Pediatric ileal pouch-anal anastomosis: functional outcomes and quality of life

Diagnosis and Treatment of Pouch Disorders in Children: A Systematic Review

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 .

Functional outcomes, quality of life, sexual function, and fertility of adult patients undergoing ileo-anal pouch anastomosis in childhood

BACKGROUND

We conducted a questionnaire-based study of pouch function, quality of life, sexual function, and fertility among patients who had undergone ileal pouch anal anastomosis (IPAA) in childhood and who are now more than 18 years old.

METHODS

A consecutive series of patients were asked to complete the following questionnaires: Pouch function score (PFS), short form 36 (SF-36), International index of erectile function (IIEF) (males), and Female sexual function index (FSFI) (females). Fertility in females was also assessed. Data are quoted as a median (SD).

RESULTS

Of 144 patients who had IPAA, 101 were eligible, and 70 responded. Mean age at surgery was 14 years, and mean current age is 26 years. Most patients had either ulcerative colitis or familial adenomatous polyposis. The questionnaire was completed by 38/70 (54%). Median PFS score was 6 (5). SF-36 were lower than previous reports. Median FSFI was 30 (7.6), 84% of possible maximum. Median IIEF was 69, 92% of possible maximum. Successful conception was reported in 5/7 women who had tried. However, there were several miscarriages and two surgical emergencies during pregnancies.

CONCLUSIONS

IPAA can be performed in childhood with similar pouch function to reported adult series. Quality of life appears poorer, but sexual function is maintained. There may be an association with adverse events in pregnancy.

LEVEL OF EVIDENCE

IV.

Early ileal pouch anal anastomosis for ulcerative colitis in children: Similar outcome to delayed pouch construction despite higher comorbidity

BACKGROUND

Children with ulcerative colitis (UC) may undergo a staged approach for restorative proctocolectomy and ileal pouch anal anastomosis (IPAA). Previous studies in adults suggest a decreased morbidity with delayed pouch creation, but pediatric studies are limited. We compared outcomes for delayed versus early pouch construction in children.

METHODS

Patients with UC undergoing IPAA were selected from the National Surgical Quality Improvement Program Pediatric database from 2012 to 2018. Patients were categorized as early (2-stage) or delayed (3-stage) pouch construction based on Current Procedural Terminology codes. Our primary outcome was any adverse event. We used a multivariable logistic regression model to assess the relationship between timing of pouch creation and adverse events.

RESULTS

We identified 371 children who underwent IPAA: 157 (42.3%) had early pouch creation and 214 (57.6%) had a delayed pouch. Those with an early pouch creation were more likely to have exposure to immunosuppressants (11% vs. 5%, p = 0.017) and steroids (30% vs. 10%, p < 0.001) at the time of surgery. After controlling for patient characteristics, there were no significant differences in adverse events between the two groups.

CONCLUSIONS

Children undergoing early pouch creation have increased exposure to steroids and immune suppressants; nevertheless, no differences in adverse events were identified.

LEVEL OF EVIDENCE

II.

Fertility and Sexual Function in Women Following Pediatric Ileal Pouch-Anal Anastomosis

PURPOSE

Ileal Pouch-Anal Anastomosis (IPAA) is the standard of care for children requiring surgical treatment of severe colitis or polyposis syndromes. This study aims is to investigate the sexual function and fertility in women after undergoing childhood IPAA.

METHODS

A prospectively maintained colon and rectal database of consenting patients was queried from January 1980 to October 2015. We included all females that replied to at least 1 survey between the ages of 20 and 45 years that had undergone IPAA younger than 20 years of age.

RESULTS

Two hundred females met inclusion criteria, whereas 149 women replied to the sexual function questions. Ulcerative colitis was diagnosed in 122 (83%) patients, with the remainder having polyposis. Seven patients had a laparoscopic proctectomy. Only 2 patients had a pelvic infection, whereas 21 had intestinal obstruction postoperatively. A severely restricted sex life was reported in 6 (5%) patients. Of the 93 (62%) women who attempted pregnancy, 68 (73%) became pregnant. Median age of pregnancy and IPAA was 34 (range 22-45) and 17 years (range 9-20), respectively. Medical intervention to assist fertilization was required in 14/68. A total of 29 women reported problems during pregnancy with 58/68 (88%) giving birth to a live baby. Elective termination was reported in 2/68 surveys. Vaginal delivery occurred in 26/58 mothers with 27/58 planned and 9/58 unplanned cesarean sections. Age at IPAA, diagnosis, procedure type, pelvic infection, and obstruction were not associated with decreased fertility. All 7 patients operated laparoscopically have become pregnant. Change in pouch function after delivery was reported in 20/68 (32%, 5 missing) surveys.

