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Dipasquale V, Antonelli E, Cannavò L, Cavatoi G, Romeo C, Trimarchi G, Navarra G, Romano C. Surgery-Related Quality of Life of Pediatric Patients With Crohn's Disease. Front Pediatr 2020; 8:608370. [PMID: 33392119 PMCID: PMC7773926 DOI: 10.3389/fped.2020.608370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 11/23/2020] [Indexed: 12/29/2022] Open
Abstract
Objective: Up to 30% of pediatric patients with Crohn's disease (CD) require surgery. The aim of the study was to evaluate long-term health-related quality of life (HRQoL) outcome in children with CD who have had ileocolonic resection. Materials and methods: This was a retrospective cross-sectional study on all pediatric patients who had undergone surgery for CD between January 2015 and December 2017 in the Pediatric Surgery and Gastroenterology Units of the University Hospital of Messina. Surgical treatment was represented by laparoscopic ileocecal resection with latero-lateral anastomosis. Patients were asked to fill in a modified version of the IMPACT III questionnaire made up of 15 closed questions before and after surgery. The questionnaire was scored on a five-point scale with 5 reporting "not a problem" and 1 "a very severe problem." The total score ranged from 15 (worst HRQoL) to 75 (best HRQoL). Frequency of relapses, reoperations, complications during follow-up, and postoperative bowel function were also studied. Results: Data were obtained in 10 patients (9 males), who underwent surgery at a median age of 13.5 years (range 13-18), after a median post-diagnosis period of 2.5 years (range 0-8). Preoperative scores were low in all 4 domains of the questionnaire. Postoperatively, HRQoL measures improved significantly (p < 0.05) about symptoms, school attendance, social and emotional functioning. Overall, nearly all patients were completely satisfied with the surgical outcome. Conclusions: HRQoL is low in CD children referred for possible operation, and surgery may positively affect the overall HRQoL. Collecting HRQoL data provides insight into the impact of treatment on children health status.
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Affiliation(s)
- Valeria Dipasquale
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Enrica Antonelli
- Pediatric Surgery Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Laura Cannavò
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Giorgio Cavatoi
- Pediatric Surgery Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Carmelo Romeo
- Pediatric Surgery Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | | | - Giuseppe Navarra
- Surgical Oncology Division, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
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Rinawi F, Zevit N, Eliakim R, Niv Y, Shamir R, Assa A. Long-Term Outcomes After Primary Bowel Resection in Pediatric-Onset Crohn's Disease. Inflamm Bowel Dis 2017; 24:149-158. [PMID: 29272491 DOI: 10.1093/ibd/izx030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is limited evidence on the long-term outcome of intestinal resection in pediatric-onset Crohn's disease (POCD) with no established predictors of adverse outcomes. We aimed to investigate clinical outcomes and predictors for adverse outcome following intestinal resection in POCD. METHODS The medical records of patients with POCD who underwent at least 1 intestinal resection between 1990 and 2014 were reviewed retrospectively. Main outcome measures included time to first flare, hospitalization, second intestinal resection, and response to nonprophylactic biologic therapy. RESULTS Overall, 121 patients were included. Median follow-up was 6 years (range 1-23.6). One hundred and seven (88%) patients experienced at least 1 postsurgical exacerbation, 52 (43%) were hospitalized, and 17 (14%) underwent second intestinal resection. Of 91 patients who underwent surgery after the year 2000, 37 (41%) were treated with antitumor necrosis factor ɑ (anti-TNFɑ) (nonprophylactic) following intestinal resection. Time to hospitalization and to second intestinal resection were shorter among patients with extraintestinal manifestations (EIMs) (HR 2.7, P = 0.006 and HR = 3.1, P = 0.03, respectively). Time to initiation of biologic treatment was shorter in patients with granulomas (HR 2.1, P = 0.038), whereas being naïve to anti-TNFɑ treatment before surgery was a protective factor for biologic treatment following surgery (HR 0.3, P = 0.005). Undergoing intestinal resection beyond the year 2000 was associated with shorter time to first flare (HR 1.9, P = 0.019) and hospitalization (HR 2.6, P = 0.028). CONCLUSION Long-term risk for flares, hospitalization, or biologic treatment is significant in POCD following bowel resection. EIMs increase the risk for hospitalization and second intestinal resection.
