Restorative proctocolectomy with ileal pouch-anal anastomosis in very young patients with refractory ulcerative colitis

Complications following ileal pouch-anal anastomosis in pediatric ulcerative colitis

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.

Outcomes Following Pouch Formation in Paediatric Ulcerative Colitis: A Study From the Porto Group of ESPGHAN

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.

Current surgical practice in pediatric ulcerative colitis: A systematic review

BACKGROUND

Surgical management of adult ulcerative colitis (UC) is well-studied, but not readily applicable to children. Restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA), performed as one-, two-, or three-stage procedure, is preferred in pediatric patients with adequate anal sphincter function.

PURPOSE

METHODS: Systematic review of Cochrane Register of Controlled Trials, PubMed, and EMBASE databases was conducted (January 1987-December 2016), in accordance with PRISMA.

RESULTS

Twelve retrospective studies were identified (568 patients total); 31, 334, and 203 patients underwent one-, two-, and three-stage procedures, respectively. Median study size was 31 patients (range 10-202), median age was 13 years (range 2-21), median follow-up was 4 years (range 0.08-16). Postoperative complications included pouchitis, bowel obstruction, stricture, fistula, pouch failure, anastomotic leak, and wound infections. Calcineurin inhibitor usage improved pediatric ulcerative colitis activity index (PUCAI) score. Higher PUCAI scores correlated with likelihood of staged procedures. Number of stages did not restrict quality of life.

CONCLUSIONS

Paucity of data exists, comparing preoperative factors leading to staged procedures in pediatric UC. This systematic review identifies an area for future studies.

LEVEL OF EVIDENCE

II.

Short- and Long-term Outcomes After Ileal Pouch Anal Anastomosis in Pediatric Patients: A Systematic Review

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.

Complications in children with ulcerative colitis undergoing ileal pouch-anal anastomosis

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.

Sacral nerve function in child patients after ileal J-pouch-anal anastomosis for ulcerative colitis

To clarify the neurological function of the puborectalis muscle (PM) in child patients with soiling after ileal J-pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), we examined the terminal motor latency in the sacral nerves that regulate the PM. Eight patients after IPAA for UC were studied (6 males and 2 females aged 11 to 13 years with a mean age of 12.8 years). All patients 6 months after IPAA showed soiling (group A) and these patients showed continence at 2 years after IPAA (group B). Group C serving as controls consisted of 16 subjects (10 males and 6 females aged 12 to 17 years with a mean age of 14.4 years). Left- and right-sided sacral nerve terminal motor latency (SNTML) tests were performed at 6 months and 2 years after IPAA in order to measure the latency of the response in the bilateral PM following magnetic stimulation of sacral nerve root segments 2 to 4 (S2-S4) of the spinal column overlying the cauda equina. The following results were obtained. (1) Right-sided SNTML: group A exhibited significant prolongation compared with groups B and C (P < 0.0001 and P < 0.0001, respectively). There was no significant difference between groups B and C (P = 0.2329). (2) Left-sided SNTML: group A exhibited significant prolongation compared with groups B and C (P = 0.0002 and P < 0.0001, respectively). There was no significant difference between groups B and C (P = 0.2315). Note that significant differences were not established between SNTML values measured on the right and left sides. Soiling in child patients 6 months after IPAA may be caused by damage to the bilateral sacral nerves during the operation. However, the damage to the sacral motor nerve improves within 2 years after IPAA.

