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Болалар хирургияси
Nurali Nurmukhammatovich NAZAROV
Tashkent Pediatric Medical Institute,
Department of Hospital Pediatric Surgery
ENDOSCOPIC SURGERY IN THE TREATMENT OF CHILDREN WITH VARIOUS
DISEASES OF THE LARGE INTESTINE
For citation:
N.N. Nazarov ENDOSCOPIC SURGERY IN THE TREATMENT OF CHILDREN
WITH VARIOUS DISEASES OF THE LARGE INTESTINE Journal of Biomedicine and Practice.
2021, vol. 6, issue 2, pp.36-42
http://dx.doi.org/10.26739/2181-9300-2021-2-6
ANNOTATION
The possibilities of endoscopic surgical correction of colon pathologies in children have been
studied. The features of endoscopic surgery for congenital pathologies of the colon in children are
assessed. The review analyzes the effectiveness of endosurgical correction of congenital colon
pathologies in children. The characteristic complications after endosurgical correction of colon
pathologies are analyzed in detail. The use of the endoscopic technique in patients with colon
pathologies allows minimizing postoperative complications.
Key words:
large intestine, congenital anomalies, endoscopic surgery, children.
Нурали Нурмухамматович НАЗАРОВ
Ташкентский педиатрический медицинский институт,
Кафедра госпитальной детской хирургии
ЭНДОСКОПИЧЕСКАЯ ХИРУРГИЯ ПРИ ЛЕЧЕНИИ ДЕТЕЙ С РАЗЛИЧНЫМИ
ЗАБОЛЕВАНИЯМИ ТОЛСТОГО КИШЕЧНИКА
АННОТАЦИЯ
Изучены возможности эндоскопической хирургической коррекции патологий толстой
кишки у детей. Дана оценка особенностям эндоскопической хирургии при врожденных
патологий толстой кишки у детей. В обзоре анализируется эффективность эндохирургической
коррекции врожденных патологий толстой кишки у детей. Подробно анализировано
характерные осложнения после эндохирургической коррекции патологий толстой кишки.
Применение эндоскопической методики у больных с патологиями толстой кишки позволяет
минимизировать послеоперационных осложнений.
Ключевые слова:
толстая кишка, врожденные аномалии, эндоскопическая хирургия,
дети.
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Нурали Нурмухамматович НАЗАРОВ
Тошкент педиатрия тиббиёт институти
Госпитал болалар хирургияси кафедраси
БОЛАЛАРДА ЙЎҒОН ИЧАКНИНГ ТУРЛИ КАСАЛЛИКЛАРИНИ ДАВОЛАШДА
ЭНДОСКОПИК ХИРУРГИЯ АҲАМИЯТИ
АННОТАЦИЯ
Мақолада болаларда йўғон ичак патологияларини эндоскопик жарроҳлик йўли билан
даволаш имкониятлари таҳлил қилинган. Болаларда йўғон ичакнинг туғма патологияларини
даволашда эндоскопик жарроҳлик усулининг ўзига хос хусусиятларига баҳо берилган.
Шунингдек мақолада болаларда йўғон ичакнинг туғма патологияларини эндоскопик
жарроҳлик усулида даволаш самарадорлиги таҳлил қилинган. Йўғон ичак туғма ривожланиш
нуқсонларини эндоскопик жарроҳлик усулида даволашдан кенйинги кузатииши мумкин
бўлган асоратлар ва уларни олдини олиш чоралари таҳлил қилинган. Йўғон ичакнинг
жарроҳлик касалликларини даволашда эндоскопик жарроҳлик усулидан фойдаланиш
операциядан кейинги асоратларни камайтириш имконини беради.
Калитсўзлар:
йўғон ичак, туғма нуқсонлар, эндосокпик жарроҳлик, болалар.
