How are pediatric colorectal tumors treated?

Updated: Jun 06, 2020
  • Author: Jaime Shalkow, MD, FACS; Chief Editor: Cameron K Tebbi, MD  more...
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Answer

Answer

Surgical resection remains the mainstay of treatment for colorectal carcinoma in adult and adolescent patients, and the sole therapy required for patients with stage I and II disease. [42]

Open colectomy has been the standard of care for the past 100 years. Complete en bloc tumor resection, including the lymphatic basin of the affected segment, has the greatest impact on survival. [18]

Treatment guidelines are based largely on evidence from older adults. Multidisciplinary care is crucial, and prompt referral to centers experienced in the care of adolescents and young adults should be considered for young patients.

Surgical site infection complicates approximately 15% of colectomy procedures. Oral antibiotic bowel preparation before elective colorectal surgery is associated with shorter postoperative length of stay and lower 30-day readmission rates, primarily because of fewer readmissions for infections. [47]  Moghadamyeghaneh et al demonstrated that a combination of mechanical and oral antibiotic preparations significantly decreased postoperative morbidity. [41]

Enhanced recovery protocols, which aim to streamline and standardize perioperative care, have demonstrated efficacy in reducing length of stay but have not resulted in reduced readmission rates. These protocols avoid the use of bowel preparation and epidurals, and encourage early ambulation, early feeding, and early transition to oral analgesia.

Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) is a viable procedure in pediatric patients, with acceptable morbidity and good long-term results with regard to gastrointestinal function, quality of life, and patient satisfaction. [65, 66]  Concerning the type of anastomosis, these authors favor stapled IPAA for prophylactic colectomy, reserving hand-sewn IPAA for patients with neoplasia. The latter is a prudent approach, because earlier dysplasia and colorectal neoplasia are the most important risk factors for developing pouch-related cancer. [65]

An ileal J-pouch is easy to create and delivers acceptable outcomes. However, an S-pouch provides an extra 1-2 cm of length, allowing for tension-free IPAA. [66]  

Because children have a long life expectancy, both functional outcomes and control of neoplastic activity of the anal canal and ileal reservoir are of utmost importance. [66]

Best results are obtained with stapled, tension-free anastomosis. Intact tissue rings, good hemostasis, and absence of air leak are imperative. Malnutrition (albumin level, < 3.5 g/dL), neoadjuvant drug toxicity, anemia (hemoglobin level, < 13.5 g/dL), and prolonged high-dose corticosteroid therapy (20 mg of prednisone daily for longer than 3 months) are prognostic factors for perioperative morbidity. Perioperative complications are not uncommon (10%); they include pelvic sepsis, anastomotic leak or stricture, pouchitis, pouch failure, bowel obstruction, and anastomotic stricture. [66]

Laparoscopic resection offers similar postoperative outcomes, pouch function, and long-term quality of life compared with open procedures. [66]   However, the learning curve for laparoscopic colectomy remains steep. The need to retract multiple organs, identify complex anatomy, and control large vessels makes the operation difficult. [42]


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