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Restorative proctocolectomy in children with ulcerative colitis utilizing rectal mucosectomy with or without
S E Dolgin1, E Shlasko, S Gorfine
1Mount Sinai Medical Center, New York, NY 10029-6574, USA.
Insights
Restorative proctectomy (RP) with rectal mucosectomy and hand-sewn ileoanal anastomosis (IAA) in children with ulcerative colitis (UC) yields good functional outcomes. Omitting routine diverting ileostomies reduces complications and morbidity associated with stomas.
Area of Science:
- Pediatric surgery
- Gastroenterology
- Colorectal surgery
Background:
- Controversies exist regarding optimal restorative proctectomy (RP) techniques for ulcerative colitis (UC).
- The efficacy of rectal mucosectomy with hand-sewn ileoanal anastomosis (IAA) versus double-stapled techniques is debated.
- The necessity of diverting ileostomies after RP for UC requires further investigation.
Purpose of the Study:
- To evaluate the outcomes of RP using rectal mucosectomy and hand-sewn IAA in pediatric UC patients.
- To compare functional results and complication rates between patients with and without diverting ileostomies.
- To determine if routine diverting ileostomies are essential following RP in this population.
Main Methods:
- A retrospective review of 30 consecutive pediatric UC patients undergoing RP with rectal mucosectomy and hand-sewn IAA.
- Patients were divided into two groups: 14 with temporary diverting ileostomies (Group 1) and 16 without (Group 2).
- Outcomes assessed included bowel movement frequency, soiling, quality of life, and complication rates.
Main Results:
- No significant difference in overall outcomes between the two groups.
- Group 2 (no ileostomy) had fewer average bowel movements (4.2 vs. 5.5) and less nighttime staining.
- Complications were lower in Group 2 (5 total) compared to Group 1 (10 total), with no peritonitis in the absence of diversion.
Conclusions:
- Restorative proctectomy with rectal mucosectomy and hand-sewn IAA provides favorable functional results in pediatric UC.
- Eliminating routine diverting ileostomies in pediatric RP for UC is safe and avoids stoma-related complications.
- This approach simplifies the surgical procedure and reduces patient morbidity.
Background:
Controversies continue concerning the best way to perform restorative proctectomy (RP) for ulcerative colitis (UC). Can rectal mucosectomy and hand-sewn ileoanal anastomosis (IAA) withstand the challenge posed by extrarectal dissection with a double-stapled technique and no mucosectomy? Is a diverting ileostomy mandatory after RP?
Methods:
The authors describe 30 consecutive children with UC who underwent RP with rectal mucosectomy and hand-sewn IAA. The authors assess the results and compare the first 14 patients (group 1) treated with temporary diverting ileostomies with the next 16 consecutive patients (group 2) without diverting ileostomies.
Results:
The average age (13.8 years in group 1 v 10.4 in group 2), duration of illness before resection (3.2 years in group 1 v 1.5 in group 2), and gender breakdown (10 of 14 were girls in group 1, 10 of 16 were girls in group 2) were similar between the two groups. Outcome was not significantly different between the two groups. Average bowel movements per 24-hour period was 5.5 in group 1 and 4.2 in Group 2. Occasional nighttime staining occurred in two patients in group 1 and five in group 2. No one suffered daytime staining in group 1, and one patient had occasional daytime staining in group 2. Average quality of life (on a scale of 0 to 5) as assessed by the patients or parents was 4.4 in group 1 and 4.9 in group 2. There were 10 total complications in group 1. One child required a permanent stoma for ileoanal separation. Two patients required reoperations for complications caused by the diverting ileostomy. The single instance of peritonitis was in group 1 caused by anastomotic leak after ileostomy closure. There were five total complications in group 2, of which, two required temporary stomas for ileoanal separations.
Conclusions:
RP with rectal mucosectomy and hand-sewn IAA in children with UC provides good functional results. Peritonitis did not occur in the absence of diversion. Eliminating routine diverting ileostomy avoids the considerable complications and morbidity from the stoma and its closure.