Minimally invasive surgery for paediatric inflammatory bowel disease: Personal experience and literature review

Increasing Adoption of Laparoscopy in Urgent and Emergent Colectomies for Pediatric Ulcerative Colitis

INTRODUCTION

While minimally invasive surgery (MIS) approaches are commonly utilized in the elective surgical setting for pediatric ulcerative colitis (UC), their role in urgent and emergent disease is less clear. We aim to assess trends in the surgical approaches for pediatric UC patients requiring urgent and emergent colectomies and their associated outcomes.

METHODS

Retrospective review of 81 pediatric UC patients identified in National Surgical Quality Improvement Program Pediatric who underwent urgent or emergent colectomy (2012-2019). Trends in approach were assessed using linear regression. Patient characteristics and clinical outcomes were stratified by approach and compared using standard univariate statistics. Multivariable analysis was used to model the influence of covariates on postoperative length of stay.

RESULTS

The proportion of MIS cases increased by 5.53% per year (P = 0.01) over the study interval. Sixty-three patients (77.8%) received MIS resections and 18 patients (22.2%) received open resections. Patients undergoing open colectomies were younger and had a higher proportion of preoperative conditions, most notably preoperative sepsis (27.8% versus 4.8%, P = 0.01), and higher American Society of Anesthesiologists [III-IV] classification (83.3% versus 58.8%, P = 0.004). Mean operative time was comparable (open, 173.6 versus MIS, 206.1 min). In the univariate analysis, open approach was associated with increased postoperative length of stay (13.1 versus 7.2 d, P = 0.002). However, after adjusting for confounders, there was no significant difference.

CONCLUSIONS

There has been a steady increase in the adoption of laparoscopy in urgent and emergent colectomy for pediatric UC. Short-term outcomes between approaches appear comparable.

Minimally Invasive Gastrointestinal Surgery: A Review

Minimally invasive surgery uses several procedures with fewer side effects (bleeding, infections, etc.), a shorter hospital stay, and less discomfort following minimally invasive surgery. Laparoscopy was one of the first forms of minimally invasive surgery. It involves doing surgery while using tiny cameras through one or more small incisions, surgical tools along with tubes. Robotic surgery is another kind of minimally invasive procedure. Along with supporting accurate, flexible, and regulated surgical procedures, it provides the physician with a three-dimensional, enlarged view of the operative site. Minimally invasive surgery continues to advance, making it an advantage for patients with a variety of illnesses. Nowadays, many surgeons prefer it to traditional surgery, which frequently necessitates a longer hospital stay and requires larger incisions. Since then, numerous surgical specialties have greatly increased their use of minimally invasive surgery. A minimally invasive procedure is preferred for the majority of patients who require gastrointestinal surgery. Minimally invasive gastrointestinal procedures are just as successful as open procedures and, in some situations, may result in more effective outcomes. While recovery from open surgeries frequently takes five to ten days in the hospital, minimally invasive surgeries are less painful for patients and hasten recovery. It is safe from the perspective of the patient and has a lower postoperative mortality rate. This procedure involves a learning curve among surgeons.

Disparities in utilization of laparoscopic colectomies in pediatric Crohn's disease✰

PURPOSE

Pediatric patients with Crohn's disease often require colectomies. The laparoscopic approach is considered safe, but there is little national data on outcomes and readmissions in this population.

METHODS

The Nationwide Readmissions Database was queried from 2010 to 2014 for patients ≤ 18 years who underwent colectomy for Crohn's disease during index admission. Patients were stratified by operative approach: laparoscopic versus open. Outcomes were compared with standard statistical methods.

