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Wong MCY, Rotondi G, Roso M, Avanzini P, Gandullia P, Arrigo S, Mattioli G. Quality of life after colectomy and ileo-jpouch-anal anastomosis in paediatric patients with ulcerative colitis. Pediatr Surg Int 2024; 40:231. [PMID: 39154135 DOI: 10.1007/s00383-024-05824-8] [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] [Accepted: 08/13/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Ulcerative Colitis (UC) is an Inflammatory Bowel Disease (IBD). Surgery is required in cases of severe acute colitis, massive hemorrhage, toxic megacolon, and perforation; in such cases colectomy and JpouchIleoanal anastomosis (IPAA) are performed. The aim of this study was to evaluate functional outcome, and patient satisfaction and Quality of Life (QoL) after surgery. MATERIAL AND METHODS Questionnaires were administered to 24 patients with UC undergoing surgery from 2011 to 2022. RESULTS Mean age at IPAA was 10.8 years. Twenty patients underwent IPAA in 3 operations, 4 patients in 2. All patients underwent laparoscopic surgery. 6 months after surgery mean level of satisfaction was 8.7/10, perception of health status was 7.4. Twenty-three patients (95.8%) recommended IPAA. For 20 patients (83.3%) surgery did not cause delay in education, while 14 patients (58.3%) played sport. The lowest number of evacuations was 9.2 per day, the highest 13.3. Seventeen patients (70.8%) had no incontinence and 15 patients (62.5%) were not affected by pouchitis. After 12 months mean satisfaction level raised up to 9.2/10, perception of health status to 8.5. School absences decreased and no other patients showed any delay in education. Seventeen (70.8%) patients played sports. The number of evacuations decreased: the lowest number was 5.1 per day, the highest 7.5. Twenty patients (83.3%) were continent and 12 (50%) did not use antibiotics. CONCLUSION Most patients show a good functional outcome in defecation frequency and continence, which has improved through time, number of pouchitis episodes has increased. Patients appear satisfied after surgery.
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Affiliation(s)
- M C Y Wong
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
| | - G Rotondi
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy.
- DINOGMI, University of Genoa, Genoa, Italy.
| | - M Roso
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
| | - P Avanzini
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
- DINOGMI, University of Genoa, Genoa, Italy
| | - P Gandullia
- Pediatric Gastroenterology and Endoscopy Department, IRCCS, Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - S Arrigo
- Pediatric Gastroenterology and Endoscopy Department, IRCCS, Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - G Mattioli
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
- DINOGMI, University of Genoa, Genoa, Italy
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Maspero M, Lavryk O, Lipman J, DeRoss A, Kessler H, Holubar S, Steele SR, Hull T. Long-term Outcomes of Straight Ileoanal Anastomoses Converted to Ileal Pouch Anal Anastomoses. J Pediatr Surg 2023; 58:1898-1902. [PMID: 37005207 DOI: 10.1016/j.jpedsurg.2023.03.001] [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: 12/29/2022] [Revised: 02/22/2023] [Accepted: 03/04/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND While ileal pouch anal anastomosis (IPAA) is the recommended way to restore intestinal continuity after total proctocolectomy, straight ileoanal anastomoses (SIAA) are still selectively performed, especially in the pediatric population. In case of SIAA failure, conversion to IPAA is possible, but reports on its outcomes are scarce. METHODS We retrospectively analyzed our prospectively collected database on pelvic pouches, and identified patients with a SIAA that was converted to IPAA. Our aim was long-term functional outcomes. RESULTS Twenty-three patients were included (14 females, median age at SIAA 15 years, median age at conversion to IPAA 19 years). The indication for SIAA was ulcerative colitis in 17 (74%) cases, indeterminate colitis in 2 (9%) cases, and familial adenomatous polyposis in 4 (17%) cases. The indication for IPAA conversion was incontinence/poor quality of life in 12 (52%) cases, sepsis in 8 (35%) cases, anastomotic stricture in 2 (9%) cases, and prolapse in one (4%) case. The majority were diverted at IPAA conversion (22, 96%). Three (13%) patients never had stoma closure, due to patient wishes, failed healing of vaginal fistula, and pelvic sepsis, respectively. After a median follow up of 109 months (28-170), pouch failure occurred in 5 additional patients. Overall pouch survival was 71% at 5 years. Median quality of life was 8/10, of health 8/10, and of energy 7/10. Median satisfaction with surgery was 9.5/10. CONCLUSION Conversion of SIAA to IPAA leads to acceptable long-term outcomes and good quality of life, and can safely be offered to patients with problems related to SIAA. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Marianna Maspero
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Olga Lavryk
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jeremy Lipman
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Anthony DeRoss
- Department of Pediatric Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Hermann Kessler
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tracy Hull
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
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Olortegui KS, Graham A, Hyman N. Staging Considerations for the Ileal Pouch-Anal Anastomosis. J Gastrointest Surg 2022; 26:1531-1536. [PMID: 35469035 DOI: 10.1007/s11605-022-05317-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/26/2022] [Indexed: 01/31/2023]
Affiliation(s)
| | - Ada Graham
- University of Chicago Medical Center, Chicago, IL, USA
| | - Neil Hyman
- University of Chicago Medical Center, Chicago, IL, USA
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Abstract
Polyps in gastrointestinal tract are mostly benign and result from hamartomas or lymphoid hyperplasia of submucosa. They usually occur as isolated lesions in children and are referred to as juvenile polyps. Multiple polyps with inherited origin are called polyposis and can be seen as a part of the syndrome. The polyps with adenomatous histopathology have malignant potential and necessitate genetic testing and colonoscopy to define the risk of cancer. Although simple endoscopic removal is adequate in the treatment of juvenile polyps, children with familial adenomatous polyposis (FAP) need total colectomy with ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA). The timing of prophylactic colectomy and the type of surgical treatment are controversial in children. The clinical features, the assessment of cancer risk, and the alternatives of the surgical treatment of polyps are reviewed in this paper.
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Affiliation(s)
- Tutku Soyer
- Department of Paediatric Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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Abstract
The incidence of paediatric Crohn's disease (CD) and ulcerative colitis (UC) is increasing. Surgical intervention is required during childhood in approximately 25% of children diagnosed with CD, and for 10% of those diagnosed with UC. Although there is evidence that the rate of surgical intervention undertaken in children is decreasing since the introduction of biologic therapy, this may only represent a delay rather than true reversal of the risk of surgery. Surgery for CD is not curative and limited resection is the key principle thus preserving bowel length. For UC, subtotal colectomy is relatively curative; ileo-anal pouch anastomosis can be performed to restore bowel continuity.
