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Akiyama S, Ollech JE, Cohen NA, Traboulsi C, Rai V, Glick LR, Yi Y, Runde J, Cohen RD, Olortegui KBS, Hurst RD, Umanskiy K, Shogan BD, Hyman NH, Rubin MA, Dalal SR, Sakuraba A, Pekow J, Chang EB, Rubin DT. Endoscopic Normalization and Transition of J-Pouch Phenotypes Over Time in Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2024:izae106. [PMID: 38916136 DOI: 10.1093/ibd/izae106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Indexed: 06/26/2024]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) who undergo proctocolectomy with ileal pouch-anal anastomosis may develop pouchitis. We previously proposed a novel endoscopic classification of pouchitis describing 7 phenotypes with differing outcomes. This study assessed phenotype transitions over time. METHODS We classified pouch findings into 7 main phenotypes: (1) normal, (2) afferent limb (AL) involvement, (3) inlet (IL) involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) pouch-related fistulas noted more than 6 months after ileostomy takedown. Among 2 endoscopic phenotypes, the phenotype that was first identified was defined as the primary phenotype, and the phenotype observed later was defined as the subsequent phenotype. RESULTS We retrospectively reviewed 1359 pouchoscopies from 426 patients (90% preoperative diagnosis of ulcerative colitis). The frequency of primary phenotype was 31% for AL involvement, 42% for IL involvement, 28% for diffuse inflammation, 72% for focal inflammation, 45% for cuffitis, 18% for pouch-related fistulas, and 28% for normal pouch. The most common subsequent phenotype was focal inflammation (64.8%), followed by IL involvement (38.6%), cuffitis (37.8%), AL involvement (25.6%), diffuse inflammation (23.8%), normal pouch (22.8%), and pouch-related fistulas (11.9%). Subsequent diffuse inflammation, pouch-related fistulas, and AL or IL stenoses significantly increased the pouch excision risk. Patients who achieved subsequent normal pouch were less likely to have pouch excision than those who did not (8.1% vs 15.7%; P = .15). CONCLUSIONS Pouch phenotype and the risk of pouch loss can change over time. In patients with pouch inflammation, subsequent pouch normalization is feasible and associated with favorable outcome.
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Affiliation(s)
- Shintaro Akiyama
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Jacob E Ollech
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Nathaniel A Cohen
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Cindy Traboulsi
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Victoria Rai
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Laura R Glick
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Yangtian Yi
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Joseph Runde
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Russell D Cohen
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | | | - Roger D Hurst
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Konstantin Umanskiy
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Benjamin D Shogan
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Neil H Hyman
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Michele A Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Sushila R Dalal
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Atsushi Sakuraba
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Joel Pekow
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Eugene B Chang
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
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Nallapaneni P, Picoraro JA. Diagnosis and Treatment of Pouch Disorders in Children: A Systematic Review. Dis Colon Rectum 2024; 67:S115-S124. [PMID: 38422401 DOI: 10.1097/dcr.0000000000003317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Restorative proctocolectomy and IPAA have become the surgical procedure of choice in pediatric patients with medically refractory colitis or familial adenomatous polyposis. OBJECTIVE This systematic review aims to assess the diagnosis and treatment of pouch disorders in pediatric patients who undergo IPAA. DATA SOURCES A literature search was performed using MEDLINE, Google Scholar, and Embase for all publications describing outcomes of pediatric IPAA. STUDY SELECTION Studies between January 1, 2000, and September 7, 2022, published in English were included. Studies were excluded on the basis of title, abstract, and full-length review. INTERVENTIONS IPAA. MAIN OUTCOME MEASURES Pouch disorders described include anastomotic leaks, pouch strictures, pouch failure, pouchitis, cuffitis, and de novo Crohn's disease of the pouch. RESULTS Thirty-three studies were included in this review, all of which were retrospective in nature. The outcomes of 2643 pediatric patients were included in the 33 studies. LIMITATIONS Management is largely informed by clinical practices in adult patients with scant data on treatment efficacy in children. CONCLUSIONS The reported incidence of disorders of the pouch in children varies widely and is likely attributable to differences in definitions and follow-up periods across studies. Pouchitis was the most frequently described outcome. The overall rate of pouch failure in children is relatively low, with de novo Crohn's disease of the pouch being the most significant risk factor. Multicenter prospective studies are needed in the pediatric population to accurately identify risk factors, standardize the assessment of pouch complications, and determine effective treatment strategies. See video from the symposium .