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Affiliation(s)
- Firas Rinawi
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Noam Zevit
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Rami Eliakim
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Sheba Medical Center -Tel Hashomer, Ramat Gan, Israel
| | - Yaron Niv
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Rabin Medical Center, Petach Tikva, Israel
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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3
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Abstract
Pediatric Crohn disease is characterized by clinical and endoscopic relapses. The inflammatory process is considered to be progressive and may lead to strictures, fistulas, and penetrating disease that may require surgery. In addition, medically refractory disease may be treated by surgical resection of inflamed bowel in an effort to reverse growth failure. The need for surgery in childhood suggests severe disease and these patients have an increased risk for recurrent disease and potentially more surgery. Data show that up to 55% of patients had clinical recurrence in the first 2 years after initial surgery. The current clinical report on postoperative recurrence in pediatric Crohn disease reviews the risk factors for early surgery and postoperative recurrence, operative risk factors for recurrence, and prevention and monitoring strategies for postoperative recurrence. We also propose an algorithm for postoperative management in pediatric Crohn disease.
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Hojsak I, Kolacek S, Hansen LF, Bronsky J, Piekkala M, Lionetti P, Skaba R, Kolho KL. Long-term outcomes after elective ileocecal resection in children with active localized Crohn's disease--a multicenter European study. J Pediatr Surg 2015; 50:1630-5. [PMID: 25913894 DOI: 10.1016/j.jpedsurg.2015.03.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 03/03/2015] [Accepted: 03/21/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this study was to investigate the therapeutic role of an elective ileocecal resection in children with active localized Crohn's disease. METHODS This was a retrospective multicenter study which included five European referral centers which included all children with Crohn's disease who underwent ileocecal surgery from 2000 to 2011 and had a minimum of 12 months follow-up. RESULTS Altogether 68 patients fulfilled inclusion criteria. Median age at diagnosis was 13.7 years (6.6-17.9 years) and at surgery 15.2 years (8.6-18.5 years). Median duration of postoperative clinical remission was 20 months (3-95 months). Overall 54 patients (79.4%) were in remission one year after surgery and 38 (55.9%) during the total postsurgical follow up (median 30 months; range 12-95 months). Z score height for age significantly improved postoperatively in children who were at the time of surgery younger than 16 years of age (mean difference 0.232 SD; p=0.029). Cox proportional hazard regression model failed to indicate risk factors associated with postsurgical relapse. CONCLUSION Elective ileocecal resection is a valid treatment option which should be considered in a subset of pediatric patients with localized Crohn's disease with the aim of achieving clinical remission and to improve growth.
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Affiliation(s)
- Iva Hojsak
- Children's Hospital Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia.
| | - Sanja Kolacek
- Children's Hospital Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Maija Piekkala
- Children's Hospital, University of Helsinki, Helsinki, Finland
| | | | - Richard Skaba
- Department of Paediatric Surgery, University Hospital Motol, Prague, Czech Republic
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5
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Kulungowski AM, Acker SN, Hoffenberg EJ, Neigut D, Partrick DA. Initial operative treatment of isolated ileal Crohn's disease in adolescents. Am J Surg 2014; 210:141-5. [PMID: 25457242 DOI: 10.1016/j.amjsurg.2014.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 06/20/2014] [Accepted: 07/16/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND We hypothesize that in children with Crohn's disease (CD) isolated to a single site, resection leads to clinical improvement, decreased medication requirements, and improved growth. METHODS A retrospective review was conducted of children with CD isolated to the terminal ileum undergoing operative intervention at Children's Hospital Colorado between 2002 and 2013. RESULTS Twenty-six patients underwent ileocecetomy (mean age at diagnosis 14.1 ± 2.6 years; mean age at resection 15.7 ± 2.5 years; median follow-up 2 ± 1.5 years). Twenty-two (84.6%) patients reported clinical improvement and 17 (65.4%) were able to decrease the number or dosage of medications. Average weight increased from the 29th to the 45th percentile (P = .09) at 1 year and to the 56th percentile (P = .02) at 3 years post resection. Average body mass index increased from the 30th to the 48th and 49th percentile at 1 and 3 years (P < .05 for both), respectively. Height increased from the 39th percentile at the time of resection to the 51st percentile at 3 years (P = nonsignificant). CONCLUSION Surgical resection of an isolated ileal segment in adolescents with CD allows for catch-up growth and reduction in medication requirements.