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Affiliation(s)
- Arun Kelay
- Department of Paediatric Surgery, University Hospital Southampton, Southampton, UK
| | - Lucinda Tullie
- Department of Paediatric Surgery, University Hospital Southampton, Southampton, UK
| | - Michael Stanton
- Department of Paediatric Surgery, University Hospital Southampton, Southampton, UK
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Current surgical practice in pediatric ulcerative colitis: A systematic review. J Pediatr Surg 2019; 54:1324-1330. [PMID: 30241963 DOI: 10.1016/j.jpedsurg.2018.08.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/13/2018] [Accepted: 08/06/2018] [Indexed: 12/15/2022]
Abstract
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.
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Drews JD, Onwuka EA, Fisher JG, Huntington JT, Dutkiewicz M, Nogalska A, Nwomeh BC. Complications after proctocolectomy and ileal pouch-anal anastomosis in pediatric patients: A systematic review. J Pediatr Surg 2019; 54:1331-1339. [PMID: 30291026 DOI: 10.1016/j.jpedsurg.2018.08.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/20/2018] [Accepted: 08/29/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND/PURPOSE Colectomy with ileal pouch-anal anastomosis (IPAA) is the standard of care for patients with familial adenomatous polyposis (FAP) and refractory ulcerative colitis (UC). The rates of postoperative complications are not well established in children. The objective of this systematic review is to establish benchmark data for morbidity after pediatric IPAA. METHODS PubMed, Embase, and The Cochrane Library were searched for studies of colectomy with IPAA in patients ≤21 years old. UC studies were limited to the anti-tumor necrosis factor-α agents era (1998-present). All postoperative complications were extracted. RESULTS Thirteen studies met the inclusion criteria (763 patients). Compared to patients with FAP, UC patients had a higher prevalence of pouch loss (10.6% vs. 1.5%). Other major complications such as anastomotic leak, abscess, and fistula were uncommon (mean prevalence 4.9%, 4.2%, and 5.0%, respectively, for patients with UC; 8.7%, 4.2%, and 4.3% for FAP). The most frequent complication was pouchitis (36.4% of UC patients). CONCLUSIONS Devastating complications from colectomy and IPAA are rare, but patients with UC have poorer outcomes than those with FAP. Much of the morbidity may therefore stem from patient or disease factors. Multicenter, prospective studies are needed to identify modifiable risks in patients with UC undergoing IPAA. LEVEL OF EVIDENCE Prognostic, level II.
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Affiliation(s)
- Joseph D Drews
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205; Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Columbus, OH, USA 43210.
| | - Ekene A Onwuka
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205; Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Columbus, OH, USA 43210.
| | - Jeremy G Fisher
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205.
| | - Justin T Huntington
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205.
| | - Michał Dutkiewicz
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205.
| | - Agata Nogalska
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205.
| | - Benedict C Nwomeh
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205; Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Columbus, OH, USA 43210.
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Lightner AL, Alsughayer A, Wang Z, McKenna NP, Seisa MO, Moir C. Short- and Long-term Outcomes After Ileal Pouch Anal Anastomosis in Pediatric Patients: A Systematic Review. Inflamm Bowel Dis 2019; 25:1152-1168. [PMID: 30668719 DOI: 10.1093/ibd/izy375] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/18/2018] [Accepted: 11/17/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Restorative proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the procedures of choice for restoration of intestinal continuity in ulcerative colitis or familial adenomatous polyposis. This systematic review aims to assess short-term postoperative and long-term functional outcomes in pediatric patients undergoing IPAA. METHODS A literature search was performed for all publications of pediatric IPAA in which short- and long-term outcomes were reported. Papers were excluded based on title, abstract, and full-length review. Data collection included patient demographics, medication use preoperatively, operative approach, 30-day postoperative outcomes, long-term functional outcomes (to maximal date of follow-up), and pouch failure rate. Outcomes were compared in those patients with and without perioperative corticosteroid exposure. Study quality and risk of bias was assessed using the Newcastle-Ottawa Scale as all studies were cohort studies. RESULTS Of 710 records reviewed, 42 full papers were included in the analysis. Rates of superficial surgical site infection, pelvic sepsis, ileus, and small bowel obstruction at <30 days were 10%, 11%, 10%, and 14%, respectively. Rates of pouchitis, stricture, chronic fistula tract, incontinence, and pouch failure were 30%, 17%, 12%, 20%, and 8%, respectively, at 37-109 months of follow-up; incontinence was significantly higher in those exposed to corticosteroids preoperatively (52% vs 20%; P < 0.001). The median daytime, nighttime, and 24-hour stool frequency were 5.3, 1.4, and 5 bowel movements, respectively. CONCLUSIONS IPAA is safe with good long-term functional outcomes in pediatric patients.
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Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester Minnesota, USA
| | - Ahmad Alsughayer
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester Minnesota, USA
| | - Zhen Wang
- Division of Health Care Policy and Research, Mayo Clinic, Rochester Minnesota, USA
| | - Nicholas P McKenna
- Division of Health Care Policy and Research, Mayo Clinic, Rochester Minnesota, USA
| | - Mohamed O Seisa
- Division of Health Care Policy and Research, Mayo Clinic, Rochester Minnesota, USA
| | - Christopher Moir
- Division ofPediatric Surgery, Mayo Clinic, Rochester Minnesota, USA
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9
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Abstract
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.