CONCLUSIONS

73% of women who desired children become pregnant, and 88% had a successful delivery after pediatric IPAA. Only 5% reported severely restricted sexual function. Changes in pouch function occurred with pregnancy and persisted in 1/3 after delivery. Minimally invasive techniques may improve fertility rates but equire continued follow-up.

LEVEL OF EVIDENCE

Level IV.

TYPE OF STUDY

Observational study.

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.

Current Approaches to Pediatric Polyposis Syndromes

Colorectal adenomatous polyposis syndromes encompass a diverse group of disorders with varying modes of inheritance and penetrance. Children may present with overt disease or within screening programs for families at high risk. We provide an overview of the array of pediatric polyposis syndromes, current screening recommendations, and surgical indications and technical considerations. Optimal disease management for these pediatric patients is still evolving and has implications for screening, surveillance, pediatric surgical management, and transition of care gastroenterologic neoplasia physicians and surgeons.

Surgical options in the treatment of ulcerative colitis

Children and young adults with ulcerative colitis tend to present with more extensive colonic disease than an adult population. The need for surgical intervention in the pediatric population with ulcerative colitis occurs earlier after diagnosis and has a greater incidence than a comparably matched adult population with an estimated need for colectomy at 5 years following diagnosis of 14-20%. Perhaps, even more than the adult population, there is a desire to restore intestinal continuity for the pediatric patient to achieve as healthy and normal quality of life as possible. With surgery playing such a prominent role in the treatment of ulcerative colitis in this age group, an understanding of the surgical treatment options that are available is important. The surgeon's awareness of the complexities of the different operations associated with proctocolectomy and reestablishing intestinal continuity may help to avoid early complications and minimize the risk of less than ideal long-term outcomes.

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.

Surgical outcomes, bowel habits and quality of life in young patients after ileoanal anastomosis for ulcerative colitis

PURPOSE

We aim to investigate the postoperative outcomes, bowel habits and quality of life (QoL) of younger pediatric ulcerative colitis (UC) patients following surgical intervention compared to an older pediatric population.

METHODS

Medical records of UC patients after colectomy with ileoanal reconstruction (2002-2013) at our institution were reviewed. Patients/parents completed a QoL, bowel habits and disease course questionnaire. Surgical outcomes, bowel habits and QoL were reported comparing the younger (≤11years old, n=26) to older (>11years old, n=38) cohorts.

RESULTS

The mean age at colectomy was 7.04±0.63years vs 14.71±0.32years in the two groups. Patients had a significant (P<0.001) reduction in stooling frequency after surgery in both age groups and had favorable rates of fecal continence. The frequency of pouchitis and postoperative small bowel obstruction was similar in both cohorts. Dehydration was slightly increased in the younger population but not significant. Anastomotic leak and stricture rates were slightly reduced in younger patients. Postoperative QoL was favorable and similar regardless of age at surgery.

CONCLUSIONS

Colectomy with ileoanal anastomosis for young children (≤11years old) with UC is without increased complications relative to older patients and maintains a postoperative QoL and stool patterns.

Long-term follow up of ileal pouch anal anastomosis in a large cohort of pediatric and young adult patients with ulcerative colitis

AIM

The study's aim is to determine long-term outcomes in a large cohort of pediatric and young adult patients who underwent proctocolectomy with ileal pouch anal anastomsis (IPAA) for ulcerative colitis (UC).

METHODS

Patients diagnosed with UC in childhood or adolescence (age≤21years) who underwent IPAA in childhood, adolescence, or young adulthood between 1982 and 1997 were contacted to determine pouch history, complications, and quality of life.

RESULTS

Data were obtained from 74 patients out of a previously reported cohort. Median age at diagnosis of UC was 15years and at surgery was 18years. Median follow-up was 20years. Complications during follow-up were pouchitis (45%), strictures (16%), fistulae (30%), obstruction (20%), and change of diagnosis to Crohn's (28%). Twenty-three percent reported no complications. Fourteen percent had pouch failure, with Crohn's and fistulae reported to be the most frequent complications. Seventy-nine percent reported being very satisfied at 20years follow-up.

