Surgical Management of Ulcerative Colitis in Children and Adolescents: A Systematic Review from the APSA Outcomes and Evidence-Based Practice Committee

INTRODUCTION

The incidence of ulcerative colitis (UC) is increasing. Roughly 20% of all patients with UC are diagnosed in childhood, and children typically present with more severe disease. Approximately 40% will undergo total colectomy within ten years of diagnosis. The objective of this study is to assess the available evidence regarding the surgical management of pediatric UC as determined by the consensus agreement of the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP).

METHODS

Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on surgical decision-making for children with UC. Questions focused on surgical timing, reconstruction, use of minimally invasive techniques, need for diversion, and risks to fertility and sexual function. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of Bias was assessed using Methodological Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized.

RESULTS

A total of 69 studies were included for analysis. Most manuscripts contain level 3 or 4 evidence from single-center retrospective reports, leading to a grade D recommendation. MINORS assessment revealed a high risk of bias in most studies. J-pouch reconstruction may result in fewer daily stools than straight ileoanal anastomosis. There are no differences in complications based on the type of reconstruction. The timing of surgery should be individualized to patients and does not affect complications. Immunosuppressants do not appear to increase surgical site infection rates. Laparoscopic approaches result in longer operative times but shorter lengths of stay and fewer small bowel obstructions. Overall, complications are not different using an open or minimally invasive approach.

CONCLUSIONS

There is currently low-level evidence related to certain aspects of surgical management for UC, including timing, reconstruction type, use of minimally invasive techniques, need for diversion, and risks to fertility and sexual function. Multicenter, prospective studies are recommended to better answer these questions and ensure the best evidence-based care for our patients.

LEVEL OF EVIDENCE

Level of evidence III.

STUDY TYPE

Systematic review.

[Comparative study on platelet transfusion in Lorraine-Champagne and Alsace in 2015]

OBJECTIVES

To find explanations for the observed differences of platelets concentrates (PC) deliveries between 2 French regions, Lorraine-Champagne (LOCH) and Alsace (ALSA).

METHODS

This is a non-interventional prospective study, performed during 30 days in 2015 in intensive care, cardiovascular surgery and onco-hematological wards of 8 LOCH and ALSA hospitals. Questionnaires listing clinical and biological parameters were attached to the prescription forms and filled in at each PC prescription.

RESULTS

In all, 290 patients, 1093 prescriptions and 1093 deliveries of PC were analyzed. The pre-transfusional context (patient weight, prophylactic or curative situation, pre-transfusional platelet count) were homogenous. The phasing of the prescription forms wording had a direct impact on the doses' formulation : 100 % of the LOCH forms were expressed in platelet quantity (PQ), vs 22 % in ALSA. The mean interval between 2 transfusions was 2.9 days in ALSA vs 4.9 days in LOCH. The mean PQ/delivery was higher in ALSA (5.6.10¹¹ vs 4.0.10¹¹ in LOCH). The delivered PQs were compared to the 2003 French recommendations that were in force in 2015. Twenty-seven percent of the LOCH delivered PQs were in the recommended interval, vs Forty-nine percent in ALSA. Due to the systematic delivery of a single PC unit, including weights>80Kg, LOCH presented 63 % insufficient PQ deliveries. Twenty-two percent of the deliveries in ALSA were over the recommended interval, mostly linked with the simultaneous delivery of a second PC.

CONCLUSION

This study identifies disparities in terms of prescription and delivery between LOCH and ALSA, which may explain their respective PC consumption levels.

Laparoscopic versus open fundoplication in infants

BACKGROUND

Laparoscopic esophagogastric fundoplication is an effective treatment for severe gastroesophageal reflux disease (GERD), although its role in the very young is still largely undetermined. We review our surgical outcome in infants with severe GERD, comparing laparoscopic (LNF) with open (ONF) Nissen fundoplication.

METHODS

This study reviewed 55 consecutive Nissen fundoplications performed for GERD on infants less than 1 year old at our institution between January 1996 and June 2000. The follow-up period for LNF averaged 14.2 months (range, 3.3-42 months), as compared with 16.5 months (range, 1-37.1 months) for ONF (p was not significant, t-test). Surgical outcome was compared in terms of the following parameters: average operative time, times to initiation and completion of feeding schedule, postoperative complications, and recurrence rates.

RESULTS

For the study, 53 infants were divided into two groups: LNF (n = 39; 73.6%) and ONF (n = 14; 26.4%). The average operating time for LNF was 120 +/- 24 min (range, 60-195 min), as compared with 91 +/- 21 min (range, 60-135 min) for ONF (p < 0.05, t-test). Time to initiation of postoperative feeding schedule was 1.3 +/- 0.3 days for LNF, as compared with 3 +/- 0.9 days for ONF (p < 0.05, t-test). Full feedings were reached in 1.7 +/- 0.6 days for LNF, as compared with 1.3 +/- 0.9 for ONF (p was not significant, t-test). During the short-term follow-up period, recurrent reflux developed in 2/14 ONF patients (14.3%) as compared with 1/39 LNF patients (2.6%) (p < 0.05).

CONCLUSIONS

We conclude that in addition to sparing infants the morbidity of celiotomy, laparoscopic Nissen fundoplication had a surgical outcome comparable to that of traditional open fundoplication in infants with severe GERD. Importantly, resumption of goal nutritional regimens was equally efficient in both groups.

Wireless replacement of the "lost" central venous line in children

Although the achievement of central venous access in children is often difficult maintenance of access is often frustrated by the tendency of the small-caliber central venous line (CVL) to thrombose despite adequate heparinization or-worse yet-be inadvertently removed. Traditional replacement over wire (Seldinger technique) is often not an option for these "lost" CVLs. Over the past 7 years we have used a wireless technique of CVL replacement to re-establish central access in children. The charts of 125 children who underwent wireless CVL replacement at various institutions between January 1995 and July 2000 were retrospectively reviewed. The wireless technique involves replacement of CVL by direct insertion through the previous catheter tract marked by the old puncture site. Plain film was used to confirm the line position postprocedure. The technique was applied predominantly to percutaneously placed 3- to 4-F CVLs with distal port thrombosis or those that had been inadvertently removed. Successful replacement was defined as re-establishment of previous line position and the ability to flush/draw blood through all ports. Wireless replacement was successful in 120 of 125 cases (96.0%). Recannulization was successful in CVLs as new as 3 days old and those removed for as long as 24 hours. Of the five unsuccessful cases, however, two CVLs were >3 weeks old, but >6 hours had elapsed since removal. The remaining three cases were CVLs that were <3 days old. There were no intra- or postoperative complications, notably air embolism. We conclude that wireless CVL replacement in children can be performed safely and successfully in children who have lost central access not amenable to replacement via the traditional Seldinger technique. The often difficult chore of re-establishing central access at a new site in small children can thus be avoided.

New trends in extracorporeal membrane oxygenation in newborn pulmonary diseases

New trends in extracorporeal membrane oxygenation (ECMO) for respiratory failure in the newborn were reviewed. Following a decade of clinical research, ECMO is now the standard treatment for newborn respiratory failure when all other conventional less-invasive treatment options have been exhausted. As of July 2000, 15,525 newborns with respiratory failure treated with ECMO have been entered into the registry of the Extracorporeal Life Support Organization with an overall survival rate of 78%. The latest improvement in ECMO technology in this group of patients includes minimally invasive modes of vascular access through percutaneous approaches to minimize morbidity. However, with advances in modes of mechanical ventilation, including high-frequency ventilation and the introduction of inhaled nitric oxide, the use and necessity for ECMO have clearly diminished for newborn respiratory failure.