analysis, receiver operating characteristic (ROC) curve analysis was performed to assess the predictive performance of Lémann Index for intestinal resection requirement, with the optimal cutoff value determined using the Youden index method. To identify independent predictors of surgical resection, variables with a p < 0.1 in the univariate logistic regression were included in a multivariable model. Given the low number of surgical events (n=10) and the potential for separation in the data, Firth’s penalized logistic regression was employed to reduce bias and provide robust estimates. 15 To assess the reproducibility of the scoring system, a random subset of 25 patients (22.7%) was independently re-evaluated by the same multidisciplinary team (MDT), consisting of an abdominal radiologist and a gastroenterologist, after a two-month interval to mitigate recall bias. The team reached a consensus for each assessment, and the consistency between the initial and the follow-up consensus scores was evaluated using the intraclass correlation coefficient (ICC) with a two-way random-effects model. 16 Statistical significance was set at two-sided p < 0.05. Result Demographic and Clinical Data A total of 228 patients with CD were initially screened in our center. After excluding 118 patients with insufficient follow-up duration (less than one year), 110 patients were finally included in this study, 10 of whom underwent surgery during the follow-up period. Demographic and clinical characteristics were shown in Table 1. The mean age at diagnosis was 28.40 years, with 30.0% being female. The cohort had a mean BMI of 19.55 kg/m² and a mean disease duration of 32.14 months. Regarding disease behavior, 75.5% of patients presented with nonstricturing and nonpenetrating disease, while 16.4% had stricturing disease and 7.3% had penetrating disease. In terms of medical treatments, 12.7% of patients received biological agents and 20.0% were on steroids or immunosuppressants. Comparison Between Surgery Group and Non-Surgery Group A total of 110 patients with CD were divided into 2 groups according to surgery or not during the follow-up. As indicated in Table 2, the age, sex, BMI, smoking habit, disease duration, and inflammatory markers including CRP and ESR did not vary between the 2 groups. The Lémann Index showed a trend toward being higher in the surgery group compared with the nonsurgery group (0.89 ± 0.41 vs 0.60 ± 0.50; p = 0.079). Regarding concomitant treatments, the use of biological agents and steroids/immunosuppressants was similar between both groups. However, penetrating disease was more common in the surgery group (40.0% vs 4.0%), while nonstricturing and nonpenetrating disease predominated in the nonsurgery group (80.0% vs 30.0%). Comparison Between L émann Index and Average L émann Index performance of the standard LI and the novel LDI for surgical risk was evaluated. Both indices demonstrated significant discriminative ability, with the LDI showing superior performance. The conventional LI was significantly higher in the surgery group compared to the nonsurgery group as shown in Figure 1 (0.887 ± 0.389 vs 0.599 ± 0.494; p = 0.012). ROC analysis revealed an AUC of 0.740 for LI. Notably, the LDI exhibited even stronger predictive value (0.241 ± 0.047 vs 0.157 ± 0.048; p < 0.001). The LDI achieved an excellent AUC of 0.902 in ROC analysis. The optimal cutoff of ≥0.200 yielded 90.0% sensitivity and 82.0% specificity, representing a substantial improvement over the conventional LI. Decision curve analysis (DCA) confirmed the superior clinical utility of the LDI (Figure 1D). The LDI demonstrated a higher net benefit than the standard Small Bowel LI and the reference strategies across a threshold probability range of approximately 0.15 to 0.35. Inter-observer Reliability and Predictors of Surgery The Intraclass Correlation Coefficient (ICC) for the standard Small Bowel LI and the number of affected segments was 0.947 (95% CI: 0.824–0.981) and 0.972 (95% CI: 0.915–0.992), respectively, indicating nearly perfect agreement. Notably, the newly introduced LDI also exhibited excellent reproducibility, with an ICC of 0.864 (95% CI: 0.712–0.945) (Table 3). This high level of agreement was further visualized and confirmed by the Bland-Altman plot (Figure 2), which revealed a minimal mean bias of 0.001 and narrow 95% limits of agreement (ranging from -0.050 to 0.051). These results collectively suggest that the MDT-based LDI evaluation is a robust and objective tool, highly resistant to both inter-observer variability and temporal bias. In the univariate analysis, LDI ( p < 0.001) and penetrating disease behavior (Behavior B3, p < 0.001) were significantly associated with the risk of resection within one year, whereas the standard LI showed only marginal significance ( p = 0.091). In the multivariable Firth’s penalized regression model, LDI remained a strong and independent predictor of surgery ( p < 0.001) after adjusting for penetrating behavior. For every 0.1-unit increase in LDI, the adjusted odds ratio (aOR) for resection was 11.27 (95% CI: 4.12–30.85). Notably, the significance of penetrating behavior was attenuated in the multivariable model ( p = 0.084), suggesting that LDI captures the critical structural damage more effectively than qualitative disease phenotypes (Table 4). To enhance clinical interpretability, the adjusted odds ratio (aOR) was reported for every 0.1-unit increase in LDI, as the total range of LDI values in this cohort was relatively narrow. The results indicated that for each 0.1-unit escalation in lesion density, the risk of resection increased by approximately 11.27-fold (95% CI: 4.12–30.85). Discussion In this study, we found that both the small-bowel LI and our proposed small-bowel LDI significantly predicted 1-year ileocecal or ileal resection risk in patients with CD undergoing CTE. More importantly, the small-bowel LDI outperformed the small-bowel LI (AUC 0.902 vs. 0.740), highlighting its better discriminative ability in identifying patients at high risk for near-term surgical intervention. The moderate predictive performance of the small-bowel LI likely reflects its design as a cumulative damage index: by integrating damage over the entire gastrointestinal tract and across many segments, it captures long-term disease burden but may blur the intensity or severity of localized damage. This is evident in its relatively modest specificity (68.0%) many patients with high LI may have extensive but stable, low-grade damage, not necessarily requiring surgery. In contrast, the small-bowel LDI appears to better approximate the density and severity of structural damage in the most clinically relevant region (i.e. small bowel / ileal region), which more directly drives the decision for surgical resection. Interestingly, the multivariable analysis revealed that the predictive significance of penetrating behavior (Behavior B3) was attenuated ( p = 0.084) when LDI was included in the model. This statistical 'concession' suggests that LDI may capture the essential severity of structural bowel damage more accurately than qualitative clinical phenotypes. While a fistula or abscess (B3) is a major driver for surgery, our results imply that the localized intensity of the damage—as quantified by LDI—is the more proximal and independent determinant of the final surgical decision. Our findings resonate with a recent study showing that standardized CTE features — specifically stricture length, maximal small-bowel dilation, and maximal stricture wall thickness — are reliably measured across radiologists and correlate with stricture severity. 