Stapled restorative proctocolectomy in children with refractory ulcerative colitis

Temporal trends in ileoanal pouch surgery for paediatric onset ulcerative colitis in England from 1997 to 2015 using hospital episode statistics

INTRODUCTION

Ileal pouch-anal anastomosis (IPAA) following colectomy for ulcerative colitis (UC) achieves restoration of intestinal continuity with potential return of continence. It is undertaken relatively infrequently in children. We aimed to investigate the national frequency of IPAA in paediatric UC and report outcomes useful for surgeon/centre benchmarking.

METHODS

Hospital Episode Statistics data were obtained for all admissions in England (1997-2015) in children (< 18 years) who underwent IPAA for UC using OPCS-4 procedural codes. Surgeon specialty, readmission, and reoperation rates were identified. Data are median (interquartile range).

RESULTS

UC was diagnosed in 7604 children in whom 346 (4.6%) underwent IPAA at age 15 [13-17] years. Laparoscopy was used in 55 (15.9%) cases and in the most recent 10 years more commonly by specialist paediatric surgeons (SPS) than general surgeons (GS) (34.3%vs14.7%, p = 0.001). National frequency of IPAA ranged from 12 to 34 annually. Where specialty was available, 95/342 (57%) cases were undertaken by GS and 147/342 (43%) cases by SPS. The proportion of cases undertaken by SPS increased significantly compared to GS over the study period, p = 0.0003. Post-operative length of stay was 8 [6-11] days. During the index admission, unplanned return to theatre was required in 25/346 (7.2%). Following discharge 58 (16.8%) were readmitted within 30 days. Overall return to theatre rate within 30 days of pouch surgery was 11.0% (38/346).

CONCLUSION

IPAA for UC within childhood is undertaken infrequently in England, with a shift towards SPS undertaking surgery. These data can be used by surgeons to benchmark outcomes.

LEVEL OF EVIDENCE

IV.

Laparoscopic robotic-assisted restorative proctocolectomy and ileal J-pouch-anorectal anastomosis in children

PURPOSE

Total proctocolectomy with ileal J-pouch-anorectal anastomosis (IPAA) remains the preferred surgical treatment for ulcerative colitis (UC) in children. Considering the well-known advantages of minimally invasive approach, and its main application for the deep pelvis, robotic surgery may be used in UC reconstructive procedures. The aim of the study is to report our experience with Robotic IPAA in children.

METHODS

Single surgeon experience on Robotic IPAA were prospectively included. Data on patient demographics, surgical details, complications, and length of stay (LOS), were collected.

RESULTS

Fifteen patients were included. Median age was 13.2 years, median body weight 45 kg. Median operative time was 240 min. Median LOS was 7 days and mean follow-up time 1 year. No intraoperative complication occurred. Five postoperative complications happened: 3 minors treated conservatively (CD I-II), 2 majors needing reintervention under anesthesia (CD IIIb). No mortality was observed.

CONCLUSION

Our preliminary experience reveals that Robotic IPAA is a safe and feasible option for the surgical treatment of UC in children. A bigger patient sample and a long-term follow-up are needed to confirm our findings.

Short- and Long-term Outcomes After Ileal Pouch Anal Anastomosis in Pediatric Patients: A Systematic Review

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.

Stapled versus hand-sewn pediatric intestinal anastomoses: A retrospective cohort study

BACKGROUND

Whereas the adult literature has demonstrated the acceptable safety profile of stapled anastomoses when compared to the hand-sewn alternative, the choice of intestinal anastomosis using sutures or staples remains inadequately investigated in children. The purpose of this study is to compare the anastomotic outcomes of both techniques in children under 5years of age.

METHODS

A retrospective analysis of patients undergoing intestinal anastomosis at a single tertiary centre (2012-2016) was undertaken. Demographics, diagnosis, anatomy, and complications were compared between the hand-sewn (HS) and stapled anastomosis (SA) groups. Primary outcomes were anastomotic leak and/or stricture requiring intervention.

RESULTS

There were 72 patients with 90 intestinal anastomoses (67 HS, 23 SA). Baseline demographics between the two anastomotic groups were comparable. The overall anastomotic complication rate was 23.9% (HS) and 17.4% (SA). In the ileocolic subgroup, anastomotic complications occurred in 3/7 HS vs. 0/5 SA (ns). There were no statistically significant differences in primary outcomes between HS and SA. All SA complications occurred with 3.5 or 3.8mm staples.

CONCLUSIONS

In our study population, no statistically significant difference between hand-sewn and stapled intestinal anastomosis outcomes was found. However, further investigation is warranted.

LEVEL OF EVIDENCE

3 (Retrospective Comparative Treatment Study).

Variables associated with loss of ileoanal pouches constructed in childhood

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.

Colectomy in pediatric ulcerative colitis: A single center experience of indications, outcomes, and complications

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.

