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Lee WG, O'Guinn ML, Keane OA, Krishna V, Mack SJ, Soliman A, Anselmo DM, Nguyen NX, Gayer CP, Kim ES, Shue EH. Evaluation of Postoperative Outcomes After Enterostomy Closure in Low Body Weight Infants: A Multi-Center Retrospective Analysis. Am Surg 2024; 90:2534-2542. [PMID: 38648035 DOI: 10.1177/00031348241248788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND The minimum weight for enterostomy closure (EC) in infants remains debated with the current acceptable cut-off of >2 kg. As enterostomy-related complications or high enterostomy output (>30cc/kg/d) may prohibit a premature infant from reaching 2 kg, additional data is needed to evaluate the safety of EC in infants <2 kg. The objective of this study was to evaluate postoperative outcomes in low body weight (<2 kg) infants undergoing EC compared to larger infants. METHODS We performed a multi-center retrospective analysis from 1/1/2012-12/31/2022 of all infants (age <1 year) who were <4 kg at time of EC. Primary outcomes included postoperative complications and 30-day mortality. Non-parametric analysis was performed using the Kruskal-Wallis one-way analysis of variance and chi-square tests. Univariable logistic regression was performed to identify factors associated with postoperative complications. RESULTS Of 92 infants, 15 infants (16.3%) underwent EC at <2 kg, 16 (17.4%) at 2-2.49 kg, 31 (33.7%) at 2.5-2.99 kg, and 30 (32.6%) at ≥3 kg. Infants <2 kg at time of EC exhibited higher rates of hyperbilirubinemia (P = .030), neurologic comorbidities (P = .030), and high enterostomy output (P = .041). There was no difference in postoperative complications (P = .460) or 30-day mortality (P = .460) between the <2 kg group and larger weight groups. Low body weight was not associated with an increased risk for developing a postoperative complication (OR: 1.001, 95% CI: 1.001-1.001; P = .032). CONCLUSION Our findings suggest that EC in infants <2 kg may be safe with comparable postoperative outcomes to larger weight infants. Thus, the timing of EC should be based on the infant's physiologic status, in contrast to a predetermined minimum weight cut-off.
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Affiliation(s)
- William G Lee
- Division of Pediatric Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - MaKayla L O'Guinn
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Olivia A Keane
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Vikram Krishna
- Division of Pediatric Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shale J Mack
- Division of Pediatric Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Antoine Soliman
- Department of Neonatology, Miller Children's and Women's Hospital, Long Beach, CA, USA
| | - Dean M Anselmo
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Pediatric Surgery, Miller Children's and Women's Hospital, Long Beach, CA, USA
| | - Nam X Nguyen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Pediatric Surgery, Miller Children's and Women's Hospital, Long Beach, CA, USA
| | - Christopher P Gayer
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Eugene S Kim
- Division of Pediatric Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eveline H Shue
- Division of Pediatric Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Pediatric Surgery, Miller Children's and Women's Hospital, Long Beach, CA, USA
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Belcher R, Kolosky T, Moore JT, Strauch ED, Englum BR. The Association of Weight With Surgical Morbidity in Infants Undergoing Enterostomy Reversal: A Study of the NSQIP-Pediatrics Database. J Pediatr Surg 2024; 59:1765-1770. [PMID: 38580546 DOI: 10.1016/j.jpedsurg.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/19/2024] [Accepted: 03/07/2024] [Indexed: 04/07/2024]
Abstract
INTRODUCTION Optimal criteria and timing for enterostomy closure (EC) in neonates is largely based on clinical progression and adequate weight, with most institutions using 2.0-2.5 kg as the minimum acceptable weight. It is unclear how the current weight cutoff affects post-operative morbidity. AIM To determine how infant weight at the time of EC influences 30-day complications. METHODS Infants weighing ≤4000 g who underwent EC were identified in the 2012-2019 ACS NSQIP-P database. Demographics, comorbidities, and 30-day outcomes were assessed using univariate analysis. Multivariable logistic regression controlling for ASA score, nutritional support, and ventilator support was used to estimate the independent association of weight on risk of 30-day complications. RESULTS A total of 1692 neonates from the NSQIP-P database during the years 2012-2019 met inclusion criteria. Neonates weighing <2.5 kg were significantly more likely to have a younger gestational age, require ventilator support, and have concurrent comorbidities. Major morbidity, a composite outcome of the individual postoperative complications, was observed in 283 (16.7%) infants. ASA classifications 4 and 5, dependence on nutritional support, and ventilator support were independently associated with increased risk of 30-day complications. With respect to weight, we found no significant difference in major morbidity between infants weighing <2.5 kg and infants weighing ≥2.5 kg. CONCLUSION Despite using a robust, national dataset, we could find no evidence that a defined weight cut-off was associated with a reduction in major morbidity, indicating that weight should not be a priority factor when determining eligibility for neonatal EC. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Rachael Belcher