Introduction
In recent years, there has been a significant increase in the incidence of inflammatory bowel
disease (IBD) in children worldwide. Up to 25% of patients with inflammatory bowel disease (IBD)
enter the clinic with symptoms under the age of 18 years [1-4]. Data from a national prospective study
in the UK show that the incidence of IBD is 5.2 per 100,000 in children aged 16 years or younger,
of which 60% is Crohn's Disease (CD), in Portugal – 6.7 per 100,000, the same frequency of BC in
children is recorded in Italy, in North America – 3-4 cases of BC per 100,000 children. Studies are
being conducted on the epidemiology of IBD in children in St. Petersburg, where the incidence of
IBD is 2 cases per 100 thousand population with a prevalence of 6 cases per 100 thousand, and the
incidence of BC is 4 times higher than the incidence of ulcerative colitis. IBD treatment is generally
medical at initial presentation, with surgery reserved for patients with disease immune to medical
treatment or complications that require emergency surgery, such as bowel obstruction, perforation or
life-threatening hemorrhage [2-4,6,7]. It is estimated that up to 80% of patients with Crohn's disease
(CD) will require surgical intervention during their lifetime [8].
The first review analyzing the results of surgical treatment of BC complications in children
was published in the early 80s of the twentieth century [36]. Of 67 children with BC, 36 (54%)
underwent primary bowel resections, the interval from diagnosis to surgery was 1-7 years. Nineteen
children subsequently underwent a second resection and 9 patients underwent a third intestinal
resection.
In Russian sources, one of the first publications discussing indications for operations in
children with BC was an article by gastroenterologists V.G. Rumyantsev and N.E. Shchigoleva [37].
Indications for the operation were recurrent intestinal obstruction, massive intestinal bleeding and
intestinal fistulas. All operative interventions in BC, given the high risk of postoperative relapse (up
to 60-70% of observations), were recommended to be performed with economical gut resection or
stoma overlay.
In the last decade, work has appeared in foreign print with the analysis of surgical
interventions in children with BC. So in the review of R.A. Diefenbach et al. It was noted that in
children with a severe course of the disease, resistance to conservative therapy or with delayed
physical development and local intestinal damage, intestinal resection was recommended to ensure a
practically healthy interval of 2-3 years.
In the domestic literature during these years, mainly published works on clinical cases of the
complicated course of BC in children. In the paper, the authors presented new indications for surgery,
such as palpable intraperitoneal infiltrate, persisting against a background of conservative therapy,
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laboratory inflammatory activity, and hypoalbuminemia in individuals with local bowel damage;
delayed physical development with deficient div weight and growth.
In the recent years, publications by Russian surgeons have appeared with the results of
laparoscopic intestinal resections in BC in children. The first experience of operations in a small
group of patients with BC is presented, laparoscopic ileocical resections in 16 patients and small
intestine resections are performed for intestinal strictures in 3 patients with intracorporal
administration of intestinal anastomosis. There were no complications.
I.Hojsak et al in a multicenter retrospective study of data from 5 European countries concluded
that planned gut resection in BC is a method of choice to be considered in children and adolescents
with limited GI involvement in order to correct for delayed physical development and achieve
remission.
Thus, many publications note that timely surgical intervention in the complicated course of
BC in children can be a good alternative to long-term surgical treatment with the possibility of gaining
a healthy interval after surgery and eliminating the delay in physical development. The main tasks of
pediatric surgeons remain to ensure severe manifestations of the disease, reduce the frequency of
complications to achieve a better quality of life. Foreign and domestic surgeons emphasize the need
to choose minimally invasive interventions with an individual combination approach in patients with
perianal BC, which is optimal for maintaining the anal continent. However, a review of the literature
showed that the features of surgical treatment of complicated BC in children and adolescents were
not fully considered without discussing the timing and objective indications for the operation, which
dictates the need for further research.