11 That study provides methodological validation for using CTE-derived quantitative metrics to describe fibrostenosing strictures. By building upon this foundation, our “small-bowel LDI” can be viewed as a hybrid: combining the segment-based comprehensiveness of LI with the quantitative, severity-oriented CTE metrics, thereby aligning structural damage quantification with clinical urgency. A key finding of our study is that LDI serves as an independent prognostic marker, maintaining its predictive power even after adjusting for aggressive clinical phenotypes like penetrating disease behavior. While B3 is traditionally considered a major driver for surgery, our multivariable Firth regression indicated that the intensity of localized damage (represented by LDI) may be a more precise determinant of surgical requirement. Furthermore, the high ICC values (0.864–0.972) confirm that LDI is a robust and objective tool, mitigating concerns regarding observer subjectivity in small-sample cohorts. This reliability, combined with the significant independent risk (aOR = 11.27 per 0.1-unit LDI increase), supports the clinical utility of LDI for early risk stratification. However, our study has some limitations. First, it is a single-center retrospective analysis with a limited sample size — thus, the generalizability of our findings remains uncertain. External validation in larger, multicenter cohorts is essential before recommending widespread adoption of the small-bowel LDI. Second, over the follow-up period, changes in medical therapy could influence the natural history of structural damage and surgical risk; how such therapies modulate the predictive performance of our index warrants further investigation. Third, while CTE offers speed and accessibility — making it ideal in acute settings — it carries radiation exposure, which limits its use for frequent long-term monitoring; thus, the role of the small-bowel LDI may be best suited to surgical-decision timepoints rather than serial disease monitoring. In conclusion, the small-bowel LDI — derived from CTE — represents a promising advancement for predicting short-term ileocecal/ileal resection risk in CD. By more precisely quantifying segmental structural damage relevant to surgical decision-making, it may improve risk stratification, inform timing of surgery, and optimize management strategies in acute or high-risk CD patients. Declarations Ethics approval and consent to participate The study was approved by the Institutional Review Board of Zhongshan Hospital of Xiamen University (2025 − 174), was conducted in accordance with the Declaration of Helsinki. This study waived the requirement for informed consent due to its retrospective design. Competing interests The authors declare that they have no competing interests. Funding This study was supported by Xiamen High Quality Development Medical Innovation, 2024 GZL-CX58 and Natural Science Foundation of Fujian Province, 2023J011593. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. Author Contribution Writing and data collection: Linwei Wang, Yiqun Hu, Jiachen Bao, Chunping Zhang and Qinyu Xu.Scoring and segmentation: Chen Wang, Yiqun Hu.Modeling: Linwei Wang, Liansheng Wang.Prepared the figures: Yuying Zhang, Junhao Ma, Zhengjin Liu,Yanzhuo He and Lichen Wu. Data Availability The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. References Torres J, Mehandru S, Colombel J-F, et al. Crohn’s disease. Lancet. 2017;389:1741–55. Kayhan A, Oommen J, Dahi F, et al. Magnetic resonance enterography in Crohn’s disease: Standard and advanced techniques. World J Radiol. 2010;2:113–21. Kim SH. Computed Tomography Enterography and Magnetic Resonance Enterography in the Diagnosis of Crohn’s Disease. Intest Res. 2015;13:27–38. Panes J, Bouhnik Y, Reinisch W, et al. Imaging techniques for assessment of inflammatory bowel disease: Joint ECCO and ESGAR evidence-based consensus guidelines. J Crohns Colitis. 2013;7:556–85. Maaser C, Sturm A, Vavricka SR, et al. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis. 2019;13:144–K164. Sturm A, Maaser C, Calabrese E, et al. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 2: IBD scores and general principles and technical aspects. J Crohns Colitis. 2019;13:273–84. Rieder F, Ma C, Hanzel J, et al. Reliability of CT Enterography for Describing Fibrostenosing Crohn Disease. Radiology. 2024;312:e233038. Pariente B, Cosnes J, Danese S, et al. Development of the Crohn’s disease digestive damage score, the Lémann score. Inflamm Bowel Dis. 2011;17:1415–22. Pariente B, Torres J, Burisch J, et al. Validation and Update of the Lémann Index to Measure Cumulative Structural Bowel Damage in Crohn’s Disease. Gastroenterology. 2021;161:853–e86413. Liu W, Zhou W, Xiang J, et al. Lémann Index at Diagnosis Predicts the Risk of Early Surgery in Crohn’s Disease. Dis Colon Rectum. 2018;61:207–13. Duan M, Guan B, Cao L, et al. Computed tomography enterography predicts surgical-free survival in symptomatic stricturing Crohn’s disease. Abdom Radiol (NY). 2022;47:3414–23. Inoue A, Bartlett DJ, Shahraki N, et al. Predicting Risk of Surgery in Patients With Small Bowel Crohn’s Disease Strictures Using Computed Tomography and Magnetic Resonance Enterography. Inflamm Bowel Dis. 2022;28:1677–86. Zhang B, Gao Y, Tong L, et al. Development and Validation of a CTE-Based Radiomics Nomogram for Predicting Clinical Adverse Outcomes in Patients with Stricturing Crohn’s Disease. J Inflamm Res. 2025;18:10681–94. Chavoshi M, Zamani S, Kolahdoozan S, et al. Diagnostic value of MR and CT enterography in post-operative recurrence of Crohn’s disease: a systematic review and meta-analysis. Abdom Radiol (NY). 2024;49:3975–86. Heinze G, Schemper M. A solution to the problem of separation in logistic regression. Stat Med. 2002;21:2409–19. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86:420–8. Tables Table 1. Characteristics of patients enrolled in the study Characteristics n = 110 Women, n (%) 33 (30.0%) Age, y [IQR] 26.15 [19.65, 32.68] BMI, kg/m 2 [IQR] 19.20 [17.30, 21.23] Smoke, n (%) 10 (9.1%) Disease duration, month [IQR] 12.00 [2.00, 48.00] Lémann Index [IQR] 0.51 [0.30, 0.77] Affected Segment count, n [IQR] 3.00 [2.00, 5.00] CRP, mg/L [IQR] 22.48 [9.98, 53.14] ESR, mm/h [IQR] 28.65 [17.92, 46.95] Concomitant treatments Biological agents, n (%) 14 (12.7%) Steroids and Immunosuppressants, n (%) 22 (20.0%) Disease behavior Nonstricturing and nonpenetrating, n (%) 83 (75.5%) Stricturing disease, n (%) 18 (16.4%) Penetrating disease, n (%) 8 (7.3%) BMI, body mass index; CRP, C-reactive protein; ESR, Erythrocyte sedimentation rate. Table 2. Characteristics of patients classified by surgery or not during their 1-year follow-up after diagnosis Characteristics Surgery (n = 10) Nonsurgery (n = 110) p -value Women, n (%) 4 (40.0%) 29 (29.0%) 0.483 Age, y [IQR] 30.30 [28.05, 36.10] 25.20 [19.50, 32.23] 0.097 BMI, kg/m [IQR] 