CONCLUSION

To our knowledge, this study represents the largest cohort with the longest follow-up of pediatric and young adult patients undergoing IPAA for UC. Change in diagnosis to Crohn's and development of fistulae are risk factors for pouch failure. Despite reported complications, IPAA remains an excellent option for pediatric patients with UC.

Fecal calprotectin: its scope and utility in the management of inflammatory bowel disease

Gastrointestinal symptoms such as abdominal pain, dyspepsia, and diarrhea are relatively nonspecific and a common cause for seeking medical attention. To date, it is challenging for physicians to differentiate between functional and organic gastrointestinal conditions and it involves the use of serological and endoscopic techniques. Therefore, a simple, noninvasive, inexpensive, and effective test would be of utmost importance in clinical practice. Fecal calprotectin (FC) is considered to be a reliable biomarker that fulfills these criteria. FC can detect intestinal inflammation, and its level correlates well with macroscopic and histological inflammation as detected by colonoscopy and biopsies, respectively. FC has a decent diagnostic accuracy for differentiating organic diseases and functional disorders because of its excellent negative predictive value in ruling out inflammatory bowel disease (IBD) in symptomatic undiagnosed patients. There is accumulating evidence that FC has been effectively used to monitor the natural course of IBD, to predict relapse, and to see the response to treatment. This novel biomarker has the ability to assess mucosal healing (MH), which is a therapeutic goal in IBD management. A literature search was carried out using PubMed with the keywords FC, IBD, intestinal inflammation, and MH. In our review, we provide an overview of the utility and scope of FC as a biomarker in patients with IBD as well as undiagnosed patients with lower gastrointestinal symptoms.

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.

Long-term outcomes of ileal pouch-anal anastomosis for pediatric chronic ulcerative colitis

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients with chronic ulcerative colitis (CUC). In the pediatric population, short-term outcomes of IPAA are excellent but long-term data limited. The purpose of this study is to report long-term functional and quality of life outcomes of IPAA in pediatric patients.

METHODS

Functional outcomes and quality of life (QoL) following IPAA in patients ≤ 18 years of age were prospectively assessed by survey over a 30 year period. Preoperative information, chronic pouchitis and pouch loss were retrospectively reviewed.

RESULTS

Over 30 years, 202 children with CUC underwent IPAA. Questionnaires were returned by 87% and median (range) survey follow-up was 181.5 (7.8-378.5) months. Postoperative day and night-time stool frequency did not increase over time though incontinence increased slightly. Quality of life (QoL) was generally excellent and stable over time. Crohn's disease (CD) was diagnosed in 33 (16%) patients during the follow-up period. Chronic pouchitis occurred in 22 patients and pouch failure in 13 patients. Kaplan Meier estimates of pouch survival at 20 years were 61% for patients with CD and 92% for CUC.

CONCLUSIONS

Ileal pouch-anal anastomosis has long-term durability as a cure for pediatric chronic ulcerative colitis, with most patients reporting stable bowel function and QoL. Chronic pouchitis and pouch failure affect a minority of patients and require further study.

Neurological function of the puborectalis muscle in patients with or without soiling after ileal J-pouch-anal anastomosis for ulcerative colitis in childhood

BACKGROUND

To clarify the puborectalis muscle (PM) function in pediatric patients with soiling after ileal J-pouch-anal anastomosis (IPAA) for ulcerative colitis, the author examined the neurological functions of the PM.

METHODS

Twelve patients 3 months after IPAA were studied (average age 13.6 years). Five patients showed soiling every day (group A1) and 7 patients showed soiling 2 to 3 days per week (Group A2). All patients 1.5 years after IPAA showed continence (group B). Twenty subjects served as a control (Group C; average age 13.5 years). Right, left and posterior sides of the sacral nerve terminal motor latency (SNTML) were measured by magnetic stimulation.

RESULTS

On the right, left and posterior sides, patients in group A1 exhibited significant prolongation of the SNTML compared with patients in groups A2, B and C (P<.05 each). Group A2 exhibited significant prolongation compared with groups B and C (P<.05 each). There were no significant differences of the SNTML between right and left sides, between right and posterior sides and between left and posterior sides in groups A1, A2, B and C.

CONCLUSIONS

The SNTML of the PM demonstrates significant latency in those children who have early post-IPAA soilage. The neurological function of the PM potentially injured during an operation may recover, and correlates with normalization of continence.