Minimally invasive surgery is now increasingly used in the management of IBD in adults,
with reduced morbidity and length of stay reported, as well as faster return to normal diet
postoperatively [9]. A Cochrane review in 2011 compared two randomized control trials (n = 120) and
demonstrated that there is no significant difference in morbidity and mortality between open and
laparoscopic surgery in IBD, indicating that laparoscopic surgery is a feasible and safe option in the
adult population [10]. In addition, the review reported improved cosmesis, reduced risk of adhesions,
and lower incidence of postoperative abdominal wall hernia formation as additional advantages of
minimally invasive surgery [10]. These potential benefits reflected in the increasing use of the
laparoscopic approach in the paediatric population. Nonetheless, the available data remain scarce and
the literature supporting laparoscopic resection for the treatment of IBD in the paediatric population
is limited [7,11,12].
The aim of this narrative review was to analyze the published evidence comparing
laparoscopic and open resectional surgery in the management of children and adolescents with IBD,
determining the role and feasibility of minimally invasive surgery in this population.
Methods
A literature search of the Pubmed and Embase databases was performed by 2 independent
researchers (A.E.P. and S.G.S.) using the search terms “inflammatory bowel disease,” “children,”
“adolescents,” “laparoscopic,” and “colectomy.” The search was confined to manuscripts published
in the English language. As this is a narrative review, ethical approval was not required.
Results
From the 22 studies identified during the search, 10 reported results on the laparoscopic
surgical management of paediatric patients with IBD and were included in the analysis. Outcomes
following surgery, including operative time, technical difficulty, postoperative management (time to
oral intake and length of opiate use), complications, and cosmesis, were compared for those children
and adolescents with IBD undergoing laparoscopic and open resectional surgery.
Operative Time and Technical Difficulty
Often quoted disadvantages of a laparoscopic resection are the high degree of technical
difficulty and potentially longer operative times associated with the procedures. This suggested in
one of the first series to report outcomes from laparoscopic surgery in the paediatric IBD population,
including 32 children that underwent surgery for UC during an 18-year period [13]. The cohort
included 25 patients who had a subtotal colectomy and end ileostomy and the outcomes of
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laparoscopic (n = 10) and open surgery (n = 15) were compared. The remaining 7 children had either
laparoscopic (n = 3) or open (n = 4) proctectomy and ileoanal pouch or single-stage proctocolectomy
and ileoanal pouch formation. Laparoscopic surgery deemed a more technically demanding approach,
particularly in the presence of thickened mesentery and friable bowel in these patients. Consequently,
the duration of some of the laparoscopic procedures was significantly longer than that of the open
ones. More specifically, operation time was longer for a mean of 104 minutes for laparoscopic
subtotal colectomy and for a mean of 140 minutes for single-stage proctocolectomy with ileoanal
pouch formation. No significant difference was identified in the operative time between open and
laparoscopic proctectomy and ileoanal pouch, although the numbers in these groups were small. Over
the course of the study, however, surgical times for laparoscopic procedures improved significantly
and were comparable to those of open surgery [13]. This was not the patient in the largest reported
series (n = 136), in which no reduction in laparoscopic operating times was observed (median time
258 minutes) [2]. Linden et al reported longer operating times with a laparoscopic approach (median
time 517 minutes vs 430 minutes) [14], whereas in one series no significant difference in operating
time was identified between laparoscopic and open restorative proctocolectomies (mean total
operating time of 443 vs 403 minutes, respectively) [11]. In general, laparoscopic resections resulted
in longer operating times between a mean of 40 and 140 minutes.
With regards to conversion to an open operation, Diamond et al [2] reported a 7.1% conversion
rate. The primary reasons identified were poor visibility and inability to complete the sigmoid
transaction via the minimally invasive approach. A similar conversion rate was reported by Courtney
et al (6.7%) [3]. Even though 0% conversion rates have also been reported [7,13,15], a rate around
7% is considered acceptable and seems comparable with the adult population (7.9%) [10].