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Affiliation(s)
- Ann M Kulungowski
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Division of Surgery, University of Colorado, School of Medicine, Aurora, CO 80045, USA.
| | - Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Division of Surgery, University of Colorado, School of Medicine, Aurora, CO 80045, USA
| | - Edward J Hoffenberg
- Department of Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado, School of Medicine, Aurora, CO 80045, USA
| | - Deborah Neigut
- Department of Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado, School of Medicine, Aurora, CO 80045, USA
| | - David A Partrick
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Division of Surgery, University of Colorado, School of Medicine, Aurora, CO 80045, USA
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Kambouri K, Gardikis S, Agelidou M, Vaos G. Local peritonitis as the first manifestation of Crohn's disease in a child. J Indian Assoc Pediatr Surg 2014; 19:100-2. [PMID: 24741214 PMCID: PMC3983759 DOI: 10.4103/0971-9261.129606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Crohn's disease (CD) can occur anywhere in the gastrointestinal tract from the mouth to the anus and sometimes it presents in a nonspecific manner. Herein we describe a case of local peritonitis as the first manifestation of CD in an 11-year-old girl, and the subsequent method of treatment.
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Affiliation(s)
- Katerina Kambouri
- Department of Pediatric Surgery, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece
| | - Stefanos Gardikis
- Department of Pediatric Surgery, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece
| | - Maria Agelidou
- Department of Pediatric Surgery, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece
| | - George Vaos
- Department of Pediatric Surgery, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece
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Abstract
IBD is a chronic disorder with disease onset ranging from early childhood to beyond the sixth decade of life. The factors that determine the age of onset currently remain unexplained. Is timing of occurrence a random event or is it indicative of different pathophysiological pathways leading to different phenotypes across the age spectrum? Over the past decade, several studies have suggested that the characteristics and natural history of IBD seem to be different according to age of onset. This heterogeneity suggests that the respective contributions of genetics, host immune system and environment to the aetiology and phenotype of Crohn's disease and ulcerative colitis are different across ages. Critical reviews that focus on differences characterizing IBD between age groups are scarce. Therefore, this Review updates the knowledge of the differences in epidemiology, clinical characteristics, and natural history of paediatric, adult and elderly-onset IBD. In addition, potential differences in host-gene-microbial interactions according to age are highlighted.
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Piekkala M, Pakarinen M, Ashorn M, Rintala R, Kolho KL. Long-term outcomes after surgery on pediatric patients with Crohn disease. J Pediatr Gastroenterol Nutr 2013; 56:271-6. [PMID: 23114471 DOI: 10.1097/mpg.0b013e318279871c] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Of pediatric patients with Crohn disease, 20% to 30% undergo surgery within 10 years. Although disease relapses and reoperations are common, long-term functional outcomes and quality of life (QoL) are unclear. METHODS In 2010, we reviewed the hospital records of all pediatric patients with CD who had undergone intestinal resections during childhood in 2 major tertiary care hospitals between 1985 and 2008 and mailed out questionnaires that asked about health outcomes and QoL. We compared the QoL of the patients and a group of matched controls randomly chosen from the Population Register Centre. RESULTS In total, 36 children had undergone bowel resection a median of 10 years earlier and had at least 2 years of follow-up. Disease activation (verified at endoscopy) requiring medical or surgical treatment occurred in 94% (median 1.8 years after primary resection). At least 1 surgical complication occurred in 77%, and 54% underwent re-resection. The patients reported a median stool frequency of 3 stools during the day and zero at night, with 33% being totally continent. Overall, 96% were completely or moderately satisfied with the outcome of the surgery. The QoL was comparable between the patients and controls, but school or work absences diminished the QoL of the patients. CONCLUSIONS Surgery for pediatric-onset CD is risky even under expert care. Disease relapses and bowel re-resections are common during the first decade after primary surgery. In the long term, however, bowel function is acceptable and the QoL is comparable between patients and their peers.