The analysis of factors associated with progression of isolated terminal ileal lesions

Objective

To assess the factors associated with the progression of isolated terminal ileal lesions (ITILs) at colonoscopy in Chinese patients.

Methods

Patients diagnosed with ITILs were enrolled. The ileoscopy was performed by two experienced gastroenterologists every 52 weeks. A logistic regression analysis was used to elucidate the factors associated with Crohn's disease (CD) and mucosal healing. A log rank test was used to assess the differences of the cumulative proportion of CD and mucosal healing in different groups at different times.

Results

(1) A total of 34 patients were included and no patient had taken nonsteroidal anti-inflammatory drug in the last 6 months; eight (23.5%) patients had a clinical diagnosis of CD, 14 (41.2%) patients achieved mucosal healing, and 12 (35.3%) patients showed no significant changes in the lesions at last follow-up. (2) The logistic regression analysis showed that only abdominal pain was a factor in the ITIL disease outcomes. (3) The cumulative proportion of CD in the abdominal pain group after 3 years was statistically higher than that in the non-abdominal pain group (42.7% vs. 6.2%, χ² = 10.129, P = 0.001). However, the cumulative proportion of mucosal healing in the non-abdominal pain group was statistically higher than that in the abdominal pain group (73.3% vs. 5.6%, χ² = 5.225, P = 0.022). (4) The numbers of lesions observed on the initial colonoscopy exams and the initial histologic findings were not related to the ITIL disease outcomes.

Conclusions

Clinical symptoms may be related to ITIL disease outcomes. Patients with abdominal pain had a high likelihood of CD, whereas those without abdominal pain had a high likelihood of mucosal healing.

Predictive value of the Pediatric Ulcerative Colitis Activity Index in the surgical management of ulcerative colitis

PURPOSE

The primary purpose of this study was to investigate the relationship between Pediatric Ulcerative Colitis Activity Index (PUCAI) and operative management. We also specifically evaluated those patients receiving tacrolimus for their disease.

METHODS

A retrospective review (1/06-1/11) identified ulcerative colitis patients (≤21 years old) undergoing restorative proctocolectomy with rectal mucosectomy and ileal pouch-anal anastomosis. Main outcomes included pre-operative PUCAI, combined versus staged procedure, and postoperative complications. Patients receiving tacrolimus within 3 months of surgical intervention were identified. PUCAI at tacrolimus induction and medication side effects were also noted.

RESULTS

Sixty patients were identified. Forty-two (70%) underwent combined and 18 (30%) had staged procedures. Pre-operative PUCAI was lower for combined versus staged patients (p = < 0.001). Furthermore, a higher pre-operative PUCAI strongly correlated with the likelihood of undergoing a staged procedure (p < 0.001). Forty-four patients (73%) received tacrolimus. Significant improvement in their PUCAI was noted from induction to pre-operative evaluation (p < 0.001). Minor and reversible side effects occurred in 46% of patients receiving tacrolimus, but complication rates were not significantly different.

CONCLUSIONS

There is a very strong correlation between the PUCAI and the likelihood of undergoing a staged procedure. A significant improvement in PUCAI occurs following preoperative tacrolimus therapy.

Self-reported assessment of health-related quality of life in children who underwent restorative proctocolectomy with ileal J-pouch anal anastomosis for ulcerative colitis

PURPOSE

To clarify health-related quality of life (HRQOL) by self-evaluation after restorative proctocolectomy with ileal J-pouch anal anastomosis (IPAA) in children with ulcerative colitis, a questionnaire using the Pediatric Quality of Life Inventory™ 4.0 (PedsQL) was administered.

METHODS

The PedsQL was administered to 13 consecutive children (mean age 14.5 years) who underwent IPAA between 2005 and 2010 in our hospital and age-matched healthy controls. The mean duration after IPAA was 2.5 years (range 0.08-6 years) at the time of this study. Healthy children completed the same questionnaire by retrospective imaging during the past 1 month by the PedsQL evaluation policy.

RESULTS

Patients' total score and each functioning score after IPAA reached the same levels as those in healthy controls. Soiling, pouchitis occurrence, and bowel movements had no significant relationship to the PedsQL total score and each functioning score.

CONCLUSIONS

Interference of physical activity, emotional status, and social life caused by refractory ulcerative colitis (UC) worsens patients' HRQOL. IPAA could resolve these problems in children with UC and result in an HRQOL comparable with that in healthy children.