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Affiliation(s)
- Padmini Nallapaneni
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
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Palm PH, Matos MC, Velazco CS. Complications following ileal pouch-anal anastomosis in pediatric ulcerative colitis. Semin Pediatr Surg 2024; 33:151405. [PMID: 38583361 DOI: 10.1016/j.sempedsurg.2024.151405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Ileal pouch-anal anastomosis (IPAA) is the procedure of choice for reconstruction after total proctocolectomy in pediatric patients with ulcerative colitis. 30-60 % of patients undergoing IPAA will experience a postoperative complication. The primary objective of this article is to address the most common complications specific to IPAA in the pediatric population and provide an up-to-date review of their presentation, risk factors, workup, and management. We also share our preferred approaches to management and prevention of complications, where relevant. We intend to provide a concise review on the topic aimed at pediatric surgeons and healthcare providers involved in the care of this population with the goal of contributing to improved outcomes and patient quality of life.
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Affiliation(s)
- Preston H Palm
- Division of Pediatric Surgery, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
| | - Monique C Matos
- Division of Pediatric Surgery, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
| | - Cristine S Velazco
- Division of Pediatric Surgery, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA.
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Rentea RM, Renaud E, Ricca R, Derderian C, Englum B, Kawaguchi A, Gonzalez K, Speck KE, Villalona G, Kulaylat A, Wakeman D, Yousef Y, Rialon K, Somme S, Lucas D, Levene T, Chang H, Baerg J, Acker S, Fisher J, Kelley-Quon LI, Baird R, Beres AL. Surgical Management of Ulcerative Colitis in Children and Adolescents: A Systematic Review from the APSA Outcomes and Evidence-Based Practice Committee. J Pediatr Surg 2023; 58:1861-1872. [PMID: 36941170 DOI: 10.1016/j.jpedsurg.2023.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/06/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023]
Abstract
INTRODUCTION The incidence of ulcerative colitis (UC) is increasing. Roughly 20% of all patients with UC are diagnosed in childhood, and children typically present with more severe disease. Approximately 40% will undergo total colectomy within ten years of diagnosis. The objective of this study is to assess the available evidence regarding the surgical management of pediatric UC as determined by the consensus agreement of the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP). METHODS Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on surgical decision-making for children with UC. Questions focused on surgical timing, reconstruction, use of minimally invasive techniques, need for diversion, and risks to fertility and sexual function. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of Bias was assessed using Methodological Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized. RESULTS A total of 69 studies were included for analysis. Most manuscripts contain level 3 or 4 evidence from single-center retrospective reports, leading to a grade D recommendation. MINORS assessment revealed a high risk of bias in most studies. J-pouch reconstruction may result in fewer daily stools than straight ileoanal anastomosis. There are no differences in complications based on the type of reconstruction. The timing of surgery should be individualized to patients and does not affect complications. Immunosuppressants do not appear to increase surgical site infection rates. Laparoscopic approaches result in longer operative times but shorter lengths of stay and fewer small bowel obstructions. Overall, complications are not different using an open or minimally invasive approach. CONCLUSIONS There is currently low-level evidence related to certain aspects of surgical management for UC, including timing, reconstruction type, use of minimally invasive techniques, need for diversion, and risks to fertility and sexual function. Multicenter, prospective studies are recommended to better answer these questions and ensure the best evidence-based care for our patients. LEVEL OF EVIDENCE Level of evidence III. STUDY TYPE Systematic review.