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Affiliation(s)
- Maija Piekkala
- Children's Hospital, Helsinki University Central Hospital and Helsinki University, Helsinki, Finland.
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9
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Boualit M, Salleron J, Turck D, Fumery M, Savoye G, Dupas JL, Lerebours E, Duhamel A, Merle V, Cortot A, Colombel JF, Peyrin-Biroulet L, Gower-Rousseau C. Long-term outcome after first intestinal resection in pediatric-onset Crohn's disease: a population-based study. Inflamm Bowel Dis 2013; 19:7-14. [PMID: 22573565 DOI: 10.1002/ibd.23004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND To describe long-term postoperative evolution of pediatric-onset Crohn's disease (CD) and identify predictors of outcome we studied a population-based cohort (1988-2004) of 404 patients (0-17 years), of which 130 underwent surgery. METHODS Risks for a second resection and first need for immunosuppressors (IS) and/or biologics were estimated by survival analysis and Cox models used to determine predictors of outcome. Impact of time of first surgery on nutritional catch-up was studied using regression. RESULTS In all, 130 patients (70 females) with a median age at diagnosis of 14.2 years (interquartile range: 12-16) were followed for 13 years (9.4-16.6). Probability of a second resection was 8%, 17%, and 29% at 2, 5, and 10 years, respectively. In multivariate analysis, age <14, stenosing (B2) and penetrating (B3) behaviors and upper gastrointestinal location (L4) at diagnosis were associated with an increased risk of second resection. Probability of receiving IS or biologics was 18%, 34%, and 47% at 2, 5, and 10 years, respectively. In multivariate analysis, L4 was a risk factor for requiring IS or biologics, while surgery within 3 years after CD diagnosis was protective. Catch-up in height and weight was better in patients who underwent surgery within 3 years after CD diagnosis than those operated on later. CONCLUSIONS In this pediatric-onset CD study, mostly performed in a prebiologic era, a first surgery performed within 3 years after CD diagnosis was associated with a reduced need for IS and biologics and a better catch-up in height and weight compared to later surgery.
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Affiliation(s)
- Médina Boualit
- Univ Lille Nord de France, CHU Lille and Lille-2 University, Gastroenterology Unit, France
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10
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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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Piekkala M, Kalajoki-Helmiö T, Martelius L, Pakarinen M, Rintala R, Kolho KL. Magnetic resonance enterography guiding treatment in children with Crohn's jejunoileitis. Acta Paediatr 2012; 101:631-6. [PMID: 22251165 DOI: 10.1111/j.1651-2227.2012.02607.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIM To determine the usefulness of magnetic resonance enterography (MRE) in treatment for paediatric patients with Crohn's disease. METHODS To evaluate small bowel involvement, 45 children with Crohn's disease were scheduled for MRE. Two radiologists blinded to the patient data independently re-evaluated the images. Findings in images were compared to macroscopic findings at surgery or endoscopy. RESULTS The terminal ileum was visualized in all with a completed procedure (43/45). The treatment remained conservative in 74% after imaging. In all 13 patients who underwent ileocolonoscopy within 3 months of MRE, the MRE findings were comparable with the macroscopic findings or revealed a more extensive disease. Bowel resection was performed in 26% after imaging. The macroscopic findings in the bowel corresponded to the MRE findings in 73%. In three MRE suggested a more severe disease than was verified intraoperatively. CONCLUSIONS Magnetic resonance enterography identifies disease involvement in the small bowel in young patients with Crohn's disease and may guide decisions on the need for intestinal surgery or adjustment of medication.
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Affiliation(s)
- M Piekkala
- Children's Hospital, University of Helsinki, Finland.
