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Kolho KL, Nikkonen A, Merras-Salmio L, Molander P. The need for surgery in pediatric patients with inflammatory bowel disease treated with biologicals. Int J Colorectal Dis 2024; 39:58. [PMID: 38661931 PMCID: PMC11045629 DOI: 10.1007/s00384-024-04634-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE Inflammatory bowel disease (IBD) in childhood often presents with a more extensive and more aggressive disease course than adult-onset disease. We aimed to evaluate if biological treatment started in childhood decreases the need for intestinal surgery over time. METHODS This was a retrospective, single-center, cohort study. All pediatric patients with IBD initiated to biological therapy at the Children's Hospital, were included in the study and followed up to the first surgical procedure or re-operation in their adulthood or until 31.12.2021 when ≥ 18 of age. Data were collected from the pediatric registry of IBD patients with biologicals and medical charts. RESULTS A total of 207 pediatric IBD patients were identified [150 with Crohn´s disease (CD), 31 with ulcerative colitis (UC), 26 with IBD unclassified (IBDU)] of which 32.9% (n = 68; CD 49, UC 13, IBDU 6) underwent intestinal surgery. At the end of a median follow-up of 9.0 years (range 2.0-25.9), patients reached a median age of 21.4 years (range 18-36). Patients who had intestinal surgery in childhood were more likely to have IBD-related surgery also in early adulthood. The duration of the disease at induction of the first biological treatment emerged as the only risk factor, with a longer duration in the surgical group than in patients with no surgery. CONCLUSION Despite initiation of biological treatment, the risk of intestinal surgery remains high in pediatric IBD patients and often the need for surgery emerges after the transition to adult IBD clinics.
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Affiliation(s)
- Kaija-Leena Kolho
- Children's Hospital, Helsinki University Hospital HUS and Helsinki University, Helsinki, Finland.
| | - Anne Nikkonen
- Children's Hospital, Helsinki University Hospital HUS and Helsinki University, Helsinki, Finland
| | - Laura Merras-Salmio
- Children's Hospital, Helsinki University Hospital HUS and Helsinki University, Helsinki, Finland
| | - Pauliina Molander
- Abdominal Center, Gastroenterology, Helsinki University Hospital HUS and Helsinki University, Helsinki, Finland
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Bajzát D, Kéri AF, Imrei M, Kói T, Párniczky A, Hegyi P, Kovács K, Váncsa S, Müller KE. Safety Analysis of Preoperative Anti-TNF-α Therapy in Pediatric IBD After Intestinal Resection: A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2023; 29:1971-1980. [PMID: 36789751 DOI: 10.1093/ibd/izac274] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Indexed: 02/16/2023]
Abstract
BACKGROUND Biological agents have transformed the management of inflammatory bowel disease (IBD). However, intestinal resection is still unavoidable in complicated IBD. It is still under debate whether antitumor necrosis factor (TNF)-α is related to higher postoperative complications in children with IBD. Therefore, we aimed to analyze data on preoperative anti-TNF-α and postoperative complications in pediatric IBD. METHODS We conducted a systematic literature search in 4 databases for studies that compared the incidence of postoperative complications between children with IBD who received anti-TNF-α treatment within 12 weeks prior to intestinal resection and who did not receive anti-TNF-α before the operation. To analyze this question, pooled odds ratios (ORs) were calculated with 95% confidence intervals (CIs). Odds ratios higher than 1 mean higher complication rate among children treated with preoperative anti-TNF-α, whereas an OR lower than 1 means lower complication rate. The I² value was calculated to measure the strength of the between-study heterogeneity, where a smaller percentage means the lower heterogeneity. RESULTS We found 8 eligible articles with 526 pediatric patients with IBD. The primary outcome was the overall complication. The pooled OR of overall complications was 1.38 (95% CI, 0.10-18.76; P = .65; I2 = 34%) in contrast, the OR of infectious and noninfectious complications were 0.59 (95% CI, 0.21-1.69; P = .16; I2 = 0%) and 0.48 (95% CI, 0.18-1.25; p = .09; I2 = 0%), although both showed a nonsignificant result. CONCLUSION There is no significant association between preoperative anti-TNF-α therapy and postoperative complications in children with IBD after intestinal resection. However, the evidence is low due to the low number of studies investigating this question.