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Affiliation(s)
- Rebecca M Rentea
- Children's Mercy-Kansas City, University of Missouri- Kansas City, Department of Pediatric Surgery, Kansas City, MO, USA
| | - Elizabeth Renaud
- Division of Pediatric Surgery, Hasbro Children's Hospital, Alpert Medical School at Brown University, Providence, RI, USA
| | - Robert Ricca
- Division of Pediatric Surgery, Prisma Health Upstate, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Christopher Derderian
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Denver, CO, USA
| | - Brian Englum
- Division of Pediatric Surgery, University of Maryland, Baltimore, MD, USA
| | - Akemi Kawaguchi
- Department of Pediatric Surgery. Children's Memorial Hermann Hospital, UTHealth, Houston, TX, USA
| | - Katherine Gonzalez
- Division of Pediatric Surgery, St. Luke's Children's Hospital, Boise, ID, USA
| | - K Elizabeth Speck
- Division of Pediatric Surgery, C.S Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | | | - Afif Kulaylat
- Division of Pediatric Surgery, Penn State Hershey, Hershey, PA, USA
| | - Derek Wakeman
- Division of Pediatric Surgery, University of Rochester, Rochester, NY, USA
| | - Yasmine Yousef
- Division of Pediatric Surgery, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Kristy Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Sig Somme
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Denver, CO, USA
| | - Donald Lucas
- Division of Pediatric Surgery, Naval Medical Center, San Diego, CA, USA
| | - Tamar Levene
- Division of Pediatric Surgery, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | - Henry Chang
- Division of Pediatric Surgery, Hopkins ALL Children's Hospital, St. Petersburg, FL, USA
| | - Joanne Baerg
- Division of Pediatric Surgery, Presbyterian Health Services, Albuquerque, NM, USA
| | - Shannon Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Denver, CO, USA
| | - Jeremy Fisher
- University Surgical Associates, UT College of Medicine, Chattanooga, TN, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Robert Baird
- Division of Pediatric Surgery, BC Women's and Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Alana L Beres
- St. Christopher's Hospital for Children, Drexel University School of Medicine, Division of Pediatric Surgery, Philadelphia, PA, USA.
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Kjaer S, Bulut O. Outcomes after transanal proctectomy with ileal pouch-anal anastomosis in adolescents. Pediatr Surg Int 2023; 39:92. [PMID: 36695985 DOI: 10.1007/s00383-023-05381-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 01/26/2023]
Abstract
PURPOSE The aim of this study was to describe our initial surgical and functional outcomes of transanal ileal pouch anastomosis (Ta-IPAA) in adolescents. METHODS A total of 16 adolescents' age ≤ 19 underwent consecutive Ta-IPAA on the indication ulcerative colitis (UC) or familiar adenomatous polyposis (FAP), between January 2018 and September 2022. Primary outcomes were postoperative complications. Secondary outcomes were conversion rates, intraoperative complications, length of hospital stay (LOS), morbidity within 30 days, surgical characteristics, and functional outcomes. RESULTS Thirteen adolescents with UC and three with FAP underwent Ta-IPAA. The median age of UC patients was 16. They had a colectomy on the indication UC followed by a Ta-IPAA. Median operating time was 247 min, and there were no conversion or intraoperative complications. Median LOS was 7 days. No anastomotic leakage was observed, and three patients had complications within the first 30 days. Three had late complications. The median bowel movements were 5, and 50% had bowel movements during the night. Three children were operated on the indication FAP with proctocolectomy and Ta-IPAA. There were no conversion or intraoperative complications, and the median bowel movements was 4. CONCLUSION Ta-IPAA approach in children seems to be feasible, safe and offers acceptable functional results.