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.

Long-term functional and quality-of-life outcomes after IPAA in children

BACKGROUND

The impact of IPAA on long-term outcomes in adults is favorable. Studies on functional outcome and quality of life in children are sparse.

OBJECTIVE

The aim of this study was to evaluate the functional and quality-of-life outcomes after IPAA in children and to investigate the possible correlations between the two.

DESIGN

Standardized validated questionnaires of bowel/psychosocial functioning and quality of life were used to assess outcome.

SETTING

This study was conducted at a tertiary medical center.

PATIENTS

All children who had surgery at <18 years of age and were followed up at our institute were included. Global Assessment of Function Scale questionnaires were used to evaluate functional outcome. Quality of life in patients >18 years at the time of follow-up was scored by using the Short Form 36 questionnaire completed by the patients. Quality of life in the younger patients at the time of follow-up was scored using the Child Health Questionarie-28 filled by the parents.

RESULTS

Data were obtained in 26 patients (25 with a preoperative diagnosis of ulcerative colitis) at a median follow-up of 6 years. The median age at surgery was 15 years. Quality of life was comparable to the general population for children >18 at the time of follow-up in 7 of 8 items, but was lower than in the general population in 7 of 12 items for those who were younger at the time of follow-up. The mean functional score was found to be negatively correlated to all 8 Short Form 36 parameters (r > 0.5; p < 0.005), but only to one of the Child Health Questionarie-28 parameters.

LIMITATIONS

This study was limited by its small sample size.

CONCLUSIONS

The functional outcomes among pediatric patients undergoing IPAA are good. Parents' perception of their child's quality of life is poorer in comparison with the perception by patients themselves when older and with no correlation to the functional results.

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.

Long-term results after restorative proctocolectomy with ileal pouch-anal anastomosis at a young age

BACKGROUND

Restorative proctocolectomy with IPAA is an optimal surgical treatment for patients with familial adenomatous polyposis and therapy resistant ulcerative colitis, few data are available on long-term results in patients who have undergone this operation at a young age.

OBJECTIVE

The aim of this study was to investigate long-term functional outcome, quality of life, body image, and sexual function after restorative proctocolectomy with IPAA in young patients with familial adenomatous polyposis or ulcerative colitis.

DESIGN, SETTINGS, AND PATIENTS

The study consisted of a retrospective review of medical records and questionnaire follow-up of 26 consecutive patients with familial adenomatous polyposis or ulcerative colitis who had undergone surgery between January 1992 and October 2008 at the Maastricht University Medical Center, were aged 10 to 24 years at the time of surgery, and had at least 1 year of follow-up after surgery.

MAIN OUTCOME MEASURES

We reviewed medical records from an institutional database regarding surgical procedures and short- and long-term complications. At the end of 2009, validated questionnaires covering bowel function (Colorectal Functional Outcome Questionnaire), quality of life (Short Form-36 and Gastrointestinal Quality of Life Index), body image and cosmesis (Body Image Questionnaire), and sexual function (International Index of Erectile Function for men and Female Sexual Function Index for women) were mailed to patients.

RESULTS

Median age at surgery was 18 years, and median follow-up was 12.5 (range, 2-18) years. Long-term colorectal complications occurred in 23 patients (88%), and were directly related to the surgery in 20 patients (77%). Five patients needed pouch excision. The questionnaire response rate was 88%. Bowel function, quality-of-life, and body image and cosmesis scores were all lower in patients than in historical normal control populations. Men did not report impotence or retrograde ejaculation, but 50% of women reported sexual dysfunction.

LIMITATIONS

This was a retrospective study in a small number of patients from a single institution with no comparison groups.

CONCLUSIONS

Restorative proctocolectomy with IPAA can be performed in young patients with an acceptable functional outcome, but at the cost of relatively high complication rates, poor body image and cosmesis, and a high rate of sexual dysfunction in women. Because young patients undergoing this surgical procedure may experience negative long-term effects, surgeons should be aware of all potential consequences, inform patients as to what to expect, and ensure long-term follow-up to deal with long-term complications.

Pediatric chronic ulcerative colitis: does infliximab increase post-ileal pouch anal anastomosis complications?

