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Shehada M, McMahon LE. Recurrent Crohn's disease. Semin Pediatr Surg 2024; 33:151403. [PMID: 38593515 DOI: 10.1016/j.sempedsurg.2024.151403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Although surgical management of the ileocolic segment in pediatric Crohn's disease is not curative, the main goal of therapy is to allow for growth, adequate nutrition, and age-appropriate development. Recurrent disease at the site of anastomosis presents as a major morbidity. Several factors have been implicated in the development of surgical recurrence though data in the literature is scarce. This review explores the epidemiology of recurrent ileocolic disease following primary surgery, indications for surgical intervention, and techniques reported in the literature. Pediatric data is scarce, and therefore, much of it is extrapolated from adult literature.
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Affiliation(s)
- Mahmoud Shehada
- Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
| | - Lisa E McMahon
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA.
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Boscarelli A, Bramuzzo M. Pediatric stricturing Crohn's disease. World J Gastroenterol 2024; 30:1651-1654. [PMID: 38617744 PMCID: PMC11008380 DOI: 10.3748/wjg.v30.i12.1651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 01/31/2024] [Accepted: 03/06/2024] [Indexed: 03/28/2024] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory disease of the digestive tract. The incidence of pediatric CD is increasing and is currently 2.5-11.4 per 100000 world-wide. Notably, approximately 25% of children with CD develop stricturing CD (SCD) that requires intervention. Symptomatic stricturing diseases refractory to pharmacological management frequently require non-pharmacological interventions. Non-pharmacological therapeutic strategies include endoscopic balloon dilatation, stricturoplasty, and surgical resection of the strictured segment. However, strictures tend to recur postoperatively regardless of treatment modality. The lifetime risk of surgery in patients with childhood SCD remains at 50%-90%. Thus, new and emerging strategies, advanced diagnostic tools, and minimally invasive approaches are under investigation to improve the outcomes and overall quality of life of pediatric patients with SCD.
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Affiliation(s)
- Alessandro Boscarelli
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS “Burlo Garofolo”, Trieste 34137, Italy
| | - Matteo Bramuzzo
- Department of Gastrointestinal Endoscopy and Nutrition, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste 34137, Italy
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Dotlacil V, Lerchova T, Lengalova M, Kucerova B, Schwarz J, Hradsky O, Rygl M, Skaba R. Kono-S anastomosis in Crohn's disease: initial experience in pediatric patients. Pediatr Surg Int 2024; 40:67. [PMID: 38438752 DOI: 10.1007/s00383-024-05648-6] [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: 01/30/2024] [Indexed: 03/06/2024]
Abstract
PURPOSE Children diagnosed with Crohn's disease (CD) often undergo ileocecal resection (ICR) during childhood. Anastomotic recurrence is a frequent finding following this procedure. Data addressing the effect of the anastomosis type on disease recurrence are scarce in the pediatric population. The Kono-S anastomosis has shown promise in reducing endoscopic, clinical, and surgical recurrence rates in adults. We aimed to report our experience with Kono-S anastomosis in children, focusing on its feasibility and postoperative complications. METHODS We retrospectively analyzed pediatric CD patients who underwent ICR with Kono-S anastomosis between August 2022 and May 2023. Data on demographics, clinical characteristics, surgery, hospitalization, and follow-up including colonoscopy were collected. Complications were classified using the Clavien-Dindo classification. RESULTS Twelve patients (7 females, 58.3%) were included. Six (50%) of the patients had the B3 luminal form of the disease (according to Paris classification). Median surgery duration was 174 (interquartile range [IQR] 161-216) minutes. Anastomosis creation took a median of 62 (IQR, 54.5-71) minutes. Median hospitalization length was 6 (IQR 4-7) days. No short- or mid-term complications were observed. Median follow-up duration was 9.5 (IQR 6.8-12) months. CONCLUSION According to our results, Kono-S anastomosis is safe and feasible in pediatric CD patients, with no observed postoperative complications. These findings support the potential benefit of using Kono-S anastomosis as a treatment approach in children with CD.
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Affiliation(s)
- Vojtech Dotlacil
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Charles University, V Uvalu 84, 150 06, Praha 5, Czech Republic.
