Ostomy Closures in Children: Variations in Perioperative Care Do Not Change the Outcome

Safety and Feasibility of Enhanced Recovery after Surgery in Pediatric Colostomy Closure

Aims

To study the safety and feasibility of enhanced recovery after surgery (ERAS) protocol in pediatric colostomy closure.

Materials and Methods

Retrospective observational study of children who underwent colostomy closure. Data were collected from the electronic medical records and telephonic follow-up calls of patients from October 2013 to October 2023, in the Department of Pediatric Surgery of a Tertiary level Medical College. The parameters obtained were age, gender, type of stoma, primary diagnosis, discrepancy in luminal diameters, time to reach full feeds, postoperative hospital stay, and complications. The protocol followed for colostomy closure included the following-no bowel preparation or nasogastric tube, no overnight fasting, single dose of antibiotic prophylaxis, avoiding opioids, packing proximal stoma till mobilization and starting early oral feeds postoperatively. The continuous parameters were expressed as mean ± standard deviation or median (range) while the descriptive parameters were expressed as number and percentage.

Results

A total of 90 patients were included in the study. Most of the patients had colostomy for anorectal malformation. Five of them had significant luminal discrepancy of 4 or more times. Full feeds were reached within 2 days in 79 patients. Postoperative hospital stay was 2-3 days in 62 patients. Six patients stayed for more than 5 days, due to complications requiring further management. We noted surgical site infection in 6 patients all of whom were managed with regular wound dressings and fecal fistula in 4 cases, two of which resolved spontaneously.

Conclusion

ERAS protocol in colostomy closure reduces the hospital stay and is cost effective, with early recovery and no added complications.

Gastrointestinal Ostomies in Children: A Primer for the Pediatrician

Despite the advancement of medical therapies in the care of the preterm neonate, in the management of short bowel syndrome and the control of pediatric inflammatory bowel disease, the need to create fecal ostomies remains a common, advantageous treatment option for many medically complex children.

Retrospective Analysis of the Outcome of Stoma Closure in Children without Preoperative Mechanical Bowel Preparation

Introduction

Stoma closure is one of the most frequently performed surgical procedures by pediatric surgeons worldwide. In this study, we studied the outcome of children undergoing stoma closures without mechanical bowel preparation (MBP) in our department.

Materials and Methods

This is a retrospective observational study of children <18 years undergoing stoma closure from 2017 to 2021. The primary endpoints were surgical site infection (SSI), incisional hernia, anastomotic leak, and mortalities. The categorical data are expressed in percentages and the continuous data are in medians and interquartile ranges. The postoperative complications were classified according to the Clavien-Dindo system.

Results

A total of 89 patients underwent stoma closure without bowel preparation during the study. The anastomosis leak and incisional hernia were seen in one patient each. The SSIs occurred in 23 patients (25.9%), which were superficial in 21 and deep in 2 patients. The Clavien-Dindo Grade III complications occurred in 2 (2.2%) patients. The median duration to start feeds and pass first stools was significantly longer in patients with ileostomy closure (P = 0.04 and 0.001, respectively).

Conclusion

The outcome of stoma closures without MBP was favorable in our study and hence it can be suggested that the use of MBP in colostomy closures can be safely avoided in children.

A comparison of surgical site infections in children after stoma reversal between purse-string and linear closure

BACKGROUND

To reduce the surgical site infections (SSI), the purse-string closure technique has been widely performed and has also been recommended in adult stoma reversal. However, for children, some debate still exists. This study aims to compare the SSI rates in children between the purse-string and the linear for the skin closure of stoma reversal.

METHODS

The data were collected from pediatric patients, who had undergone either purse-string or linear closure for elective surgery of stoma reversal from two university hospitals between January 2016 and December 2019.

RESULTS

The purse-string and linear closure had been performed on 31 and 45 patients, respectively. At 30 days after surgery, three patients in the purse-string closure group had developed SSI compared to 14 patients in the linear closure group (9.7 vs. 31.1%, p = 0.028). Furthermore, there had been no significant difference in the overall post-operative complications. In multivariate analysis, the SSI had been significantly lower in patients with purse-string closure (OR 0.21, 95% CI 0.05-0.86, p = 0.029).

CONCLUSION

By employing the purse-string closure technique for skin closure of stoma reversal, there had been a significantly lower SSI rate compared to linear closure with no difference in the length of hospital stay.

Incisional hernia after abdominal surgery in infants: A retrospective analysis of incidence and risk factors

PURPOSE

Incisional hernia (IH) is a complication following abdominal surgery extensively studied in adults but less so in infants. This study aimed to identify the incidence, high risk diseases and risk factors of IH following abdominal surgery in infants.

METHODS

Infants undergoing abdominal surgery before the age of three years in our tertiary centre between 1998 and 2018 were included. Patient demographics, peri‑operative details and the course during follow up were retrospectively extracted from patient records. Multivariate logistic regression was performed to identify risk factors.