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Affiliation(s)
- Daniel P Ryan
- Department of Pediatric Surgery, MassGeneral Hospital for Children, Harvard Medical School, 55 Fruit St, Boston, Massachusetts 02114.
| | - Daniel P Doody
- Department of Pediatric Surgery, MassGeneral Hospital for Children, Harvard Medical School, 55 Fruit St, Boston, Massachusetts 02114
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Maxwell EC, Dawany N, Baldassano RN, Mamula P, Mattei P, Albenberg L, Kelsen JR. Diverting Ileostomy for the Treatment of Severe, Refractory, Pediatric Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2017; 65:299-305. [PMID: 28045769 DOI: 10.1097/mpg.0000000000001498] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Diverting ileostomy is used as a temporizing therapy in patients with perianal Crohn disease; however, little data exist regarding its use for colonic disease. The primary aim of the present study was to determine the role of diversion in severe refractory colonic inflammatory bowel disease (IBD) in a pediatric population. METHODS Retrospective study of patients who underwent diverting ileostomy at The Children's Hospital of Philadelphia from 2000 to 2014 for the management of severe, refractory colonic IBD. Clinical variables were compared in the 1 year before ileostomy and 1 year after diversion. Surgical and disease outcomes including changes in diagnosis were reviewed through 2015. RESULTS Twenty-four patients underwent diverting ileostomy for refractory colonic disease. Initial diagnoses were Crohn disease in 10 (42%), ulcerative colitis in 1 (4%), and IBD-unclassified in 13 patients (54%). Comparing data before and after surgery, there were statistically significant improvements in height and weight velocities, height velocity z score, blood transfusion requirement, hemoglobin, and hospitalization rates. Chronic steroid use decreased from 71% to 22%. At the conclusion of the study, 10 patients had undergone subsequent colectomy, 7 had successful bowel reanastomosis, and 7 remain diverted. Seven patients (29%) had a change in diagnosis. There were 13 surgical complications in 7 subjects, including prolapse reduction, stoma revision, and resection of ischemic bowel. CONCLUSIONS In pediatric patients with refractory colonic IBD, diverting ileostomy can be a successful intervention to induce clinical stability. Importantly, diversion is a steroid-sparing therapy and allows additional time to clarify the diagnosis.
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Affiliation(s)
- Elizabeth C Maxwell
- *Department of Pediatrics †Department of Biomedical Health Informatics, The Children's Hospital of Philadelphia ‡Perelman School of Medicine, University of Pennsylvania §Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
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Abdelaal K, Jaffray B. Variables associated with loss of ileoanal pouches constructed in childhood. J Pediatr Surg 2017; 52:281-285. [PMID: 27890312 DOI: 10.1016/j.jpedsurg.2016.11.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 11/08/2016] [Indexed: 01/11/2023]
Abstract
AIMS To quantify the incidence of loss of an ileoanal pouch in children and to identify variables associated this event. METHODS Logistic regression of possible explanatory variables: age, sex, indication for procto-colectomy, pre-operative continence status, use of immunosuppressive drugs, open or laparoscopic surgery, number of stages, anastomotic leak, operative complication excluding anastomotic leak, performance of revisional surgery, albumin concentration and platelet count at time of surgery, rank order in series. Univariate logistic regression was used to identify significant variables which were then assessed in a multivariate model and construction of Kaplan-Meier graphs. RESULTS 103 children, 56 girls, underwent ileoanal pouch at median age 14years (SD 3.7). Indications and mean age were: ulcerative colitis (n=71, 14years), polyposis syndromes (n=13, 15years), chronic idiopathic constipation (n=9, 11years), Hirschsprung's disease (n=4, 1year), Crohn's disease (n=2, 16years), and fibrosing colonopathy (n=2, 11years). 13 patients had their pouch excised or permanently diverted. Three patients had successful revisional pouch surgery. Only pre-operative fecal incontinence and anastomotic leak were significantly associated with pouch excision/diversion, however on multivariate analysis, only fecal incontinence remained significant, odds ratio 21 (95%CI 1.8-235, p=0.01). Pouch survival was significantly worse where there was fecal incontinence pre-operatively, p<0.0001 or an anastomotic leak, p<0.001. CONCLUSIONS 13% of children subjected to restorative procto-colectomy ultimately receive a permanent ileostomy. Fecal incontinence prior to surgery is a relative contra-indication. Anastomotic leak increases the probability of later pouch excision. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Khaled Abdelaal
- Department of paediatric surgery, The Great North Children's Hospital, Queen Victoria Road, Newcastle upon Tyne NE1 4LP
| | - Bruce Jaffray
- Department of paediatric surgery, The Great North Children's Hospital, Queen Victoria Road, Newcastle upon Tyne NE1 4LP.
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Surgical outcomes, bowel habits and quality of life in young patients after ileoanal anastomosis for ulcerative colitis. J Pediatr Surg 2016; 51:1246-50. [PMID: 27417342 DOI: 10.1016/j.jpedsurg.2016.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 01/26/2016] [Accepted: 03/03/2016] [Indexed: 02/08/2023]
Abstract
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.
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Hirata A, Uchino M, Bando T, Hirose K, Chohno T, Sasaki H, Horio Y, Nakamura S, Hida N, Hori K, Tomita N, Takahashi Y, Takesue Y, Ikeuchi H. Long-term outcomes and sex differences after restorative proctocolectomy in pediatric patients with ulcerative colitis. J Pediatr Surg 2016; 51:454-60. [PMID: 26561247 DOI: 10.1016/j.jpedsurg.2015.10.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/01/2015] [Accepted: 10/11/2015] [Indexed: 01/18/2023]
Abstract
BACKGROUND Restorative proctocolectomy (RPC) for ulcerative colitis (UC) could result in a higher patient quality of life, avoiding frequent disease flares; however, pouch failures and pouch-related complications (PRCs) can develop. PURPOSE No cohort studies have examined pouch failure and the differences between adult and pediatric patients or the sex differences in pediatric UC. Therefore, the pouch failure rates were compared between adults and pediatric patients, and pouch failure and PRCs in pediatric UC were evaluated. METHODS UC patients who underwent RPC between January 1987 and June 2014 at Hyogo College of Medicine were included. Patient background characteristics, PRCs, and pouch failure were reviewed. RESULTS A total of 1347 adult UC patients and 90 (51 boys, 39 girls) pediatric UC patients were included in the study. The cumulative rate of pouch failure at 10years after RPC was significantly higher in pediatric UC (9.5%) than in adult UC (2.1%; p<0.01). In pediatric UC, the independent risk factors for pouch failure were pouchitis (hazard ratio (HR) 19.3) and anal fistula (HR 5.5). Although a sex difference was not seen in pouch failure, an independent risk factor for PRCs was being a girl (HR 2.5). CONCLUSIONS Pouch failure was more common in pediatric than in adult UC. PRCs after RPC were more common in girls in pediatric UC.