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Taylor Kolosky
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - James T Moore
- Division of Pediatric and Urologic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eric D Strauch
- Division of Pediatric and Urologic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brian R Englum
- Division of Pediatric and Urologic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
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Eeftinck Schattenkerk LD, Vogel I, de Jong JR, Tanis PJ, Gorter R, Tabbers M, van Heurn LWE, Musters G, Derikx JPM. Impact of Presence, Level, and Closure of a Stoma on Growth in Young Children: A Retrospective Cohort Study. Eur J Pediatr Surg 2024; 34:282-289. [PMID: 37003263 PMCID: PMC11076102 DOI: 10.1055/a-2067-4847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION A stoma will cause nutrients loss which could result in impaired growth. Impaired growth can negatively impact long-term development. This study aims to evaluate: (1) the effect of stomas on growth comparing small bowel stoma versus colostomy and (2) if early closure (within 6 weeks), proximal small bowel stoma (within 50 cm of Treitz), major small bowel resection (≥ 30 cm), or adequate sodium supplementation (urinary level ≤ 30 mmol/L) influences growth. METHODS Young children (≤ 3 years) treated with stomas between 1998 and 2018 were retrospectively identified. Growth was measured with weight-for-age Z-scores. Malnourishment was defined using the World Health Organization's definition. Comparison between changes in Z-scores at creation, closure, and a year following closure was done by Friedman's test with post hoc Wilcoxon's signed rank test or Wilcoxon's rank-sum test when necessary. RESULTS In the presence of a stoma in 172 children, 61% showed growth decline. Severe malnourishment was seen at the time of stoma closure in 51% of the patients treated by small bowel stoma and 16% of those treated by colostomy. Within a year following stoma closure, 67% showed a positive growth trend. Having a proximal small bowel stoma and undergoing major small bowel resection led to significantly lower Z-scores at closure. Adequate sodium supplementation and early closure did not lead to significant changes in Z-scores. CONCLUSION Stomas have a negative impact on growth in the majority of children. This impact might be decreased by preventing small bowel stomas when possible, specifically proximal stomas, and limiting small bowel resection. Since stoma closure is essential in reversing the negative effect on growth, we opt that early closure might result in an early shift to catch-up growth.
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Affiliation(s)
| | - Irene Vogel
- Department of Surgery, Amsterdam UMC Locatie AMC, Amsterdam, the Netherlands
| | - Justin R. de Jong
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pieter J. Tanis
- Department of Surgery, Erasmus MC, Rotterdam, Zuid-Holland, the Netherlands
| | - Ramon Gorter
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
| | - Merit Tabbers
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - L. W. Ernest van Heurn
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Gijsbert Musters
- Department of Pediatric Surgery, Amsterdam UMC Locatie AMC, Amsterdam, the Netherlands
| | - Joep P. M. Derikx
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Awouters M, Vanuytsel T, Huysentruyt K, De Bruyne P, Van Hoeve K, Hoffman I. Nutritional management of high-output ileostomies in paediatric patients is vital and more evidence-based guidelines are needed. Acta Paediatr 2024; 113:861-870. [PMID: 38389122 DOI: 10.1111/apa.17163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 02/12/2024] [Indexed: 02/24/2024]
Abstract
AIM Paediatric patients with high-output ileostomies (HOI) face an elevated risk of complications. This study aimed to comprehensively review the existing literature and offer nutritional management recommendations for paediatric patients with an HOI. METHODS PubMed and Embase were searched for relevant English or French language papers up to 31 June 2022. The emphasis was placed on studies involving paediatric ileostomy patients, but insights were obtained from adult literature and other intestinal failure pathologies when these were lacking. RESULTS We identified 16 papers that addressed nutritional issues in paediatric ileostomy patients. Currently, no evidence supports a safe paediatric HOI threshold exceeding 20 mL/kg/day on two consecutive days. Paediatric HOI patients were at risk of dehydration, electrolyte disturbances, micronutrient deficiencies and growth failure. The primary dietary choice for neonates is bolus feeding with breastmilk. In older children, an enteral fluid restriction should be installed favouring isotonic or slightly hypotonic glucose-electrolyte solutions. A diet that is high in calories, complex carbohydrates and proteins, low in insoluble fibre and simple carbohydrates, and moderate in fat is recommended. CONCLUSION Adequate nutritional management is crucial to prevent complications in children with an HOI. Further research is needed to establish more evidence-based guidelines.