Minimally invasive surgery for paediatric inflammatory bowel disease: Personal experience and literature review

The incidence of paediatric inflammatory bowel disease (PIBD) has dramatically increased in the last 20 years. Although first reported in mid 1970s’, diagnostic laparoscopy has started to be routinely adopted in paediatric surgical practice since late 1990s’. Minimally invasive surgery was first limited to diagnostic purposes. After 2002 it was also applied to the radical treatment of PIBD, either Crohn’s disease (CD) or Ulcerative colitis. During the last decade minimally invasive approaches to PIBD have gained popularity and have recently became the “gold standard” for the treatment of such invalidating and troublesome chronic diseases. The authors describe and track the historical evolution of minimally invasive surgery for PIBD and address all available opportunities, including most recent advancements such as robotic surgery, single port approaches and minimally invasive treatment of perianal fistulising CD. A systematic review of all series of PIBD treated with minimally invasive approaches published so far is provided in order to determine the incidence and type of patients’ complications reported up to present days. The authors also describe their experience with minimally invasive surgery for PIBD and will report the results of 104 laparoscopic procedures performed in a series of 61 patients between January 2006 and December 2014.

The pediatric pouch in inflammatory bowel disease: a primer for the gastroenterologist

Pediatric severe ulcerative colitis that is resistant to current medical treatment can successfully be managed surgically with a colectomy, ileal pouch creation and pouch-anal anastomosis. Key issues that should be considered and discussed before the pouch option can be offered include alternative surgical procedures, pouch function expectations, risk of surgical leak, pelvic sepsis, anastomotic strictures, acute and chronic pouch inflammation, Crohn's disease of the pouch and risk of reduced fertility for females. A long-term risk is malignancy of the residual colonic tissue. The decision to proceed with a pouch or not poses a substantial emotional burden to the child and family. Despite the risk of surgical complications and pouch inflammatory and functional challenges, the overwhelming majority of children and their families are satisfied with their pouch surgery outcomes. Further study is needed to assess preoperative risk predictors, prevention and treatment of complications.

Management of pediatric ulcerative colitis: joint ECCO and ESPGHAN evidence-based consensus guidelines

BACKGROUND AND AIMS

Pediatric ulcerative colitis (UC) shares many features with adult-onset disease but there are some unique considerations; therefore, therapeutic approaches have to be adapted to these particular needs. We aimed to formulate guidelines for managing UC in children based on a systematic review (SR) of the literature and a robust consensus process. The present article is a product of a joint effort of the European Crohn's and Colitis Organization (ECCO) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).

METHODS

A group of 27 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to ESPGHAN and ECCO members. A list of 23 predefined questions were addressed by working subgroups based on a SR of the literature.

RESULTS

A total of 40 formal recommendations and 68 practice points were endorsed with a consensus rate of at least 89% regarding initial evaluation, how to monitor disease activity, the role of endoscopic evaluation, medical and surgical therapy, timing and choice of each medication, the role of combined therapy, and when to stop medications. A management flowchart, based on the Pediatric Ulcerative Colitis Activity Index (PUCAI), is presented.

CONCLUSIONS

These guidelines provide clinically useful points to guide the management of UC in children. Taken together, the recommendations offer a standardized protocol that allows effective, timely management and monitoring of the disease course, while acknowledging that each patient is unique.

Steroids and poor nutrition are associated with infectious wound complications in children undergoing first stage procedures for ulcerative colitis

BACKGROUND

Risk factors for postoperative infections have not been evaluated in pediatric patients with ulcerative colitis (UC). This review was undertaken to evaluate the effects of immunosuppressive therapy and other preoperative factors on infectious wound complications in children undergoing first stage surgical therapy for UC.

METHODS

A 10-year retrospective review of children under 18 years of age receiving first stage surgical therapy for UC at a major children's hospital was performed. Preoperative clinical and treatment variables were identified and correlated with postoperative wound complications.

RESULTS

A total of 51 children were identified: 19 underwent colectomy with ileo-anal-pouch anastomosis and 32 underwent total abdominal colectomy with Hartmann's pouch. A total of 20 infectious complications were identified in 18 patients. Preoperative steroid use was associated with a greater postoperative wound infection rate. Preoperative hemoglobin less than 10 g/dL (P < .05) and albumin less than 3 g/dL (P = 0.1) were associated with greater rates of postoperative infection. Preoperative body mass index and other immunosuppressive agents did not influence postoperative infectious morbidity.

