Chugh Priyanka V, Nes Emily K, Fénnich Hajar, Staffa Steven J, Etskovitz Haley B, Duggan Christopher P, Jaksic Tom, Carey Alexandra N, Modi Biren P
Department of Surgery, Boston Children's Hospital, Boston, MA, USA.
Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
J Pediatr Surg. 2025 Jun;60(6):162118. doi: 10.1016/j.jpedsurg.2024.162118. Epub 2024 Dec 20.
Anastomotic ulcers (AUs) are a rare cause of morbidity in intestinal failure (IF). Prior studies of AUs have been small, descriptive reports. We evaluated a large cohort of IF patients to identify risk factors and describe treatment strategies for AUs.
This was a retrospective, case-control study of IF patients within an interdisciplinary pediatric intestinal rehabilitation program from 2013 to 2023. Each case was a child who had a bowel resection, with intestinal failure (IF) meeting the American Society for Parenteral and Enteral Nutrition (ASPEN) definition of IF, with localized, peri-anastomotic ulceration on GI endoscopy. Each case was matched with 2 controls (children with IF but without an AU diagnosis), based on sex and time since intestinal failure diagnosis. Cases and controls were compared using conditional logistic regression on clinically relevant risk factors.
Of 588 patients followed in our program and screened, 31 (5.3 %) cases were identified. Median duration from initial surgery to AU diagnosis was 6 years, and ulcers were noted to be close to the entero-colonic anastomosis in 23 (77.4 %). The ulcers were noted to be <50 % of circumference in 9 (29 %), ≥50 % circumference in 7 (22.6 %) and multiple in 15 (48.4 %). Median follow up after AU diagnosis was 2.17 years. On multivariable analysis, AU was associated with increased bowel length (OR 1.65 for each 10 % increase in percent expected bowel length, CI 1.01, 2.7) and longer duration of parenteral nutrition (PN) in years (OR 1.68, CI 1.09, 2.6). Of the 31 cases, 10 (32.3 %) required at least one red blood cell transfusion. Initial medical management with antibiotics, anti-inflammatory medications, and/or enteral steroids was utilized in 29 (93.5 %). Of these, 8 ultimately failed medical management, as defined by the clinical team, and underwent surgery (7) or endoscopic coagulation (1). Initial procedural intervention was performed with endoscopic coagulation in 1 case and surgery in 1 case, of which the patient required repeat surgery.
In this large cohort of IF patients, AU occurred in 5.3 % of patients. Most patients can be managed medically but surgery may be ultimately required in select patients. The odds of AU increased with greater percent expected bowel length and longer PN duration.
吻合口溃疡（AU）是肠衰竭（IF）患者发病的罕见原因。既往关于AU的研究规模较小，多为描述性报告。我们评估了一大群IF患者，以确定危险因素并描述AU的治疗策略。
这是一项对2013年至2023年期间参加跨学科儿科肠道康复项目的IF患者进行的回顾性病例对照研究。每个病例均为接受过肠切除的儿童，其肠衰竭（IF）符合美国肠外和肠内营养学会（ASPEN）对IF的定义，且在胃肠内镜检查时发现局部吻合口周围溃疡。根据性别和自肠衰竭诊断后的时间，每个病例与2名对照（患有IF但未诊断为AU的儿童）进行匹配。使用条件逻辑回归对临床相关危险因素对病例和对照进行比较。
在我们项目中随访并筛查的588例患者中，确定了31例（5.3%）病例。从初次手术到AU诊断的中位时间为6年，23例（77.4%）的溃疡靠近结肠-结肠吻合口。9例（29%）的溃疡周长<50%，7例（22.6%）的溃疡周长≥50%，15例（48.4%）为多发溃疡。AU诊断后的中位随访时间为2.17年。多变量分析显示，AU与肠长度增加（预期肠长度每增加10%，比值比为1.65，可信区间为1.01,2.7）和肠外营养（PN）持续时间延长（以年为单位）相关（比值比为1.68，可信区间为1.09,2.6）。在31例病例中，10例（32.3%）至少需要一次红细胞输血。29例（93.5%）采用了抗生素、抗炎药物和/或肠内类固醇进行初始药物治疗。其中，8例最终药物治疗失败（根据临床团队的定义），接受了手术（7例）或内镜下凝血治疗（1例）。1例患者进行了内镜下凝血治疗，1例患者进行了手术，其中该患者需要再次手术。
在这一大群IF患者中，5.3%的患者发生了AU。大多数患者可以通过药物治疗，但部分患者最终可能需要手术。AU的发生几率随着预期肠长度百分比的增加和PN持续时间的延长而增加。