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Affiliation(s)
- Marijke Awouters
- Department of Paediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Koen Huysentruyt
- Department of Paediatric Gastroenterology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Pauline De Bruyne
- Department of Paediatric Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Karen Van Hoeve
- Department of Paediatric Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Ilse Hoffman
- Department of Paediatric Gastroenterology, University Hospitals Leuven, Leuven, Belgium
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Nwachukwu I, Visa A, Holbrook C, Tan YW. Identifying Risk Factors for Surgical Site Infection After Stoma Closure in Infants for Targeted Implementation of Surgical Site Infection Reduction Bundle. Surg Infect (Larchmt) 2024; 25:185-191. [PMID: 38394295 DOI: 10.1089/sur.2023.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024] Open
Abstract
Background: To determine risk factors for surgical site infection (SSI) in infants after stoma closure, to identify at-risk patients, plan timing of surgery, and implement SSI-reduction strategies. Patients and Methods: A single center retrospective comparison study of all children less than one year of age who underwent enterostomy closure (2018-2020) with SSI diagnosed through a prospective surveillance program, using criteria from Public Health England (PHE). Demographics and risk factors, types of SSI, systemic sepsis, mortality and length of stay were compared between SSI and non-SSI. Significant factors associated with SSI were analyzed in a multivariate binomial logistic regression model. Results: Eighty-nine stoma closures were performed, most commonly for necrotizing enterocolitis (NEC) and anorectal malformation. Fourteen had SSI (16%): 12 superficial and two deep; three developed systemic sepsis, but no 30-day mortality. Surgical site infection was associated with NEC (12/14 vs. 32/75; p = 0.003), younger age (median 76 vs. 89 days; p = 0.014), lower corrected gestation (cutoff: 39 weeks gestation; 11/14 vs. 27/75; p = 0.004) and lower weight (cutoff: 2.2 kg; 7/14 vs. 16/75; p = 0.032), compared with non-SSI. After correcting for age, gestation, and weight, logistic regression showed NEC was an independent predictor for SSI (odds ratio [OR], 12; 95% confidence interval [CI],1.2-125). The at-risk cohort (n = 56; 63%) had seven-fold increased risk of SSI and four-fold longer hospital stay, which may be the target for SSI-reduction strategies. Conclusions: Necrotizing enterocolitis-related stoma closure is at increased risk for SSI. Considerations for delaying stoma closure until achieving 39 weeks gestation or 2.2 kg in weight may further reduce SSI. Targeting SSI-reduction strategies using these criteria may improve resource-rationalization.
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Affiliation(s)
- Ijeoma Nwachukwu
- Paediatric Surgery, Evelina London Children's Hospital, Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Arjun Visa
- Paediatric Surgery, Evelina London Children's Hospital, Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Charlotte Holbrook
- Paediatric Surgery, Evelina London Children's Hospital, Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Yew-Wei Tan
- Paediatric Surgery, Evelina London Children's Hospital, Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Fumita T, Terui K, Shibata R, Takenouchi A, Komatsu S, Oita S, Yoshizawa H, Hirano Y, Yoshino Y, Saito T, Hishiki T. Surgical outcomes of very-early-onset ulcerative colitis: retrospective comparative study with older pediatric patients. Pediatr Surg Int 2024; 40:73. [PMID: 38451357 PMCID: PMC10920427 DOI: 10.1007/s00383-024-05662-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE The study compares the surgical outcomes of very-early-onset ulcerative colitis (VEO-UC), which is a rare disease diagnosed in pediatric patients < 6 years, with those of older pediatric patients with ulcerative colitis (UC). METHODS A retrospective observational study of 57 pediatric patients with UC was conducted at a single center. The study compared surgical complications and postoperative growth between the two groups. RESULTS Out of the 57 patients, 6 had VEO-UC, and 5 of them underwent total colectomy. Compared with the surgical cases of older patients with UC (n = 6), the rate of postoperative complications in patients with VEO-UC (n = 5) was not significantly different, except for high-output ileostomy (80% vs. 0% at 3 weeks postoperatively, p = 0.02). The rate of postoperative central venous catheter (CVC) placement at > 90 days was higher in patients with VEO-UC (100% vs. 17%, p = 0.02). The median change in the Z-score of height before and 2 years after colectomy was not significantly different between VEO-UC and older patients (1.1 vs. 0.3, p = 0.13). CONCLUSION With regard to complications and outcomes, total colectomy for VEO-UC patients and that for older pediatric UC patients is comparable. However, high-output ileostomy and the long duration of CVC placement may pose management challenges.