| | - Tereza Lerchova
- Department of Paediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | | | - Barbora Kucerova
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Charles University, V Uvalu 84, 150 06, Praha 5, Czech Republic
| | - Jan Schwarz
- Department of Paediatrics, Faculty of Medicine in Pilsen, Faculty Hospital, Charles University in Prague, Pilsen, Czech Republic
| | - Ondrej Hradsky
- Department of Paediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Michal Rygl
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Charles University, V Uvalu 84, 150 06, Praha 5, Czech Republic
| | - Richard Skaba
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Charles University, V Uvalu 84, 150 06, Praha 5, Czech Republic
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Alvisi P, Faraci S, Scarallo L, Congiu M, Bramuzzo M, Illiceto MT, Arrigo S, Romano C, Zuin G, Miele E, Gatti S, Aloi M, Renzo S, Caldaro T, Labriola F, De Angelis P, Lionetti P. Major Abdominal Surgery for Pediatric Crohn's Disease in the Anti-TNF Era: 10-Year Analysis of Data From the IBD Registry of Italian Society of Pediatric Gastroenterology, Hepatology, and Nutrition. Inflamm Bowel Dis 2024:izad310. [PMID: 38180842 DOI: 10.1093/ibd/izad310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND The natural history of Crohn's disease (CD) can result in complications requiring surgery. Pediatric data are scarce about major abdominal surgery. The IBD Registry from the Italian Society of Pediatric Gastroenterology, Hepatology, and Nutrition has been active since 2008 and collects data from major pediatric IBD centers in Italy. The aim of the present report was to explore the prevalence of major abdominal surgery among children affected by CD in an era when antitumor necrosis factor (anti-TNF-α) agents were already used so that we might appraise the incidence of surgical-related complications and identify the factors associated with postoperative disease recurrence. METHODS We retrospectively analyzed data from patients enrolled in the registry from January 2009 to December 2018. Patients with monogenic IBD and patients undergoing surgery for perianal disease were excluded. RESULTS In total, 135 of 1245 patients were identified. We report the prevalence of major abdominal surgery of 10.8%. Pediatric surgeons performed the procedure in 54.1% of cases, and a laparoscopic approach was used in 47.4% of surgical procedures. Seventeen patients (12.6%) experienced a total of 21 early postoperative complications, none of which was severe. A laparoscopic approach was the only factor negatively associated with the occurrence of postoperative complications (odds ratio, 0.22; 95% confidence interval, 0.06-0.8; P = .02). Fifty-four (40%) patients experienced postoperative endoscopic recurrence, and 33 (24.4%) of them experienced postoperative clinical recurrence. The postoperative treatment with anti-TNF-α drugs was significantly associated with a reduced risk of endoscopic recurrence (odds ratio, 0.19; 95% confidence interval, 0.05-0.79; P = .02). CONCLUSION In our cohort, the overall prevalence of major abdominal surgery was low, as well as the rate of surgical-related complications. Postoperative anti-TNF-α therapy seems be protective against endoscopic recurrence.
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Affiliation(s)
- Patrizia Alvisi
- Pediatric Gastroenterology Unit, Pediatric Department, Maggiore C.A. Pizzardi Hospital, Bologna, Italy
| | - Simona Faraci
- Digestive Diseases Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Luca Scarallo
- Pediatric Gastroenterology and Nutrition Unit, Meyer Children's Hospital, Florence, Italy
- Department NEUROFARBA, University of Florence, Florence, Italy
| | - Marco Congiu
- Residency School of Pediatrics, University of Bologna, Bologna, Italy
| | - Matteo Bramuzzo
- Institute for Maternal and Child Health, IRCSS Burlo Garofolo, Trieste, Italy
| | | | - Serena Arrigo
- Pediatric Gastroenterology and Endoscopy Unit, IRCCS G. Gaslini Children's Hospital, Genoa, Italy
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood G. Barresi, University of Messina, Messina, Italy
| | - Giovanna Zuin
- Pediatric Unit, Fondazione IRCCS San Gerardo dei Tintori Hospital, Monza, Italy
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Simona Gatti
- Institute for Maternal and Child Health, IRCSS Burlo Garofolo, Trieste, Italy
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Sara Renzo
- Pediatric Gastroenterology and Nutrition Unit, Meyer Children's Hospital, Florence, Italy
| | - Tamara Caldaro
- Digestive Diseases Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Flavio Labriola
- Pediatric Gastroenterology Unit, Pediatric Department, Maggiore C.A. Pizzardi Hospital, Bologna, Italy
| | - Paola De Angelis
- Digestive Diseases Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Paolo Lionetti
- Pediatric Gastroenterology and Nutrition Unit, Meyer Children's Hospital, Florence, Italy
- Department NEUROFARBA, University of Florence, Florence, Italy
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Egberg MD, Zhang X, Phillips M, Kappelman MD. Trends in Surgical Recurrence Among Pediatric Crohn's Disease Patients Using Administrative Claims Data. CROHN'S & COLITIS 360 2023; 5:otad003. [PMID: 36846098 PMCID: PMC9951729 DOI: 10.1093/crocol/otad003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Indexed: 02/23/2023] Open
Abstract
Background Despite the growing armamentarium of medical therapies for Crohn's disease (CD), well over half of patients with CD will require surgical intervention. We estimated the surgical recurrence risk and characterized postoperative treatment and colonoscopy use in pediatric CD patients using a large, geographically diverse administrative claims database. Methods We analyzed postresection pediatric (≤18 years) CD patients identified in the 2007-2018 IQVIA Legacy PharMetrics administrative claims database using diagnosis and procedural codes. We estimated the surgical recurrence risk over time, characterized postoperative treatments, and reported the frequency of colonoscopy 6-15 months postoperatively. Results Among 434 pediatric CD patients who underwent intestinal resection (median age 16 years, 46% female), risk of surgical recurrence was 3.5%, 4.6%, and 5.3% at 1, 3, and 5 years, respectively. Patients were most commonly prescribed an immune modulator (33%), anti-tumor necrosis factor agent (32%), or antibiotic (27%) postoperatively. Among 281 patients with ≥15 months of follow-up, 24% underwent colonoscopy 6-15 months postoperatively. Conclusions Surgical recurrence risk increases over time and the low colonoscopy rates and treatment variation postoperatively represent an opportunity for practice improvement.