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Affiliation(s)
- Soeren Kjaer
- Department of Surgical Gastroenterology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark. .,Copenhagen IBD-Center, Copenhagen, Denmark.
| | - Orhan Bulut
- Department of Surgical Gastroenterology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark.,Copenhagen IBD-Center, Copenhagen, Denmark.,Institut of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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6
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Runde J, Erondu A, Akiyama S, Traboulsi C, Rai V, Glick LR, Yi Y, Ollech JE, Cohen RD, Skowron KB, Hurst RD, Umanskiy K, Shogan BD, Hyman NH, Rubin MA, Dalal SR, Sakuraba A, Pekow J, Chang EB, Rubin DT. Outcomes of Ileoanal Pouch Anastomosis in Pediatric Ulcerative Colitis Are Worse in the Modern Era: A Time Trend Analysis Outcomes Following Ileal Pouch-Anal Anastomosis in Pediatric Ulcerative Colitis. Inflamm Bowel Dis 2022; 28:1386-1394. [PMID: 35040964 PMCID: PMC9434476 DOI: 10.1093/ibd/izab319] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Despite significant differences in surgical outcomes between pediatric and adult patients with ulcerative colitis (UC) undergoing colectomy, counseling on pediatric outcomes has largely been guided by data from adults. We compared differences in pouch survival between pediatric and adult patients who underwent total proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS This was a retrospective single-center study of patients with UC treated with IPAA who subsequently underwent pouchoscopy between 1980 and 2019. Data were collected via electronic medical records. We stratified the study population based on age at IPAA. Differences between groups were assessed using t tests and chi-square tests. Kaplan-Meier curves were used to compare survival probabilities. Differences between groups were assessed using a log-rank test. RESULTS We identified 53 patients with UC who underwent IPAA before 19 years of age and 329 patients with UC who underwent IPAA at or after 19 years of age. Subjects who underwent IPAA as children were more likely to require anti-tumor nerosis factor (TNF) postcolectomy compared with adults (41.5% vs 25.8%; P < .05). Kaplan-Meier estimates revealed that pediatric patients who underwent IPAA in the last 10 years had a 5-year pouch survival probability that was 28% lower than that of those who underwent surgery in the 1990s or 2000s (72% vs 100%; P < .001). Further, children who underwent IPAA and received anti-TNF therapies precolectomy had the most rapid progression to pouch failure when compared with anti-TNF-naive children and with adults who were either exposed or naive precolectomy (P < .05). CONCLUSIONS There are lower rates of pouch survival for children with UC who underwent IPAA following the uptake of anti-TNF therapy compared with both historical pediatric control subjects and contemporary adults.
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Affiliation(s)
- Joseph Runde
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Comer Children’s Hospital, Chicago, IL, USA
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Amarachi Erondu
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Shintaro Akiyama
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Cindy Traboulsi
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Victoria Rai
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Laura R Glick
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Yangtian Yi
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Jacob E Ollech
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Russell D Cohen
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Kinga B Skowron
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Roger D Hurst
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Konstatin Umanskiy
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Benjamin D Shogan
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Neil H Hyman
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Michele A Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Sushila R Dalal
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Atsushi Sakuraba
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Joel Pekow
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Eugene B Chang
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
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Picoraro JA, Shen B. The Pediatric Pouch Deserves Precision. Inflamm Bowel Dis 2022; 28:1469-1471. [PMID: 35040991 DOI: 10.1093/ibd/izab321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Joseph A Picoraro
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
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Shen B, Kochhar GS, Kariv R, Liu X, Navaneethan U, Rubin DT, Cross RK, Sugita A, D'Hoore A, Schairer J, Farraye FA, Kiran RP, Fleshner P, Rosh J, Shah SA, Chang S, Scherl E, Pardi DS, Schwartz DA, Kotze PG, Bruining DH, Kane SV, Philpott J, Abraham B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P, McCormick JT, Picoraro JA, Silverberg MS, Bernstein CN, Sandborn WJ, Vermeire S. Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol 2021; 6:826-849. [PMID: 34416186 DOI: 10.1016/s2468-1253(21)00101-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis is an option for most patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. Although the construction of an ileal pouch substantially improves patients' health-related quality of life, the surgery is, directly or indirectly, associated with various structural, inflammatory, and functional adverse sequelae. Furthermore, the surgical procedure does not completely abolish the risk for neoplasia. Patients with ileal pouches often present with extraintestinal, systemic inflammatory conditions. The International Ileal Pouch Consortium was established to create this consensus document on the diagnosis and classification of ileal pouch disorders using available evidence and the panellists' expertise. In a given individual, the condition of the pouch can change over time. Therefore, close monitoring of the activity and progression of the disease is essential to make accurate modifications in the diagnosis and classification in a timely manner.