RESULTS

There were 2833 patients (47% female) who underwent a colectomy via laparoscopic (58%) vs. open (42%) approach. Index admissions were elective 55% of the time. Most operations were right hemicolectomy (86%), followed by total colectomy (8%). Of the study population, 489 (17%) were diverted with an ostomy. Readmission rates at 30 days and 1 year were 9% and 18%, respectively. The most common diagnoses at readmission were intra-abdominal infection (16%), small bowel obstruction (16%), and surgical site infection (9%). Laparoscopy was more commonly performed during elective admissions (63% vs. 44%), for patient with private insurance (72% vs. 39%), and for patients in the highest income quartile (66% vs. 48% in the lowest income quartile), all p<0.001. Length of stay was longer on index admission for open colectomy (8[5-12] days vs. 6[4-11] days, p<0.001), while cost was similar ($17,754[$12,375-$30,625] vs. $17,017[$11,219-$27,336], p = 0.104). There were no differences in readmission rate, intraabdominal infection or small bowel obstruction.

CONCLUSION

In pediatric patients, laparoscopic colectomy for Crohn's disease is safe and is associated with shorter hospitalization and equivalent hospital costs compared to the open procedure. Socioeconomic disparities in laparoscopic utilization exist and warrant future investigation.

LEVEL OF EVIDENCE

Level III.

New Insights and Advances in Pathogenesis and Treatment of Very Early Onset Inflammatory Bowel Disease

Very early onset inflammatory bowel disease (VEO-IBD) is characterized by multifactorial chronic recurrent intestinal inflammation. Compared with elderly patients, those with VEO-IBD have a more serious condition, not responsive to conventional treatments, with a poor prognosis. Recent studies found that genetic and immunologic abnormalities are closely related to VEO-IBD. Intestinal immune homeostasis monogenic defects (IIHMDs) are changed through various mechanisms. Recent studies have also revealed that abnormalities in genes and immune molecular mechanisms are closely related to VEO-IBD. IIHMDs change through various mechanisms. Epigenetic factors can mediate the interaction between the environment and genome, and genetic factors and immune molecules may be involved in the pathogenesis of the environment and gut microbiota. These discoveries will provide new directions and ideas for the treatment of VEO-IBD.

[Minimally invasive and robot-assisted surgery for chronic inflammatory bowel disease : Current status and evidence situation]

The majority of cases of inflammatory bowel disease (IBD) can be treated by minimally invasive surgery. The advantages of standard laparoscopic approaches compared to open surgery with respect to short-term and long-term outcome parameters have been adequately proven with evidence level 1 for ileocecal resection in Crohn's disease. For many other indications there are at least several larger registry or case-control studies that have shown advantages for laparoscopy. For robot-assisted surgery the feasibility has principally been demonstrated for IBD, whereby at least for ulcerative colitis limited data suggest comparable results to the standard laparoscopic approach. Single port approaches have so far not been able to demonstrate any relevant advantages in IBD surgery. Major advantages for transanal minimally invasive surgery (TAMIS) for performing restorative proctocolectomy could not be demonstrated in two larger case-controlled studies but it was at least shown to be a comparable alternative to standard laparoscopy. Overall, it seems unlikely that the recently described new laparoscopic approaches will result in measurable advantages for the patient in comparison to standard laparoscopy as the access trauma is not significantly changed. In general, the indications to perform minimally invasive surgery must always be based on the basic principles of IBD surgery and contraindications have to be considered in individual cases as the advantages of laparoscopic approaches are levelled out in the long run.

EARLY AND LONG-TERM OUTCOME OF SURGICAL INTERVENTION IN CHILDREN WITH INFLAMMATORY BOWEL DISEASE

Background:

Although children with inflammatory bowel disease (IBD), disease control is possible through medical procedures, but surgical intervention is indicated in some cases.

Aim:

To evaluated long-term surgical outcomes in children with IBD.

Methods:

This retrospective cohort study was done on 21 children suffering IBD with surgical indication admitted to a referral children hospital in Tehran in 2019. The baseline information was collected by reviewing the recorded files and children were followed-up to assess surgical outcome.

