Incidence of dysplasia in pelvic pouches in pediatric patients after ileal pouch-anal anastomosis for ulcerative colitis.

BACKGROUND: The purpose of this study was to evaluate the incidence of dysplasia and the mucosal adaptation patterns of pelvic pouches in children and adolescents who had undergone ileal pouch-anal anastomosis for ulcerative colitis. METHODS: Between 1982 and 1996, 176 pediatric patients with ulcerative colitis underwent ilial pouch-anal anastomosis. Seventy-six patients were followed up after surgery at the Cleveland Clinic. Pouch biopsy specimens were reviewed for dysplasia and to determine mucosal adaptation patterns. Fifty-eight of the 76 patients had an average of three mucosal biopsies during a mean follow-up of 5 years. Demographic and surgical data were abstracted from archives of medical records. All previously obtained pouch biopsy specimens were re-evaluated by a single pathologist to ensure standardized interpretation. RESULTS: No dysplasia was identified in screening specimens of 76 children and adolescents including 5 patients who showed dysplasia in resected colon specimens. The pattern of mucosal adaptation was categorized using previously reported criteria. Type A was defined as normal mucosa or mild villous atrophy with no or mild inflammation. Type B mucosa showed transient atrophy with temporary moderate inflammation followed by normalization of architecture. Type C mucosa was defined as a pattern of persistent atrophy with severe inflammation. In the study cohort, the patterns of mucosal adaptation, type A (56.9%; n = 33), type B (32.8%; n = 19), and type C (10.3%; n = 6), were comparable with those reported in adults. The rate of pouch failure and diagnosis of Crohn's disease were similar in each group and were not related to the specific adaptation pattern. Most of the patients with type C mucosa had clinical symptoms of pouchitis requiring periodic antibiotic therapy. No dysplasia was identified in any biopsy specimen reviewed. CONCLUSIONS: Similar morphologic changes can be seen in ileal pouches in pediatric and adult patients. There seemed to be no increased risk of dysplasia in children and young adults who had undergone ilial pouch-anal anastomosis surgery for ulcerative colitis during a 5 year follow-up. Because the long-term risk of development of dysplasia is unknown, an initial screening should be performed 5 years after the creation of a pelvic pouch in children or when the total disease duration exceeds 7 years. Once identified, patients with Type C mucosa should have annual screening for dysplasia until further data become available.

The effects of a psychological preparation program on anxiety in children and adolescents undergoing gastrointestinal endoscopy.

BACKGROUND: Like adults, children often experience anxiety associated with medical procedures. The purpose of this study was to investigate the effects of a program of psychological preparation for children undergoing endoscopy. METHODS: Sixty patients aged 6 to 19 years (mean, 12.2 years) were randomized into one of two groups. Group 1 received routine preparation before endoscopy. Group 2 received psychological preparation consisting of demonstration of materials that would be encountered during the procedure, use of a doll as a model, or use of a book with photographs of a child who had previously undergone endoscopy. Patients in both groups completed the Spielberger State-Trait Anxiety Inventory in the clinic and just before endoscopy. The Observational Scale of Behavioral Distress was completed by a blinded observer during each procedure. The attending physician (blinded) assessed patient cooperation. Vital signs were recorded in clinic and just before endoscopy. Parents and patients completed questionnaires after endoscopy. RESULTS: Analysis of the Spielberger State-Trait Anxiety Inventory showed patients in group 2 were significantly less anxious before endoscopy (p < 0.0001). They also required less meperidine (p < eq 0.04) per kilogram body weight and were more cooperative during the examination (p = 0.042). There was significantly less autonomic nervous system stimulation in those who had undergone psychological preparation (change in heart rate, p < 0.001; change in systolic blood pressure, p = 0.04). Statistically significant differences were found in the patients' response to questions after endoscopy regarding perceived anxiety during the procedure (p = 0.003) and the parents' response to questions regarding their own conditions (p = 0.026) and that of their child (p < 0.001). CONCLUSION: Psychological preparation before endoscopy significantly decreases patient and parental anxiety. Such preparation may allow for a reduction in sedative medications and thereby enhance procedural safety.

Ileal pouch-anal anastomosis in children with ulcerative colitis.

SUMMARY: : This study is a retrospective review of all pediatric patients with ulcerative colitis who underwent colectomy and ileal pouch-anal anastomosis (IPAA) between 1982 and 1992 at the Cleveland Clinic Foundation. The purpose of the review was to determine the effectiveness of IPAA in treating children with ulcerative colitis. Demographic, preoperative, and surgical data were abstracted from archival research of medical records. Quality-of-life information was obtained from patient or parent interviews. Ninety-one children were identified during the study period with a median age of 14.2 years. The principal indication for colectomy was intractable symptoms despite vigorous medical therapy. J-pouches (n = 51) and S-pouches (n = 38) were most commonly constructed. Median follow-up was 1.9 years after ileostomy closure. Thirty early complications (occurring within 30 days of pouch construction) were documented in 21 patients, and 57 late complications (occurring after 30 days) were documented in 34 patients. Small bowel obstruction was the most common early postoperative complication and accounted for 13 of 30 early complications; reoperation was required in four of nine patients. Pouchitis was the most frequent late complication (15 episodes in 12 patients), followed by perineal infection (14 episodes in eight patients), and anastomotic stricture (10 episodes in nine patients). Pouch type, age at colectomy, and disease interval from colectomy to pouch construction were analyzed with relation to the frequency of pouchitis, anastomotic stricture, sepsis, and incontinence. An S-pouch had been used in eight of nine patients with an anastomotic stricture (p = 0.004). The disease interval and age at initial surgery had no bearing on the presence of late complications. The pouches of four female patients were excised as a result of pelvic infection and were subsequently converted to continent ileostomies. Quality-of-life information was obtained for 78 patients. Daytime continence was complete in 67 (86%) children and nocturnal continence was complete in 56 (72%) patients. Seventy-three (94%) patients were very satisfied with their quality of life after IPAA. We conclude that IPAA is an effective surgical procedure for children with ulcerative colitis and results in a relatively normal pattern of defecation with a good long-term functional outcome. Early postoperative complications are common, but only a few patients require further hospitalization or surgery. The most common late complication is pouchitis, which responds to medical treatment. Continence is preserved in the majority of the children, and overall satisfaction with the operation is high.