J. L. Mueller1, A. J. Kaplan1, C. L. Griggs1 1Massachusetts General Hospital, Pediatric Surgery, Boston, MA, USA
Introduction: Compared to adults, children with Crohn’s disease often have a more aggressive phenotype. Despite numerous advances in the treatment of Crohn’s disease and the age of biologics, many patients progress to surgical management. Little is known about predictors of surgical management in the pediatric population. We therefore evaluated a cohort of pediatric Crohn’s patients treated surgically to identify predictors of early surgical intervention.
Methods: All patients previously diagnosed with pediatric Crohn’s disease who underwent ileocecal resection at a single institution between 2014 and 2021 were included. Variables collected included gender, race, age at diagnosis, location of disease, symptoms at diagnosis, number of prescribed medications, number and type of biologic agents, time to surgery, indication for surgery, and urgency of surgery. Data was analyzed using two sample t-tests, Chi-squared test, and ANOVA.
Results: 51 patients were included in the study. They were majority female (60.8%) and white (85.7%). The mean diagnosis age was 13.6 years (SD 3.5). 58% had small bowel and colonic disease, 38% had small bowel disease only, and 4% had colonic disease only. At diagnosis, 86.1% had abdominal pain, 44.4% had weight loss, 25% had diarrhea, and 19.4% had hematochezia. The mean number of medications prescribed prior to surgery was 3.1 (SD 2.1). 76% of patients had been prescribed a biologic, while 30% of patients had trialed two or more biologics. Infliximab was prescribed most frequently (64%) followed by adalimumab (36%). Only 4 patients trialed other biologics, including certolizumab, ustekinumab, and vedolizumab. The median time from diagnosis to surgery was 2.5 years (IQR 0.4-6.1). The most common indication for surgery was a stricture (66.7%), which resulted in obstruction in 60% of cases. Other common indications for surgery included abscess (33.3%), fistula (31.3%), and failure to thrive/refractory pain (25.5%). 70% of cases were elective and 30% were urgent and/or occurred during a disease related hospitalization. Patients who underwent early surgical intervention (<2.5 years from time of diagnosis) were diagnosed at an older age (15.8 versus 11.3 years, p<0.001) yet had surgery at a younger age (16.5 versus 18.5 years, p=0.04), had been prescribed fewer medications (2.0 versus 4.3, p<0.001), and were less likely to have trialed two or more biologics (7.7% versus 54.2%, p=0.001) when compared to patients who underwent surgery ≥2.5 years from diagnosis. The indications for and urgency of surgery were similar for the two groups.
Conclusion: The majority of patients with pediatric Crohn’s disease who were treated surgically at our institution developed ileal stricturing disease requiring surgical intervention. Patients who underwent earlier surgical intervention were older at time of diagnosis and had been treated with fewer medications overall and fewer biologic agents prior to surgery.