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Affiliation(s)
- Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA.
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Revital Kariv
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Xiuli Liu
- Department of Pathology and Immunology, Washington University, MO, USA
| | - Udayakumar Navaneethan
- IBD Center and IBD Interventional Unit, Center for Interventional Endoscopy, Orlando Health, Orlando, FL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Raymond K Cross
- Inflammatory Bowel Disease Program, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Akira Sugita
- Department of Clinical Research and Department of Inflammatory Bowel Disease, Yokohama Municipal Citizens Hospital Yokohama, Japan
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Belgium
| | - Jason Schairer
- Department of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - Philip Fleshner
- Division of Colorectal Surgery, University of California-Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Joel Rosh
- Department of Pediatric Gastroenterology, Goryeb Children's Hospital-Atlantic Health, Morristown, NJ, USA
| | - Samir A Shah
- Alpert Medical School of Brown University and Miriam Hospital, Gastroenterology Associates, Providence, RI, USA
| | - Shannon Chang
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Ellen Scherl
- New York Presbyterian Hospital, Jill Roberts Center for IBD, Weill Cornell Medicine, Gastroenterology and Hepatology, New York, NY, USA
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David A Schwartz
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paulo G Kotze
- IBD Outpatients Clinic, Catholic University of Paraná, Curitiba, Brazil
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Bincy Abraham
- Houston Methodist and Weill Cornell Medical College, Houston, TX, USA
| | - Jonathan Segal
- Department of Gastroenterology and Hepatology, Hillingdon Hospital, Uxbridge, UK
| | - Rocio Sedano
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Maia Kayal
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Stuart Bentley-Hibbert
- Department of Radiology, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - Dino Tarabar
- IBD Clinical Center, University Hospital Center Dr Dragiša Mišović, Belgrade, Serbia
| | - Sandra El-Hachem
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Priya Sehgal
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - James T McCormick
- Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Joseph A Picoraro
- Department of Pediatrics, Columbia University Irving Medical Center-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Mark S Silverberg
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, Toronto, ON, Canada
| | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - William J Sandborn
- Department of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Séverine Vermeire
- Department of Gastroenterology, University hospitals Leuven, Leuven, Belgium
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Outcomes Following Pouch Formation in Paediatric Ulcerative Colitis: A Study From the Porto Group of ESPGHAN. J Pediatr Gastroenterol Nutr 2020; 71:346-353. [PMID: 32541197 DOI: 10.1097/mpg.0000000000002805] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Contemporary pediatric data on pouch outcomes are sparse, especially in the era of laparoscopic surgeries. We aimed to assess outcomes and predictors in children with ulcerative colitis/inflammatory bowel disease (IBD)-unclassified who underwent colectomy and ileal pouch-anal anastomosis. METHODS This was a multicenter retrospective cohort study from 17 IBD centers affiliated with the pediatric IBD Porto group of ESPGHAN. An electronic REDcap system was used to collate baseline characteristics, demographic, clinical, management and surgical data, short- and long-term outcomes, and to identify potential predictors of pouch outcome. RESULTS Of the 129 patients included, 86 (67%) developed pouchitis during follow-up of median 40 months (interquartile range 26-72), of whom 33 (26%) with chronic pouchitis. Patients operated on by surgeons performing <10 pouch surgeries/year had a higher rate of chronic pouchitis (11/27 [41%] vs 8/54 [15%], P = 0.013) on both univariable and multivariable analyses and also associated with time to pouchitis (P = 0.018) and chronic pouchitis (P = 0.020). At last follow-up, overall pouch performance was rated good/excellent in 86 (74%) patients. Time from colectomy to pouch formation was not associated with pouch outcomes. Despite higher rate of nonsevere surgical complications among children undergoing colectomy at <10 years of age (7/16 [44%] vs 10/92 [11%], P = 0.003), functional outcome and pouchitis rate did not differ. CONCLUSIONS Pouchitis rate in children with ulcerative colitis/IBD unclassified is high. Surgeon experience is the major modifiable risk factor for pouch outcome. Our analyses suggest that pouch surgery can also be performed successfully in young children.