Results:

The rate of early complications after surgery was 47.6%; they included intestinal perforation in 4.8%, peritonitis in 4.8%, wound infection in 23.8%, pelvic abscesses in 14.3%, deep vein thrombosis in 4.8%, intestinal obstruction in 9.5%, pancreatitis in 9.5% and anal fissure in 4.8%. The mean duration of follow-up for patients was 6.79±4.24 years. The rate of delayed complications during follow up was 28.6%. Accordingly, long-term free-complication survival rate during 5-10 years after surgery was 92.3% and 56.4%, respectively. Among the early features, lack of prior drug treatment and bleeding as indication for surgery, were two predictors of long-term surgical complications.

Conclusion:

Standard surgery in the treatment of IBD in children with surgical indication is associated with favorable outcome, although short- and long-term surgical complications are also predictable.

Colectomies in children with inflammatory bowel disease: a national referral centre experience

OBJECTIVES

Few studies have reported on the utility and efficacy of laparoscopic colectomy in the paediatric population. We aim to compare the characteristics and outcomes of children with inflammatory bowel disease (IBD) who underwent open vs laparoscopic treatment at our centre.

METHODS

A 10-year retrospective review was performed. Collected data included demographics, indication for surgery, operative characteristics, histopathology results, post-operative course and peri-operative complications.

RESULTS

A total of 58 patients underwent subtotal colectomy for IBD, with 38 laparoscopic procedures. The cohort included 33 males and 25 females with a mean age at surgery of 12.9 ± 3.3 years. The pre-operative diagnosis was ulcerative colitis in n = 41, Crohn's disease in n = 5 and indeterminate colitis in n = 11. There was an 84.2% concordance between the pre-operative and the post-operative histological diagnoses. Overall, 34 (58.6%) patients had complications, of which 19 (32.7%) patients required return to theatre. The complication rate was significantly smaller for laparoscopic compared to open procedures (42.1% vs 75%) as well as for elective compared with emergency colectomies (38.4% vs 75%). Four patients (10.5%) required conversion to open approach.

CONCLUSIONS

Laparoscopic approach is feasible and safe in most paediatric patients with IBD and has a lower complication rate and better recovery than open procedures, especially when performed in an elective setting.

Paediatric inflammatory bowel disease: review with a focus on practice in low- to middle-income countries

Inflammatory bowel disease (IBD) should be considered in any child with a persistently altered bowel habit. Growth failure may be a consequence and there may also be extra-intestinal manifestations. Oesophago-gastroduodenoscopy and colonoscopy and conventional histopathology are the diagnostic tools of choice in IBD. The identification and management of children with IBD in resource-poor settings is difficult and there are few data on its prevalence in low- and middle-income countries. The main challenges are a lack of resources and infrastructure including trained personnel in settings where there are other priorities for maintaining the health and wellbeing of children. The identification and management of children with inflammatory bowel conditions often depends on the enthusiasm, skill and commitment of a few dedicated individuals. Abbreviations: ADA: Adalimumab; CD: Crohn disease; ECCO: European Crohn's and Colitis Organisation; EEN: exclusive enteral nutrition; ESPGHAN: European Society for Paediatric Gastroenterology Hepatology and Nutrition; FMT: faecal microbiota transplantation; GDP: gross domestic product; HIC: high-income countries; IBD: inflammatory bowel disease; IBDU: inflammatory bowel disease unclassified; IC: ileocolonoscopy; IFX: infliximab; IPAA: ileal pouch anal anastomosis; LMIC: low- and middle-income countries; MH: mucosal healing; OGD: oesophago-gastroduodenoscopy; PCDAI: Paediatric Crohn's Disease Activity Index; PIBD: paediatric inflammatory bowel disease; PUCAI: Paediatric Ulcerative Colitis Activity Index; UC: ulcerative colitis; UGIT: upper gastrointestinal tract; VEO-IBD: very early-onset IBD; WLE: white light endoscopy; 5-ASA: 5 aminosalicylic acid; 6-MP: 6-mercaptopurine.

Hematopoietic Stem Cell Transplantation From Unrelated Donors in 2 Cases of Interleukin-10 Receptor Deficiency: Is Surgery Not a Requirement?

