title: Endoscopic ultrasound to guide the combined medical and surgical management of pediatric perianal Crohn's disease.
abstract: BACKGROUND
  Perianal fistulas are a debilitating manifestation of Crohn's disease (CD) in the pediatric population and present a management challenge. The aims of this study were to describe our experience using endoscopic ultrasound (EUS) to guide management of perianal CD (PCD) in a pediatric population, and determine whether using EUS to monitor healing after seton placement improves outcomes.
  
  
  METHODS
  We conducted a retrospective study of 2 cohorts: pediatric subjects with PCD who underwent EUS and pediatric subjects who underwent seton placement between 2002 and 2007.
  
  
  RESULTS
  In all, 25 children underwent a total of 42 EUS procedures. Of 28 EUSs performed to evaluate suspected perianal disease, complex fistulizing disease was identified in 15 (54%). Setons were placed after most EUSs demonstrating complex fistulizing disease and after none demonstrating superficial or no fistulizing disease. Of 14 EUSs performed to monitor healing around a seton, 7 (50%) demonstrated persistent peri-seton inflammation. Setons were more often left in place after an EUS revealing persistent inflammation (86% versus 0%), and the patients were more likely to have a biologic initiated or changed (57% versus 0%). Among all subjects who underwent seton placement, time from seton removal to recurrence was longer for those followed by EUS compared to those followed by physical exam only; however, we were not powered to test for statistical significance.
  
  
  CONCLUSIONS
  EUS to guide the combined medical and surgical management of PCD is feasible in the pediatric population. Larger prospective studies are needed to determine if EUS-directed management improves outcomes in pediatric patients with PCD.
authors.affiliation: Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Vanderbilt University School of Medicine, Nashville, TN 37232-0696, USA. michael.rosen@vanderbilt.edu
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Rosen
authors.forename: Dedrick E
authors.initials: DE
authors.lastname: Moulton
authors.forename: Tatsuki
authors.initials: T
authors.lastname: Koyama
authors.forename: Walter M
authors.initials: WM
authors.lastname: Morgan
authors.forename: Stephen E
authors.initials: SE
authors.lastname: Morrow
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Herline
authors.forename: Roberta L
authors.initials: RL
authors.lastname: Muldoon
authors.forename: Paul E
authors.initials: PE
authors.lastname: Wise
authors.forename: D Brent
authors.initials: DB
authors.lastname: Polk
authors.forename: David A
authors.initials: DA
authors.lastname: Schwartz
mesh_terms: D000293:Adolescent; D000465:Algorithms; D001003:Anal Canal / Q000000981:diagnostic imaging / Q000601:surgery; D015331:Cohort Studies; D003131:Combined Modality Therapy; D003424:Crohn Disease / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy; D013505:Digestive System Surgical Procedures; D019160:Endosonography / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D012003:Rectal Fistula / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy; D012189:Retrospective Studies; D016896:Treatment Outcome; D014945:Wound Healing; D055815:Young Adult