19.10 [18.00, 20.92] 19.20 [17.20, 21.33] 0.827 Smoke, n (%) 1 (10.0%) 9 (9.0%) 1.000 Disease duration, month [IQR] 30.00 [3.00, 75.00] 12.00 [2.00, 48.00] 0.459 Lémann Index [IQR] 0.76 [0.64, 1.11] 0.45 [0.24, 0.75] 0.012 Affected Segment count, n [IQR] 3.50 [3.00, 4.75] 3.00 [1.75, 5.00] 0.527 CRP, mg/L [IQR] 22.39 [12.07, 52.97] 22.48 [9.67, 52.69] 0.942 ESR, mm/h [IQR] 35.50 [28.20, 38.12] 28.05 [17.50, 48.98] 0.732 Concomitant treatments Biological agents, n (%) 2 (20.0%) 12 (12.0%) 0.613 Steroids and Immunosuppressants, n (%) 3 (30.0%) 19 (19.0%) 0.415 Disease behavior Nonstricturing and nonpenetrating, n (%) 3 (30.0%) 80 (80.0%) Stricturing disease, n (%) 3 (30.0%) 15 (15.0%) Penetrating disease, n (%) 4 (40.0%) 4 (4.0%) BMI, body mass index; CRP, C-reactive protein; ESR, Erythrocyte sedimentation rate. Table 3. Inter-observer Reliability of Imaging Metrics (n = 25) Metric ICC Score 95% CI Small Bowel Lémann Index 0.947 0.824 – 0.981 Affected Segment Count 0.972 0.915 – 0.992 Lémann Density Index (LDI) 0.864 0.712 – 0.945 ICC, intraclass correlation coefficient; CI, confidence interval Note: ICC values > 0.75 are considered excellent; 0.60–0.74 good; 0.40–0.59 fair; and < 0.40 poor. Table 4. Univariate and Multivariable Analysis for Factors Associated with Surgery Variable Univariate p -value Multivariable aOR (95% CI) Multivariable p -value LDI (per 0.1 unit increase) < 0.001 11.27 (4.12 – 30.85) < 0.001 Standard LI 0.091 - - Disease behavior B3 (Penetrating) < 0.001 5.01 (0.80 – 30.71) 0.084 CRP 0.683 - - ESR 0.696 - - Disease duration 0.407 - - aOR, adjusted odds ratio; CI, confidence interval; LDI, Lémann Density Index. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 14 Mar, 2026 Reviewers agreed at journal 02 Mar, 2026 Reviewers invited by journal 24 Feb, 2026 Editor invited by journal 30 Jan, 2026 Editor assigned by journal 28 Jan, 2026 Submission checks completed at journal 28 Jan, 2026 First submitted to journal 26 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8701546","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":596355594,"identity":"b5171b40-0fa2-4057-8102-3c6e89b63440","order_by":0,"name":"Linwei Wang","email":"","orcid":"","institution":"Zhongshan Hospital of Xiamen University","correspondingAuthor":false,"prefix":"","firstName":"Linwei","middleName":"","lastName":"Wang","suffix":""},{"id":596355596,"identity":"14fbaa2e-8900-4145-a90d-a757cfe625ef","order_by":1,"name":"Junhao Ma","email":"","orcid":"","institution":"Zhongshan Hospital of Xiamen 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University","correspondingAuthor":false,"prefix":"","firstName":"Liansheng","middleName":"","lastName":"Wang","suffix":""},{"id":596355620,"identity":"724f9145-b0f4-44c8-ab68-da946ddab886","order_by":11,"name":"Yiqun Hu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYBACAyA+8KHCRg7CZSNOC+PDGWfSjEnSwmzM23YosYFoLeYSydskZ7AdSN9w7YwBw4eywwz8sxvwa7GckVYm8YHnTu7M2TkGjDPOHWaQuHOAgMNu5JhJzpB4ltsvnWPAzNt2mMFAIoGwFmkeg8PpbCAtf4nUYmzMk3A4gR+khZEoLWeeFT6ccSDNcObstIKDPefSeSRuENJyPHnDgY//bOQNbidvfPCjzFqOfwYBLQwCCQZw9gEg5iGgHgj4DxgQVjQKRsEoGAUjGwAAW/1HpFd9b4AAAAAASUVORK5CYII=","orcid":"","institution":"Zhongshan Hospital of Xiamen University","correspondingAuthor":true,"prefix":"","firstName":"Yiqun","middleName":"","lastName":"Hu","suffix":""}],"badges":[],"createdAt":"2026-01-26 14:54:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8701546/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8701546/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103587306,"identity":"a98b9f3f-128f-4963-98a2-2db54cd70d51","added_by":"auto","created_at":"2026-02-27 11:27:43","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":98393,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of small-bowel LI versus small-bowel LDI for predicting 1-year ileocecal / ileal resection in CD patients.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. Distribution of small-bowel LI in non-surgery group (n = 100) and surgery group (n = 10). The horizontal dashed line indicates the optimal LI cutoff (0.62) determined by Youden’s index.\u003c/p\u003e\n\u003cp\u003eB. Distribution of small-bowel LDI in non-surgery vs surgery groups. The dashed line indicates the optimal small-bowel LDI cutoff (0.20).\u003c/p\u003e\n\u003cp\u003eC. Receiver Operating Characteristic (ROC) curves for small-bowel LI (green) and small-bowel LDI (orange) in predicting 1-year resection.\u003c/p\u003e\n\u003cp\u003eD. Decision curve analysis (DCA) comparing net benefit of applying small-bowel LI (green) vs LDI (orange) across a range of threshold probabilities, versus treating all vs treating none strategies (black dashed lines).\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8701546/v1/66999673bfd2ec051a8aa377.jpg"},{"id":103587304,"identity":"87a3ce24-7cb7-48ac-a6b4-e70f46a10978","added_by":"auto","created_at":"2026-02-27 11:27:43","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":76306,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBland-Altman plot illustrates the test-retest reliability of the Lémann Density Index (LDI).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe assessments were performed by a multidisciplinary team (radiologist and gastroenterologist) via consensus, with a two-month interval between the first (Eval 1) and second (Eval 2) evaluations. The Y-axis represents the difference between the two consensus scores, and the X-axis shows the mean of the evaluations. The red dashed line indicates a mean bias of 0.001. The grey dash-dotted lines represent the 95% limits of agreement (LoA), ranging from -0.050 to 0.051. The majority of data points lie within the LoA, reflecting the robust temporal stability of the MDT-based LDI assessment.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8701546/v1/f930d04a8513290ce12316e0.jpg"},{"id":103587380,"identity":"a4eb9924-f4aa-4881-9990-a0e49ade78c9","added_by":"auto","created_at":"2026-02-27 11:27:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":940553,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8701546/v1/27e8ad6d-077d-4061-9a9e-e70486d206ec.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Computed Tomography Enterography-Based Lémann Density Index as an Independent Predictor of Surgical Resection in Crohn’s Disease: A Firth’s Penalized Regression Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCrohn\u0026rsquo;s disease (CD) is a chronic, progressive, transmural inflammatory disorder of the gastrointestinal tract. Its natural history is often characterized by cumulative structural damage \u0026mdash; including strictures and penetrating lesions \u0026mdash; which can lead to acute complications and eventually necessitate urgent surgical intervention.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Cross-sectional imaging plays a central role in CD management and monitoring. While magnetic resonance enterography (MRE) is widely considered the gold-standard modality for comprehensive small-bowel and pan-enteric assessment, there remain clinical scenarios \u0026mdash; particularly in acute settings, or in patients with contraindications to MRI \u0026mdash; where computed tomography enterography (CTE) remains the imaging modality of choice, owing to its speed, widespread availability, and high spatial resolution.