RESULTS

The incidence of incisional hernia was 5.2% (107/2055). Necrotizing enterocolitis (12%), gastroschisis (19%), and omphalocele (17%) had the highest incidences of IH. Wound infection (OR: 5.3, 95%-CI:2.9-9.5), preterm birth (OR: 4.2, 95%-CI:2.6-6.7) and history of stoma (OR 1.7, 95%-CI:1.1-2.8) were significant risk factors for IH. Whilst age at surgery, surgical approach and total number of operations did not significantly influence IH development. The IH resolved in 15% (16/107) without surgery.

CONCLUSION

One in twenty infants experiences IH following abdominal surgery, which is higher than previously described. Understanding the incidence of IH and associated risk factors will allow physicians to identify infants that may be at increased risk for IH and to possibly act pre-emptively.

Early enteral feeding after pediatric abdominal surgery: A systematic review of the literature

INTRODUCTION

Traditionally enteral nutrition has been delayed following abdominal surgery in children, to prevent complications. However, recent evidence in the adult literature refutes the supposed benefits of fasting and suggests decreased complications with early enteral nutrition (EEN). This review aimed to compile the evidence for EEN in children in this setting.

METHODS

Databases Pubmed, EmBase, Medline and reference lists were searched for articles containing relevant search terms according to PRISMA guidelines. First and second authors reviewed abstracts. Studies containing patients less than 18 years undergoing abdominal surgery, with feeding initiated earlier than standard practice, were included. Studies including pyloromyotomy were excluded. Primary outcome was length of stay (LOS). Secondary outcomes included time to full enteral nutrition, time to stool and postoperative complications.

RESULTS

Fourteen articles met inclusion criteria - five on neonatal abdominal surgery, three on gastrostomy formation and six on intestinal anastomoses. There were three randomized control trials (RCTs), five cohort studies, four historical control trials, one nonrandomized trial and one case series. Nine studies showed a decreased LOS with EEN. Most studies which reported time to full enteral nutrition showed improvement with EEN; however, time to stool was similar in most studies. Postoperative complications were either decreased or not statistically different in EEN groups in all studies.

CONCLUSION

Studies to date in a limited number of procedures suggest EEN appears safe and effective in children undergoing abdominal surgery. Although robust evidence is lacking, there are clear benefits in LOS and time to full feeds, and no increase in complications.

LEVEL OF EVIDENCE

IV.

New Medical Device Acquisition During Pediatric Severe Sepsis Hospitalizations

OBJECTIVES

Severe sepsis is a significant cause of healthcare utilization and morbidity among pediatric patients. However, little is known about how commonly survivors acquire new medical devices during pediatric severe sepsis hospitalization. We sought to determine the rate of new device acquisition (specifically, tracheostomy placement, gastrostomy tube placement, vascular access devices, ostomy procedures, and amputation) among children surviving hospitalizations with severe sepsis. For contextualization, we compare this to rates of new device acquisition among three comparison cohorts: 1) survivors of all-cause pediatric hospitalizations; 2) matched survivors of nonsepsis infection hospitalizations; and 3) matched survivors of all-cause nonsepsis hospitalization with similar organ dysfunction.

DESIGN

Observational cohort study.

SETTING

Nationwide Readmission Database (2016), including all-payer hospitalizations from 27 states.

PATIENTS

Eighteen-thousand two-hundred ten pediatric severe sepsis hospitalizations; 532,738 all-cause pediatric hospitalizations; 16,173 age- and sex-matched nonsepsis infection hospitalizations; 15,025 organ dysfunction matched all-cause nonsepsis hospitalizations; and all with live discharge.

MEASUREMENTS AND MAIN RESULTS

Among 18,210 pediatric severe sepsis hospitalizations, 1,024 (5.6%) underwent device placement. Specifically, 3.5% had new gastrostomy, 3.1% new tracheostomy, 0.6% new vascular access devices, 0.4% new ostomy procedures, and 0.1% amputations. One-hundred forty hospitalizations (0.8%) included two or more new devices. After applying the Nationwide Readmissions Database sampling weights, there were 55,624 pediatric severe sepsis hospitalizations and 1,585,194 all-cause nonsepsis hospitalizations with live discharge in 2016. Compared to all-cause pediatric hospitalizations, severe sepsis hospitalizations were eight-fold more likely to involve new device acquisition (6.4% vs 0.8%; p < 0.001). New device acquisition was also higher in severe sepsis hospitalizations compared with matched nonsepsis infection hospitalizations (5.1% vs 1.2%; p < 0.01) and matched all-cause hospitalizations with similar organ dysfunction (4.7% vs 2.8%; p < 0.001).

CONCLUSIONS

In this nationwide, all-payer cohort of U.S. pediatric severe sepsis hospitalizations, one in 20 children surviving severe sepsis experienced new device acquisition. The procedure rate was nearly eight-fold higher than all-cause, nonsepsis pediatric hospitalizations, and four-fold higher than matched nonsepsis infection hospitalizations.