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Affiliation(s)
- Dorina Bajzát
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Adrienn F Kéri
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Marcell Imrei
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Tamás Kói
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Stochastics, Institute of Mathematics, Budapest University of Technology and Economics, Budapest, Hungary
| | - Andrea Párniczky
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Kinga Kovács
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Szilárd Váncsa
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Katalin Eszter Müller
- Heim Pál National Pediatric Institute, Budapest, Hungary
- Department of Family Care Methodology, Faculty of Health Science, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
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Tang Z, Sun S, Ji M, Shi P, Wang Y, Huang Z, Huang Y. Long-term outcomes after enterostomy for very early-onset inflammatory bowel disease with interleukin-10 signaling deficiency. BMC Gastroenterol 2023; 23:404. [PMID: 37986047 PMCID: PMC10661559 DOI: 10.1186/s12876-023-03051-4] [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: 12/24/2022] [Accepted: 11/10/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Very early-onset inflammatory bowel disease (VEOIBD) with interleukin-10 (IL10R) signaling deficiency usually requires enterostomy in patients who are refractory to traditional treatment. This study aimed to evaluate long-term outcomes after enterostomy for VEOIBD patients with IL10R signaling deficiency. METHODS The medical records of all patients undergoing enterostomy for signaling deficiency were retrospectively assessed during 2012.1-2022.7 in a tertiary teaching hospital, Children's Hospital of Fudan University, Shanghai, China. Data on disease history, diagnosis and details of enterostomy and stoma closure and follow-up were collected. Univariate and multivariate logistic regression analyses were used to evaluate the risk factors associated with the long-term outcome of delayed stoma closure. RESULTS A total of 46 patients underwent an enterostomy, 19 who required emergency enterostomy and 27 with selective enterostomy. After ten years of follow-up, 35 patients underwent hematopoietic stem cell transplantation (HSCT), and 25 patients were alive after HSCT. The median timeframe between HSCT and stoma closure was 19.6 [15.9,26.2] months. Nineteen patients underwent stoma closure and had an average age of 3.9 ± 1.5 years; 6 patients were waiting for stoma closure. Based on a univariate logistic model, risk factors significantly associated with late stoma closure were age at enterostomy and age at HSCT. However, multivariate logistic regression showed no statistically significant factor associated with late stoma closure. There was no significant difference between the stoma closure group and delay closure group in the z scores of weight for age at follow up. CONCLUSIONS This study determined the long-term outcomes after enterostomy for VEOIBD with interleukin-10 signaling deficiency. The appropriate time point of enterostomy and HSCT may improve quality of life in the long term.
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Affiliation(s)
- Zifei Tang
- Department of Gastroenterology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, Minhang District, 201102, China
| | - Song Sun
- Department of Surgery, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Min Ji
- Department of Radiology, Children's Hospital of Fudan University, 201102, Shanghai, China
| | - Peng Shi
- Pediatric Clinical Research Unit, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Yuhuan Wang
- Department of Gastroenterology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, Minhang District, 201102, China
| | - Zhiheng Huang
- Department of Gastroenterology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, Minhang District, 201102, China.
| | - Ying Huang
- Department of Gastroenterology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, Minhang District, 201102, China.
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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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Xia K, Gao RY, Wu XC, Yin L, Chen CQ. Timing of individualized surgical intervention in Crohn’s disease. World J Gastrointest Surg 2022; 14:1320-1328. [PMID: 36632120 PMCID: PMC9827570 DOI: 10.4240/wjgs.v14.i12.1320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/24/2022] [Accepted: 12/01/2022] [Indexed: 12/27/2022] Open
Abstract
Crohn’s disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract with an increasing incidence worldwide. Comprehensive therapy for CD focuses on symptom control and healing the intestinal mucosa to improve the quality of life and prevent complications. Surgical intervention plays a vital role in comprehensive therapy. However, deciding the optimal timing for surgical intervention has long been a focus of controversy. This review provides insights into the timing of surgery for CD and guides clinicians in daily treatment.
