Delay J-pouch surgery for colitis until adolescence: researchers

Last Updated: 2018-04-04

By Scott Baltic

NEW YORK (Reuters Health) - In children with very-early-onset inflammatory bowel disease (VEO-IBD), J-pouch reconstruction/ileal pouch-anal anastomosis (IPAA) surgery should be delayed until adolescence, because of the possibility that the diagnosis might change over time, new research suggests.

Canadian researchers found that about a quarter of patients in their retrospective single-center study who initially were diagnosed with ulcerative colitis (UC) or inflammatory bowel disease unclassified (IBD-U) were later diagnosed with Crohn's disease.

Even as the incidence of IBD in children is increasing, the report notes, it can be difficult to distinguish between Crohn's disease, UC and IBD-U. What's more, children with early-onset disease are more likely to see a change in their diagnosis.

Although IPAA surgery typically can lead to good functional outcomes and quality of life in patients with UC, the procedure is more controversial for patients with Crohn's disease.

Dr. Jacob C. Langer of The Hospital for Sick Children in Toronto and colleagues believe theirs to be the first study to specifically look at the likelihood of a child with an initial diagnosis of UC or IBD-U eventually changing to a diagnosis of Crohn's disease.

"Many surgeons are currently doing reconstructive surgery for children with colitis at a young age," Dr. Langer told Reuters Health by email. "We believe that our study supports a different approach in which the surgeon waits until the child is an adolescent. In this sense we think the findings are practice-altering."

"We believe that young children with colitis who need their colon removed should have a subtotal colectomy (leaving the rectum in place) and an ileostomy, and then should wait until adolescence before considering reconstructive surgery to get rid of the ileostomy," he added.

The findings were published online March 10 in the Journal of Pediatric Surgery.

From a database of pediatric IBD cases, the researchers identified 25 patients with disease diagnosed before age 10 who underwent subtotal colectomy with end ileostomy. Cases of infectious colitis were excluded.

Thirteen of the 25 patients were female, and nine patients had a family history of IBD. Median age at diagnosis was 5.4 years, and median follow-up was 7.1 years from initial diagnosis.

At initial presentation, there were 14 diagnoses of UC, seven of IBD-U, and four of Crohn's disease. The median age at subtotal colectomy was 7.4 years. Eight patients (32%) had one or more complications. Six UC patients, one IBD-U patient and one Crohn's patient underwent pouch surgery, at a median of two years after colectomy.

Eleven patients had changes in their initial diagnoses, at a median age of 11 years, and five of them went on to have a pouch surgery. Five patients with initial diagnoses of UC or IBD-U were later diagnosed with Crohn's.

"The complications of (Crohn's disease) following IPAA are significant enough for us to recommend that pouch reconstruction be delayed until adolescence," the authors concluded.

SOURCE: https://bit.ly/2Je4xuF

J Pediatr Surg 2018.