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Amil-Dias J, Kolacek S, Turner D, Pærregaard A, Rintala R, Afzal NA, Karolewska-Bochenek K, Bronsky J, Chong S, Fell J, Hojsak I, Hugot JP, Koletzko S, Kumar D, Lazowska-Przeorek I, Lillehei C, Lionetti P, Martin-de-Carpi J, Pakarinen M, Ruemmele FM, Shaoul R, Spray C, Staiano A, Sugarman I, Wilson DC, Winter H, Kolho KL. Surgical Management of Crohn Disease in Children: Guidelines From the Paediatric IBD Porto Group of ESPGHAN. J Pediatr Gastroenterol Nutr 2017; 64:818-835. [PMID: 28267075 DOI: 10.1097/mpg.0000000000001562] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The incidence of Crohn disease (CD) has been increasing and surgery needs to be contemplated in a substantial number of cases. The relevant advent of biological treatment has changed but not eliminated the need for surgery in many patients. Despite previous publications on the indications for surgery in CD, there was a need for a comprehensive review of existing evidence on the role of elective surgery and options in pediatric patients affected with CD. We present an expert opinion and critical review of the literature to provide evidence-based guidance to manage these patients. Indications, surgical options, risk factors, and medications in pre- and perioperative period are reviewed in the light of available evidence. Risks and benefits of surgical options are addressed. An algorithm is proposed for the management of postsurgery monitoring, timing for follow-up endoscopy, and treatment options.
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Affiliation(s)
- Jorge Amil-Dias
- *Department of Pediatrics, Centro Hospitalar, S. João, Porto, Portugal †Children's Hospital Zagreb, Faculty of Medicine, Zagreb, Croatia ‡The Juliet Keidan Institute of Pediatric Gastroenterology & Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel §Department of Pediatrics, Hvidovre University Hospital, Hvidovre, Denmark ||Pediatric Surgery, Children's Hospital, University of Helsinki, Helsinki, Finland ¶Department of Pediatric Gastroenterology, University Hospital Southampton, Southampton, UK #Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Warsaw, Poland **Department of Pediatrics, University Hospital Motol, Prague, Czech Republic ††Queen Mary's Hospital for Children, Epsom and St Helier NHS Trust, Surrey ‡‡Chelsea and Westminster Hospital, London, UK §§Paris-Diderot Sorbonne-Paris-Cité University and Robert Debré Hospital, Paris, France ||||Pediatric Gastroenterology and Hepatology, Dr. von Hauner Children's Hospital, Ludwig Maximilians-University, Munich, Germany ¶¶St George's, University of London, London, UK ##Boston Children's Hospital and Harvard Medical School, Boston, MA ***Department NEUROFARBA, University of Florence - Meyer Hospital, Florence, Italy †††Unit for the Comprehensive Care of Pediatric Inflammatory Bowel Disease, Hospital Sant Joan de Déu, Barcelona, Spain ‡‡‡Department of Pediatric Gastroenterology, Necker Enfants Malades University Hospital, Sorbonne Paris Cité University, Paris Descartes University, Institut IMAGINE - INSERM U1163, Paris, France §§§Pediatric Gastroenterology Institute, Ruth Children's Hospital, Rambam Medical Center, Haifa, Israel ||||||Department of Pediatric Gastroenterology, Bristol Royal Hospital for Children, Bristol, UK ¶¶¶Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II," Naples, Italy ###Department of Pediatric Surgery, Leeds Children's Hospital, Leeds General Infirmary, Leeds, UK ****Child Life and Health, University of Edinburgh, Scotland, UK ††††MassGeneral Hospital for Children, Harvard Medical School, Boston, MA ‡‡‡‡Children's Hospital, University of Helsinki, Helsinki, Finland
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Abstract
Transitioning an adolescent patient to an internist/gastroenterologist's care requires an understanding of the specific issues and challenges involved in the diagnosis and management of paediatric inflammatory bowel disease (IBD). Even though diagnostic criteria, as well as methods are the same in children and adults, younger patients may experience more insidious presentations. A high level of suspicion is necessary for an early and accurate diagnosis. Management of IBD in the paediatric population begins with the assessment of disease extent and activity as well as the identification of potentially serious complications (such as malnutrition, growth/sexual retardation and osteoporosis), which are often present at the time of diagnosis. Treatment includes not only medical, nutritional or surgical therapy but also a multidisciplinary or holistic approach taking into consideration the psychological as well as social impact of the disease on the patient and family.
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Affiliation(s)
- Barbara Désir
- Division of Gastroenterology, Hepatology and Nutrition, Sainte Justine Hospital, 3175 Côte Ste Catherine Road, Montreal, QC, Canada H3T 1C5
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Abstract
Dietary antigens may act as important stimuli of the mucosal immune system and have led to the study of nutritional therapy for IBD. Patients with active CD respond to bowel rest, along with total enteral nutrition or TPN. Bowel rest and TPN are as effective as corticosteroids at inducing remission for patients with active CD, although benefits are short-lived. Enteral nutrition is consistently less effective than conventional corticosteroids for treatment of active CD. Use of palatable, liquid polymeric diets in active CD is controversial, but these diets are of equal efficacy when compared with elemental diets. UC has not been treated effectively with either elemental diets or TPN. Fish oil contains n-3-PUFA, which inhibits production of proinflammatory cytokines and has some benefit in the treatment of CD. Topical applications of short-chain fatty acids have benefited diversion colitis and distal UC, whereas probiotics hold promise in the treatment of pouchitis.