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Affiliation(s)
- Akihiro Hirata
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Motoi Uchino
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
| | - Toshihiro Bando
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Kei Hirose
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Teruhiro Chohno
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hirofumi Sasaki
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yuki Horio
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Shiro Nakamura
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Nobuyui Hida
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Kazutoshi Hori
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Naohiro Tomita
- Department of Lower Gastroenterological Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yoshiko Takahashi
- Division of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yoshio Takesue
- Division of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hiroki Ikeuchi
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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14
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Colectomy in pediatric ulcerative colitis: A single center experience of indications, outcomes, and complications. J Pediatr Surg 2016; 51:277-81. [PMID: 26653944 DOI: 10.1016/j.jpedsurg.2015.10.077] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 10/30/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND/PURPOSE There is a paucity of data on outcomes and complications of colectomy for pediatric ulcerative colitis (UC). This study reports the experience of a regional center for 18years. METHODS Patients were identified from a prospective database and data obtained by note review. Median height/weight-SDS were calculated preoperatively and postoperatively. Data are expressed as median values (range). RESULTS 220 patients with UC (diagnosed <17years) were identified, and 19 (9%) had undergone colectomy. Age at diagnosis was 11.6years (1.3-16.5), and 42% of patients were male. Time from diagnosis to surgery was 2.2years (0.1-13.1). All patients had failed maximal medical therapy. Fifteen patients had urgent scheduled operation, and 4 had emergency procedures, with 2 for (11%) acute-severe colitis (1 Clostridium difficile colitis) and 2 for acute-severe colitis with toxic dilatation. All initial procedures were subtotal-colectomy with ileostomy. Nine patients (47%) had early complications (during initial admission), 7 (37%) requiring reoperation. Six (32%) had late complications, with 5 requiring laparotomy. No patients had both early and late complications. Height-SDS was -0.27 before surgery and -0.23 (maximal follow-up). Weight-SDS was 0.32 and 0.05 (maximal follow-up). CONCLUSION Approximately 1/11 children with UC required colectomy during childhood. Half of patients had acute complications, and 1/3 of patients required another operation during their first admission. 1/3 of patients developed late complications.
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Tomita R. Neurological function of the puborectalis muscle in patients with or without soiling after ileal J-pouch-anal anastomosis for ulcerative colitis in childhood. J Pediatr Surg 2014; 49:1626-30. [PMID: 25475807 DOI: 10.1016/j.jpedsurg.2014.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 07/07/2014] [Accepted: 07/07/2014] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Ryouichi Tomita
- Department of Surgery, Nippon Dental University School of Life Dentistry, Tokyo 173-0032, Japan; Department of Surgery, Nihon University School of Medicine, Tokyo 173-0032, Japan.
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Chronisch-entzündliche Darmerkrankungen (CED). PÄDIATRISCHE GASTROENTEROLOGIE, HEPATOLOGIE UND ERNÄHRUNG 2013. [PMCID: PMC7498796 DOI: 10.1007/978-3-642-24710-1_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Uchida K, Araki T, Kusunoki M. History of and current issues affecting surgery for pediatric ulcerative colitis. Surg Today 2012. [PMID: 23203770 DOI: 10.1007/s00595-012-0434-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pediatric ulcerative colitis (UC) is reportedly more extensive and progressive in its clinical course than adult UC. Therefore, more aggressive initial therapies and more frequent colectomies are needed. When physicians treat pediatric UC, they must consider the therapeutic outcome as well as the child's physical and psychological development. Mucosal proctocolectomy with ileal J-pouch anal anastomosis is currently recommended as a standard curative surgical procedure for UC in both children and adults worldwide. This procedure was developed 100 years after the first surgical therapy, which treated UC by colon irrigation through a temporary inguinal colostomy. Predecessors in the colorectal and pediatric surgical fields have struggled against several postoperative complications and have long sought a surgical procedure that is optimal for children. We herein describe the history of the development of surgical procedures and the current issues regarding the surgical indications for pediatric UC. These issues differ from those in adults, including the definition of toxic megacolon on plain X-rays, the incidence of colon carcinoma, preoperative and postoperative steroid complications, and future growth. Surgeons treating children with UC should consider the historical experiences of pioneer surgeons to take the most appropriate next step to improve the surgical outcomes and patients' quality of life.
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Affiliation(s)
- Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan,
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Abstract
Colorectal disease in pediatric patients includes a spectrum of diseases, many of which have a significant impact on quality of life and warrant long-term follow-up and treatment into adulthood. Although many diseases, such as inflammatory bowel disease and colon cancer, are managed similar to adults, other disease processes are more common to pediatric patients and are the focus of this article.
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Affiliation(s)
- David M Gourlay
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Abstract
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.
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Abstract
BACKGROUND/AIMS There has been no systematic review of natural history studies of pediatric-onset inflammatory bowel disease (IBD). We conducted a systematic review focused on understanding the long-term risks of growth failure, disease reclassification and extension, hospitalizations, cancer and death among patients with childhood IBD. METHODS PubMed searches and subsequent data abstraction were performed by 2 independent investigators. Studies published full in english with a 5-year minimum average follow-up in at least 30 patients with IBD onset before age 18 years. RESULTS We evaluated 41 total studies (only 2 population-based studies) with 3505 Crohn's disease (CD) patients, 2071 ulcerative colitis (UC) patients, and 461 indeterminate colitis (IC). Growth failure was reported in CD (10% and 56%) more often than UC (0% to 10%) or non-IBD controls. Improvements in growth occurred after surgical resection in patients with CD. There was an increase in disease reclassification over time from UC and indeterminate colitis diagnosis to CD diagnosis. Patients with CD had higher number of hospitalizations and hospital days per year in comparison with UC patients in most studies. The reported surgery rates in CD ranged between 10% and 72%; the colectomy rates in UC ranged between 0% and 50%. Cancers were reported in 6 CD patients during a total 18,270 patient-years (PY) follow-up, and 8 UC patients in 18,115 PY. Deaths directly related to IBD were 63 during 39,719 PY. CONCLUSIONS Childhood-onset IBD patients had growth failure reported in patients with CD more often than those with UC, had a reclassification of disease type to CD over time. Higher rates of surgery and hospitalizations were found with CD than with UC. The risk of cancer and death is low in this population.