BACKGROUND

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) is a common surgical approach to chronic ulcerative colitis (CUC). Preoperative use of Infliximab (IFX) has raised concern of increased postoperative complications. We sought to compare outcomes of pediatric patients (≤ 18 years) who were treated with IFX before IPAA to those who did not.

METHODS

Patients (≤ 18 years of age) who underwent IPAA from 2003 to 2008 for CUC were included, and their records were retrospectively reviewed for preoperative medications, operative technique, and 1-year postoperative complications (leak, wound infection, small bowel obstruction, pouchitis). Subjects were divided into 2 groups--those who received IFX preoperatively and those who did not.

RESULTS

Eleven patients received IFX preoperatively, and 27 children did not. All complications following IPAA were more frequent in the IFX group compared to controls (55% vs 26%). Small bowel obstruction was significantly higher in the IFX group (55% vs 7%). Long-term complications occurred in 64% of the IFX group and 61% of the controls.

CONCLUSION

Children that were treated with IFX prior to IPAA suffered twice as many postoperative complications. Long-term outcomes are similar. Currently, we recommend colectomy with end ileostomy for patients that receive IFX within 8 weeks of colectomy for CUC.

Single-incision laparoscopic colon and rectal surgery for pediatric inflammatory bowel disease and polyposis syndromes

BACKGROUND

Minimally invasive procedures for inflammatory bowel disease have been shown to improve recovery in children. We report our initial experience with single-incision laparoscopic operations for pediatric intestinal disease.

METHODS

We retrospectively reviewed 12 procedures in 11 patients (4 women) from March 2010 to January 2011. Procedures were conducted by using standard laparoscopic instruments.

RESULTS

Mean age was 15 years (9-17 years). Procedures included three total abdominal colectomies, four two-stage ileal-pouch anal anastomosis (IPAA), two single-stage IPAA, two three-stage IPAA, and one ileocectomy. An accessory umbilical port was used in 6 cases. Mean operating time was 287 minutes. Mean length of stay was 4.1 days (3-9 days). Postoperative complications have occurred in 5 patients (42%). Anastomotic leak occurred in 2 patients with IPAA without protective ileostomy, 1 operative small bowel obstruction, 1 pelvic abscess and portal vein thrombosis, and 1 readmission for dehydration. Both patients who had leaked have recovered well and had their stomas reversed. Mean follow-up is 190 days. Average number of daily bowel movements is 4.5. Pouchitis has occurred in 50% (4/8) of patients.

CONCLUSIONS

Single-incision laparoscopic surgery for pediatric intestinal disease is safe and feasible by using standard laparoscopic instruments. We do not advocate IPAA without a stoma due to the high rate of anastomotic leak. Continued experience will shorten operative times and reduce complications.

Treating teens: considerations when adolescents want to use complementary and alternative medicine

In this article we examine decision-making about complementary and alternative medicine use when the patient is an adolescent. A case scenario describes patient-parent conflict when a 14-year-old boy who was diagnosed with ulcerative colitis that has continued to progress even with medication refuses recommended surgery despite his physician's and parents' support for that option; he prefers homeopathy instead. We address (1) who has decision-making authority about treatment for young people, (2) how to determine if a young person can consent to or refuse treatment, (3) special considerations when counseling and treating adolescents (whether they can decide about treatment for themselves), and (4) parent-child conflicts about treatment. In addition, we suggest ways that health care providers can foster a trusting relationship with patients and parents.

Surgical treatment of chronic inflammatory bowel disease in children

Surgery for chronic inflammatory bowel disease (IBD) is increasingly often necessary in children. This study aimed at assessing the results of these operations in order to facilitate adequate preoperative counseling. We reviewed patients treated from 1992 to 2009. The operations, complications and functional outcome were recorded. For those with preserved rectal defecation, continence (Koivusalo score) and quality of life (standardized questionnaire) were assessed in the long term. Eighty five of 192 patients had Crohn disease (CD), 107 of 192 had ulcerative colitis (UC), and 3 of 192 had indeterminate colitis (IC). 12 of 85 CD patients (15%) aged 14 (12-19) years required 13 resections, 1 stricturoplasty, 1 transplantation and 6 other operations including 3 permanent enterostomies for anorectal involvement. Removal of the involved bowel led to significant improvement of nutritional status, growth and quality of life. The transplanted patient had a striking recovery but eventually died 1 year later of unrelated complications. 29 of 107 UC patients (26%) aged 11 (2-15) years required 87 operations. Nine had emergency colectomy for toxic megacolon (3, one death) or severe hemorrhage (6). 28 had restorative proctocolectomy and ileoanostomy (RPCIA) without (16) or with (12) J-pouch under protective ileostomy. Complications were frequent (40%). Permanent ileostomy was required in five children (17%). Twelve months postoperatively, RPCIA patients had 6.5 (2-13) stools/day; all were continent during daytime, and 25% have nocturnal leaks. Mean Koivusalo score (5-12) was 8.8 ± 2. Quality of life was good in all. All attended normal school and 7 the university, 4 work and 60% of those older than 18 years have sexual partners. Three of 107 children treated as UC with RPCIA had ultimately IC (3%) and were permanently diverted. The nature of IBD involves frustrating surgery. However, it may change life for CD patients and provide a reasonably good quality of life for UC after the first year. Pediatric surgeons should be able to provide adequate preoperative counseling to patients and families.