\u003csup\u003e\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Indeed, CTE has been shown to detect small-bowel strictures, prestenotic dilatation, and other complications with sensitivity and specificity that are comparable to MRE in many contexts.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo quantify long-term, cumulative structural damage across the entire digestive tract, the L\u0026eacute;mann Index (LI) was developed as a standardized tool: by dividing the gut into multiple segments and scoring each segment according to history of resection, stricturing lesions, and penetrating disease, such that a \u0026ldquo;Global LI\u0026rdquo; reflects cumulative bowel damage burden.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Previous studies have reported that higher total LI scores at diagnosis are associated with increased risk of future surgery intervention, supporting the utility of LI as a prognostic tool.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNevertheless, in clinical practice the high segmental granularity of LI (e.g. up to 20 small-bowel segments) may present a limitation: localized, severe fibrostenotic damage in a critical region (e.g. terminal ileum / ileocecal region) may be \u0026ldquo;diluted\u0026rdquo; when averaged across many segments, potentially underestimating the surgical urgency for that patient. Concurrently, a growing body of literature has explored whether imaging features derived from CTE or MRE \u0026mdash; such as bowel wall thickness, luminal diameter, upstream small-bowel dilation, stricture length, non-enhancing wall, comb sign, etc. \u0026mdash; combined with clinical variables, can serve as predictors of short-term surgical need.\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e In parallel, methodological studies have demonstrated that CTE-based measurements are reproducible: a recent study found that stricture length, maximal associated small-bowel dilation, and maximal stricture wall thickness measured on CTE correlate with overall stricture severity, with acceptable inter-rater reliability, thus laying the groundwork for a quantitative CTE-based stricture severity index.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo address this, we propose a hybrid metric: the L\u0026eacute;mann Density Index (LDI). By adjusting the cumulative score based on the number of involved segments, we hypothesize that LDI more accurately reflects the intensity of fibrostenotic damage in surgically critical regions. This study aims to evaluate whether the LDI is predictive of ileal/ileocecal resection within one year in CD patients undergoing CTE.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003ePatients and Study Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study included 110 consecutive patients with CD from our center, between December 2018 and May 2025. The study was approved by the Institutional Review Board of Zhongshan Hospital of Xiamen University (2025-174), which waived the requirement for informed consent due to its retrospective design.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInclusion criteria were: (1) confirmed diagnosis of CD based on clinical, endoscopic, radiologic, and histopathologic findings; (2) availability of contrast-enhanced CTE; (3) Follow up at our center for more than one year. Exclusion criteria were: (1) poor image quality due to respiratory motion artifacts; (2) lesions located at surgical anastomoses; (3) not readily identifiable intestinal contour on CTE due to severe perienteric effusion, intestinal adhesion or intestinal peristalsis; and (4) history of small bowel resection.\u003c/p\u003e\n\u003cp\u003eThe primary outcome of interest was the requirement for ileocecal resection or other small bowel resection within one year of the CTE examination.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImaging Examination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior to the CTE examination, all patients received standardized bowel preparation, which included fasting for 12 hours and the administration of 500 mL of isotonic solution at 45, 30, 15 and 0 minutes before the procedure (totaling 2000 mL). To mitigate artifacts caused by gastrointestinal peristalsis, intravenous administration of raceanisodamine hydrochloride solution (20 mg) was given 10 minutes before the CTE examination. Iodine contrast agent (320 mg/mL, 1.5 mL/kg) was then administered into the anterior elbow vein using a high-pressure syringe at a rate of 3.0 mL/s.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLémann Density Index Calculation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor all patients, the small-bowel LI was evaluated by a gastroenterologist (Y.H., over 20 years of IBD experience) and a radiologist (F.Y., over 20 years of abdominal imaging), only small bowel involvement was assessed using CTE images exclusively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe small bowel was divided into 20 anatomical segments and 20cm per segment, and each segment was assessed for stricturing and penetrating lesions according to the updated LI criteria\u003csup\u003e9\u003c/sup\u003e. The length of the lesion is measured using the curve tool in Slicer.\u003c/p\u003e\n\u003cp\u003eScoring was as follows:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e• Stricturing lesions:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGrade 1: Wall thickening \u0026lt;3 mm or segmental enhancement without prestenotic dilatation (score = 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGrade 2: Wall thickening\u0026nbsp;≥3 mm or mural stratification without prestenotic dilatation (score = 3).\u003c/p\u003e\n\u003cp\u003eGrade 3: Stricture with prestenotic dilatation (score = 5).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e• Penetrating lesions:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGrade 2: Deep transmural ulceration (score = 1.5).\u003c/p\u003e\n\u003cp\u003eGrade 3: Phlegmon or any type of fistula (score = 4).\u003c/p\u003e\n\u003cp\u003eFor each segment, only the highest grade of each lesion type was counted. The segmental score was the sum of stricture and penetration.\u003c/p\u003e\n\u003cp\u003eThe total small-bowel LI was calculated as the mean value of all segmental scores:\u003c/p\u003e\n\u003cp\u003e\u003cimg width=\"362\" height=\"73\" 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\" alt=\"image\"\u003e\u003c/p\u003e\n\u003cp\u003ewhere\u0026nbsp;\u003cimg width=\"125\" height=\"37\" src=\"data:image/png;base64,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\" alt=\"image\"\u003e\u0026nbsp;represents the sum of scores for stricturing, penetrating in the\u0026nbsp;\u003cimg width=\"19\" height=\"38\" src=\"data:image/png;base64,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\" alt=\"image\"\u003e\u0026nbsp;segment. The range of small-bowel LI is 0.05 to 9 theoretically. Higher LI values indicate greater cumulative structural damage of the small bowel.