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Technical considerations in children undergoing laparoscopic ileal-J-pouch anorectal anastomosis for ulcerative colitis. Pediatr Surg Int 2012; 28:351-6. [PMID: 22127486 DOI: 10.1007/s00383-011-3030-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Sub-total colectomy and restorative proctocolectomy with j-pouch ileo-anorectal anastomosis is the treatment of choice in children with ulcerative colitis uncontrolled with medical therapy. OBJECTIVE To present some technical considerations about children undergoing laparoscopic ileal-J-pouch anorectal anastomosis. SETTINGS AND PATIENTS All patients with ulcerative colitis undergoing laparoscopic ileal-J-pouch anorectal anastomosis were evaluated from January 2006 to February 2011. INTERVENTION The new technical innovations herein are (1) total laparoscopic approach, (2) a very short 3-cm J-pouch ileal reservoir created outside the stoma incision, (3) preservation of the entire anal canal and the Knight-Griffen double stapled anastomosis, less than 3 cm from the dentate line, (4) use of a Multiple Instrument Access Port system in the stoma skin incision to reduce the number of port site incisions and (5) proctectomy performed using only an electrosurgical vessels sealing device thus avoiding clips to close rectal pedicle. RESULTS Seventeen laparoscopic ileo J-pouch low rectal anastomosis were performed by the same surgical staff. Three complications occurred postoperatively: one bowel obstruction, one ileostomy prolapse, and one anastomotic stricture. Satisfactory functional results were achieved in all, there was no significant perineal excoriation and quality of life was excellent. CONCLUSIONS A Multiport Instrument Access Port placed in the stoma site allowed the use of more instruments through a single incision. The very short ileo J-pouch low rectal anastomosis has been shown to be a safe, feasible, and effective reconstructive procedure.
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Gilmour J, Harrison C, Asadi L, Cohen MH, Vohra S. Treating teens: considerations when adolescents want to use complementary and alternative medicine. Pediatrics 2011; 128 Suppl 4:S161-6. [PMID: 22045858 DOI: 10.1542/peds.2010-2720d] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Joan Gilmour
- Osgoode Hall Law School, York University, Toronto, Ontario, Canada
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Saklani AP, Marsden N, Davies M, Carr ND, Beynon J. Outcome after restorative proctocolectomy in children and adolescents. Colorectal Dis 2011; 13:1148-52. [PMID: 20796002 DOI: 10.1111/j.1463-1318.2010.02403.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The results including function and quality of life (QOL) of restorative proctocolectomy (RPC) performed in children and adolescents with ulcerative colitis (UC), familial adenomatous polyposis (FAP) and idiopathic megarectum were determined. METHOD Twenty-one patients of a median age of 15 (10-17) years underwent RPC between 1995 and 2006. The indication, use of covering ileostomy, morbidity and mortality were recorded. A structured questionnaire was completed by telephone interview to assess long-term function. The Cleveland Clinic Scoring (CCS) System was used for the assessment of faecal incontinence and the modified McMaster proforma for QoL. RESULTS There was no mortality. At a median follow-up of 65.5 (26-168) months, all patients had an intact pouch. One had a long-standing ileostomy. Median daytime and nocturnal stool frequencies were 4 (2-16) and 0 (0-3). The mean CCS was 1.47, with only one patient scoring more than 10. Eighteen of 20 patients were satisfied with the result; two patients had a worse QoL (McMaster score >8). One patient had a permanent stoma following pouch sepsis and one had symptoms of pouchitis. CONCLUSION RPC can be performed in children and adolescents with good functional outcome and acceptable QoL.
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Affiliation(s)
- A P Saklani
- Colorectal Department, Singleton Hospital, Sketty Lane, Swansea, UK.
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Seetharamaiah R, West BT, Ignash SJ, Pakarinen MP, Koivusalo A, Rintala RJ, Liu DC, Spencer AU, Skipton K, Geiger JD, Hirschl RB, Coran AG, Teitelbaum DH. Outcomes in pediatric patients undergoing straight vs J pouch ileoanal anastomosis: a multicenter analysis. J Pediatr Surg 2009; 44:1410-7. [PMID: 19573671 DOI: 10.1016/j.jpedsurg.2009.01.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Revised: 01/01/2009] [Accepted: 01/02/2009] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Rupa Seetharamaiah
- Section of Pediatric Surgery, C S Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI 48109, USA
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Pakarinen MP, Natunen J, Ashorn M, Koivusalo A, Turunen P, Rintala RJ, Kolho KL. Long-term outcomes of restorative proctocolectomy in children with ulcerative colitis. Pediatrics 2009; 123:1377-82. [PMID: 19403505 DOI: 10.1542/peds.2008-2086] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Long-term outcomes of restorative proctocolectomy for pediatric-onset ulcerative colitis are unclear. METHODS Questionnaires on health outcomes and quality of life were mailed to patients with childhood-onset ulcerative colitis who had undergone proctocolectomy with ileoanal anastomosis in 2 university hospitals between 1985 and 2005. Investigators not involved in the surgical management of the patients approached participants. Matched control children were randomly chosen from the Population Register Centre of Finland. RESULTS Fifty-two (66%) patients and 117 (37%) controls responded. After a mean follow-up of 10 years, at least 1 surgical complication had occurred in 39 (75%) patients, and 28 (54%) had undergone reoperation. Only 1 failure of ileoanal anastomosis occurred. Ulcerative colitis had been reclassified as Crohn disease in 6 (12%) patients. Pouchitis occurred in 37 (73%) patients. The median stool frequency was 5 for day and 1 for night, but 46% used medication to control stool frequency. Nighttime soiling was reported by 56% of the patients. The mean overall quality-of-life score, the mean BMI (22 kg/m(2) for both), and the number of subjects (aged >20 years) with offspring (14% vs 15%) was similar to the population-based controls. CONCLUSIONS Stool frequency after restorative proctocolectomy in children with ulcerative colitis is stable and comparable to those of adult patients. Although nighttime incontinence is common, general health status and overall quality of life are comparable to the normal population.
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Affiliation(s)
- Mikko P Pakarinen
- Section of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki, PO Box 281, FIN-00029 HUS, Helsinki, Finland.