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12
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Van Assche G, Dignass A, Reinisch W, van der Woude CJ, Sturm A, De Vos M, Guslandi M, Oldenburg B, Dotan I, Marteau P, Ardizzone A, Baumgart DC, D'Haens G, Gionchetti P, Portela F, Vucelic B, Söderholm J, Escher J, Koletzko S, Kolho KL, Lukas M, Mottet C, Tilg H, Vermeire S, Carbonnel F, Cole A, Novacek G, Reinshagen M, Tsianos E, Herrlinger K, Oldenburg B, Bouhnik Y, Kiesslich R, Stange E, Travis S, Lindsay J. The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Special situations. J Crohns Colitis 2010; 4:63-101. [PMID: 21122490 DOI: 10.1016/j.crohns.2009.09.009] [Citation(s) in RCA: 526] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 09/28/2009] [Accepted: 09/28/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Gert Van Assche
- Division of Gastroenterology, Leuven University Hospitals, 49 Herestraat, BE 3000, Leuven, Belgium.
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13
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Lee YJ, Oh SH, Kim KM. The Principles of Drug Therapy of Crohn's Disease in Child and Adolescent. ACTA ACUST UNITED AC 2010. [DOI: 10.5223/kjpgn.2010.13.suppl1.s59] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Yeoun Joo Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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14
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Strong SA, Koltun WA, Hyman NH, Buie WD. Practice parameters for the surgical management of Crohn's disease. Dis Colon Rectum 2007; 50:1735-46. [PMID: 17690937 DOI: 10.1007/s10350-007-9012-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Scott A Strong
- Fletcher Allen Health Care, 111 Colchester Avenue, Fletcher 301, Burlington, Vermont 05401, USA
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15
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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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16
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Singh Ranger G, Lamparelli MJ, Aldridge A, Chong SK, Mitton SG, Albanese A, Kumar D. Surgery results in significant improvement in growth in children with Crohn's disease refractory to medical therapy. Pediatr Surg Int 2006; 22:347-52. [PMID: 16518590 DOI: 10.1007/s00383-006-1664-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2006] [Indexed: 01/06/2023]
Abstract
Inflammatory bowel disease (IBD) in children can cause significant impairment in linear growth, and delay in pubertal onset. The aim of this study was to assess the impact of surgery on linear growth in children with Crohn's disease (CD) who were resistant to medical therapy, and had documented evidence of growth impairment. We performed a retrospective study on eight consecutive patients with refractory disease who had attended the paediatric IBD clinic. All patients underwent surgery as part of their treatment. Height and weight were recorded at least 6 months prior to surgery, at the time of surgery, and 6 months post surgery. Growth velocities and height Z-scores were calculated. All patients had evidence of sustained growth suppression prior to surgery. Three patients had evidence of growth failure. There was a significant increase in height velocity from 0.15 cm/month before surgery to 0.54 cm/month after surgery (P = 0.006). There was also a significant decrease in the modified Harvey-Bradshaw index (HBI) of disease activity from 2.00 before surgery, to 0.84 after surgery (P = 0.003). Improvements in height Z-score and weight velocity after surgery were not significant on statistical analysis. Our study demonstrates that before surgery, children with CD refractory to therapy have sustained growth suppression, and in some cases may even have growth failure. Surgical intervention before puberty appears to result in a significant improvement in height velocity and disease activity. These findings need to be further investigated with carefully designed prospective studies.
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Affiliation(s)
- Gurpreet Singh Ranger
- Academic Department of Colorectal Surgery, St. George's Hospital Medical School, Blackshaw Road, Tooting, SW17 0QT, London, UK.
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17
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Caprilli R, Gassull MA, Escher JC, Moser G, Munkholm P, Forbes A, Hommes DW, Lochs H, Angelucci E, Cocco A, Vucelic B, Hildebrand H, Kolacek S, Riis L, Lukas M, de Franchis R, Hamilton M, Jantschek G, Michetti P, O'Morain C, Anwar MM, Freitas JL, Mouzas IA, Baert F, Mitchell R, Hawkey CJ. European evidence based consensus on the diagnosis and management of Crohn's disease: special situations. Gut 2006; 55 Suppl 1:i36-58. [PMID: 16481630 PMCID: PMC1859996 DOI: 10.1136/gut.2005.081950c] [Citation(s) in RCA: 328] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This third section of the European Crohn's and Colitis Organisation (ECCO) Consensus on the management of Crohn's disease concerns postoperative recurrence, fistulating disease, paediatrics, pregnancy, psychosomatics, extraintestinal manifestations, and alternative therapy. The first section on definitions and diagnosis reports on the aims and methods of the consensus, as well as sections on diagnosis, pathology, and classification of Crohn's disease. The second section on current management addresses treatment of active disease, maintenance of medically induced remission, and surgery of Crohn's disease.