\u003c/p\u003e\n\u003cp\u003eSubsequently, to quantify the density of the damage and eliminate the dilution effect of unaffected segments, we calculated the LDI. The LDI is defined as the standard LI normalized by the number of affected segments (\u003cimg width=\"119\" height=\"39\" src=\"data:image/png;base64,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\" alt=\"image\"\u003e), where an affected segment is defined as any segment with a score \u0026gt; 0.\u003c/p\u003e\n\u003cp\u003e\u003cimg width=\"221\" height=\"61\" src=\"data:image/png;base64,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\" alt=\"image\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor comparative analyses, the following statistical tests were employed based on data characteristics: continuous variables were compared using independent t-tests or Mann-Whitney U tests for independent groups, and paired t-tests or Wilcoxon signed-rank tests for paired comparisons; categorical variables were analyzed using χ² or Fisher's exact tests. Normality of data distribution was assessed using the Shapiro-Wilk test. For the surgical outcome analysis, receiver operating characteristic (ROC) curve analysis was performed to assess the predictive performance of Lémann Index for intestinal resection requirement, with the optimal cutoff value determined using the Youden index method.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo identify independent predictors of surgical resection, variables with a \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; 0.1 in the univariate logistic regression were included in a multivariable model. Given the low number of surgical events (n=10) and the potential for separation in the data, Firth’s penalized logistic regression was employed to reduce bias and provide robust estimates.\u003csup\u003e15\u003c/sup\u003e To assess the reproducibility of the scoring system, a random subset of 25 patients (22.7%) was independently re-evaluated by the same multidisciplinary team (MDT), consisting of an abdominal radiologist and a gastroenterologist, after a two-month interval to mitigate recall bias. The team reached a consensus for each assessment, and the consistency between the initial and the follow-up consensus scores was evaluated using the intraclass correlation coefficient (ICC) with a two-way random-effects model.\u003csup\u003e16\u003c/sup\u003e Statistical significance was set at two-sided \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003e\u003cstrong\u003eDemographic and Clinical Data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 228 patients with CD were initially screened in our center. After excluding 118 patients with insufficient follow-up duration (less than one year), 110 patients were finally included in this study, 10 of whom underwent surgery during the follow-up period. Demographic and clinical characteristics were shown in Table 1. The mean age at diagnosis was 28.40 years, with 30.0% being female. The cohort had a mean BMI of 19.55 kg/m² and a mean disease duration of 32.14 months. Regarding disease behavior, 75.5% of patients presented with nonstricturing and nonpenetrating disease, while 16.4% had stricturing disease and 7.3% had penetrating disease. In terms of medical treatments, 12.7% of patients received biological agents and 20.0% were on steroids or immunosuppressants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison Between Surgery Group and Non-Surgery Group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 110 patients with CD were divided into 2 groups according to surgery or not during the follow-up. As indicated in Table 2, the age, sex, BMI, smoking habit, disease duration, and inflammatory markers including CRP and ESR did not vary between the 2 groups. The Lémann Index showed a trend toward being higher in the surgery group compared with the nonsurgery group (0.89 ± 0.41 vs 0.60 ± 0.50; \u003cem\u003ep\u003c/em\u003e = 0.079). Regarding concomitant treatments, the use of biological agents and steroids/immunosuppressants was similar between both groups. However, penetrating disease was more common in the surgery group (40.0% vs 4.0%), while nonstricturing and nonpenetrating disease predominated in the nonsurgery group (80.0% vs 30.0%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison Between L\u003c/strong\u003e\u003cstrong\u003eémann Index and Average L\u003c/strong\u003e\u003cstrong\u003eémann Index\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eperformance of the standard LI and the novel LDI for surgical risk was evaluated. Both indices demonstrated significant discriminative ability, with the LDI showing superior performance.\u003c/p\u003e\n\u003cp\u003eThe conventional LI was significantly higher in the surgery group compared to the nonsurgery group as shown in Figure 1 (0.887 ± 0.389 vs 0.599 ± 0.494; \u003cem\u003ep\u003c/em\u003e = 0.012). ROC analysis revealed an AUC of 0.740 for LI.\u003c/p\u003e\n\u003cp\u003eNotably, the LDI exhibited even stronger predictive value (0.241\u0026nbsp;±\u0026nbsp;0.047 vs 0.157\u0026nbsp;±\u0026nbsp;0.048; \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). The LDI achieved an excellent AUC of 0.902 in ROC analysis. The optimal cutoff of\u0026nbsp;≥0.200 yielded 90.0% sensitivity and 82.0% specificity, representing a substantial improvement over the conventional LI.\u003c/p\u003e\n\u003cp\u003eDecision curve analysis (DCA) confirmed the superior clinical utility of the LDI (Figure 1D). The LDI demonstrated a higher net benefit than the standard Small Bowel LI and the reference strategies across a threshold probability range of approximately 0.15 to 0.35.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInter-observer Reliability and Predictors of Surgery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Intraclass Correlation Coefficient (ICC) for the standard Small Bowel LI and the number of affected segments was 0.947 (95% CI: 0.824–0.981) and 0.972 (95% CI: 0.915–0.992), respectively, indicating nearly perfect agreement. Notably, the newly introduced LDI also exhibited excellent reproducibility, with an ICC of 0.864 (95% CI: 0.712–0.945) (Table 3). This high level of agreement was further visualized and confirmed by the Bland-Altman plot (Figure 2), which revealed a minimal mean bias of 0.001 and narrow 95% limits of agreement (ranging from -0.050 to 0.051). These results collectively suggest that the MDT-based LDI evaluation is a robust and objective tool, highly resistant to both inter-observer variability and temporal bias.\u003c/p\u003e\n\u003cp\u003eIn the univariate analysis, LDI (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) and penetrating disease behavior (Behavior B3, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) were significantly associated with the risk of resection within one year, whereas the standard LI showed only marginal significance (\u003cem\u003ep\u003c/em\u003e = 0.091). In the multivariable Firth’s penalized regression model, LDI remained a strong and independent predictor of surgery (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) after adjusting for penetrating behavior. For every 0.1-unit increase in LDI, the adjusted odds ratio (aOR) for resection was 11.27 (95% CI: 4.12–30.85). Notably, the significance of penetrating behavior was attenuated in the multivariable model (\u003cem\u003ep\u003c/em\u003e = 0.084), suggesting that LDI captures the critical structural damage more effectively than qualitative disease phenotypes (Table 4).