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Fichera A, Ragauskaite L, Silvestri MT, Elisseou NM, Rubin MA, Hurst RD, Michelassi F. Preservation of the anal transition zone in ulcerative colitis. Long-term effects on defecatory function. J Gastrointest Surg 2007; 11:1647-52; discussion 1652-3. [PMID: 17906906 DOI: 10.1007/s11605-007-0321-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Accepted: 09/03/2007] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The anal transition zone (ATZ) after ileal pouch anal anastomosis (IPAA) for ulcerative colitis is considered at risk for dysplasia and persistent or recurrent disease activity. The long-term fate of the ATZ and the effects of histologic changes on defecatory function are not well-known. METHODS To evaluate the inflammatory and preneoplastic changes of the ATZ in patients without preoperative dysplasia, yearly biopsies of the ATZ were obtained and functional results recorded on a questionnaire/diary. Histologic changes were correlated with simultaneous assessment of defecatory function. RESULTS Between 1992 and 2006, 225 patients underwent a stapled IPAA. A total of 238 successful biopsies of the ATZ were performed. There was no dysplasia found. Acute inflammation was noted in 4.6%, chronic inflammation in 84.9%, and normal mucosa in 10.5% of cases. Patients with chronic inflammation reported an average of 6.2+/-1.7 bowel movements/day and 93.2% of them were able to delay a bowel movement for at least 30 min. The presence of chronic ATZ inflammation did not seem to have a negative impact on function, with 96.1% of patients reporting perfect continence, and only 5.3% using protective pads. CONCLUSIONS Preservation of the ATZ in selected patients is safe and offers excellent long-term functional results. New onset dysplasia was not noted. Chronic inflammation had limited clinical impact. Presence of ATZ inflammation in a total of 89.5% of patients warrants life-long surveillance with biopsies.
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Ba'ath ME, Mahmalat MW, Kapur P, Smith NP, Dalzell AM, Casson DH, Lamont GL, Baillie CT. Surgical management of inflammatory bowel disease. Arch Dis Child 2007; 92:312-6. [PMID: 16670116 PMCID: PMC2083695 DOI: 10.1136/adc.2006.096875] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIM To evaluate the outcome and morbidity after major surgical interventions for inflammatory bowel disease (IBD). METHODS Retrospective case note analysis of 227 children referred to a tertiary referral centre between 1994 and 2002 for treatment of IBD. RESULTS 26 of 125 children with Crohn's disease (21%) required surgical management. 13 with disease proximal to the left colon underwent limited segmental resections and primary anastomosis, without significant morbidity. Primary surgery for 13 children with disease distal to the transverse colon included 6 subtotal-colectomies or panprocto-colectomies. All seven children undergoing conservative segmental resections (three with primary anastomosis, four with stoma formation), required further colonic resection or defunctioning stoma formation. All three children undergoing primary anastomosis developed a leak or fistula formation. 22 of 102 children with ulcerative colitis (22%) required surgery. Definitive procedures (n = 17) included J-pouch ileoanal anastomosis (n = 11), ileorectal anastomosis (n = 2), straight ileoanal anastomosis (n = 3), and proctectomy/ileostomy (n = 1). Five children await restorative surgery after subtotal colectomy. Median daily stool frequency after J-pouch surgery was 5 (range 3-15), and 10 of 11 children reported full daytime continence. All three children with straight ileoanal anastomosis had unacceptable stool frequency and remain diverted. CONCLUSION The complication rate after resectional surgery for IBD was 57% for Crohn's disease, and 31% for ulcerative colitis. In children with Crohn's disease, limited resection with primary anastomosis is safe proximal to the left colon. Where surgery is indicated for disease distal to the transverse colon, subtotal or panproctocolectomy is indicated, and an anastomosis should be avoided. Children with ulcerative colitis had a good functional outcome after J-pouch reconstruction. However, the overall failure rate of attempted reconstructive surgery was 24%, largely owing to the poor results of straight ileoanal anastomosis.
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Affiliation(s)
- M E Ba'ath
- Department of Paediatric Surgery, Royal Liverpool Children's Hospital NHS Trust, Liverpool, UK
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Koivusalo A, Pakarinen MP, Rintala RJ. Surgical complications in relation to functional outcomes after ileoanal anastomosis in pediatric patients with ulcerative colitis. J Pediatr Surg 2007; 42:290-5. [PMID: 17270537 DOI: 10.1016/j.jpedsurg.2006.10.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Antti Koivusalo
- Children's Hospital, University of Helsinki, 00290 Helsinki, Finland.
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Hait EJ, Bousvaros A, Schuman M, Shamberger RC, Lillehei CW. Pouch outcomes among children with ulcerative colitis treated with calcineurin inhibitors before ileal pouch anal anastomosis surgery. J Pediatr Surg 2007; 42:31-4; discussion 34-5. [PMID: 17208537 DOI: 10.1016/j.jpedsurg.2006.09.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE The purpose of this article is to describe the outcomes of the pouches of 14 children with ulcerative colitis (UC) who were pretreated with calcineurin inhibitors before they underwent their ileal pouch anal anastomosis (IPAA) surgery. METHODS An institutional review board-approved retrospective review of the charts of consecutive patients with UC treated with calcineurin inhibitors before undergoing IPAA surgery at a tertiary pediatric center between 1998 and 2003 was performed. The primary endpoint was pouch outcome after at least 2 years of follow-up (healthy pouch, acute pouchitis, chronic refractory pouchitis, or pouch failure); the secondary endpoints were early postoperative complications, number of stages, and time between stages. RESULTS Fourteen of 53 consecutive patients who underwent IPAA for UC were treated with calcineurin inhibitors before their surgery (26%; 6 with cyclosporine and 8 with tacrolimus). All 14 patients were concomitantly treated with systemic steroids. Ten patients (71%) were also taking 6-mercaptopurine or azathioprine, and 9 (64%) were also taking mesalamine. Three patients (21%) had healthy pouches with no clinical evidence of pouchitis, 6 (43%) had at least one episode of acute pouchitis (average of 2 episodes per year), 3 (21%) had chronic relapsing pouchitis, and 2 (14%) were later determined to have Crohn's disease. There was no pouch failure. Two patients (14%) had an early postoperative complication (intraabdominal abscess, anastomotic stricture). Five patients (36%) had a 2-staged procedure, and 8 (64%) had a 3-staged procedure. For the 2-staged procedures, the mean time between the first and second stages was 3.14 months (range, 3-4 months). For the 3-staged procedures, the mean time between the first and second stages was 4.25 months (range, 2-6 months) and that between the second and third stages was 4 months (range, 2.5-6 months). CONCLUSIONS In this series, chronic pouchitis was an infrequent complication among children who were pretreated with calcineurin inhibitors. Calcineurin inhibitor use did not lead to or portend increased early postoperative complications or affect the number or duration of surgical stages. Further studies are required to determine if preoperative calcineurin inhibitors improve pouch outcomes or facilitate the performance of 2-staged procedures.