CONCLUSIONS

The majority of pediatric patients who require operative intervention for UC are debilitated from their disease and medication use. Children with normal serum albumin and hemoglobin who are not on steroid therapy have a low risk of postoperative infectious complications.

Surgical complications in relation to functional outcomes after ileoanal anastomosis in pediatric patients with ulcerative colitis

BACKGROUND

Significant surgical complications are common in patients with ulcerative colitis who undergo proctocolectomy. We assessed the effects of these complications on the functional outcomes of such patients.

MATERIALS AND METHODS

The medical records of 47 consecutive patients who underwent ileoanal anastomosis (IAA; J-pouch IAA, n = 37; straight IAA [SIAA], n = 10) for ulcerative colitis between 1985 and 2004 at a median age of 13.7 years (range, 5.5-19.3 years) were reviewed. Anastomotic leakage and stenosis, fistula, intestinal obstruction (IO), wound complications, pouchitis/enterocolitis (no/once/recurrent), permanent ileostomy, and ultimate diagnosis of Crohn's disease were recorded and correlated with the functional outcome measures of stooling frequency (6 months, 2 years, present), present incidence of soiling, and continence score (range, 0-12).

RESULTS

The median postoperative follow-up period was 10 years (range, 1-21 years). Twenty-six (55%) of the 47 patients had surgical complications (J-pouch IAA, 21/37 [57%]; SIAA, 5/10 [50%]; P = nonsignificant). These complications specifically included stenosis of IAA in 4 (9%) patients (SIAA 2), pelvic abscess/sepsis in 4 (9%) patients, late fistula in 4 (9%) patients (SIAA 1), early IO in 8 (23%) patients (SIAA 1), late IO in 14 (27%) patients (SIAA 3), J-pouch prolapse in 1 patient, and wound complications in 7 (15%) patients (SIAA 1). Twenty-three (49%) patients had pouchitis, which recurred in 13 (28%). Ileoanal anastomosis stenosis, IO, J-pouch prolapse, wound complications, and pouchitis did not worsen functional outcomes. In 4 patients with pelvic sepsis, early stooling frequency and the continence score were lower than those in the rest of the patients (P < .05). Crohn's disease was ultimately diagnosed in 3 (6%) patients (SIAA 1), 2 of whom (SIAA 1) had permanent ileostomy formation.

CONCLUSIONS

Significant surgical complications are common after IAA. Complications do not generally worsen functional outcomes, except in those patients with septic complications or the ultimate diagnosis of Crohn's disease.

Restorative Proctocolectomy for Pediatric Patients with Ulcerative Colitis

PURPOSE

A restorative proctocolectomy has become an elective surgical treatment for patients with ulcerative colitis (UC). In children with UC, however, the role of this procedure has not yet been well evaluated. We investigated the postoperative status of pediatric patients with UC regarding the side effects of steroids, postoperative complications, and growth.

METHODS

The medical records of 15 patients with UC who underwent a restorative proctocolectomy between August 1993 and October 2003 were retrospectively reviewed.

RESULTS

Their mean age was 12.6 +/- 3.4 years (range 5.7-15.7; boys: 9, girls: 6). All patients had total colitis, except for one who had left-sided colitis. The mean cumulative dose of preoperative prednisolone was 6201 +/- 7980 mg (mean +/- SD). The operative indications were an unsuccessful response to medical treatments in 12 patients (80%) and severe colitis in 3 patients (20%). Surgery was performed in one stage in 6 patients and in two stages in 9 patients. Seven patients (47%) demonstrated growth retardation at the time of operation. Steroid-related complications were seen in 3 cases, i.e., steroid myopathy, glaucoma, and cataracts, respectively. As early postoperative complications, an intestinal obstruction was seen in 2 patients, peritonitis in 1, and pancreatitis in 1. As late complications, anastomotic stenosis was observed in 5 patients, pouchitis in 4, residual proctitis in 3, and anal or proctovaginal fistula in 2. An intestinal obstruction, peristomal pyoderma gangrenosum, and dehydration each was seen in 1 patient. A growth "catch-up" was obtained for all but one patient. All patients became free of corticosteroids.

