Long-term Single-centre Outcomes After Proctocolectomy With Ileoanal Anastomosis for Paediatric Ulcerative Colitis

Abstract

Background and Aims: Childhood-onset ulcerative colitis [UC] requires total colectomy in onequarter of patients at some point of their disease. The study objective was to evaluate long-term outcomes after proctocolectomy with ileoanal anastomosis [IAA] for paediatric UC. Methods: Medical records of all children undergoing proctocolectomy with IAA for UC during 1985-2016 in Helsinki University Hospital were retrospectively assessed. Data on disease history, diagnostic and operative details, occurrence of surgical complications, functional outcome, postoperative diagnosis of Crohn's disease [CD] and pouch failure were collected. Risk factors for IAA failure were analysed with Cox regression. Results: Of 87 patients, 85 [98%] had UC and 2 [2%] inflammatory bowel disease unclassified [IBD-U] preoperatively. Altogether 66% underwent two-stage and 34% underwent three-stage procedures. During 7.8 [4.1-14.5] years' follow-up, nine [10%] patients were diagnosed with postoperative CD. Postoperative leakages [n = 8, 9%] and strictures [n = 10, 11%] were equally common, whereas fistulas [78% vs 9%, p <0.001] and abscesses [56% vs 14%, p = 0.009] were more frequent among patients with later CD diagnosis. At latest follow-up, eight [9%]patients had been converted to a permanent ileostomy and others reported daytime stooling frequency of 5 [4-7] and 0.5 [0-1] at night. CD diagnosis (hazard ratio [HR] = 23.3, p = 0.005), postoperative abscesses [HR = 16.3, p = 0.013] and fistulas [HR = 20.9, p = 0.007] as well as three-stage surgery [p = 0.018] increased risk for ileostomy.Conclusions: For paediatric UC, long-term surgical and functional outcomes after proctocolectomy with IAA are reassuring. Need for three-stage surgery and occurrence of postoperative fistulas and abscesses, but not leakages or strictures, associate with postoperative CD diagnosis and the risk for ileostomy.

Outcomes Following Pouch Formation in Paediatric Ulcerative Colitis

“…Although the majority of patients who developed pouchitis did so within the first year as found in previous studies (17), the first episode could occur after 2 or 3 years. Although this is higher than previous reports among adults with a pouchitis rate of 23% to 46% (10), and closer to a recent report of a pouchitis rate of 70% (29), importantly, we also found that 71% of patients had good or excellent pouch function at 1 year with a median of 5 (IQR 4-6) bowel movements daily, consistent with existing pediatric data (7,12,30,31).…”

“…Our findings are in the higher range of previously reported pouchitis rates in children with IBD, 31-73% [11][12][13] depending on definition and time of follow-up. We also found that 71% of patients had good or excellent pouch function at 1 year with a median of 5 (IQR 4-6) bowel movements daily, consistent with existing pediatric data 11,14,28,29 .…”

Surgery and paediatric inflammatory bowel disease

“…90% of patients in another study would recommend IPAA surgery to others (97). Pouch abandonment and conversion to permanent ileostomy following IPAA undertaken in childhood is reported to occur in 9% and 13% of patients in two series, albeit with a relatively short median follow-up of 7 and 4 years, respectively (98,99).…”

Late Abdominal Reoperations after Surgery for Necrotizing Enterocolitis and Spontaneous Intestinal Perforation

“…This figure exceeds the SBO risk reported after appendectomy (from 1 to 10%) 1,2, 7 or after open cholecystectomy (6.4%) 1 is similar than 10 to 25% reported in general intestinal surgery, 8 but less than 29% reported with proctocolectomy with ileoanal anastomosis. 9 Fredriksson et al 10 Only SB affected 0.6 (0.1-3.9) 0.60 1.4 (0.1-13) 0.80 0.9 (0.2-3.8) 0.96…”

“…This figure exceeds the SBO risk reported after appendectomy (from 1 to 10%) 1,2,7 or after open cholecystectomy (6.4%) 1 is similar than 10 to 25% reported in general intestinal surgery, 8 but less than 29% reported with proctocolectomy with ileoanal anastomosis. 9 Fredriksson et al After an acute phase of NEC, conservatively managed patients may develop intestinal strictures mostly in the colon, 11 whereas in surgical patients intestinal anastomotic strictures may develop. 12 In a reoperation for SBO after acute onset of NEC or SIP, it may be impossible to determine whether the actual cause of obstruction was adhesions, anastomotic stricture, or both.…”