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Affiliation(s)
- Elizabeth J Hait
- The Center for Inflammatory Bowel Disease, Children's Hospital Boston, Harvard University, Boston, MA 02115, USA
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Tilney HS, Constantinides V, Ioannides AS, Tekkis PP, Darzi AW, Haddad MJ. Pouch-anal anastomosis vs straight ileoanal anastomosis in pediatric patients: a meta-analysis. J Pediatr Surg 2006; 41:1799-808. [PMID: 17101347 DOI: 10.1016/j.jpedsurg.2006.06.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Restorative proctocolectomy is the treatment of choice for pediatric patients with refractory colitis, inherited polyposis syndromes, and some with colonic aganglionosis. Evidence concerning the optimal method of reconstruction is, however, sparse. METHODS Studies comparing outcomes from ileal pouch-anal anastomosis (IPAA) and straight ileoanal anastomosis (SIAA) were identified by searching Medline, Ovid, and Embase. Suitable studies were selected and data extracted for meta-analysis. RESULTS Of 13 studies identified by literature search, 5 satisfied the inclusion criteria, comprising a total of 306 patients, 86 of whom (28.1%) underwent SIAA, and the remainder, IPAA. Pouch failure was more common in the SIAA group (odds ratio, 3.21; confidence interval, 1.24-8.34), as were abdominal salvage procedures (odds ratio, 9.5; confidence interval, 3.14-28.77). Short-term adverse events were similar between the 2 groups, with the exception of perianal sepsis, the higher frequency of which, in SIAA, just reached statistical significance. Bowel frequency was lower in the IPAA patients, although few studies presented functional data in a comparable form. CONCLUSIONS There are few good-quality studies that compare the outcomes from SIAA and IPAA, meaning that caution should be exercised in the generalization of the results of this meta-analysis, which suggests pouch procedures to be favorable in terms of reconstruction survival and functional outcome.
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Affiliation(s)
- Henry S Tilney
- Department of Surgical Oncology and Technology, Imperial College London, St. Mary's Hospital, W2 1NY London, UK
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Russell GJ. Pouchitis Following Ileal Pouch Anal Anastomosis. SEMINARS IN COLON AND RECTAL SURGERY 2006. [DOI: 10.1053/j.scrs.2006.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Uchida K, Araki T, Toiyama Y, Yoshiyama S, Inoue M, Ikeuchi H, Yanagi H, Miki C, Yamamura T, Kusunoki M. Preoperative steroid-related complications in Japanese pediatric patients with ulcerative colitis. Dis Colon Rectum 2006; 49:74-9. [PMID: 16283565 DOI: 10.1007/s10350-005-0213-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to clarify a limit for steroid therapy in patients with ulcerative colitis through analyzing the preoperative major steroid-related complications and to define when alternative therapies, including surgery, should be performed in pediatric ulcerative colitis patients. METHODS The medical records of 28 pediatric and 57 adult patients with ulcerative colitis who underwent total proctocolectomy and ileal J-pouch-anal anastomosis were reviewed. The relationship between the preoperative dose of glucocorticoids and major steroid-related complications, as well as the surgery variables, was evaluated. RESULTS Significantly higher incidences of growth retardation, osteoporosis, glaucoma, and cataracts were noted in pediatric patients than in adult patients. In pediatric patients, major steroid-related complications occurred at a significantly lower preoperative total dosage of glucocorticoids/body weight (mg/kg) or preoperative total dosage of glucocorticoids/body surface area (mg/m2) than in adult patients. A similar surgical procedure was performed in both pediatric and adult patients. The presence of major steroid-related complications can lower a patient's long-term quality of life. CONCLUSIONS Evidence-based guidelines for the recommended dose of glucocorticoids according to body weight or body surface area are needed. To allow patients to feel well and maintain a good quality of life, early introduction of alternative treatments, including surgery, should be considered.
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Affiliation(s)
- Keiichi Uchida
- Second Department of Surgery, Mie University School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
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Mattioli G, Castagnetti M, Gandullia P, Torrente F, Jasonni V, Barabino AV. Stapled restorative proctocolectomy in children with refractory ulcerative colitis. J Pediatr Surg 2005; 40:1773-9. [PMID: 16291168 DOI: 10.1016/j.jpedsurg.2005.07.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Girolamo Mattioli
- Department of Paediatric Surgery, G. Gaslini Research Institute, University of Genoa, 16147-Genoa, Italy
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Wewer V, Hesselfeldt P, Qvist N, Husby S, Paerregaard A. J-pouch ileoanal anastomosis in children and adolescents with ulcerative colitis: functional outcome, satisfaction and impact on social life. J Pediatr Gastroenterol Nutr 2005; 40:189-93. [PMID: 15699695 DOI: 10.1097/00005176-200502000-00020] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Vibeke Wewer
- Department of Paediatrics, H. S. Hvidovre Hospital, University of Copenhagen, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark.
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Ceriati E, Deganello F, De Peppo F, Ciprandi G, Silveri M, Marchetti P, Ravà L, Rivosecchi M. Surgery for ulcerative colitis in pediatric patients: functional results of 10-year follow-up with straight endorectal pull-through. Pediatr Surg Int 2004; 20:573-8. [PMID: 15322840 DOI: 10.1007/s00383-004-1232-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2004] [Accepted: 05/11/2004] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Emanuela Ceriati
- Department of Paediatric Surgery, Paediatric Hospital Bambino Gesù, Via Cassia 569, 00189 Rome, Italy.
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Abstract
Ulcerative colitis is a chronic relapsing inflammatory disorder of the colonic mucosa of unknown etiology. The inflammatory process involves the mucosa and submucosa in a continuous segment of bowel with rectal involvement in almost all cases. Since its etiology is unknown, therapy is directed at modulating the inflammatory response in order to control symptoms and to prevent relapses. 5-aminosalicylates and corticosteroids have been the most widely used therapeutic agents for treatment of ulcerative colitis. Recently, experience has been gained with the use of other immunomodulators, such as mercaptopurine, azathioprine, methotrexate, cyclosporine, and tacrolimus, in pediatric patients. Colectomy is indicated in patients with severe colitis who do not respond to intensive medical therapy. The care of children with ulcerative colitis not only involves control of symptoms from gastrointestinal and extraintestinal manifestations, but also optimizing growth and development. The complications of chronic inflammation and long-term medical therapy must be weighed against the risks and benefits of surgery for children and adolescents with this condition.
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Affiliation(s)
- David A Gremse
- Division of Pediatric Gastroenterology and Nutrition, University of South Alabama College of Medicine, #5321, 1504 Springhill Avenue, Mobile, AL 36604, USA.