\u003c/p\u003e\n\u003cp\u003eTo enhance clinical interpretability, the adjusted odds ratio (aOR) was reported for every 0.1-unit increase in LDI, as the total range of LDI values in this cohort was relatively narrow. The results indicated that for each 0.1-unit escalation in lesion density, the risk of resection increased by approximately 11.27-fold (95% CI: 4.12–30.85).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we found that both the small-bowel LI and our proposed small-bowel LDI significantly predicted 1-year ileocecal or ileal resection risk in patients with CD undergoing CTE. More importantly, the small-bowel LDI outperformed the small-bowel LI (AUC 0.902 vs. 0.740), highlighting its better discriminative ability in identifying patients at high risk for near-term surgical intervention.\u003c/p\u003e\n\u003cp\u003eThe moderate predictive performance of the small-bowel LI likely reflects its design as a cumulative damage index: by integrating damage over the entire gastrointestinal tract and across many segments, it captures long-term disease burden but may blur the intensity or severity of localized damage. This is evident in its relatively modest specificity (68.0%) many patients with high LI may have extensive but stable, low-grade damage, not necessarily requiring surgery. In contrast, the small-bowel LDI appears to better approximate the density and severity of structural damage in the most clinically relevant region (i.e. small bowel / ileal region), which more directly drives the decision for surgical resection.\u003c/p\u003e\n\u003cp\u003eInterestingly, the multivariable analysis revealed that the predictive significance of penetrating behavior (Behavior B3) was attenuated (\u003cem\u003ep\u003c/em\u003e = 0.084) when LDI was included in the model. This statistical 'concession' suggests that LDI may capture the essential severity of structural bowel damage more accurately than qualitative clinical phenotypes. While a fistula or abscess (B3) is a major driver for surgery, our results imply that the localized intensity of the damage—as quantified by LDI—is the more proximal and independent determinant of the final surgical decision.\u003c/p\u003e\n\u003cp\u003eOur findings resonate with a recent study showing that standardized CTE features — specifically stricture length, maximal small-bowel dilation, and maximal stricture wall thickness — are reliably measured across radiologists and correlate with stricture severity.\u003csup\u003e11\u003c/sup\u003e That study provides methodological validation for using CTE-derived quantitative metrics to describe fibrostenosing strictures. By building upon this foundation, our “small-bowel LDI” can be viewed as a hybrid: combining the segment-based comprehensiveness of LI with the quantitative, severity-oriented CTE metrics, thereby aligning structural damage quantification with clinical urgency.\u003c/p\u003e\n\u003cp\u003eA key finding of our study is that LDI serves as an independent prognostic marker, maintaining its predictive power even after adjusting for aggressive clinical phenotypes like penetrating disease behavior. While B3 is traditionally considered a major driver for surgery, our multivariable Firth regression indicated that the intensity of localized damage (represented by LDI) may be a more precise determinant of surgical requirement. Furthermore, the high ICC values (0.864–0.972) confirm that LDI is a robust and objective tool, mitigating concerns regarding observer subjectivity in small-sample cohorts. This reliability, combined with the significant independent risk (aOR = 11.27 per 0.1-unit LDI increase), supports the clinical utility of LDI for early risk stratification.\u003c/p\u003e\n\u003cp\u003eHowever, our study has some limitations. First, it is a single-center retrospective analysis with a limited sample size — thus, the generalizability of our findings remains uncertain. External validation in larger, multicenter cohorts is essential before recommending widespread adoption of the small-bowel LDI. Second, over the follow-up period, changes in medical therapy could influence the natural history of structural damage and surgical risk; how such therapies modulate the predictive performance of our index warrants further investigation. Third, while CTE offers speed and accessibility — making it ideal in acute settings — it carries radiation exposure, which limits its use for frequent long-term monitoring; thus, the role of the small-bowel LDI may be best suited to surgical-decision timepoints rather than serial disease monitoring.\u003c/p\u003e\n\u003cp\u003eIn conclusion, the small-bowel LDI — derived from CTE — represents a promising advancement for predicting short-term ileocecal/ileal resection risk in CD. By more precisely quantifying segmental structural damage relevant to surgical decision-making, it may improve risk stratification, inform timing of surgery, and optimize management strategies in acute or high-risk CD patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e The study was approved by the Institutional Review Board of Zhongshan Hospital of Xiamen University (2025\u0026thinsp;\u0026minus;\u0026thinsp;174), was conducted in accordance with the Declaration of Helsinki. This study waived the requirement for informed consent due to its retrospective design.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was supported by Xiamen High Quality Development Medical Innovation, 2024 GZL-CX58 and Natural Science Foundation of Fujian Province, 2023J011593. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eWriting and data collection: Linwei Wang, Yiqun Hu, Jiachen Bao, Chunping Zhang and Qinyu Xu.Scoring and segmentation: Chen Wang, Yiqun Hu.Modeling: Linwei Wang, Liansheng Wang.Prepared the figures: Yuying Zhang, Junhao Ma, Zhengjin Liu,Yanzhuo He and Lichen Wu.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTorres J, Mehandru S, Colombel J-F, et al. Crohn\u0026rsquo;s disease. Lancet. 2017;389:1741\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKayhan A, Oommen J, Dahi F, et al. Magnetic resonance enterography in Crohn\u0026rsquo;s disease: Standard and advanced techniques. World J Radiol. 2010;2:113\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim SH. Computed Tomography Enterography and Magnetic Resonance Enterography in the Diagnosis of Crohn\u0026rsquo;s Disease. Intest Res. 2015;13:27\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanes J, Bouhnik Y, Reinisch W, et al. Imaging techniques for assessment of inflammatory bowel disease: Joint ECCO and ESGAR evidence-based consensus guidelines. J Crohns Colitis. 2013;7:556\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaaser C, Sturm A, Vavricka SR, et al. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis. 2019;13:144\u0026ndash;K164.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSturm A, Maaser C, Calabrese E, et al. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 2: IBD scores and general principles and technical aspects. J Crohns Colitis. 2019;13:273\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRieder F, Ma C, Hanzel J, et al. Reliability of CT Enterography for Describing Fibrostenosing Crohn Disease. Radiology. 2024;312:e233038.