JPGN Journal Club: January 2025
Happy holidays, everyone! Here’s JPGN Journal Club, led by Dr Jake Mann. Don’t forget ESPGHAN’s other educational offerings: https://www.espghan.org/knowledge-center – on 2025.I.15 the GI Winter School, on I.30 the Monothematic Conference on Steatotic Liver Disease in Children, and on III.05 the GI Immunology Master Class: From pathogenesis to clinical management of EGID, coeliac disease, and IBD. Jake’s choices for discussion today: From J Pediatr Gastroenterol Nutr, by Fioretti et al., writing from Edinburgh, “A decade of real‐world clinical experience with 8‐week azithromycin–metronidazole combined therapy in paediatric Crohn's disease”, and from Pediatr Transpl, by Channaoui et al., writing from Brussels, “Failure to rescue pediatric recipients of living donor liver transplantation : A single-center study of technical complications in 500 primary grafts”. The JPGN article addresses one of several options for initial remission induction in mild to moderately active Crohn’s disease. One choice is total parenteral alimentation ; another is corticosteroids ; and a third, that studied by Fioretti et al., is combined antibiotic treatment with azithromycin and metronidazole, which reportedly has been assessed in only twice before. Among 44 children thus treated at Edinburgh, after 8 weeks 28 entered remission – 64%. Among the 38 children who completed the treatment course (6 could not tolerate the treatment), again 28 entered remission – 74%. The authors conclude that the combined therapy studied is an acceptable approach in at least some children with Crohn’s disease. They do not, however, assess their experience with the other two approaches mentioned or cite the results of others’ work: How effective is total parental alimentation, how effective is corticosteroid treatment? Without those data this article can not be optimally used in choosing among therapeutic options. “Failure to rescue” is a recently introduced concept in assessment of quality of care. The Brussels group use it to mean “death of a complication of surgery”. In severe liver disease, without liver transplantation all patients suffer from “failure to rescue”, and die ; liver transplantation is per se an attempt at rescue, and when a complication of that attempt supervenes, a complication that is not successfully treated and that ends in death, a “failure to rescue” has occurred. Channaoui et al. examined rates of death and of graft loss at 1 and 5 years after living-donor liver transplantation in 500 children through the “failure-to-rescue” lens, tallying instances of arterial, venous, and biliary-tract complications and further tallying death and graft loss that could be ascribed to such complications. Biliary-tract complications were most numerous, but arterial complications led to the most deaths and graft losses. A great deal of information is supplied on aetiologies of liver disease, age at liver transplantation, and surgical technique, but remarkably little is made of what the reader has ploughed through (or skimmed over) : The authors do not speculate on how these factors contribute to “failure to rescue”. Instead, they in conclusion offer rather general suggestions for avoiding arterial and venous complications, but not biliary-tract complications, and comment that “failure-to-rescue” analyses may hold promise for better clinical care. Perhaps they may, but they may also simply be old wine in new bottles, mortality-and-morbidity reviews with a fashionable name. Literature Fioretti MT et al. A decade of real‐world clinical experience with 8‐week azithromycin–metronidazole combined therapy in paediatric Crohn's disease. J Pediatr Gastroenterol Nutr 2024 Dec 9. DOI : 10.1002/jpn3.12430. PMID : 39648957 Channaoui A et al. Failure to rescue pediatric recipients of living donor liver transplantation : A single-center study of technical complications in 500 primary grafts. Pediatr Transpl 2024 Nov; 28(7):e14861. DOI : 10.1111/petr.14861. PMID : 39320008
