Elsevier

Journal of Pediatric Surgery

Volume 54, Issue 12, December 2019, Pages 2554-2558
Journal of Pediatric Surgery

Colorectal Conditions
Medical and surgical management of pediatric perianal crohn's disease: A systematic review

https://doi.org/10.1016/j.jpedsurg.2019.08.036Get rights and content

Abstract

Background

The timely management of pediatric Crohn's disease (CD), and specifically perianal CD, is important owing to the possible adverse effects on growth, development, and quality of life. Perianal involvement is increasingly common, with up to 62% of pediatric CD patients affected. Presently, literature addressing the management of perianal CD has focused primarily on adults, with findings that cannot always be extrapolated to the pediatric population. We aimed to review the rates of healing, recurrence, and need for surgical intervention in perianal CD to provide evidence-based recommendations for the ideal management in children.

Method

We conducted a systematic review of CENTRAL, PubMed, Medline, and EMBASE databases (January 1997–December 2017) in accordance with PRISMA. Two independent reviewers performed data extraction.

Result

Ten studies met the inclusion criteria with a combined total of 538 patients. Median study population size was 17 (range 7–276), with a median age at intervention of 13.9 years (range 1–18). Seton placement allowed complete healing in 28.6% of children. Similar results (28.5%) were seen in children undergoing fecal diversion. One study demonstrated complete resolution of fistulizing disease in 70% of children treated with infliximab (IFX). One quarter of patients treated with IFX required further surgical intervention for disease control. Recurrence occurred most frequently in children undergoing Seton placement alone (5/14, 35.7%), compared with IFX (46/197, 23.4%) and combination therapy (12/276, 4.3%).

Conclusion

In the pediatric population, a combination of medical and surgical treatment is required to control perianal CD, with fewer side effects.

Level of evidence

Level II.

Section snippets

Background

Crohn's disease (CD) is defined as a chronic inflammatory bowel disease (IBD) affecting anywhere from the mouth to the anus. Both the etiology and pathogenesis of IBD remain poorly understood. Pediatric IBD, in particular CD, has increased in both incidence and prevalence worldwide over the last two decades, with Western countries having the highest reported rates of IBD. Perianal disease may affect 10%–62% of children, compared with 25%–80% of adults with CD [1,2]. Perianal CD in the pediatric

Study selection

Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, a systematic review of the literature was conducted. The project was also registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018085979), managed by the National Institute for Health Research.

The Cochrane Register of Controlled Trials (CENTRAL), PubMed, Medline and EMBASE databases were systematically reviewed to identify all studies that were published

Results

Ninety-one studies matched the search criteria. Ten studies met the inclusion criteria and were suitable for analysis (Fig. 1). Nine studies were retrospective and one was a subset of a randomized trial. There was a total of 538 patients. Of these, 289 patients had combined medical and surgical management: infliximab (IFX), 197; Seton, 14; 6-mercaptopurine (6-MP), 14; fistulectomy, 11; fecal diversion, 7; and 6 azathioprine (AZA), 6. The median size of the study population was 17 (range 7–276

Discussion

The management of perianal CD in the pediatric population is highly variable. Each treatment must be tailored to the individual, based upon disease severity and associated complications. The current literature on the management of pediatric perianal CD is limited and there is no standardized approach to treatment regimens. This systematic review extensively searched the literature in an attempt to provide recommendations for the management of this increasingly common condition.

The NASPGHAN

Acknowledgments

Associate Professor Sebastian King's position as an Academic Paediatric Surgeon is possible owing to a generous grant from The Royal Children's Hospital Foundation.

References (14)

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Cited by (17)

  • Anti TNF treatment of complex perianal fistulas in children without luminal Crohn's disease: Is it an option?

    2022, Journal of Pediatric Surgery
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    The specific etiology of perianal abscesses and fistulas, which may develop prior to or following symptoms of luminal Crohn's disease, is poorly understood [10]. However, guidelines for management of perianal fistulas in CD are well established, and optimally involve a combined approach of abscess drainage with Seton insertion plus anti TNF and antibiotics [3,10–13]. In contrast, reports regarding prevalence and treatment options for children with CPF in the absence of luminal CD are sparse.

  • Pediatric Inflammatory Bowel Disease for General Surgeons

    2022, Surgical Clinics of North America
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    Setons are inert foreign material (vessel loop, rubber drain, silk suture) that are attached to themselves and remain in place until the area has healed. This allows maximal medical therapy to occur uninterrupted due to recurrent infection without injury to the sphincter complex.13 Systematic review of pediatric patients with perianal disease demonstrate recurrence rates between 1 and 2 years of 35.7%, 23.4%, and 4.3% for Seton placement alone, infliximab therapy alone, and combination therapy, respectively.13

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Disclosures

Funding: This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Conflict of interest: None.

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