Paediatric ulcerative colitis surgery: Italian survey

BACKGROUND AND AIMS

Recent epidemiological studies showed an increase in ulcerative colitis among children, especially in its aggressive form, requiring surgical treatment. Although medical therapeutic strategies are standardized, there is still no consensus regarding indications, timing and kind of surgery. This study aimed to define the surgical management of paediatric ulcerative colitis and describe attitudes to it among paediatric surgeons.

METHODS

This was a retrospective cohort study. All national gastroenterology units were invited to participate. From January 2009 to December 2013, data on paediatric patients diagnosed with ulcerative colitis that required surgery were collected.

RESULTS

Seven units participated in the study. Seventy-one colectomies were performed (77.3% laparoscopically). Main surgical indications were a severe ulcerative colitis attack (33.8%) and no response to medical therapies (56.3%). A three-stage strategy was chosen in 71% of cases. Straight anastomosis was performed in 14% and J-pouch anastomosis in 86% of cases. A reconstructive laparoscopic approach was used in 58% of patients. Ileo-anal anastomosis was performed by the Knight-Griffen technique in 85.4% and by the pull-through technique in 9.1% of patients. Complications after colectomy, after reconstruction and after stoma closure were reported in 12.7, 19.3 and 35% of cases, respectively.

CONCLUSIONS

This study shows that there is general consensus regarding indications for surgery. The ideal surgical technique remains under debate. Laparoscopy is a procedure widely adopted for colectomy but its use in reconstructive surgery remains limited. Longer follow-up must be planned to define the quality of life of these patients.

Role of surgery in pediatric ulcerative colitis

Pediatric ulcerative colitis (UC) has a more extensive and progressive clinical course than adult UC. Therefore, more aggressive initial therapies and more frequent surgical treatments are needed. The therapeutic goal is to gain clinical and laboratory control of the disease with minimal adverse effects while permitting the patient to function as normally as possible. Approximately 5-10 % of patients with UC require acute surgical intervention because of fulminant colitis refractory to medical therapy. 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 review will focus on the current issues regarding the surgical indications for pediatric UC, the technical details of procedures and results of most recent published series to take the most appropriate next step to improve the surgical outcomes and patients' quality of life.

History of and current issues affecting surgery for pediatric ulcerative colitis

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.

Technical considerations in children undergoing laparoscopic ileal-J-pouch anorectal anastomosis for ulcerative colitis

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.

Laparoscopic approach for children with inflammatory bowel diseases

BACKGROUND

Minimally invasive surgery is being increasingly applied to inflammatory bowel diseases (IBDs). Few pediatric series from selected research have been described to date. This study describes a unicentric experience of laparoscopic treatment of children with IBDs.

MATERIALS AND METHODS

All consecutive patients with IBDs between February 2006 and February 2010 who underwent laparoscopic treatment were included. We reviewed notes and recorded demographic data, indications, perioperative management, surgical details, length of surgery, complications, postoperative management, length of hospitalization and functional outcome.

RESULTS

We performed 25 procedures on 16 patients (12 ulcerative colitis, 3 Crohn's disease, and 1 indeterminate colitis). Median age was 12 years. A total of 50% patients underwent elective surgery; 11 underwent staged laparoscopic subtotal colectomy (LSTC) followed by J-pouch ileorectal anastomosis (JPIRA). Three patients underwent straight LSTC + JPIRA. All procedures included protective ileostomy. Length of surgery ranged between 120 and 380 min depending on the procedure (LSTC ± JPIRA). No conversion was required. Length of hospitalization ranged between 3 and 18 days. We observed six complications (24%) mainly represented by adhesions that were effectively treated laparoscopically. Ten patients were restored (ileostomy closure) and were assessed for continence that turned out to be good in 80%.

CONCLUSIONS

Laparoscopy proved to be feasible, safe and effective for the treatment of IBD in children. Although we observed a relatively low incidence of complications, stoma site adhesions still remain the major issue, which can be effectively dealt with laparoscopically. Functional outcome as well as cosmesis is satisfactory. As results are encouraging, at present we prefer laparoscopy for the surgical treatment of IBD in pediatric patients.

Surgical treatment of chronic inflammatory bowel disease in children

Surgery for chronic inflammatory bowel disease (IBD) is increasingly often necessary in children. This study aimed at assessing the results of these operations in order to facilitate adequate preoperative counseling. We reviewed patients treated from 1992 to 2009. The operations, complications and functional outcome were recorded. For those with preserved rectal defecation, continence (Koivusalo score) and quality of life (standardized questionnaire) were assessed in the long term. Eighty five of 192 patients had Crohn disease (CD), 107 of 192 had ulcerative colitis (UC), and 3 of 192 had indeterminate colitis (IC). 12 of 85 CD patients (15%) aged 14 (12-19) years required 13 resections, 1 stricturoplasty, 1 transplantation and 6 other operations including 3 permanent enterostomies for anorectal involvement. Removal of the involved bowel led to significant improvement of nutritional status, growth and quality of life. The transplanted patient had a striking recovery but eventually died 1 year later of unrelated complications. 29 of 107 UC patients (26%) aged 11 (2-15) years required 87 operations. Nine had emergency colectomy for toxic megacolon (3, one death) or severe hemorrhage (6). 28 had restorative proctocolectomy and ileoanostomy (RPCIA) without (16) or with (12) J-pouch under protective ileostomy. Complications were frequent (40%). Permanent ileostomy was required in five children (17%). Twelve months postoperatively, RPCIA patients had 6.5 (2-13) stools/day; all were continent during daytime, and 25% have nocturnal leaks. Mean Koivusalo score (5-12) was 8.8 ± 2. Quality of life was good in all. All attended normal school and 7 the university, 4 work and 60% of those older than 18 years have sexual partners. Three of 107 children treated as UC with RPCIA had ultimately IC (3%) and were permanently diverted. The nature of IBD involves frustrating surgery. However, it may change life for CD patients and provide a reasonably good quality of life for UC after the first year. Pediatric surgeons should be able to provide adequate preoperative counseling to patients and families.