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Affiliation(s)
- Kai Xia
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Ren-Yuan Gao
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Xiao-Cai Wu
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Lu Yin
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Chun-Qiu Chen
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
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Balbale SN, Schäfer WLA, Davis T, Blake SC, Close S, Perry JE, Zarate RP, Ingram MC, Strople J, Johnson JK, Holl JL, Raval MV. Age- and Sex-Specific Needs for Children Undergoing Inflammatory Bowel Disease Surgery: A Qualitative Study. J Surg Res 2022; 274:46-58. [PMID: 35121549 DOI: 10.1016/j.jss.2021.12.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 11/10/2021] [Accepted: 12/27/2021] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The use of enhanced recovery protocols (ERP) is extending to pediatric surgical populations, such as patients with inflammatory bowel diseases (IBDs). Given the variation in age- and sex-specific characteristics of pediatric IBD patients, it is important to understand the unique needs of subgroups, such as male versus female or preadolescent versus older patients, when implementing ERPs. We gathered clinician, patient, and caregiver perspectives on age- and sex-specific needs for children undergoing IBD surgery. METHODS We used semistructured interviews and focus groups to assess ERP needs and perceived differences in needs between preadolescent (10-13 y), older (14-19 y), male, and female IBD patients. Participants included clinicians, patients who had recent IBD surgery, and patients' caregivers. RESULTS Forty-eight clinicians, six patients, and eight caregivers participated. Three broad categories of themes emerged: concerns, needs, and experiences related to the (1) surgical care process; (2) continuum of IBD care; and (3) suggestions to make surgical care more patient centered. With regard to surgical care processes, stakeholders reported different communication needs for preadolescent and older children. Key themes about the continuum of IBD care were the need (1) for support from child life specialists and (b) to address young women's health issues. Suggestions to make surgical care more patient centered included providing older children with patient experiences that reflect their perspective as young adults. CONCLUSIONS The findings highlight the need to adopt a patient-centered approach for ERP use that actively addresses age- and sex-specific factors while engaging patients and caregivers as partners with clinicians to improve surgical care for children with IBD.
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Affiliation(s)
- Salva N Balbale
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Willemijn L A Schäfer
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Teaniese Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia
| | - Sarah C Blake
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Sharron Close
- Department of Pediatric Advanced Practice Nursing, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Joseph E Perry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Raul Perez Zarate
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Martha-Conley Ingram
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jennifer Strople
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Julie K Johnson
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jane L Holl
- Department of Neurology, Biological Sciences Division and Center for Healthcare Delivery Science and Innovation, University of Chicago, Chicago, Illinois
| | - Mehul V Raval
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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A baseline assessment of enhanced recovery protocol implementation at pediatric surgery practices performing inflammatory bowel disease operations. J Pediatr Surg 2020; 55:1996-2006. [PMID: 32713714 PMCID: PMC7606356 DOI: 10.1016/j.jpedsurg.2020.06.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/17/2020] [Accepted: 06/07/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Enhanced recovery protocols (ERPs) have been used to improve patient outcomes and resource utilization after surgery. These evidence-based interventions include patient education, standardized anesthesia protocols, and limited fasting, but their use among pediatric populations is lagging. We aimed to determine baseline recovery practices within pediatric surgery departments participating in an ERP implementation trial for elective inflammatory bowel disease (IBD) operations. METHODS To measure baseline ERP adherence, we administered a survey to a staff surgeon in each of the 18 participating sites. The survey assessed demographics of each department and utilization of 21 recovery elements during patient encounter phases. Mixed-methods analysis was used to evaluate predictors and barriers to ERP element implementation. RESULTS The assessment revealed an average of 6.3 ERP elements being practiced at each site. The most commonly practiced elements were using minimally invasive techniques (100%), avoiding intraabdominal drains (89%), and ileus prophylaxis (72%). The preoperative phase had the most elements with no adherence including patient education, optimizing medical comorbidities, and avoiding prolonged fasting. There was no association with number of elements utilized and total number of surgeons in the department, annual IBD surgery volume, and hospital size. Lack of buy-in from colleagues, electronic medical record adaptation, and resources for data collection and analysis were identified barriers. CONCLUSIONS Higher intervention utilization for IBD surgery was associated with elements surgeons directly control such as use of laparoscopy and avoiding drains. Elements requiring system-level changes had lower use. The study characterizes the scope of ERP utilization and the need for effective tools to improve adoption. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Mixed-methods survey.