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Affiliation(s)
- R Caprilli
- John Radcliffe Hospital, Oxford OX3 9DU, UK
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18
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Markowitz J, Markowitz JE, Bousvaros A, Crandall W, Faubion W, Kirschner BS, Perrault J, Rosh J, Winter H. Workshop report: prevention of postoperative recurrence in Crohn's disease. J Pediatr Gastroenterol Nutr 2005; 41:145-51. [PMID: 16056092 DOI: 10.1097/01.mpg.0000172746.86973.ef] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- James Markowitz
- Division of Pediatric Gastroenterology, Schneider Chidren's Hospital, North Shore-LIJ Health System, New Hyde Park, NY 11040, and University of Chicago, Chicago, IL, USA.
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19
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Jacobstein DA, Baldassano RN. Use of 6-mercaptopurine/azathioprine as the immunomodulator of choice for moderately active Crohn's disease: balance. Inflamm Bowel Dis 2005; 11:203-5. [PMID: 15677916 DOI: 10.1097/00054725-200502000-00016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Douglas A Jacobstein
- Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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20
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Hyams JS. Use of 6-mercaptopurine/azathioprine as the immunomodulator of choice for moderately active Crohn's disease: pro. Inflamm Bowel Dis 2005; 11:197-9. [PMID: 15677914 DOI: 10.1097/00054725-200502000-00014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Jeffrey S Hyams
- Digestive Diseases and Nutrition Division, Connecticut Children's Medical Center, Hartford, Connecticut 06106, USA.
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21
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Higuero T, Merle C, Thiéfin G, Coussinet S, Jolly D, Diebold MD, Zeitoun P, Cadiot G. Jejunoileal Crohn's disease: a case-control study. ACTA ACUST UNITED AC 2004; 28:160-6. [PMID: 15060461 DOI: 10.1016/s0399-8320(04)94871-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIMS Jejunoileitis might be a severe form of Crohn's disease (CD). The aim of the study was to evaluate clinical characteristics, therapeutics modalities and long-term outcome in CD patients with jejunoileitis (CDJI). METHODS All patients with CDJI followed in the department of Gastroenterology from 1963 to 1999 were included and compared to matched (on Year of CD diagnosis) CD controls without jejunoileitis. Data were obtained from retrospective review of medical charts. RESULTS Eighteen patients with CDJI were compared to 36 matched CD controls. Median follow-up was 7.65 Years in both groups. At time of CDJI diagnosis the following signs were significantly more frequent in patients with jejunoileal CD than in controls: malnutrition (39% vs 3%), pain suggesting obstruction (33% vs 8%), vomiting (28% vs 5%). Patients with CDJI were more frequently male: M/F ratio=2.0/1.1 (P=0.33). Upper digestive involvement (esophagus, stomach and duodenum) (67% vs 36%, P=0.04) and small intestine strictures (61% vs 19%, P=0.06) were more frequent in CDJI. Initial management was more "aggressive" in CDJI than in controls: steroids in 62% vs 30%, azathioprine in 39% vs 3%, total parenteral nutrition in 28% vs 8% and surgery in 33% vs 17%. During follow-up, the need for azathioprine therapy and surgery were more frequent in CDJI than in controls (extensive small bowel resection in two patients). In 10 of 18 patients, jejunoileitis involvement was diagnosed with a median delay of 3.6 Years (range: 0.5-14.5) after CD diagnosis and at time of CD diagnosis in the 8 others; outcome after CDJI diagnosis was similar in these 2 groups. CONCLUSION The main revealing signs of jejunoileitis in CD patients are obstruction and malnutrition. Patients with CDJI require more often azathioprine and surgery than CD patients without jejunoileitis. Jejunoileitis is a severe form of CD more frequently complicated by extensive small bowel resection.