CONCLUSION

A restorative proctocolectomy was found to be an effective treatment alternative even in children with UC when conservative therapy proves to be ineffective.

Stapled restorative proctocolectomy in children with refractory ulcerative colitis

OBJECTIVE

The aim of this study was to review the results after stapled restorative proctocolectomy among children with refractory ulcerative colitis.

PATIENTS AND METHODS

Clinical records of 16 consecutive children with refractory ulcerative pancolitis undergoing colectomy and stapled straight ileoanal anastomosis at a median age of 8.3 years (range, 3.1-14.9 years) were reviewed. Periodical clinical examinations and endoscopies with biopsies above (terminal ileum) and below (columnar cuff) the anastomosis were carried out during follow-up. Median follow-up after bowel restoration lasted 5.3 years (range, 1.2-9.6 years).

RESULTS

Two major complications occurred (12.5%), 1 episode of sepsis treated conservatively and 1 bowel perforation proximal to the anastomosis treated with a temporary diverting ileostomy. All the anastomoses were functional at the end of the study. The columnar cuff averaged 2.6 cm in length and presented signs of persistent inflammation (cuffitis) in 94% of children. Inflammation responded poorly to any medical treatment but was symptomatic in 1 case only. Ileal inflammation was detected endoscopically in 31% of patients and histologically in 62.5%. No case of dysplasia or cancer was recorded. At final follow-up, children had an average of 7.1 +/- 3.1 bowel movements per day; full daytime and nighttime continence were achieved in 87.5% and 62.5% of cases, respectively. A severe inflammation of the columnar cuff was associated with an increased risk of nighttime incontinence.

CONCLUSIONS

Stapled ileoanal anastomosis in children with pancolitis is associated with low morbidity. Refractory cuffitis persists in almost all patients but is mostly asymptomatic, although it could be associated with nighttime incontinence.

J-pouch ileoanal anastomosis in children and adolescents with ulcerative colitis: functional outcome, satisfaction and impact on social life

OBJECTIVES

The aim of this study was to evaluate, over a 10-year period, severe surgical complications, functional outcome, patient satisfaction and impact on social life after colectomy and J-pouch ileoanal anastomosis for children and adolescents <18 years with ulcerative colitis.

METHODS

Data were extracted retrospectively from medical records and obtained by mailed questionnaire.

RESULTS

Thirty patients (18 girls) with a median age of 15 years (range, 7-17 years) were identified. Two patients (7%) had the J-pouch removed because of intractable diarrhea. Twenty-seven of 28 patients with preserved J-pouch answered the questionnaire. The median follow-up was 3.7 years (range, 0.3-9.2 years). Surgical complications included eight of 30 patients (27%) with small bowel obstruction, one of 30 (4%) with intra-abdominal abscess and two of 30 (7%) with perforation of the small intestine. The median number of daytime bowel movements was six (range, 3-10) and the median number of nighttime bowel movements was one (range, 0-2). Twelve patients (44%) were completely continent for stool and mucus, 12 patients (44%) leaked now and then and three (12%) leaked often or always. Antibiotic treatment for pouchitis was given in 13 patients (48%). Seventeen patients (63%) were completely satisfied with the operation, nine patients (33%) found the result fairly good and one patient (4%) was not satisfied. Twenty-six patients (96%) reported their health as completely or fairly good.

CONCLUSIONS

The majority of patients with an intact J-pouch had an acceptable functional result with respect to defecation frequency, continence and number of pouchitis episodes. Most patients reported being satisfied with the procedure.

The effect of ageing on function and quality of life in ileal pouch patients: a single cohort experience of 409 patients with chronic ulcerative colitis

OBJECTIVE

To evaluate in what manner ageing affects functional outcome and quality of life (QoL) in patients with chronic ulcerative colitis (CUC) after ileal pouch-anal anastomosis (IPAA).

