Total proctocolectomy with ileal pouch-anal anastomosis (T-IPAA) in childhood is a surgical procedure mainly applied to familial adenomatous polyposis (FAP) or ulcerative colitis (UC), but it can be applied to non-FAP/non-UC disease (NFNU). Studies regarding the role of T-IPAA who underwent the operation in childhood, especially in terms of long-term gastrointestinal function, complications, and quality of life (QOL) are limited. The aim of this study was to evaluate the characteristics of patients receiving T-IPAA and to compare their bowel function outcomes and QOL.
Patients aged ≤18 years at the time of T-IPAA were included. Their medical records were retrospectively reviewed. Krickenbeck classification, Cleveland Clinic Incontinence (CCI) score, 36-item Short-form Health Survey Questionnaire, and Gastrointestinal Quality of Life Index were used for the evaluation of bowel function and QOL. The median follow-up period was 9.8 years.
Of the 25 patients, 9 had FAP, 9 had UC, and 7 had NFNU. NFNU include 3 of Hirschsprung disease, 2 of intestinal neuronal dysplasia, and 2 of imperforate anus. The median age at T-IPAA was 17.8, 14.2, and 9.3 years for FAP, UC, and NFNU, respectively (p=0.001). Bowel function was satisfactory in terms of voluntary bowel movement (VBM), soiling, and constipation. VBM and constipation were not different between the groups, but soiling was most in NFNU (100%, p=0.047). However, QOL was best in the NFNU group in surveys (p=0.034 and 0.004, respectively).
T-IPAA could be safely applied not only for FAP and UC but also for other diseases in selective cases, with caution.
Ulcerative colitis, one of the inflammatory bowel disease, is primarily managed medically with combinations of 5-ASA and steroids. However, this chronic disease requires surgical management if symptoms persist or complications develop despite medical management. The clinical course, the indications and outcome for surgical management of pediatric ulcerative colitis patients were studied from medical records retrospectively. Twenty-one patients under the age of 15 who were endoscopically diagnosed with ulcerative colitis at the Seoul National University Children's Hospital between January, 1988 and January, 2003 were subjected to the study. Mean follow up period was 3 years and 10 months. The mean age was 10.3 years old. All patients received medical management primarily after diagnosis and 8 patients (38%) eventually required surgical management. Of 13 patients who received medical management only, 7 patients (53%) showed remission, 4 patients are still on medical management, and 2 patients expired due to congenital immune deficiency and hepatic failure owing to sclerosing cholangitis respectively. In 8 patients who received surgical management, 1 patient underwent surgery due to sigmoid colon perforation and 7 patients due to intractability of medical management. The perforated case received colon segmental resection and the other 7 patients recieved total protocolectomy with ileal pouch-anal anastomosis. One patient expired postoperatively due to pneumonia and sepsis. One patient is still on medical management because of mild persistent hematochezia after surgery. The other operated patients are showing good prognosis without any management. Pediatric ulcerative colitis patients can be surgically managed if the patient is intractable to medical management or if complications such as perforation is present. Total protocolectomy & ileal pouch-anal anastomosis is thought to be the adequate surgical method.
A total of 30 cases of the peptic ulcer in children, who underwent operations from January 1981 to December 1995 because of complications at Department of the Surgery, Chonbuk National University Medical School, is reviewed. Twenty-three were males (76.7%), 7 females (23.3%) and male was preponderant at 3.3:1. There were 25 cases (83.3%) age 10 to 15 years, 3 (10.0%) between 2 and 9 years, and 2 (6.7%) below 2. The ulcer was located at duodenum in 27 (90.0%), and at stomach in 3 cases (10.0%). Complications were perforation in 19 cases (63.3%), pyloric obstruction in 9 (30.0%) and bleeding in 2 (6.7%). For perforation, truncal vagotomy with pyloroplasty was done in 11 cases, truncal vagotomy with hemigastrectomy and gastrojejunostomy in 6, and simple closure in 2 cases. For obstruction, truncal vagotomy with hemigastrectomy and gastrojejunostomy was done in 5, and truncal vagotomy and pyloroplasty in 3 cases. For bleeding lesions, truncal vagotomy and pyloroplasty was performed in 2 cases. Ten postoperative complications developed in 9 patients; adhesive ileus in 5, recurrence in 2, pneumonia 2, and wound seroma 1 case. One patient developed a primary duodenal perforation and another a recurrent obstruction. Both of patients had symptoms for more than 3 years and were treated with truncal vagotomy and pyloroplasty for the primary operations. Hospital stay was 11.5 days for the patient with perforated ulcer, 11.0 days for the patient with pyloric obstruction, and 14.5 days for the child with bleeding. Average hospital period was 11.6 days. To reduce recurrences after operation, extensive procedure such as distal gastrectomy with vagotomy at the first operation should be considered in case with severe complication or with patients who have been symptomatic for long periods.
Idiopathic small bowel ulceration distal to the duodenum is rare. Less than 5 % of the reported cases were in children. In the majority of the patients, a single ulcer of unknown cause is found in the jejunum or ileum. The diagnosis is difficult and usually made at the time of surgical exploration for complications, such as perforation, hemorrhage or obstruction. We treated a pediatric patient with perforation of an idiopathic ileal ulceration. The child was an ll-year-old boy who sustained blunt abdominal trauma. The involved ileal segment was resected. Pathologic findings were compatible with idiopathic small bowel ulceration. The clinical and pathological aspects of idiopathic ulcerations are discussed, and the literature reviewed.
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