Stapled intestinal anastomoses in infants

BACKGROUND

We reviewed our experience with stapled intestinal anastomoses in infants younger than 1 year and compared operative data and outcome to that of infants who underwent hand-sewn anastomoses.

METHODS

Infants younger than 1 year who underwent an intestinal anastomosis over an 8-year period were identified. Stapled anastomoses were constructed in a side-to-side fashion using standard or endoscopic linear cutters. Outcome variables including operative time, anastomotic failure, and death were recorded.

RESULTS

Two hundred ninety-five subjects were identified. Hand-sewn anastomoses were performed in 189 cases and stapled anastomoses in 106. Patients who had a stapled anastomosis were older (105 vs 44 days) and larger (5.2 vs 3.1 kg), although 25 stapled anastomoses were performed in infants between 600 and 1000 g. When a stapled anastomosis was used operative time was significantly reduced overall (102 vs 128 minutes) and for individual procedures including resection for necrotizing enterocolitis (85 vs 132 minutes) and colostomy closure (104 vs 141 minutes). There was no difference between hand-sewn and stapled anastomoses in the incidence of adhesive obstruction, stricture, or leak.

CONCLUSIONS

When permitted by intestinal size in infants younger than 1 year, stapled anastomoses were safe and effective and significantly reduced operative time.

Steroids and poor nutrition are associated with infectious wound complications in children undergoing first stage procedures for ulcerative colitis

BACKGROUND

Risk factors for postoperative infections have not been evaluated in pediatric patients with ulcerative colitis (UC). This review was undertaken to evaluate the effects of immunosuppressive therapy and other preoperative factors on infectious wound complications in children undergoing first stage surgical therapy for UC.

METHODS

A 10-year retrospective review of children under 18 years of age receiving first stage surgical therapy for UC at a major children's hospital was performed. Preoperative clinical and treatment variables were identified and correlated with postoperative wound complications.

RESULTS

A total of 51 children were identified: 19 underwent colectomy with ileo-anal-pouch anastomosis and 32 underwent total abdominal colectomy with Hartmann's pouch. A total of 20 infectious complications were identified in 18 patients. Preoperative steroid use was associated with a greater postoperative wound infection rate. Preoperative hemoglobin less than 10 g/dL (P < .05) and albumin less than 3 g/dL (P = 0.1) were associated with greater rates of postoperative infection. Preoperative body mass index and other immunosuppressive agents did not influence postoperative infectious morbidity.

CONCLUSIONS

The majority of pediatric patients who require operative intervention for UC are debilitated from their disease and medication use. Children with normal serum albumin and hemoglobin who are not on steroid therapy have a low risk of postoperative infectious complications.

Systematic review of dysplasia after restorative proctocolectomy for ulcerative colitis

Background

The aim of this systematic review was to assess the prevalence and site of dysplasia after restorative proctocolectomy (RPC) for ulcerative colitis (UC), and to identify risk factors that could be used in a surveillance programme.

Methods

Medical databases were searched for potentially relevant publications between 1978 and 2006. Studies that dealt with RPC for UC and postoperative surveillance were included. Two researchers independently performed study selection, quality assessment, data extraction and analysis.

Results

Twenty-three observational studies and case series were included, with a total of 2040 patients. The pooled prevalence of confirmed dysplasia in the pouch, anal transitional zone or rectal cuff was 1·13 (range 0–18·75) per cent. The prevalence of high-grade dysplasia, low-grade dysplasia and indefinite for dysplasia was 0·15 (range 0–4·49), 0·98 (range 0–15·62) and 1·23 (range 0–25·28 per cent) respectively. Dysplasia was equally frequent in the pouch and rectal cuff or anal transitional zone. Dysplasia and cancer identified before or at operation seemed to be significant predictors of the development of dysplasia. Pouchitis and duration of follow-up were not of predictive value.

Conclusion

Although based on low-level evidence from uncontrolled studies, the prevalence of dysplasia observed after RPC was remarkable. A surveillance programme that takes into account the risk factors found is therefore advocated.

Surgical complications in relation to functional outcomes after ileoanal anastomosis in pediatric patients with ulcerative colitis

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.