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Aytac E, Esen E, Aydinli HH, Kirat HT, Schwartzberg DM, Remzi FH. Transabdominal re-do pouch surgery in pediatric patients for failed ileal pouch anal anastomosis: a case matched study. Pediatr Surg Int 2019; 35:895-901. [PMID: 31165911 DOI: 10.1007/s00383-019-04493-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Data regarding safety and feasibility of re-do ileal pouch anal anastomosis (IPAA) for failed ileal pouch in children are limited. In this study, we compared the short- and long-term outcomes of re-do IPAA in pediatric and adult populations in a case-matched setting. METHODS Between March 2007 and June 2017, pediatric patients undergoing a transabdominal re-do IPAA by single surgeon were reviewed and case matched with adult counterparts. Short- and long-term outcomes including complications, functional outcomes, and quality of life of the two groups were compared. RESULTS 60 patients were included (pediatric, n = 30; adult, n = 30). Time between index IPAA and re-do IPAA was shorter in the pediatric group (30 ± 26 vs 86 ± 74 months, p = 0.001). In the pediatric population, the existing pouch was more commonly used to construct the re-do pouch (n = 19 vs n = 12, p = 0.07). There was a trend towards the presence of less postoperative complications in pediatric group (n = 13 vs n = 20, p = 0.07). There were no reoperations or mortality. Long-term pouch survival was comparable between two groups (p = 0.96). Six re-do IPAAs failed in the study period. CONCLUSION Re-do IPAA is safe and feasible in pediatric population with failed IPAA and can be performed with similar short- and long-term outcomes compared to adults in experienced hands.
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Affiliation(s)
- Erman Aytac
- Department of General Surgery, School of Medicine, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey.,Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Eren Esen
- Department of General Surgery, School of Medicine, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey.,Department of Colorectal Surgery, NYU Langone Medical Center, IBD Center, 23rd Floor, New York, NY, 10016, USA
| | - H Hande Aydinli
- Department of Colorectal Surgery, NYU Langone Medical Center, IBD Center, 23rd Floor, New York, NY, 10016, USA.,Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Hasan T Kirat
- Department of Colorectal Surgery, NYU Langone Medical Center, IBD Center, 23rd Floor, New York, NY, 10016, USA.,Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - David M Schwartzberg
- Department of Colorectal Surgery, NYU Langone Medical Center, IBD Center, 23rd Floor, New York, NY, 10016, USA
| | - Feza H Remzi
- Department of Colorectal Surgery, NYU Langone Medical Center, IBD Center, 23rd Floor, New York, NY, 10016, USA. .,Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA.