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Denning NL, Kallis MP, Kvasnovsky CL, Lipskar AM. Outcomes of Initial Subtotal Colectomy for Pediatric Inflammatory Bowel Disease. J Surg Res 2020; 255:319-324. [PMID: 32593890 DOI: 10.1016/j.jss.2020.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/28/2020] [Accepted: 05/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Subtotal colectomy with end ileostomy (STC-I) has been well established in the adult literature as an initial surgical treatment for refractory inflammatory bowel disease (IBD)-related colitis. However, in the pediatric population, the efficacy of this approach has been less well characterized, likely because of concerns regarding the advisability of leaving a diseased rectum in situ. Our aim was to examine the outcomes after STC-I for refractory IBD at our pediatric tertiary care center. METHODS An institutional review board-approved retrospective review of patients aged 5-21 y who underwent operative treatment with initial STC-I for medically refractory IBD from January 2010 to August 2018. Only complications related to the STC-I were considered; complications subsequent to reconstruction are excluded from analysis. Early complications were defined as occurring within 60 d of STC-I. We performed descriptive statistics using the Fisher exact test and the Student t-test, as appropriate. RESULTS Over the study period, 37 patients (aged 12.3 ± 4.2 y) underwent STC-I, with 73.0% performed laparoscopically. Patients were predominately male (51.4%) and Caucasian (48.6%). Thirty-one (83.8%) colectomies were performed for ulcerative colitis, two (5.4%) for Crohn disease, and four (10.8%) for indeterminate colitis. Nutritional status improved postcolectomy. Albumin levels of 3.3 ± 0.8 preoperatively increased to 4.3 ± 0.47 postoperatively (P < 0.001). Colonic bleeding was stopped by STC-I with increases in the hematocrit from 30.5 ± 6.8 preoperative to 38.9 ± 4.1 postoperatively (P < 0.001). Average time to discontinuation of IBD-related medications was 4 wk (n = 27). Forty-eight percent required outpatient rectal treatment for proctitis. Patients did well long term, with 67.5% reestablishing intestinal continuity at our institution. Average postoperative length of stay was shorter in the laparoscopic group compared with those undergoing open operations (5.1 ± 2.2 versus 6.9 ± 1.6 d, P = 0.03). Readmission rate at 30 d was 21.1%. Patients experiencing unplanned readmission or unplanned operations were similar between groups (30% versus 33.3%, P = 0.85 and 30% versus 18.5%, P = 0.45, respectively). Overall, 14 (37.8%) patients experienced a complication with many patients experiencing multiple complications. Early complications occurred in nine (24.3%) patients. Late complications also occurred in 24.3% of patients. There were four (10.8%) patients with five admissions for bowel obstruction, two of whom required operative intervention (5.4%). CONCLUSIONS Use of STC-I as an initial procedure in the treatment of refractory IBD-related colitis in children is a safe and reasonable surgical approach that allows weaning from immunosuppressing mediations and stops colonic bleeding. Implementing a laparoscopic approach to subtotal colectomy provides further benefit by reducing postoperative length of stay.
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Affiliation(s)
- Naomi-Liza Denning
- Division of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health System, New York, New York; Department of Surgery, Zucker School of Medicine at Hofstra/Northwell Health System, Manhasset, New York
| | - Michelle P Kallis
- Division of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health System, New York, New York; Department of Surgery, Zucker School of Medicine at Hofstra/Northwell Health System, Manhasset, New York
| | - Charlotte L Kvasnovsky
- Division of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health System, New York, New York
| | - Aaron M Lipskar
- Division of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health System, New York, New York; Department of Surgery, Zucker School of Medicine at Hofstra/Northwell Health System, Manhasset, New York.
