The incidence of venous thromboembolism in children following colorectal resection for inflammatory bowel disease: A multi-center study

Surgery for ulcerative colitis

Ulcerative colitis (UC) has a more severe presentation and rapid progression in pediatric patients, resulting in a greater need for surgical intervention compared to adults. Though medical management of UC has advanced with new biologic therapies, surgery continues to play an important role when disease progresses in the form of worsened or persistent symptoms, hemodynamic instability, or sepsis. The goals of surgical management are to restore intestinal continuity with a functional pouch when possible. While the literature has been growing regarding studies of pediatric patients with UC, high level of evidence studies are limited and most recommendations are based on adult studies. Similar to adults, pediatric patients who have ileal pouches created require surveillance for recurrent disease and cancer surveillance. Unique issues for pediatric patients include monitoring of growth and appropriate transition to adult care after adolescence. This review includes indications for surgical management, overview of staged surgical approaches, and the technical details of the three-stage approach.

Venous Thromboembolic Complications in Pediatric Gastrointestinal Diseases: Inflammatory Bowel Disease and Intestinal Failure

In children with gastrointestinal disorders such as inflammatory bowel disease (IBD) and intestinal failure (IF), the risk of venous thromboembolism (VTE) is increased. VTE may lead to pulmonary embolism, sepsis and central line infection, stroke and post-thrombotic syndrome. The purpose of this review is to summarize current knowledge and recent advances around VTE management in pediatric gastroenterology with a focus on IBD and IF. The VTE incidence in children with IBD is reported to be around 4-30 per 10,000 patient-years, with higher incidences for hospitalized children. While in general, IF is less common than IBD, the VTE incidence in children with IF is around 750 per 10,000 patient-years. The most common risk factors for development of VTE involve deviations leading to Virchow's triad (endothelial damage, stasis, and hypercoagulability) and include active inflammation, particularly with colonic involvement, presence of a central venous catheter, underlying thrombophilia, reduced mobility, surgery, and hospitalization. Classes of anticoagulants used for treatment of VTE are low molecular weight heparins and vitamin K antagonists. However, the use of direct oral anticoagulants for treatment or prevention of VTE has not been studied in this pediatric population yet. Pediatric gastroenterologists apply different VTE prevention and treatment strategies due to lack of literature and lack of consensus. We discuss the role of primary and secondary prophylactic use of anticoagulants, and provide tools and recommendations for screening, prevention and management for the specific pediatric populations.

Occurrence of Thromboembolism in Paediatric Patients With Inflammatory Bowel Disease: Data From the CEDATA-GPGE Registry

OBJECTIVE

Among patients with inflammatory bowel disease (IBD), the risk of thromboembolism (TE) is increased, representing a relevant cause of morbidity and mortality. In contrast to other extraintestinal IBD manifestations, TE receives much less attention because of its low incidence, estimated at merely 0.4-0.9% in hospitalised children with IBD.

METHODS

Cases with TE, as documented in the German-Austrian Paediatric IBD registry gesellschaft für pädiatrische gastroenterologie und ernährung - large paediatric patient registry (CEDATA-GPGE), were analyzed retrospectively. For all patients with signs of TE, a questionnaire was filled in by the treating paediatric gastroenterologist.

RESULTS

Over 10 years, 4,153 paediatric patients with IBD (0-18 years) were registered in the registry, and 12 of them identified with TE. Eight patients were diagnosed with ulcerative colitis (UC), three with Crohn's disease (CD), and one with IBD-unclassified. The median age at IBD diagnosis was 10 years and at the manifestation of TE 13 years, respectively, with a median latency to TE of 2 years. Prevalence of TE was 0.3%, with a significantly higher risk for patients with UC than CD (OR 5.9, CI 1.56-22.33, p = 0.008). More girls than boys were affected (f:m = 7:5) without reaching significance. Approximately 90% of patients experienced TE during active disease, with relevant cerebral and limb involvement in 6/12 patients. Various risk factors, e.g., hospitalisation, coagulopathy, or anaemia were identified. TE management included intensive care and surgery. Among the 12 patients, 11 recovered fully, in which one patient has focal epilepsy as a sequela.

CONCLUSION

Paediatric patients with IBD have a substantially increased risk for TE. Risk factors, such as those identified should be considered when managing paediatric IBD and preventive measures for those hospitalised taken routinely. Initiating pharmacological thromboprophylaxis is challenging for the lack of published trials on efficacy and safety in paediatric IBD but should be considered carefully in each case.

Epidemiology and Risk Factors of Portal Venous System Thrombosis in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with inflammatory bowel disease (IBD) may be at risk of developing portal venous system thrombosis (PVST) with worse outcomes. This study aims to explore the prevalence, incidence, and risk factors of PVST among patients with IBD.

METHODS

PubMed, Embase, and Cochrane Library databases were searched. All the eligible studies were divided according to the history of colorectal surgery. Only the prevalence of PVST in patients with IBD was pooled if the history of colorectal surgery was unclear. The incidence of PVST in patients with IBD after colorectal surgery was pooled if the history of colorectal surgery was clear. Prevalence, incidence, and risk factors of PVST were pooled by only a random-effects model. Subgroup analyses were performed in patients undergoing imaging examinations. Odds ratios (ORs) with 95% CIs were calculated.

RESULTS

A total of 36 studies with 143,659 patients with IBD were included. Among the studies where the history of colorectal surgery was unclear, the prevalence of PVST was 0.99, 1.45, and 0.40% in ulcerative colitis (UC), Crohn's disease (CD), and unclassified IBD, respectively. Among the studies where all the patients underwent colorectal surgery, the incidence of PVST was 6.95, 2.55, and 3.95% in UC, CD, and unclassified IBD after colorectal surgery, respectively. Both the prevalence and incidence of PVST became higher in patients with IBD undergoing imaging examinations. Preoperative corticosteroids therapy (OR = 3.112, 95% CI: 1.017-9.525; p = 0.047) and urgent surgery (OR = 1.799, 95% CI: 1.079-2.998; p = 0.024) are significant risk factors of PVST in patients with IBD after colorectal surgery. The mortality of patients with IBD with PVST after colorectal surgery was 4.31% (34/789).

CONCLUSION

PVST is not rare, but potentially lethal in patients with IBD after colorectal surgery. More severe IBD, indicated by preoperative corticosteroids and urgent surgery, is associated with a higher risk of PVST after colorectal surgery. Therefore, screening for PVST by imaging examinations and antithrombotic prophylaxis in high-risk patients should be actively considered.

SYSTEMATIC REVIEW REGISTRATION

Registered on PROSPERO, Identifier: CRD42020159579.

Blood Banking and Transfusion Medicine Challenges During the COVID-19 Pandemic

SARS-CoV-2 (also known as COVID-19) has been an unprecedented challenge in many parts of the medical field with blood banking being no exception. COVID-19 has had a distinctly negative effect on our blood collection nationwide forcing blood banks, blood centers, and the US government to adopt new policies to adapt to a decreased blood supply as well as to protect our donors from COVID-19. These policies can be seen distinctly in patient blood management and blood bank operations. We are also faced with developing policies and procedures for a nontraditional therapy, convalescent plasma; its efficacy and safety is still not completely elucidated as of yet.