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Mamula P, Markowitz JE, Brown KA, Hurd LB, Piccoli DA, Baldassano RN. Infliximab as a novel therapy for pediatric ulcerative colitis. J Pediatr Gastroenterol Nutr 2002; 34:307-11. [PMID: 11964959 DOI: 10.1097/00005176-200203000-00017] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The role of infliximab (anti-tumor necrosis factor alpha antibody) therapy in ulcerative colitis (UC) is not well defined. There are only two reports published describing its use in UC. The authors describe their experience with open-label use of infliximab in children with moderate to severe UC. METHODS The authors collected data on all consecutive pediatric patients with UC who received infliximab at The Children's Hospital of Philadelphia until July 2001. The primary measured outcome was clinical response at 2 days and 2 weeks after infliximab infusion, as measured by the Lichtiger colitis activity index (LCAI) score and the Physician Global Assessment (PGA). Tolerance of the infusions and adverse events were recorded. RESULTS Nine patients qualified for clinical response analysis. The median Lichtiger colitis activity index score decreased from 11 before the infusion to 1 at 2 days and 2 weeks after the infusion, respectively (P = 0.01 for 2 days and 2 weeks). Seven of nine (77%) patients had decreased activity of their disease measured by the Physician Global Assessment. Corticosteroid therapy was discontinued in six (66%) patients. An infusion reaction developed (generalized pruritus and facial flushing) in two patients and an elevated anti-nuclear antibody (ANA) titer of 1:1280 developed in one patient. CONCLUSION Infliximab is associated with short-term clinical improvement in children and adolescents with moderate to severe UC.
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Affiliation(s)
- Petar Mamula
- Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Abstract
BACKGROUND/PURPOSE The choice of ileo-anal reconstruction method in children undergoing proctocolectomy remains controversial. Although in adults ileo-anal pouch reconstruction has gained overall acceptance, many paediatric surgeons still advocate straight ileo-anal pull-through. The aim of this study was to assess the outcome and long-term functional results in children who have undergone proctocolectomy and ileo-anal anastomosis (IAA) with a J-pouch. METHODS Medical records of 40 consecutive children who had proctocolectomy and J-pouch IAA between 1991 and 1999 were reviewed for early and late complications, fecal frequency, day- and night-time continence, and pouchitis. The indication for surgery was ulcerative colitis (UC) in 29 (median age at operation, 13 years; range, 9 to 16), Hirschsprung's disease (HD) in 10 (median age at operation, 1.5 years; range, 1 month to 5 years), and familial adenomatous polyposis (FAP) in 1 (age at operation, 6 years). Six of the HD patients had primary pull-through for total colonic aganglionosis and 4 a redo operation for failed primary reconstruction of long segment aganglionosis. RESULTS There were no fatalities. Early complications (wound infection, early bowel obstruction, prolonged fever) occurred in 12 of 29 (41%) and late complications (bowel obstruction 9, pouch fistula 2) in 11 of 29 (38%) of the UC patients. Overall, 16 of 29 (53%) of the UC patients had complications. All patients with early complications were on systemic steroids at the time of the operation. Pouchitis occurred in 30% of the patients. None of the pouches had to be removed. At last follow-up all patients were continent during the day, 2 patients used protective pads during the night because of occasional staining. The median bowel frequency per 24 hours was 4 (range, 2 to 7); only 2 patients (7%) had to empty their bowel during the night. One (10%) of the HD patients had wound infection, and 3 had episodes of postoperative enterocolitis. Pouchitis-type symptoms have not occurred in HD patients. The median bowel frequency for 24 hours was 3 (range, 2 to 5). None of the HD patients needs to evacuate during the night. The 4 HD patients who are older than 3 years of age are continent. CONCLUSIONS J-pouch IAA is a feasible method of reconstruction in children requiring proctocolectomy. Major complication are common but occur mainly in immunosuppressed patients suffering from UC. Despite high incidence of complications, long-term functional results in terms of continence and bowel frequency are excellent and ensure good quality of life in the great majority of patients.
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Affiliation(s)
- R J Rintala
- Department of Pediatric Surgery, Children's Hospital, University of Helsinki, Helsinki, Finland
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Walker-Smith JA. Chronic inflammatory bowel disease in children: a complex problem in management. Postgrad Med J 2000; 76:469-72. [PMID: 10908372 PMCID: PMC1741682 DOI: 10.1136/pmj.76.898.469] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- J A Walker-Smith
- University Department of Paediatric Gastroenterology, Royal Free and University College Medical School, Hampstead, London, UK
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Durno CA, Sherman P, Williams T, Shuckett B, Dupuis A, Griffiths AM. Magnetic resonance imaging to distinguish the type and severity of pediatric inflammatory bowel diseases. J Pediatr Gastroenterol Nutr 2000; 30:170-4. [PMID: 10697136 DOI: 10.1097/00005176-200002000-00014] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The distinction between ulcerative colitis and Crohn's disease is important, because treatment options and clinical course may vary. Magnetic resonance imaging (MRI) allows noninvasive transmural assessment of the intestine and may facilitate differentiation of ulcerative colitis from Crohn's disease. The objective of this prospective study was to determine whether MRI differentiates Crohn's disease from ulcerative colitis in children as effectively as colonoscopy with mucosal biopsies. METHODS Fifteen patients underwent colonoscopy with biopsies followed by abdominal MRI. The MRI diagnosis, determined by two radiologists independently completing a standardized form was compared with the gastroenterologic diagnosis. RESULTS After colonoscopy and review of histology, Crohn's disease was diagnosed in nine patients, ulcerative colitis in five, and indeterminate colitis in one, who was excluded from study. Agreement of the MRI diagnosis with the gastroenterologic diagnosis was 4 of 4 (100%) for ulcerative colitis, 4 of 10 (40%) for Crohn's disease considering both radiologists, and 5 of 10 (50%) for Crohn's disease for each radiologist individually. Percentage of enhancement by MRI did not correlate with the severity of inflammation determined at endoscopy among the patients with Crohn's disease (r = -0.3, P = 0.366). There was agreement on severity of inflammation in three of four patients with ulcerative colitis. CONCLUSIONS Current MRI interpretation of inflammatory bowel disease did not adequately recognize Crohn's disease in children. Therefore, colonoscopy with biopsy remains the most accurate tool for determining the type and severity of inflammatory bowel disease in children and adolescents.
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Affiliation(s)
- C A Durno
- Division of Gastroenterology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
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