Available online 28 March 2024, 151401

Author links open overlay panel, ABSTRACT

Management of pediatric-onset Crohn's disease uniquely necessitates consideration of growth, pubertal development, psychosocial function and an increased risk for multiple future surgical interventions. Both medical and surgical management are rapidly advancing; therefore, it is increasingly important to define the role of surgery and the breadth of surgical options available for this complex patient population. Particularly, the introduction of biologics has altered the disease course; however, the ultimate need for surgical intervention has remained unchanged. This review defines and evaluates the surgical techniques available for management of the most common phenotypes of pediatric-onset Crohn's disease as well as identifies critical perioperative considerations for optimizing post-surgical outcomes.

Section snippetsINTRODUCTION

Crohn's disease (CD) is a chronic inflammatory condition which manifests as progressive intestinal damage in predisposed individuals with unknown environmental exposures.1, 2, 3 Although the exact etiopathogenesis remains elusive, there is evidence for 71 susceptibility loci on 17 chromosomes which results in intestinal immune dysfunction and abnormal interactions with typical symbiotic intestinal commensal microbiota.1,4,5 This ultimately produces the characteristic patchy intestinal luminal

Surgical Indications

In pediatric-onset CD, surgical intervention is necessitated in three principal circumstances—failure of medical therapy, growth failure, and management of disease complications. Inadequacy of medical therapy may manifest as the escalation of symptoms despite optimized maintenance therapy or the development of antibodies to biologics rendering them ineffective. Furthermore, avoidance of long-term corticosteroid dependence is essential in children due to metabolic consequences and deleterious

Small Bowel and Ileocolonic Resections

Disease activity in pediatric CD most commonly (53%) presents in a patchy distribution in both the ileum and colon while 16% have isolated ileocecal disease and only 4% have disease isolated proximal to the terminal ileum.47 In patients with limited active small bowel or ileocolonic disease, segmental resection to grossly negative margins is sufficient, rarely requiring proximal diversion. Within the adult literature, the type of anastomosis has been found to impact short and long-term outcomes

Enhanced Recovery Protocols

Enhanced recovery protocols (ERPs) are a collection of standardized interventions with demonstrated improvements in postoperative outcomes, resource utilization and patient satisfaction while expediting recovery.140,141 Widespread adoption in adult colorectal surgery has demonstrated decreased complication rates, opioid utilization, length of stay and hospital costs; however, there is a lack of utilization of ERPs in pediatric surgery with less than 20% of surveyed pediatric surgeons reporting

CONCLUSION

CD can result in significant morbidity and diminished quality of life for patients of all ages; however, pediatric-onset CD demands unique considerations regarding a patient's growth, pubertal development and psychosocial function and their increased need for surgical interventions.160 Although advances in medical therapy have significantly altered the disease course for CD, ultimate need for surgical intervention remains unchanged.9,22 Surgical advances have been complimentary in improving

DISCLOSURE

All authors have no conflicts of interest to disclose. There is no funding to declare.

ACKNOWLEDGEMENTS

Table 1 was adapted from an article published by BMC (Springer Nature) and is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

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