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Affiliation(s)
- Matthew D Egberg
- Address correspondence to: Matthew D. Egberg, MD, MPH, MMSc, Division of Pediatric Gastroenterology and Hepatology, Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, #4101, Chapel Hill, NC 27599, USA ()
| | - Xian Zhang
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael Phillips
- Department of Surgery, Division of Pediatric General Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael D Kappelman
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Department of Medicine, Division of Adult Gastroenterology, Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Recurrence rates following ileo-colic resection in pediatric patients with Crohn's disease. Pediatr Surg Int 2023; 39:83. [PMID: 36645480 DOI: 10.1007/s00383-022-05346-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Ileo-colic resection (ICR) is an important therapeutic option for Crohn's disease (CD) patients. There are limited updated data of clinical and endoscopic post-operative recurrence (POR) in pediatric patients with CD for the long run. We aimed to determine recurrence rates following ICR over an extended period of time and asses its risk factors. METHODS This is a single-center retrospective review of 35 patients with CD between the ages of 6 and 17.9 years who required ICR between 2003 and 2021 at Schneider Children Medical Center of Israel. Medical charts were reviewed at different time-points post-ICR. RESULTS Clinical recurrence following ICR was demonstrated in only 11.4% and 28.6% (n = 4, n = 10) in the first two and five years-much lower rates than what was reported so far. We found no specific risk factor that correlated with clinical recurrence, although patients that were treated with early prophylaxis of anti-TNF medications following ICR tend to have less recurrence. CONCLUSIONS We found lower POR following ICR, especially in the first years after surgery-which can be attributed to close surveillance and early medical treatment. Such surveillance seems to improve recurrence rates in the first years following ICR.
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The Influence of the Introduction of Biologic Agents on Surgical Intervention in Paediatric Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2022; 75:308-312. [PMID: 35666884 DOI: 10.1097/mpg.0000000000003510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To determine how the use of biological therapy is associated with surgical intervention for paediatric inflammatory bowel disease (PIBD) at a population level. METHODS Hospital Episode Statistics data were obtained for all admissions within England (1997-2015), in children aged 0-18 years, with an ICD-10 code for diagnosis of Crohn disease (CD), ulcerative colitis (UC), or inflammatory bowel disease-unclassified (IBD-U). Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures codes for major surgical resection associated with PIBD and for biological therapy were also obtained. Data are presented as median values (interquartile range). RESULTS In total, 22,645 children had a diagnosis of PIBD of which 13,722 (61%) had CD, 7604 (34%) had UC, and 1319 (5.8%) cases had IBD-U. Biological therapy was used in 4054 (17.9%) cases. Surgical resection was undertaken in 3212 (14%) cases, more commonly for CD than UC (17.5 vs 10.3%, P < 0.0001). Time from diagnosis to major surgical resection was 8.3 (1.2-28.2) months in CD and 8.2 (0.8-21.3) months in UC. As the time-frame of the dataset progressed, there was a decreased rate of surgical intervention ( P = 0.04) and an increased use of biological therapy ( P < 0.0001). Additionally, the number of new diagnoses of PIBD increased. CONCLUSIONS The introduction of biologic agents has been associated with a reduction in cases undergoing surgery in children with a known diagnosis of PIBD. As time progresses we will be able to determine whether biological therapies prevent the need for surgery altogether or just delay this until adulthood.
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Abstract
BACKGROUND Ileocecectomy related to stricturing, fistula formation, or medically refractory disease is commonly required in patients with Crohn disease (CD). Limited research exists in endoscopic recurrence (ER) in pediatric inflammatory bowel disease (IBD). In this study, we sought to determine ER rates and the impact of therapy duration before surgery in pediatric patients with CD. METHODS This was a single-center retrospective review of patients with CD between the ages of 2 to 20 years who required ileocecectomy between January 2015 and December 2019 at Nationwide Children's Hospital. Follow-up endoscopies, laboratory values, medications, and sPCDAI scores were recorded at 6, 12, 24, and 36 months post-resection wherever available. Modified Rutgeert scores (mRS) were independently assigned to post-resection colonoscopy images by 3 trained investigators. Post-resection outcomes were compared between patients on CD therapy >30 days before resection (late surgery) to those started on CD therapy <30 days before resection (early surgery). RESULTS A total of 48 patients underwent ileocecectomy, with a mean age at time of resection of 17 years (+/-2.3). In total, 88% of patients had a post-resection endoscopy and 57% had an endoscopy within 12 months of resection. Twenty-nine percentage had ER with a mRS ≥i2. There was no statistical difference in endoscopic and clinical outcomes after resection between the early and late surgery groups. CONCLUSIONS Post-resection endoscopic recurrence after ileocecectomy was found in 29% of our center's pediatric CD population based on mRS. Post-resection outcomes were not affected by therapy duration before resection.
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