Postoperative Management
Introduction of oral intake is an important parameter in the management of patients after
surgery. Laparoscopic surgery in adults is considered a less invasive approach, with reduced
incidence of ileus in the postoperative period and consequently earlier introduction of oral feeding
[16]. This observation was also reported in the surgical management of paediatric patients with IBD
[3,17]. Two studies have reported introduction of oral fluids in these patients after laparoscopic
surgery after an average of 3 days, which compares with 6 days following an open resection [2,13].
In 1 cohort, clear fluids were introduced at 4 days after laparoscopic colorectal surgery and regular
diet at day 5. Data published from adult studies show that there is no significant difference in length
of opiate use between the 2 groups [10]. However, it is predicted that pain management and early
mobilization are more readily feasible after laparoscopic surgery. This concurs with the data reported
in the paediatric population with opiate analgesia being required for 2–3 days postoperatively in the
laparoscopic group, versus up to 6 days in the open surgery group [2,7,13].
Postoperative Complications
In the adult population with IBD, the Cochrane review of 2011 concluded that there is no
difference in morbidity and mortality between 2 approaches. Similar evidence has been reported in
the paediatric population. Of note, the overall incidence of complications was higher in the open
subgroup in only 1 study (0% vs 7%), mainly due to the increased rate of infective complications.
Conversely, in 1 series a higher incidence of complications was identified in the laparoscopic group
(12.5% vs 0%). However, the size of the series is small and the only complication reported was a
urine infection. Different series reported overall complication rates between 20 and 62.8% after
laparoscopic colorectal procedures. However, in these series, no open group sample was included
for comparison. In addition, if laparoscopic surgery is compared between the adult and paediatric
population, there is no difference in the complication rates (23% vs 20%, respectively).
The higher
complication rate observed in 1 of the series can most likely be attributed to the fact that most of the
patients were on active medical treatment for their IBD at the time of the operation, with 59% being
on steroids.
Small bowel obstruction (SBO) was the most common postoperative complication, with
incidence ranging between 3% and 23%. No clear association was identified between SBO rates and
surgical approach, even though a trend toward increased rates was seen with open colorectal
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procedures. Small bowel obstruction was more common after open procedures in 1 series and
occurred in 23% of patients (vs 5% of laparoscopic patients). However, some series reported
conflicting data, with SBO seen in 3–13% of patients after laparoscopic surgery. In 1 cohort the
reason hypothesized for SBO in laparoscopic surgery was the formation of an internal hernia caused
by a tight window between the fixed terminal ileum and the abdominal wall. When this was accounted
for using a number of different surgical techniques, SBO rates dropped significantly from 37.5% to
12.5%.
Other significant complications reported following resectional surgery in IBD included
anastomotic leak (2.2%), haemorrhage (4.3%), anastomotic stricture (13% after laparoscopic vs 28%
after open surgery), rectal stump dehiscence (6.3%), intraabdominal fistulae (2.4%), and abscesses
(7.1%). Infective complications were more prevalent in the open group, with intraabdominal fistulae,
pouchitis, and sepsis occurring more frequently. It is important to note that half way through 1 of the
2 studies, open procedures were no longer performed electively; hence, the open group included only
patients requiring an emergency procedure, who have an acknowledged higher risk of developing
complications.
Intraoperative blood loss was lower during laparoscopic colorectal procedures and this
was attributed to the good haemostatic control achieved by the use of laparoscopic energy sealing
devices, as well as meticulous surgical technique and attention to fine detail.
Length of Hospital Stay
The early introduction of oral diet and less analgesia requirements associated with
laparoscopic surgery, with no increase in the complication rate compared with open surgery, may
translate to shorter hospital stay. Not surprisingly, this has been demonstrated in most series. The
median reported length of stay varied between 5 and 8 days, whereas only 1 study reported similar
length of stay at a median of 7 days in both their study groups. Flores et al reported a significantly
shorter length of stay with laparoscopic surgery, with a mean of 8 days in hospital versus 19 days
following open surgery. Similar data were reported by Courtney et al (6.7 days with laparoscopic vs
10.5 days with open surgery). Sheth and Jaffray noted longer lengths of stay postoperatively
compared with other series, but again patients after minimally invasive surgery were discharged 2
days earlier (15 days for laparoscopic surgery vs 17 days for open surgery).