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11
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Drews JD, Onwuka EA, Fisher JG, Huntington JT, Dutkiewicz M, Nogalska A, Nwomeh BC. Complications after proctocolectomy and ileal pouch-anal anastomosis in pediatric patients: A systematic review. J Pediatr Surg 2019; 54:1331-1339. [PMID: 30291026 DOI: 10.1016/j.jpedsurg.2018.08.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/20/2018] [Accepted: 08/29/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND/PURPOSE Colectomy with ileal pouch-anal anastomosis (IPAA) is the standard of care for patients with familial adenomatous polyposis (FAP) and refractory ulcerative colitis (UC). The rates of postoperative complications are not well established in children. The objective of this systematic review is to establish benchmark data for morbidity after pediatric IPAA. METHODS PubMed, Embase, and The Cochrane Library were searched for studies of colectomy with IPAA in patients ≤21 years old. UC studies were limited to the anti-tumor necrosis factor-α agents era (1998-present). All postoperative complications were extracted. RESULTS Thirteen studies met the inclusion criteria (763 patients). Compared to patients with FAP, UC patients had a higher prevalence of pouch loss (10.6% vs. 1.5%). Other major complications such as anastomotic leak, abscess, and fistula were uncommon (mean prevalence 4.9%, 4.2%, and 5.0%, respectively, for patients with UC; 8.7%, 4.2%, and 4.3% for FAP). The most frequent complication was pouchitis (36.4% of UC patients). CONCLUSIONS Devastating complications from colectomy and IPAA are rare, but patients with UC have poorer outcomes than those with FAP. Much of the morbidity may therefore stem from patient or disease factors. Multicenter, prospective studies are needed to identify modifiable risks in patients with UC undergoing IPAA. LEVEL OF EVIDENCE Prognostic, level II.
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Affiliation(s)
- Joseph D Drews
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205; Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Columbus, OH, USA 43210.
| | - Ekene A Onwuka
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205; Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Columbus, OH, USA 43210.
| | - Jeremy G Fisher
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205.
| | - Justin T Huntington
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205.
| | - Michał Dutkiewicz
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205.
| | - Agata Nogalska
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205.
| | - Benedict C Nwomeh
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205; Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Columbus, OH, USA 43210.
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12
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Lightner AL, Alsughayer A, Wang Z, McKenna NP, Seisa MO, Moir C. Short- and Long-term Outcomes After Ileal Pouch Anal Anastomosis in Pediatric Patients: A Systematic Review. Inflamm Bowel Dis 2019; 25:1152-1168. [PMID: 30668719 DOI: 10.1093/ibd/izy375] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/18/2018] [Accepted: 11/17/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Restorative proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the procedures of choice for restoration of intestinal continuity in ulcerative colitis or familial adenomatous polyposis. This systematic review aims to assess short-term postoperative and long-term functional outcomes in pediatric patients undergoing IPAA. METHODS A literature search was performed for all publications of pediatric IPAA in which short- and long-term outcomes were reported. Papers were excluded based on title, abstract, and full-length review. Data collection included patient demographics, medication use preoperatively, operative approach, 30-day postoperative outcomes, long-term functional outcomes (to maximal date of follow-up), and pouch failure rate. Outcomes were compared in those patients with and without perioperative corticosteroid exposure. Study quality and risk of bias was assessed using the Newcastle-Ottawa Scale as all studies were cohort studies. RESULTS Of 710 records reviewed, 42 full papers were included in the analysis. Rates of superficial surgical site infection, pelvic sepsis, ileus, and small bowel obstruction at <30 days were 10%, 11%, 10%, and 14%, respectively. Rates of pouchitis, stricture, chronic fistula tract, incontinence, and pouch failure were 30%, 17%, 12%, 20%, and 8%, respectively, at 37-109 months of follow-up; incontinence was significantly higher in those exposed to corticosteroids preoperatively (52% vs 20%; P < 0.001). The median daytime, nighttime, and 24-hour stool frequency were 5.3, 1.4, and 5 bowel movements, respectively. CONCLUSIONS IPAA is safe with good long-term functional outcomes in pediatric patients.