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Denning NL, Glick RD, Rich BS. Outpatient follow-up after pediatric surgery reduces emergency department visits and readmission rates. J Pediatr Surg 2020; 55:1037-1042. [PMID: 32171531 DOI: 10.1016/j.jpedsurg.2020.02.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 02/20/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE The factors affecting outpatient follow-up (OFU) after pediatric surgery have not been well studied. We evaluate factors impacting OFU and the effect of OFU in pediatric surgical patients. METHODS A retrospective review of all pediatric patients operated on by the Division of Pediatric Surgery from February 1st to September 30th, 2017, and subsequently discharged was performed. RESULTS 1242 patients were identified. Overall OFU was 69.6%. Language and distance between patient residence and the hospital had no impact on OFU. Inpatient surgical patients followed-up at a higher rate than ambulatory surgical patients (72.7% vs 64.8%, p < 0.01). Out-of-system transfers had the lowest OFU rate at 52.8% (p < 0.001). Insurance type and patient age had a significant impact on OFU rates. Thirty-day ED visit and readmission rates were significantly lower in those patients with OFU than in those without (8.8% vs 12.7%, p = 0.04 and 3.7% to 11.0%, p < 0.001, respectively). OFU was more beneficial in patients with inpatient procedures or longer hospitalization lengths of stay than in the cohort of ambulatory patients. CONCLUSIONS Socioeconomic status, hospital presentation, and procedural complexity influenced rates of OFU. OFU was associated with significant reductions in 30-day ED visits and readmissions, and this benefit was more pronounced for complex procedures or patients. TYPE OF STUDY Retrospective review. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Naomi-Liza Denning
- Cohen Children's Medical Center, Division of Pediatric Surgery, Northwell Health, 269-01 76(th) Ave, Queens, NY 11040
| | - Richard D Glick
- Cohen Children's Medical Center, Division of Pediatric Surgery, Northwell Health, 269-01 76(th) Ave, Queens, NY 11040
| | - Barrie S Rich
- Cohen Children's Medical Center, Division of Pediatric Surgery, Northwell Health, 269-01 76(th) Ave, Queens, NY 11040.
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Rhodes HL, Cusick E. Single-center review of staged restorative proctectomy for ulcerative colitis. J Pediatr Surg 2020; 55:278-281. [PMID: 31759652 DOI: 10.1016/j.jpedsurg.2019.10.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/26/2019] [Indexed: 12/22/2022]
Abstract
AIM The purpose of this study was review results of pediatric patients undergoing total colectomy and restorative surgery for ulcerative colitis (UC) in a regional pediatric surgical center. METHODS A retrospective case note analysis of consecutive patients undergoing colectomy for UC between 1995 and 2014 was performed. Early complications were defined as occurring within 30 days of surgery. Data was expressed as median (range). RESULTS Of 39 children who had colectomy (59% female), 21 J-pouch procedures (20 three-staged) were undertaken at our center at median age 13 years (6-17 years). Length of stay (LOS) after colectomy was 8 days (6-21) with five early and eight late complications. LOS after J-pouch ileo-anal anastomosis was 7 days (5-19 days) with two early and three late complications. After ileostomy closure LOS was 6 days (4-16 days) with three early and two late complications. The most frequent complication following each surgical stage was bowel obstruction. There was only one pouch loss, which was secondary to development of Crohn's disease (CD), and three other patients with J-pouches also subsequently developed CD 1.5 to 10 years after their original colectomy but retained their pouch. Bowel frequency at 1-2 years post J-pouch in 14 patients was a median of 4 per 24 h (2-7 per 24 h). CONCLUSION When all three postoperative stages were considered, two thirds of patients developed complications resulting in 15 additional visits to the operating theater. One in five patients subsequently developed CD after J-pouch. This should be carefully considered during pre-operative counseling. TYPE OF STUDY Retrospective Study. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Hannah L Rhodes
- Department of Paediatric Surgery, Bristol Royal Hospital for Children, 24 Upper Maudlin Street, Bristol, BS2 8BJ, United Kingdom; Bristol Renal, Dorothy Hodgkin Building, University of Bristol, Bristol, BS1 3NY, United Kingdom
| | - Eleri Cusick
- Department of Paediatric Surgery, Bristol Royal Hospital for Children, 24 Upper Maudlin Street, Bristol, BS2 8BJ, United Kingdom.