Prospective study of health-related quality of life and restorative proctocolectomy in children

PURPOSE

Although restorative proctocolectomy has become the standard surgical treatment for ulcerative colitis and familial adenomatous polyposis, there are no prospective studies in children of the impact of this intervention on health-related quality of life.

METHODS

A prospective study of health-related quality of life in children with ulcerative colitis or familial adenomatous polyposis undergoing restorative proctocolectomy was performed. Patients and their parents who agreed to participate completed standardized health-related quality-of-life surveys (Medical Outcomes Study Short Form-36 and Child Health Questionnaire Parent Form) within one month before colectomy and approximately one year after completion of their surgery.

RESULTS

Of the 60 patients who agreed to participate, 44 completed surveys at the appropriate time periods allowing comparison. The parents of 28 of these subjects also completed paired surveys. Before colectomy, patients with ulcerative colitis had substantially lower health-related quality-of-life scores, which were also mirrored in parental surveys. Following surgery patients with ulcerative colitis had significant improvement in 7 of 8 Medical Outcomes Study Short Form-36 patient subscales and all 6 corresponding Child Health Questionnaire Parent Form parental subscales of health-related quality of life. Patients with familial adenomatous polyposis showed improvement in the bodily pain subscale alone, whereas their corresponding parental surveys only showed improvement in the mental health subscale.

CONCLUSION

There are clearly significant adverse affects on health-related quality of life in children with ulcerative colitis that dramatically improved following restorative proctocolectomy.

Outcomes in pediatric patients undergoing straight vs J pouch ileoanal anastomosis: a multicenter analysis

BACKGROUND

Outcomes remain controversial for patients undergoing straight (SIAA) vs J pouch (JPAA) ileoanal anastomosis, particularly in children where fewer such cases are performed. Our 3 centers have had extensive experience with both techniques. Thus, we had the unique opportunity to compare outcomes within the same centers.

METHODS

We retrospectively analyzed 250 children after proctocolectomy with either SIAA or JPAA, for the first 3 years after pull-through. A functional stooling score was developed to further assess outcomes. Data were analyzed using chi(2) tests and generalized linear mixed models for repeated measures.

RESULTS

Two hundred three patients had sufficient data for complete analysis (42% males; mean surgery age, 15 +/- 7years). Surgical indications were ulcerative colitis (168) and familial adenomatoid polyposis (35). Surgical procedures included SIAA (112) and JPAA (91). Daytime and nighttime stooling frequencies were significantly higher (P < .013) for SIAA patients at 1 to 24 months after pull-through; however, stooling frequencies began approximating each other by this time. Symptomatic pouchitis (compared to enteritis after SIAA) was significantly higher in JPAA patients (odds ratio, 4.5; confidence interval, 2.32-8.72). Frequency of pouchitis declined with time. There was no significant difference in the incidence of surgical complications between the 2 groups. Finally, continence rates were strikingly good in both groups compared to previously reported series.

CONCLUSION

Straight ileoanal anastomosis and JPAA are associated with considerable morbidity; SIAA has higher stool frequency and JPAA has increased pouchitis. Over time, we found that problems improved, and functional stooling scores became similar. JPAA had consistently lower stool frequency and better continence rates; however, these differences were small and may have minimal clinical significance. In addition, such differences need to be balanced against the high rate of pouchitis with JPAA. Continence was excellent regardless of the technique.

