Division of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health System, New York, New York; Department of Surgery, Zucker School of Medicine at Hofstra/Northwell Health System, Manhasset, New York.
Division of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health System, New York, New York.
J Surg Res. 2020 Nov;255:319-324. doi: 10.1016/j.jss.2020.05.026. Epub 2020 Jun 25.
Subtotal colectomy with end ileostomy (STC-I) has been well established in the adult literature as an initial surgical treatment for refractory inflammatory bowel disease (IBD)-related colitis. However, in the pediatric population, the efficacy of this approach has been less well characterized, likely because of concerns regarding the advisability of leaving a diseased rectum in situ. Our aim was to examine the outcomes after STC-I for refractory IBD at our pediatric tertiary care center.
An institutional review board-approved retrospective review of patients aged 5-21 y who underwent operative treatment with initial STC-I for medically refractory IBD from January 2010 to August 2018. Only complications related to the STC-I were considered; complications subsequent to reconstruction are excluded from analysis. Early complications were defined as occurring within 60 d of STC-I. We performed descriptive statistics using the Fisher exact test and the Student t-test, as appropriate.
Over the study period, 37 patients (aged 12.3 ± 4.2 y) underwent STC-I, with 73.0% performed laparoscopically. Patients were predominately male (51.4%) and Caucasian (48.6%). Thirty-one (83.8%) colectomies were performed for ulcerative colitis, two (5.4%) for Crohn disease, and four (10.8%) for indeterminate colitis. Nutritional status improved postcolectomy. Albumin levels of 3.3 ± 0.8 preoperatively increased to 4.3 ± 0.47 postoperatively (P < 0.001). Colonic bleeding was stopped by STC-I with increases in the hematocrit from 30.5 ± 6.8 preoperative to 38.9 ± 4.1 postoperatively (P < 0.001). Average time to discontinuation of IBD-related medications was 4 wk (n = 27). Forty-eight percent required outpatient rectal treatment for proctitis. Patients did well long term, with 67.5% reestablishing intestinal continuity at our institution. Average postoperative length of stay was shorter in the laparoscopic group compared with those undergoing open operations (5.1 ± 2.2 versus 6.9 ± 1.6 d, P = 0.03). Readmission rate at 30 d was 21.1%. Patients experiencing unplanned readmission or unplanned operations were similar between groups (30% versus 33.3%, P = 0.85 and 30% versus 18.5%, P = 0.45, respectively). Overall, 14 (37.8%) patients experienced a complication with many patients experiencing multiple complications. Early complications occurred in nine (24.3%) patients. Late complications also occurred in 24.3% of patients. There were four (10.8%) patients with five admissions for bowel obstruction, two of whom required operative intervention (5.4%).
Use of STC-I as an initial procedure in the treatment of refractory IBD-related colitis in children is a safe and reasonable surgical approach that allows weaning from immunosuppressing mediations and stops colonic bleeding. Implementing a laparoscopic approach to subtotal colectomy provides further benefit by reducing postoperative length of stay.
在成人文献中，次全结肠切除加回肠造口术（STC-I）已被广泛确立为治疗难治性炎症性肠病（IBD）相关结肠炎的初始手术治疗方法。然而，在儿科人群中，这种方法的疗效特征描述较少，这可能是因为担心保留病变直肠的合理性。我们的目的是在我们的儿科三级护理中心检查难治性 IBD 患者接受 STC-I 后的结果。
对 2010 年 1 月至 2018 年 8 月接受初始 STC-I 治疗的因药物难治性 IBD 而接受手术治疗的 5-21 岁患者进行机构审查委员会批准的回顾性研究。仅考虑与 STC-I 相关的并发症；排除重建后发生的并发症。早期并发症定义为 STC-I 后 60 天内发生。我们使用 Fisher 精确检验和学生 t 检验进行描述性统计，具体情况如下。
在研究期间，37 例患者（年龄 12.3±4.2 岁）接受了 STC-I 治疗，其中 73.0%采用腹腔镜进行。患者主要为男性（51.4%）和白种人（48.6%）。31 例（83.8%）结肠切除术用于溃疡性结肠炎，2 例（5.4%）用于克罗恩病，4 例（10.8%）用于不确定结肠炎。术后营养状况改善。白蛋白水平从术前的 3.3±0.8 增加到术后的 4.3±0.47（P<0.001）。STC-I 停止了结肠出血，血细胞比容从术前的 30.5±6.8 增加到术后的 38.9±4.1（P<0.001）。停止 IBD 相关药物的平均时间为 4 周（n=27）。48%的患者需要门诊直肠治疗直肠炎。患者长期预后良好，67.5%的患者在我院重新建立了肠道连续性。与开腹手术相比，腹腔镜组的平均术后住院时间更短（5.1±2.2 与 6.9±1.6 天，P=0.03）。30 天的再入院率为 21.1%。两组患者的计划外再入院或计划外手术发生率相似（30%与 33.3%，P=0.85 和 30%与 18.5%，P=0.45）。总体而言，14 例（37.8%）患者发生并发症，许多患者发生多种并发症。9 例（24.3%）患者发生早期并发症。24.3%的患者也发生了晚期并发症。有 4 例（10.8%）患者发生 5 次肠梗阻，其中 2 例需要手术干预（5.4%）。
在儿童难治性 IBD 相关结肠炎的治疗中，将 STC-I 作为初始治疗方法是一种安全合理的手术方法，可减少免疫抑制药物的使用并停止结肠出血。采用腹腔镜进行次全结肠切除术可进一步缩短术后住院时间。