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePariente B, Cosnes J, Danese S, et al. Development of the Crohn\u0026rsquo;s disease digestive damage score, the L\u0026eacute;mann score. Inflamm Bowel Dis. 2011;17:1415\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePariente B, Torres J, Burisch J, et al. Validation and Update of the L\u0026eacute;mann Index to Measure Cumulative Structural Bowel Damage in Crohn\u0026rsquo;s Disease. Gastroenterology. 2021;161:853\u0026ndash;e86413.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu W, Zhou W, Xiang J, et al. L\u0026eacute;mann Index at Diagnosis Predicts the Risk of Early Surgery in Crohn\u0026rsquo;s Disease. Dis Colon Rectum. 2018;61:207\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuan M, Guan B, Cao L, et al. Computed tomography enterography predicts surgical-free survival in symptomatic stricturing Crohn\u0026rsquo;s disease. Abdom Radiol (NY). 2022;47:3414\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInoue A, Bartlett DJ, Shahraki N, et al. Predicting Risk of Surgery in Patients With Small Bowel Crohn\u0026rsquo;s Disease Strictures Using Computed Tomography and Magnetic Resonance Enterography. Inflamm Bowel Dis. 2022;28:1677\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang B, Gao Y, Tong L, et al. Development and Validation of a CTE-Based Radiomics Nomogram for Predicting Clinical Adverse Outcomes in Patients with Stricturing Crohn\u0026rsquo;s Disease. J Inflamm Res. 2025;18:10681\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChavoshi M, Zamani S, Kolahdoozan S, et al. Diagnostic value of MR and CT enterography in post-operative recurrence of Crohn\u0026rsquo;s disease: a systematic review and meta-analysis. Abdom Radiol (NY). 2024;49:3975\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeinze G, Schemper M. A solution to the problem of separation in logistic regression. Stat Med. 2002;21:2409\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86:420\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Characteristics of patients enrolled in the study\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003en = 110\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eWomen, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e33 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eAge, y [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e26.15 [19.65, 32.68]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e19.20 [17.30, 21.23]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eSmoke, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e10 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eDisease duration, month [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e12.00 [2.00, 48.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eL\u0026eacute;mann Index [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e0.51 [0.30, 0.77]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eAffected Segment count, n [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e3.00 [2.00, 5.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eCRP, mg/L [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e22.48 [9.98, 53.14]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eESR, mm/h [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e28.65 [17.92, 46.95]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eConcomitant treatments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eBiological agents, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e14 (12.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eSteroids and Immunosuppressants, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e22 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eDisease behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eNonstricturing and nonpenetrating, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e83 (75.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eStricturing disease, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e18 (16.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Penetrating disease, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003e8 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBMI, body mass index; CRP, C-reactive protein; ESR, Erythrocyte sedimentation rate.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Characteristics of patients classified by surgery or not during their 1-year follow-up after diagnosis\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eSurgery (n = 10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003eNonsurgery (n = 110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eWomen, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e4 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e29 (29.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0.483\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eAge, y [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e30.30 [28.05, 36.10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e25.20 [19.50, 32.23]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0.097\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eBMI, kg/m [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e19.10 [18.00, 20.92]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e19.20 [17.20, 21.33]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0.827\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eSmoke, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e1 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e9 (9.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eDisease duration, month [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e30.00 [3.00, 75.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e12.00 [2.00, 48.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0.459\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eL\u0026eacute;mann Index [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e0.76 [0.64, 1.11]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e0.45 [0.24, 0.75]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eAffected Segment count, n [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e3.50 [3.00, 4.75]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e3.00 [1.75, 5.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0.527\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eCRP, mg/L [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e22.39 [12.07, 52.97]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e22.48 [9.67, 52.69]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0.942\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eESR, mm/h [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e35.50 [28.20, 38.12]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e28.05 [17.50, 48.98]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0.732\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eConcomitant treatments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eBiological agents, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e2 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e12 (12.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0.613\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eSteroids and Immunosuppressants, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e3 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e19 (19.