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Affiliation(s)
- Toby O Graham
- University of Pittsburgh Medical Center, 200 Lothrop Street, M-Level, PUH, Pittsburgh, PA 15213, USA.
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Diamond IR, Langer JC. Laparoscopic-assisted versus open ileocolic resection for adolescent Crohn disease. J Pediatr Gastroenterol Nutr 2001; 33:543-7. [PMID: 11740226 DOI: 10.1097/00005176-200111000-00006] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Laparoscopic-assisted ileocolic resection for Crohn disease has been reported as an acceptable alternative to the open procedure in adults. We evaluated our experience with this procedure in the adolescent population. METHODS All adolescents undergoing ileocolic resection for Crohn disease during a 3-year period were retrospectively reviewed. Intraoperative and early postoperative results were analyzed, comparing those undergoing the laparoscopic-assisted approach with those having open resection. RESULTS Eleven patients (mean age, 15.6 years) underwent open and 12 patients (mean age, 16.5 years) underwent laparoscopic-assisted resection. None had undergone previous resection. The two groups did not differ with respect to time from diagnosis to surgery, indications for surgery, preoperative medical therapy, operative time, or length of intestine resected. One patient in the laparoscopic-assisted group was converted to an open procedure. There were no intraoperative complications in either group. Although no statistically significant differences were noted for number of days on narcotic, total dosage of narcotic, and time to regular diet, patients undergoing laparoscopic-assisted resection were discharged 2.2 days earlier (5.4 vs. 7.6; P < 0.05). There was one wound infection and one intraabdominal abscess in the open resection group, and a single patient in the laparoscopic-assisted group with postoperative fever and a wound infection. CONCLUSIONS Laparoscopic-assisted ileocolic resection is a safe alternative to open surgery in adolescent patients with Crohn disease.
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Affiliation(s)
- I R Diamond
- Division of Pediatric General Surgery, University of Toronto, Toronto, Ontario, Canada
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Abstract
OBJECTIVES My objective was to revisit the issues and approaches raised in a seminal article published in Pediatrics in 1976 by A. Frederick North, Jr, entitled "When Should a Child Be in the Hospital?" Dr North proposed a set of nine criteria to guide the evaluation of appropriateness of admission to hospital. These were based on a core assertion that, "The need to hospitalize a child is dependent on the special services which the child requires rather than upon the diagnosis." This original work antedated more recent activities and publications in the area of appropriateness evaluation as applied to pediatrics (such as the Pediatric Appropriateness Evaluation Protocol), but is more context-specific than later works in the field. METHODS A review of the literature concerning temporal trends in hospital use for children in North America was undertaken. This was done to place some of the subsequent observations in a macrocontext of overall trends in hospital use. A review of the English language literature focusing on alternatives to hospitalization and contextual evolution affecting patterns of hospital care for children is presented. Factors influencing each of the nine admission criteria proposed by North are reviewed and discussed in turn. RESULTS Overall rates of hospitalization declined by 46% and 41% in the United States and Canada, respectively, during the 1971 to 1993 interval. The relative composition by diagnostic category in two specific pediatric hospital settings also evolved substantially during the 2 decades. Many of North's specific criteria required extensive revision or updating to match the contextual realities of the 1990s. CONCLUSIONS Although important overall shifts have occurred in the absolute levels and relative composition of pediatric hospitalization, Dr North's core assertion, relating to the need for specific services driving the need for hospitalization, has largely stood the test of time.
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Affiliation(s)
- G Dougherty
- Departments of Pediatrics and Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
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Abstract
Inflammatory bowel disease in children encompasses at least two forms of intestinal inflammation: ulcerative colitis and Crohn's disease. These two disease processes are differentiated based on clinical presentation, radiologic findings, endoscopic findings, histologic evaluation, and exclusion of alternative causes. The treatment and operative interventions are reviewed.
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Affiliation(s)
- M B Statter
- Department of Surgery and Pediatrics, University of Chicago Pritzker School of Medicine, Wyler Children's Hospital, Illinois
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Abstract
Many patients with the inflammatory bowel diseases, Crohn's disease, or ulcerative colitis have significant protein-calorie malnutrition and micronutrient deficiencies. Factors that contribute to these nutritional deficits include inadequate nutrient intake, malabsorption, excessive nutrient secretion across the diseased gastrointestinal tract, drug-nutrient interactions, and increased nutrient requirements. In this review, the use of enteral and parenteral nutrition support as primary therapy for active Crohn's disease and ulcerative colitis is discussed. Other roles for nutrition support in patients with inflammatory bowel disease, including preoperative nutrition support, nutritional treatment of intestinal fistulas and growth retardation, and home parenteral nutrition for gut failure, are also reviewed.
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