Early Experience with Variant Two-Stage Approach in Surgical Management of Inflammatory Bowel Disease Colitis in the Pediatric Population

Laparoscopic Robotic-Assisted Restorative Proctocolectomy and Ileal J-Pouch-Anorectal Anastomosis in Children: Shifting to a Two Stage-Approach

Background: Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is the gold standard surgical treatment for patients with ulcerative colitis (UC) unresponsive to medical therapy and those with familial adenomatous polyposis. Robotic IPAA is a safe and feasible option for the surgical treatment of UC in children. The feasibility of IPAA without ileostomy has been demonstrated in adult in the modified two-stage approach. Aim: The aim of the study was to examine feasibility, outcomes, and complications of robotic modified two-stage approach for RPC with IPAA in pediatric patients comparing it with robotic three-stage approach. Methods: All patients aged 4-18 years who underwent operative treatment for medically refractory UC were included. Demographic and clinical features, age at colectomy and at reconstructive surgery, intraoperative details and complications, and postoperative outcomes were analyzed. Results: Thirteen patients were included in the study (6 males, 7 females). Ileostomy was fashioned in 8 patients at the time of RPC and IPAA (Group 1); in 5 patients the bowel continuity was reintegrated at the time of IPAA (Group 2). No intraoperative complications and no conversions were recorded. One patient of Group 1 had a postoperative pouch complication. The 5 patients who underwent a two-stage procedure did not show short-term complications. No statistical differences were found between the groups in short-term (P = .48) and long-term complications (P = .07). Conclusions: Modified two-stage IPAA is a safe and feasible option in pediatric patients with UC, and RALS offers advantages over other techniques for the precision of rectal dissection and ileo-anal anastomosis.

Surgical management of complicated Crohn's disease

Surgical management of pediatric Crohn's disease is fundamentally palliative, aiming to treat the sequalae of complicated disease while preserving intestinal length. Multidisciplinary discussion of risk factors and quality of life should take place prior to operative intervention. Though the surgical management of pediatric Crohn's disease is largely based on the adult literature, there are considerations specific to the pediatric population - notably disease and treatment effects on growth and development. Intrabdominal abscess is approached with percutaneous drainage when feasible, reserving surgical intervention for the patient who is unstable or failing medical therapy. Pediatric patients with fibrostenotic disease should be considered for strictureplasty when possible, for maximum preservation of bowel length. Patients with medically refractory Crohn's proctocolitis should be treated initially with fecal diversion without proctocolectomy.

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.

Does the timing of pouch creation in 2-stage operations for pediatric patients with ulcerative colitis matter?

INTRODUCTION

Children with fulminant ulcerative colitis(UC) traditionally undergo 2-stage operations: restorative-proctocolectomy(RP/IPAA) and ileostomy followed by ostomy closure. In the biologic era, surgeons have modified their strategy: initial subtotal-colectomy/diversion, followed by RP/IPAA without diversion. Yet, evidence on efficacy and functional outcomes with the "modified 2-stage" approach is limited in children. We sought to compare the timing of pouch creation in 2-stage operations to determine outcomes.

METHODS

This is a retrospective study of children with UC undergoing either a traditional 2-stage RP/IPAA or modified 2-stage RP/IPAA between 2010 and 2019. Complications (leak, stricture, wound-infection) were recorded at 90-days and 1 year from 2nd operation.

RESULTS

N = 57 (Traditional n = 40, Modified n = 17). Median time to surgery from consultation was shorter in the modified-group (7 vs.25 days, p = 0.01). Preoperatively, the modified-group had lower albumin(p = 0.01), higher CRP(p = 0.01), and more frequently took biologics within 90-daysp=0.001). After re-establishing intestinal continuity, stricture requiring dilation was higher in the traditional-group (59% vs.18%, p = 0.008). No difference in pouch leak (p = 0.38), bowel obstruction(p = 0.35), loperamide dose(p = 0.21), or incontinence(p = 0.38) was observed.

CONCLUSION

Delaying pouch creation to the second operation without a protective ileostomy as a modified 2-stage is safe in a sicker and more acute pediatric population.

Modified two-stage restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: a systematic review and meta-analysis of observational research

PURPOSE

Restorative proctocolectomy (RPC) is performed for patients with refractory ulcerative colitis (UC). This operation is performed in 2 or 3 stages and involves forming a diverting loop ileostomy thought to protect patients from complications related to anastomotic leak. However, some advocate for a modified 2-stage approach, consisting of subtotal colectomy followed by completion proctectomy and ileal pouch anal anastomosis without diverting ileostomy. We present a systematic review and meta-analysis comparing postoperative complication rates between modified 2-stage and traditional RPC with ileal pouch anal anastomosis.

METHODS

Records were sourced from PubMed/Embase databases. Studies comparing postoperative complications following RPC for ulcerative colitis (UC) were selected according to PRISMA guidelines comparing modified 2-stage (exposure), classic 2-stage, and 3-stage approaches (comparators). The primary outcome measure was safety as measured by postoperative complication rates. We employed random effects meta-analysis.

RESULTS

We included ten observational studies including 1727 patients (38% modified 2-stage). Among pediatric patients, modified 2-stage approaches had higher rates of anastomotic leak than 3-stage approaches (p = 0.03). Among adult cohorts with lower preoperative biologic use rates, modified 2-stage approaches had lower leak rates than classic 2-stage approaches (p < 0.001).

CONCLUSIONS

The modified 2-stage approach may be safe for adult patients who otherwise require a 3-stage approach while reducing costs and length of stay. Pediatric patients may benefit from lower leak rates when receiving 3-stage compared with modified 2-stage approaches, especially when on biologics. The modified 2-stage approach may be safer than the classic 2-stage approach for adult patients with lower biologic exposure.