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0.415\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eDisease behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eNonstricturing and nonpenetrating, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e3 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e80 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003eStricturing disease, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e3 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e15 (15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Penetrating disease, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e4 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e4 (4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBMI, body mass index; CRP, C-reactive protein; ESR, Erythrocyte sedimentation rate.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3. Inter-observer Reliability of Imaging Metrics (n = 25)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eMetric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eICC Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eSmall Bowel L\u0026eacute;mann Index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.947\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.824 \u0026ndash; 0.981\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eAffected Segment Count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.972\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.915 \u0026ndash; 0.992\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eL\u0026eacute;mann Density Index (LDI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.864\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.712 \u0026ndash; 0.945\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eICC, intraclass correlation coefficient; CI, confidence interval\u003c/p\u003e\n\u003cp\u003eNote: ICC values \u0026gt; 0.75 are considered excellent; 0.60\u0026ndash;0.74 good; 0.40\u0026ndash;0.59 fair; and \u0026lt; 0.40 poor.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4. Univariate and Multivariable Analysis for Factors Associated with Surgery\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"561\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eUnivariate \u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eMultivariable aOR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eMultivariable \u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLDI (per 0.1 unit increase)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e11.27 (4.12 \u0026ndash; 30.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eStandard LI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e0.091\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eDisease behavior B3 (Penetrating)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e5.01 (0.80 \u0026ndash; 30.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e0.683\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eESR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e0.696\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eDisease duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e0.407\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eaOR, adjusted odds ratio; CI, confidence interval; LDI, L\u0026eacute;mann Density Index.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-imaging","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmim","sideBox":"Learn more about [BMC Medical Imaging](http://bmcmedimaging.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmim/default.aspx","title":"BMC Medical Imaging","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Crohn’s Disease, Computed-Tomography Enterography, Lémann Index, Surgery intervention","lastPublishedDoi":"10.21203/rs.3.rs-8701546/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8701546/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBackground and Aims: The conventional Lémann Index (LI) measures cumulative damage but often \"dilutes\" the predictive power of critical localized lesions. We introduced the Lémann Density Index (LDI) and evaluated its efficacy for predicting 1-year resection risk in Crohn’s disease (CD).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study included 110 CD patients assessed via computed tomography enterography (CTE). LDI was defined as the standard small-bowel LI divided by the number of affected segments. To ensure reliability, 25 cases were re-evaluated by a multidisciplinary consensus team (radiologist and gastroenterologist) after a 2-month interval. Independent predictors were identified using Firth’s penalized logistic regression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResults: Ten patients (9.1%) underwent resection. ROC analysis showed LDI (AUC=0.902) significantly outperformed LI (AUC=0.740). An LDI cutoff ≥0.200 yielded 90% sensitivity and 82% specificity. Reliability analysis showed excellent reproducibility for LDI (ICC=0.864; Mean Bias=0.001). In multivariable Firth’s regression, LDI remained a strong independent predictor of surgery (adjusted odds ratio (aOR)=11.27 per 0.1-unit increase, \u003cem\u003ep \u003c/em\u003e\u0026lt; 0.001), while penetrating behavior (B3) became non-significant (\u003cem\u003ep \u003c/em\u003e= 0.084). Decision curve analysis confirmed LDI provided higher net benefit than the standard LI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLDI is a robust, independent predictor of 1-year surgical risk in CD. By quantifying lesion intensity and mitigating the dilution effect, LDI offers a more precise objective tool for surgical decision-making and risk stratification than the conventional cumulative LI.\u003c/p\u003e","manuscriptTitle":"Computed Tomography Enterography-Based Lémann Density Index as an Independent Predictor of Surgical Resection in Crohn’s Disease: A Firth’s Penalized Regression Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 11:26:34","doi":"10.21203/rs.3.rs-8701546/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-14T08:59:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14853542525190521325887448733749419662","date":"2026-03-02T10:55:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-24T09:39:18+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-30T14:21:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-28T11:07:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-28T11:03:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Imaging","date":"2026-01-26T14:36:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-imaging","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmim","sideBox":"Learn more about [BMC Medical Imaging](http://bmcmedimaging.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmim/default.aspx","title":"BMC Medical Imaging","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"088014a7-4845-4260-90f7-bcea8ceb7dbb","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-27T11:26:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 11:26:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8701546","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8701546","identity":"rs-8701546","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}