Ileal pouch-anal anastomosis for ulcerative colitis: technical considerations

Total colectomy with ileal pouch-anal anastomosis has emerged as the preferred surgical treatment for ulcerative colitis. The operation has evolved over the last few decades. Various technical issues are discussed, including types of reservoir, options for mesenteric lengthening, method and level of ileoanal anastomosis (hand-sewn versus stapled), and rationale for staging. Anticipated postoperative problems and strategies for management are discussed.

Quality of life in paediatric gastrointestinal and liver disease: a systematic review

OBJECTIVES

To identify and appraise all studies relating to and instruments developed to measure quality of life (QOL) in children with gastrointestinal or liver diseases.

METHODS

A literature search was undertaken using MEDLINE, EMBASE, CINAHL, and PsycINFO to identify relevant articles published up to the end of 2005. These were reviewed by both authors and data were extracted using a standardised form. Articles were excluded if no attempt was made to measure QOL, they did not relate to children ages <17 years, they did not relate to gastrointestinal or liver diseases, or they were review articles. Quality of life instruments identified were rated according to proposed criteria.

RESULTS

From a total of 2379 articles identified in the initial search, a total of 2309 were excluded, leaving 70 included studies. These were assigned to the following categories: inflammatory bowel disease, n = 17; cystic fibrosis, n = 20; liver disease, n = 11; surgery, n = 15; and miscellaneous, n = 7. These studies describe the impact that these diseases have on the QOL of affected children. A total of 11 disease-specific QOL instruments and 1 generic instrument with a chronic disease module were identified, but only 5 of these fulfilled the proposed quality criteria and can be recommended for future use.

CONCLUSIONS

Chronic gastrointestinal and liver diseases can have an enormous effect on the QOL of affected individuals and their families. A number of disease-specific paediatric QOL instruments have been developed and validated. Quality of life is an important outcome that should be incorporated into clinical practice and measured when treatments are evaluated. Future research should explore how QOL can best be improved in children in whom it is severely impaired.

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.

Role of fecal calprotectin as a biomarker of intestinal inflammation in inflammatory bowel disease

Calprotectin is an abundant neutrophil protein found in both plasma and stool that is markedly elevated in infectious and inflammatory conditions, including inflammatory bowel disease (IBD). We conducted a systematic review of the published literature regarding fecal calprotectin to evaluate its potential as a noninvasive marker of neutrophilic intestinal inflammation. Reference ranges for fecal calprotectin have been established in healthy adults and children, and elevated concentrations of fecal calprotectin have been demonstrated in numerous studies of patients with IBD. Fecal calprotectin correlates well with histological inflammation as detected by colonoscopy with biopsies and has been shown successfully to predict relapses and detect pouchitis in patients with IBD. Fecal calprotectin has been shown to consistently differentiate IBD from irritable bowel syndrome because it has excellent negative predictive value in ruling out IBD in undiagnosed, symptomatic patients. Fecal calprotectin also may be useful in determining whether clinical symptoms in patients with known IBD are caused by disease flares or noninflammatory complications/underlying irritable bowel syndrome and in providing objective evidence of response to treatment. Although more studies are needed to define fully the role of fecal calprotectin, convincing studies and growing clinical experience point to an expanded role in the diagnosis and management of IBD.

Surgery for ulcerative colitis in pediatric patients: functional results of 10-year follow-up with straight endorectal pull-through

Children and adolescents affected by ulcerative colitis (UC) frequently require colectomy because of refractory or chronic symptoms. The aim of this paper is to present our experience and 10-year follow-up results of 28 patients who underwent endorectal pull-through (ERPT) as surgical treatment for UC, with special regard to surgical complications, stooling patterns (frequency of defecation, stool consistency, urgency period), fecal incontinence, and quality of life. A retrospective chart review of these patients was performed to evaluate age at colectomy, indication for surgical treatment, operative procedures, technical details, and early or late complications. Frequency of defecation was less than twice per day in two patients, between three and five times per day in nine patients, and more than six times per day in 10 patients. Stool consistency was normal in 14 patients, loose in five, and liquid in only two cases. Urgency period was normal (minutes) in 14 patients, short (seconds) in four, and absent in three. Ten patients (47%) have perfect or good fecal continence, whereas 11 (52%) patients present moderate to total incontinence. The self-reported emotional health was good in most of the patients. A large number are progressing well at school and are coping with their operations. Studies of quality of life in UC patients who underwent surgical treatment in childhood or adolescence, comparing as well the results according to the surgical technique adopted, must be encouraged.

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.