Mutations in interleukin-10 and its receptors cause infantile inflammatory bowel disease (IBD), a hyperinflammatory disorder characterized by severe, treatment-refractory colitis, multiple abscesses, and enterocutaneous fistulas. Patients with infantile IBD often require several surgical interventions, including complete colectomy, and hematopoietic stem cell transplantation is currently the only known medical therapy. Traditionally, operative management has been preferred before stem cell transplantation because of the latter's increased susceptibility to procedural complications; however, surgical intervention could be delayed, and possibly reconsidered, because our 2 patients with infantile IBD demonstrated a rapid response to treatment via engraftment.

Management of Paediatric Ulcerative Colitis, Part 1: Ambulatory Care-An Evidence-based Guideline From European Crohn's and Colitis Organization and European Society of Paediatric Gastroenterology, Hepatology and Nutrition

BACKGROUND

The contemporary management of ambulatory ulcerative colitis (UC) continues to be challenging with ∼20% of children needing a colectomy within childhood years. We thus aimed to standardize daily treatment of pediatric UC and inflammatory bowel diseases (IBD)-unclassified through detailed recommendations and practice points.

METHODS

These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the Paediatric IBD Porto group of European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). An extensive literature search with subsequent evidence appraisal using robust methodology was performed before 2 face-to-face meetings. All 40 included recommendations and 86 practice points were endorsed by 43 experts in Paediatric IBD with at least an 88% consensus rate.

RESULTS

These guidelines discuss how to optimize the use of mesalamine (including topical), systemic and locally active steroids, thiopurines and, for more severe disease, biologics. The use of other emerging therapies and the role of surgery are also covered. Algorithms are provided to aid therapeutic decision-making based on clinical assessment and the Paediatric UC Activity Index (PUCAI). Advice on contemporary therapeutic targets incorporating the use of calprotectin and the role of therapeutic drug monitoring are presented, as well as other management considerations around pouchitis, extraintestinal manifestations, nutrition, growth, psychology, and transition. A brief section on disease classification using the PIBD-classes criteria and IBD-unclassified is also part of these guidelines.

CONCLUSIONS

These guidelines provide a guide to clinicians managing children with UC and IBD-unclassified management to provide modern management strategies while maintaining vigilance around appropriate outcomes and safety issues.

Surgical options in the treatment of ulcerative colitis

Children and young adults with ulcerative colitis tend to present with more extensive colonic disease than an adult population. The need for surgical intervention in the pediatric population with ulcerative colitis occurs earlier after diagnosis and has a greater incidence than a comparably matched adult population with an estimated need for colectomy at 5 years following diagnosis of 14-20%. Perhaps, even more than the adult population, there is a desire to restore intestinal continuity for the pediatric patient to achieve as healthy and normal quality of life as possible. With surgery playing such a prominent role in the treatment of ulcerative colitis in this age group, an understanding of the surgical treatment options that are available is important. The surgeon's awareness of the complexities of the different operations associated with proctocolectomy and reestablishing intestinal continuity may help to avoid early complications and minimize the risk of less than ideal long-term outcomes.

Minimally invasive surgery for inflammatory bowel disease: Current perspectives

The surgical management of complicated and recurrent inflammatory bowel disease (IBD), has remained a challenge. Minimally invasive surgery (MIS), in the form of laparoscopic resections, single port approach and robotic-assisted dissections in the management of IBD, have been examined in several prospective studies. All of them have shown advantages over open surgery in terms of reduction of physical trauma of surgery, recovery time, better cosmetic outcomes and shorter hospitalization. However, it is important to appreciate that not all patients with IBD are suitable for MIS, so a combination of both open and MIS should be adopted to achieve optimum outcomes. A review on this subject performed by Neumann et al in this issue of World Journal of Gastrointestinal Pharmacology and Therapeutics have provided evidence in support of the contemporary practice of MIS in the management of IBD and the accompanying commentary further critically evaluates their application in clinical practice.