APSA Paper
Pouch outcomes among children with ulcerative colitis treated with calcineurin inhibitors before ileal pouch anal anastomosis surgery

https://doi.org/10.1016/j.jpedsurg.2006.09.006Get rights and content

Abstract

Purpose

The purpose of this article is to describe the outcomes of the pouches of 14 children with ulcerative colitis (UC) who were pretreated with calcineurin inhibitors before they underwent their ileal pouch anal anastomosis (IPAA) surgery.

Methods

An institutional review board–approved retrospective review of the charts of consecutive patients with UC treated with calcineurin inhibitors before undergoing IPAA surgery at a tertiary pediatric center between 1998 and 2003 was performed. The primary endpoint was pouch outcome after at least 2 years of follow-up (healthy pouch, acute pouchitis, chronic refractory pouchitis, or pouch failure); the secondary endpoints were early postoperative complications, number of stages, and time between stages.

Results

Fourteen of 53 consecutive patients who underwent IPAA for UC were treated with calcineurin inhibitors before their surgery (26%; 6 with cyclosporine and 8 with tacrolimus). All 14 patients were concomitantly treated with systemic steroids. Ten patients (71%) were also taking 6-mercaptopurine or azathioprine, and 9 (64%) were also taking mesalamine. Three patients (21%) had healthy pouches with no clinical evidence of pouchitis, 6 (43%) had at least one episode of acute pouchitis (average of 2 episodes per year), 3 (21%) had chronic relapsing pouchitis, and 2 (14%) were later determined to have Crohn's disease. There was no pouch failure. Two patients (14%) had an early postoperative complication (intraabdominal abscess, anastomotic stricture). Five patients (36%) had a 2-staged procedure, and 8 (64%) had a 3-staged procedure. For the 2-staged procedures, the mean time between the first and second stages was 3.14 months (range, 3-4 months). For the 3-staged procedures, the mean time between the first and second stages was 4.25 months (range, 2-6 months) and that between the second and third stages was 4 months (range, 2.5-6 months).

Conclusions

In this series, chronic pouchitis was an infrequent complication among children who were pretreated with calcineurin inhibitors. Calcineurin inhibitor use did not lead to or portend increased early postoperative complications or affect the number or duration of surgical stages. Further studies are required to determine if preoperative calcineurin inhibitors improve pouch outcomes or facilitate the performance of 2-staged procedures.

Section snippets

Materials and methods

A retrospective review of the charts of consecutive patients with UC treated with calcineurin inhibitors before their IPAA surgery at a tertiary pediatric center between 1998 and 2003 was performed. Approval for the study was obtained from the institutional review board of the Children's Hospital Boston before it was initiated. Fifteen patients who underwent IPAA surgery and received systemic calcineurin inhibitors before their surgery were identified. One patient was lost to follow-up before 2

Results

Of 53 consecutive patients with UC who underwent IPAA at the Children's Hospital Boston between 1998 and 2003, 14 (26%) received systemic calcineurin inhibitor therapy to control their disease before undergoing colectomy (6 with cyclosporine and 8 with tacrolimus). The mean age of the patients was 14.6 years (range, 5.5-18.6 years). There were 8 girls and 6 boys. Twelve patients (86%) had pancolitis, and 2 (14%) had left-sided disease. Tacrolimus was given twice daily and titrated to maintain

Discussion

In this series, we described 14 children with severe UC who were treated with calcineurin inhibitors in an attempt to control their disease but who ultimately required IPAA surgery. Cyclosporine and tacrolimus are 2 types of calcineurin inhibitors used to treat severe UC in children. Calcineurin is a serine threonine phosphatase that is responsible for activating pro-inflammatory transcription factors. By inhibiting the nuclear factor of activated T cells, these drugs prevent the production of

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Presented at the 37th Annual Meeting of the American Pediatric Surgical Association, May 20–24, 2006, Hilton Head, SC.

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