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Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester Minnesota, USA
| | - Ahmad Alsughayer
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester Minnesota, USA
| | - Zhen Wang
- Division of Health Care Policy and Research, Mayo Clinic, Rochester Minnesota, USA
| | - Nicholas P McKenna
- Division of Health Care Policy and Research, Mayo Clinic, Rochester Minnesota, USA
| | - Mohamed O Seisa
- Division of Health Care Policy and Research, Mayo Clinic, Rochester Minnesota, USA
| | - Christopher Moir
- Division ofPediatric Surgery, Mayo Clinic, Rochester Minnesota, USA
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13
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Gonzalez DO, Nwomeh BC. Complications in children with ulcerative colitis undergoing ileal pouch-anal anastomosis. Semin Pediatr Surg 2017; 26:384-390. [PMID: 29126508 DOI: 10.1053/j.sempedsurg.2017.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Total colectomy with ileal pouch-anal anastomosis (IPAA) is considered the standard procedure for the surgical management of ulcerative colitis. Despite the widespread utility of the procedure, as many as 75% of patients who undergo IPAA, experience at least 1 complication. This review highlights difficult intraoperative scenarios and complications of pouch surgery in children, including intraoperative, postoperative, and functional complications. Intraoperative scenarios include insufficient mesenteric length and positive leak tests. Postoperative complications include surgical site infection, anastomotic leak, stricture, fistula, pouchitis, small bowel obstruction, and pouch failure. Less common complications include afferent limb syndrome, pouch prolapse, and superior mesenteric artery syndrome. Functional complications include incontinence, impaired quality of life, infertility, and sexual dysfunction. Despite complications, most patients are satisfied with their outcomes and report an improvement in their lifestyle.
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Affiliation(s)
- Dani O Gonzalez
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Benedict C Nwomeh
- Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, Ohio 43205.
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14
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Diederen K, Sahami SS, Tabbers MM, Benninga MA, Kindermann A, Tanis PJ, Oomen MW, de Jong JR, Bemelman WA. Outcome after restorative proctocolectomy and ileal pouch–anal anastomosis in children and adults. Br J Surg 2017; 104:1640-1647. [DOI: 10.1002/bjs.10678] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 05/23/2017] [Accepted: 07/13/2017] [Indexed: 12/30/2022]
Abstract
Abstract
Background
Studies comparing the outcome of ileal pouch–anal anastomosis (IPAA) in children and adults are scarce. This complicates decision-making in young patients. The aim of this study was to compare adverse events and pouch function between children and adults who underwent IPAA.
Methods
This cross-sectional cohort study included all consecutive children (aged less than 18 years) and adults with a diagnosis of inflammatory bowel disease or familial adenomatous polyposis who underwent IPAA in a tertiary referral centre between 2000 and 2015. Adverse events were assessed by chart review, and pouch function by interview using a pouch function score (PFS).
Results
In total, 445 patients underwent IPAA: 41 children (median age 15 years) and 404 adults (median age 39 years), with a median follow-up of 22 (i.q.r. 8–68) months. Being overweight (P = 0·001), previous abdominal surgery (P = 0·018), open procedures (P < 0·001) and defunctioning ileostomy (P = 0·014) were less common among children than adult patients. The occurrence of anastomotic leakage, surgical fistulas, chronic pouchitis and Crohn's of the pouch was not associated with paediatric age at surgery, nor was pouch failure. The development of anastomotic strictures was associated with having IPAA surgery during childhood (odds ratio 4·22, 95 per cent c.i. 1·13 to 15·77; P = 0·032). Pouch function at last follow-up was similar in the children and adult groups (median PFS 5·0 versus 6·0 respectively; P = 0·194).
Conclusion
Long-term pouch failure rates and pouch function were similar in children and adults. There is no need for a more cautious attitude to use of IPAA in children based on concerns about poor outcome.
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Affiliation(s)
- K Diederen
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - S S Sahami
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M M Tabbers
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - M A Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - A Kindermann
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M W Oomen
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - J R de Jong
- Department of Paediatric Surgery, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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