SUMMARY BACKGROUND DATA

Short-term function and QoL after IPAA is good. However, patients are usually young, and little is known about the influence of time and ageing on long-term outcomes after IPAA.

METHODS

Using a standardized questionnaire, functional outcome, QoL, and complications were assessed prospectively in a cohort of 409 patients followed annually for 15 years after IPAA.

RESULTS

Follow-up was complete in the single cohort of 409 patients and functional and QoL outcomes summarized at 5, 10, and 15 years. Daytime stool frequency changed little (mean 6), while nighttime frequency increased from 1 stool to 2 stools. Incontinence for gas and stool increased from 1% to 10% during the day and from 2% to 24% at night over 15 years. The cumulative probability of pouchitis increased from 28% at 5 years to 38% at 10 years and to 47% at 15 years. Bowel obstruction and stricture were other principal long-term complications. At 15 years, 91% of patients had kept the same job. Work was not affected by the surgery in 83%, while social activities, sports, traveling, and sexual life all improved after surgery and did not deteriorate over time.

CONCLUSIONS

These long-term results in a single cohort of 409 IPAA patients are unique and are likely a more accurate reflection of long-term outcome than has been previously reported. These data support the conclusion that IPAA is a durable operation for patients requiring proctocolectomy for CUC; functional and QoL outcomes are good, predictable, and stable for 15 years after operation.

Pediatric inflammatory bowel disease

PURPOSE OF THIS REVIEW

The prevalence of early-onset inflammatory bowel disease has been on the rise, with children and adolescents currently accounting for approximately 30% of all patients with this condition. Remarkable new advances in diagnostic modalities and therapy for adults with inflammatory bowel disease, and further information about the role of genetics in determining susceptibility to disease make the review of the recent literature in pediatric inflammatory bowel disease more timely than ever.

RECENT FINDINGS

In the area of genetics, new studies provide strong evidence for genetic susceptibility to disease, and match genotype with phenotypic presentation. A few studies examine the use of noninvasive diagnostic modalities, such as MRI, and biomarkers (fecal lactoferrin) in pediatric inflammatory bowel disease. Remarkable new agents in therapy for adults with inflammatory bowel disease have been empirically administered to children with inflammatory bowel disease. The first attempts to systematically study the effects of these agents in children and adolescents are reviewed here. Furthermore, new studies revise our notion of surgical outcomes in pediatric inflammatory bowel disease.

SUMMARY

Although premature for clinical practice application, the role of genetic testing in determining disease susceptibility and assisting with prognosis and course of therapy is clearly evolving and needs further study. As new therapeutic agents join the available treatments of inflammatory bowel disease it is imperative to include pediatric patients in clinical trials. The goals of future studies will be to alter the natural history of early-onset inflammatory bowel disease, reduce the frequency of recurrences, and perhaps reduce requirements for surgical intervention.

Current therapy of ulcerative colitis in children

Ulcerative colitis presents in childhood in 10% of those affected, usually with pancolitis. Important features in management include growth, development and avoidance of treatment toxicity. This review addresses the current treatment options including both the paediatric evidence-based experience and areas where paediatric practice is informed by adult studies. Standard treatments include sulfasalazine or 5-aminosalicylates, corticosteroids, purine derivatives (azathioprine or 6-mercaptopurine) and surgery. Other immunosuppressant therapies and the emerging roles for biological therapies and probiotics are discussed.

Sacral nerve terminal motor latency after ileal J pouch-anal anastomosis for ulcerative colitis

Using a new transcutaneous magnetic stimulation technique, sacral nerve terminal motor latencies (SNTML) were measured after ileal J pouch-anal anastomosis in eight patients with ulcerative colitis, and the results were compared with those obtained from 15 normal subjects. The conduction delay of the SNTML in patients with soiling was significantly longer than that of the continent group as well as that of normal subjects (P < 0.01). There were no significant differences in the conduction delay between the continent group and the control subjects. These findings therefore support the hypothesis that such soiling, which is sometimes seen after ileal J pouch-anal anastomosis, is partly due to damage to the sacral nerves.