Surgery and paediatric inflammatory bowel disease

A Comparison of Clinical Outcomes of Colectomies for Pediatric and Adult Patients With Inflammatory Bowel Disease

Background: Crohn's disease (CD) and ulcerative colitis (UC) are prevalent in adult and pediatric populations, but their differences are not well studied using national data. We compared the clinical outcomes of these patients using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) databases.Methods: Colectomy cases for CD and UC, the 2 major forms of inflammatory bowel disease (IBD), were compared between adult and pediatric patients using the 2017-2019 ACS NSQIP databases. Various clinical factors were analyzed, with postoperative complications being the primary outcome of interest.Results: We identified 542 pediatric and 5174 adult CD patients and 360 pediatric and 1292 adult UC patients. Adults with CD or UC were more likely to be on steroids preoperatively (CD: 60.15% vs 24.54%; UC: 65.63% vs 51.39%). Children with IBD were more likely to have preoperative transfusions (CD: 1.48% vs .33%; UC: 8.33% vs .62%), systemic inflammatory response syndrome (CD: 3.51% vs .93%; UC: 12.78% vs 3.10%), or sepsis (CD: 1.85% vs .66%; UC: 1.39% vs .31%). Unplanned reoperations were more common among pediatric patients in both disease states compared to adults (CD: 6.27% vs 4.10%; UC: 11.11% vs 4.26%), with P-values for all factors described as ≤.02. Multivariate logistic regression found pediatric age to be associated with higher odds of needing a reoperation among UC patients but not CD patients.Conclusion: Pediatric patients were sicker at the time of surgery, and those with either disease were more likely to require a reoperation within 30 days.

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

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.

Use of the Kono-S anastomosis in pediatric Crohn's disease: a single-institution experience

OBJECTIVES

About 24% of children with Crohn's Disease (CD) require surgery. In 2003, Kono et al. described a novel anastomosis reported to decrease the rate of anastomotic CD recurrence. Subsequent studies have reproduced these outcomes, but none has demonstrated its effect in pediatric patients. This study evaluates short-term outcomes of pediatric patients following ileocolic resection and Kono-S anastomosis.

METHODS

A retrospective review of patients < 18 years old who underwent ileocolic resection followed by Kono-S anastomosis compared with those who underwent a stapled anastomosis.

RESULTS

Nine Kono-S patients were matched with nine patients preceding them who received traditional side-to-side and end-to-side anastomoses. All patients underwent minimally invasive surgery. Demographics, pre-operative medication usage, and symptom profiles were not significantly different. Traditional anastomosis (TA) patients had longer lengths of stay (4.6 vs 2.9 days; p = 0.03) but had no statistically significant differences in blood loss, procedure length, and pathologic findings. One Kono-S patient had a superficial surgical site infection, and one TA patient had an anastomotic leak requiring reoperation within 30 days. More TA patients experienced post-operative symptoms at both 30-day and 6-month follow-up (66.7% vs 33.3%; p = 0.16 and 77.8% vs 25%; p = 0.03).

CONCLUSION

The Kono-S anastomosis appears to be safe in pediatric CD when compared to traditional stapled anastomoses.

Role of mechanical and oral antibiotic bowel preparation in children with Hirschsprung's disease undergoing colostomy closure and pull-through

BACKGROUND

Mechanical and oral antibiotic bowel preparation (MOABP) has been performed routinely before colorectal surgery in children, but the necessity was questioned recently. We evaluated the utility of MOABP in children with Hirschsprung's disease (HSCR) undergoing colostomy closure and pull-through.

METHODS

The medical records of pediatric patients with HSCR who underwent colostomy closure and pull-through in a single center from January 2010 to January 2020 were reviewed. The use of MOABP was noted. The incidence of postoperative complications, duration of postoperative antibiotic therapy, total hospital cost and length-of-stay were compared between patients receiving MOABP and no bowel preparation (NBP).

RESULTS

A total of 64 patients were included in the study: 33 received MOABP and 31 had NBP. The respective postoperative complications in the MOABP and NBP groups were: intra-abdominal infection (18.2% vs. 29.0%), wound infection (9.1% vs. 16.1%), anastomotic leak (0 vs. 0), intestinal obstruction (6.1% vs. 0) and enterocolitis (3.03% vs. 12.90%). The duration of antibiotic therapy was 4.91±4.21 and 5.23±3.77 days (P=0.75) and hospitalization was 18.21±7.26 and 16.26±6.63 days (P=0.27) respectively. The total hospital cost in the MOABP group (4,720.14±1,858.89 USD) was higher than in the NBP group (3,749.06±2,009.97 USD) (P=0.049).

CONCLUSIONS

We did not find any clear benefit of MOABP in children with HSCR before colostomy closure and pull-through. However, a multicenter randomized controlled trial is needed to more definitely determine the best preoperative approach for children with HSCR.