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Tang Z, Huang Z, Yan W, Zhang Y, Shi P, Dong K, Gong Y, Ji M, Wang Y, Yu Z, Huang Y. Complications of enterostomy and related risk factor analysis of very early onset inflammatory bowel disease with interleukin-10 signalling deficiency: a single-centre retrospective analysis. BMC Gastroenterol 2020; 20:8. [PMID: 31931724 PMCID: PMC6958732 DOI: 10.1186/s12876-020-1160-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 01/01/2020] [Indexed: 11/23/2022] Open
Abstract
Background Interleukin-10 (IL10) signalling pathway deficiency results in severe very early onset inflammatory bowel disease (VEOIBD), and enterostomy is often inevitable. However, studies in these surgical populations are lacking. This study aims to determine the enterostomy characteristics, postoperative complications and related risk factors in enterostomy patients. Methods From March 1, 2015, to December 31, 2018, patients with IL10R-mutation who underwent enterostomy were recruited for analysis. We collected data on the patients’ clinical characteristics, enterostomy characteristics, postoperative complications and related risk factors. Results Twelve patients required emergency enterostomy, and 10 patients underwent elective enterostomy. Twelve patients experienced postoperative complications, including wound infection (27.3%), wound dehiscence (18.2%), reoperation (18.2%), etc. Compared with the pre-enterostomy values, there was a decrease in C-reactive protein (CRP) (P = 0.001), an increase in albumin (P = 0.001) and an improvement in the weight-for-age (P = 0.029) and body mass index (BMI) Z-scores (P = 0.004) after enterostomy. There was a significant difference between the pre-operation and postoperation medicine expenses (P = 0.002). Univariate binary logistic regression analysis revealed a statistically significant influence of CRP (OR: 1.43, 95% CI: 1.07–1.91, P = 0.016) and a tendency towards a significant influence of intestinal perforation, albumin level, BMI Z-score and weighted paediatric Crohn’s disease activity index (wPCDAI). Multivariate logistic regression analysis showed that CRP (OR: 1.40), wPCDAI (OR: 2.88) and perforation (OR: 1.72) showed a tendency to behave as independent risk factors for postoperative complications, but the results were not significant (all P > 0.05). Conclusions Surgery and enterostomy showed benefits for VEOIBD with IL-10 signalling deficiency. The timing of intervention, potential postoperative complications, economic burden and other related problems should be considered.
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Affiliation(s)
- Zifei Tang
- Department of Gastroenterology, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, People's Republic of China
| | - Zhiheng Huang
- Department of Gastroenterology, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, People's Republic of China.
| | - Weili Yan
- Department of Clinical Epidemiology, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Yi Zhang
- Department of Clinical Epidemiology, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Peng Shi
- Department of Information, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Kuiran Dong
- Department of Surgery, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Ying Gong
- Department of Radiology, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Min Ji
- Department of Radiology, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Yuhuan Wang
- Department of Gastroenterology, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, People's Republic of China
| | - Zhuowe Yu
- Department of Gastroenterology, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, People's Republic of China
| | - Ying Huang
- Department of Gastroenterology, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, People's Republic of China.
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13
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Kao AM, Arnold MR, Prasad T, Schulman AM. The impact of abnormal BMI on surgical complications after pediatric colorectal surgery. J Pediatr Surg 2019; 54:2300-2304. [PMID: 31104834 DOI: 10.1016/j.jpedsurg.2019.04.020] [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: 11/08/2018] [Revised: 03/23/2019] [Accepted: 04/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND/PURPOSE While childhood obesity is a growing problem, the implications of BMI on elective pediatric surgery remains poorly described. This study evaluates the impact of obesity on surgical outcomes after elective colorectal procedures. METHODS Children ages 2-18 years undergoing elective colorectal surgery for IBD were identified from the NSQIP-Pediatric database. Patients were classified as underweight (UW), normal weight (NW), overweight (OW) and obese (OB) based on their age- and sex-adjusted BMI. Postoperative complications were compared between cohorts. RESULTS 858 patients (14.8% UW, 64.3% NW, 13.1% OW, 7.8% OB) were identified, with overall complications occurring in 15.3% and SSI in 10.1%. Obese/overweight patients had higher rates of deep incisional SSI (4.5%OB, 4.5%OW, 0%NW, p=0.002) and superficial wound disruption (5.4%OB, 5.8%OW, 1.6%NW, p=0.04). Incremental increase in BMI by 1.0kg/m2 was associated with 4.3% increased likelihood of developing deep incisional SSI and 2.3% increase of superficial wound disruption. Obese/overweight children also had increased incidence of septic shock and UTI, as well as longer operative times, days of mechanical ventilation and LOS. CONCLUSIONS Increasing BMI was associated with increased wound complications in IBD patients undergoing elective intestinal surgery. Preoperative optimization and weight loss strategies may potentially reduce SSI and other infectious complications. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Angela M Kao
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, MEB Suite 601, Charlotte, NC 28203.
| | - Michael R Arnold
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, MEB Suite 601, Charlotte, NC 28203
| | - Tanushree Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28204
| | - Andrew M Schulman
- Division of Pediatric Surgery, Levine Children's Hospital, 1900 Randolph Rd, #210, Charlotte, NC 28207
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