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22
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Arnott IDR, Watts D, Ghosh S. Review article: is clinical remission the optimum therapeutic goal in the treatment of Crohn's disease? Aliment Pharmacol Ther 2002; 16:857-67. [PMID: 11966492 DOI: 10.1046/j.1365-2036.2002.01242.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Currently, the therapeutic end-point in the treatment of Crohn's disease is the remission of symptoms, but recent data confirm that mucosal inflammation may continue in the absence of symptoms. Furthermore, emerging evidence indicates that such subtle, sub-clinical mucosal inflammation leads to clinical relapse. The assessment of mucosal inflammation has become easier with the availability of faecal calprotectin assay. Current anti-inflammatory therapy often leaves low-grade mucosal inflammation untreated, and therefore recurrent relapses occur. We need to investigate whether the therapeutic end-point of anti-inflammatory medications needs to be more rigorous and to aim at complete mucosal healing, confirmed by the normalization of mucosal inflammatory markers such as faecal calprotectin concentrations. Immunosuppressive therapy with azathioprine/ 6-mercaptopurine currently offers the best mucosal healing treatment with reduction of relapses, but newer biological agents might offer less toxic therapy. Clinical trials to test the feasibility and efficacy of such a paradigm shift in the medical management of Crohn's disease are now warranted.
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Affiliation(s)
- I D R Arnott
- Gastrointestinal Unit, Department of Medical Sciences, University of Edinburgh, Western General Hospital, Edinburgh, UK
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23
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Abstract
The epidemiology, aetiology, clinical features, diagnosis, and treatment of Crohn's disease and ulcerative colitis in children are reviewed, and areas for further research identified.
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Affiliation(s)
- H R Jenkins
- Department of Child Health, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK.
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24
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Baldassano RN, Han PD, Jeshion WC, Berlin JA, Piccoli DA, Lautenbach E, Mick R, Lichtenstein GR. Pediatric Crohn's disease: risk factors for postoperative recurrence. Am J Gastroenterol 2001; 96:2169-76. [PMID: 11467649 DOI: 10.1111/j.1572-0241.2001.03876.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Postoperative recurrence of Crohn's disease in adults has been extensively studied; however, the course of Crohn's disease after surgery in children has not been well defined. The aim of this study was to examine the postoperative course of pediatric Crohn's disease and the factors that may predict early postoperative recurrence. METHODS We identified 100 resective surgeries in 79 children with Crohn's disease seen at the Children's Hospital of Philadelphia between 1978 and 1996. A retrospective, multivariable analysis of factors potentially influencing postoperative clinical recurrence was performed. Preoperative and postoperative height measurements were compared, and z scores were computed for height-for-age. Two-tailed t test was used for the analysis. RESULTS Clinical recurrence rates were 17% at 1 yr, 38% at 3 yr, and 60% at 5 yr. Patients with colonic Crohn's disease had a significantly shorter postoperative recurrence-free interval (median 1.2 yr) than patients with ileocecal (median 4.4 yr) or diffuse disease (median 3.0 yr) (p = 0.01). On multivariable analysis, a high Pediatric Crohn's Disease Activity Index at the time of surgery (p = 0.01) and preoperative use of 6-mercaptopurine (6-MP) (p < 0.005) were also independently associated with higher postoperative recurrence rates. There was a significant improvement in z scores for height (p = 0.04) after surgery. CONCLUSIONS In children undergoing resective surgery for Crohn's disease, high rates of postoperative Crohn's disease recurrence are associated with severe disease at the time of surgery, colonic Crohn's disease, and the preoperative use of 6-MP. Patients who require preoperative use of 6-MP are likely to suffer from a more aggressive disease and would benefit from postoperative 6-MP prophylaxis. Height growth was improved after intestinal resection for Crohn's disease.
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Affiliation(s)
- R N Baldassano
- Children's Hospital of Philadelphia, Department of Pediatrics, Pennsylvania 19104-4283, USA
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