Cosmesis
Although laparoscopic surgery is considered to be preferable to open surgery in terms of
improved cosmesis, there are no current published data to support this. Interestingly, in 1 series 40%
of children were unsatisfied with the cosmetic results following laparoscopic surgery.
Discussion
Laparoscopic surgery is widely practised in the management of IBD in the adult population.
The benefits of a minimally invasive approach include reduced postoperative pain and morbidity and
a shorter hospital stay. Nonetheless, it is a more technically demanding operation and careful patient
selection is warranted.
Patients with no previous abdominal surgery, low div mass index, and
favourable div habitus are the ideal candidates. In addition, technical difficulty is increased in
patients of IBD because of the fact that the bowel may be friable resulting in challenging handling
and mobilization.
With regards to the paediatric population, data remain limited. Furthermore, many reports on
the utilization of minimally invasive techniques in colorectal surgery in this population include
patients with non-IBD-related problems, such as polyposis syndromes, constipation, and
Hirschsprung disease. Even in those studies that report outcomes following IBD surgery, the data are
heterogeneous due to the inclusion of adult patients and patients needing surgery for CD and UC. In
addition, these studies generally have a small sample size, while no randomized trials of laparoscopic
versus open surgery in the paediatric IBD population have been published. Because of all these
limitations, any conclusions should be considered with caution. Nonetheless, the published literature
supports the feasibility of minimally invasive surgery for IBD in children and adolescents. The
increased technical difficulties and the generally small experience in this population may result in
longer operative times. However, with increasing experience, operative time may be reduced.
Complication rates and length of stay are generally reported as either comparable or reduced in the
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laparoscopic group.
This may translate into a quicker return to educational activities and the patient's
psychosocial health being less affected. Furthermore, the economic burden to the overall healthcare
system may be reduced.
It is thought that with laparoscopic surgery, superior cosmesis may improve div image after
surgery. However, only 1 study has quantifiable data showing results on cosmesis in the paediatric
population, reporting a 40% rate of patient-reported dissatisfaction with the cosmetic results. Further
data in the paediatric population are needed in this area. More recently, case reports have advocated
the potential role of single incision minimally invasive surgery in the management of children and
adolescents with IBD.
18–21
Single incision laparoscopic surgery carries the theoretical advantage of
reduced hospital stay and improved cosmesis, with less chance for wound infection and incisional
hernias. The technique has considerable technical challenges however, and further data are needed to
clarify the role of this approach in the paediatric population.
It becomes clear that despite some potential advantages, the laparoscopic approach increases
the complexity of the surgery in these patients. In addition to a dedicated paediatric gastroenterology
team, a specialized colorectal surgical team with significant experience and technical expertise in
minimally invasive surgery is required. The role and contribution of all the members of the
multidisciplinary team, including nursing staff on the ward and in theatres, IBD specialist nurses,
play specialists, and psychologists, is paramount in the different aspects and phases of care.
Furthermore, the use of specialized and potentially costly, disposable laparoscopic surgical
equipment should also be considered. Therefore, minimally invasive surgery for the management of
children and adolescents with IBD should be practised in the tertiary hospital setting, in which
appropriate clinical pathways can be instituted by appropriate teams.
Notwithstanding the small numbers and poor quality of the published data, current evidence
suggests that laparoscopic colorectal surgery is safe and feasible for the management of IBD in the
paediatric population and should be considered a management option. Key factors for successful
outcome are careful patient selection by an experienced IBD surgical team within a paediatric
gastroenterology multidisciplinary IBD team.
Footnotes
Abbreviations: CD = Crohn disease, IBD = inflammatory bowel disease, SBO = small bowel
obstruction, UC = ulcerative colitis.
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