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Affiliation(s)
- Takashi Fumita
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan.
| | - Ryohei Shibata
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Ayako Takenouchi
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Shugo Komatsu
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Satoru Oita
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Hiroko Yoshizawa
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Yuichi Hirano
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Yusaku Yoshino
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Takeshi Saito
- Department of Pediatric Surgery, Chiba Children's Hospital, Chiba, Japan
| | - Tomoro Hishiki
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
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Patel AD, Casini G, Hagan JL, Debuyserie A, Vogel AM, Gollins L, Hair AB, Fernandes CJ, Premkumar MH. Factors associated with enteral autonomy after reanastomosis in infants with intestinal failure and ostomy: A descriptive cohort study. JPEN J Parenter Enteral Nutr 2024; 48:74-81. [PMID: 37872873 DOI: 10.1002/jpen.2570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 10/04/2023] [Accepted: 10/18/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND To determine variables associated with outcomes in infants with intestinal failure (IF) and ostomy following reanastomosis (RA). METHODS A single-center, descriptive cohort study of 120 infants with IF and a stoma from January 2011 to December 2020 with subsequent RA during initial hospitalization. The primary outcome was achievement of enteral autonomy (EA) following RA. Other outcomes were duration of hospital stay, and mortality. Penalized logistic regression and linear regression were used for data analysis. RESULTS The median gestational age was 26 weeks, and the median birth weight was 890 g. Three infants died. The median duration between ostomy creation and RA was 80 days (interquartile range; 62.5, 100.5). For each additional day of discontinuity, the odds of EA decreased by 2% (odds ratio [OR] = 0.980; 95% confidence interval [CI]: 0.962, 0.999; P = 0.038), and death increased by 4.2% (OR = 1.042; 95% CI: 1.010, 1.075; P = 0.009). For each additional mL/kg/day of enteral feeds at RA, the odds of EA increased by 7.5% (OR = 1.075; 95% CI: 1.027, 1.126, P = 0.002) and duration of hospital stay decreased by 0.35 days (slope coefficient = -0.351; 95% CI: -0.540, -0.163; P < 0.001). CONCLUSION Shorter duration of intestinal discontinuity and enteral nutrition before RA could positively influence EA and duration of stay in infants with IF and ostomy following RA.
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Affiliation(s)
- Arjun D Patel
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Gina Casini
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph L Hagan
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Anne Debuyserie
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Adam M Vogel
- Departments of Surgery and Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Laura Gollins
- Division of Neonatology, Texas Children's Hospital, Houston, Texas, USA
| | - Amy B Hair
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Caraciolo J Fernandes
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Muralidhar H Premkumar
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
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Vogel I, Eeftinck Schattenkerk LD, Venema E, Pandey K, de Jong JR, Tanis PJ, Gorter R, van Heurn E, Musters GD, Derikx JPM. Major stoma related morbidity in young children following stoma formation and closure: A retrospective cohort study. J Pediatr Surg 2022; 57:402-406. [PMID: 34949444 DOI: 10.1016/j.jpedsurg.2021.11.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/09/2021] [Accepted: 11/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little is known about stoma related morbidity in young children. Therefore, the aim of this study is to assess major morbidity after stoma formation and stoma closure and its associated risk factors. METHODS All consecutive young children (age ≤ three years) who received a stoma between 1998 and 2018 at our tertiary referral center were retrospectively included. The incidence of major stoma related morbidity (Clavien-Dindo grade ≥III) was the primary outcome. This was separately analysed for stoma formation alone, stoma closure alone and all stoma interventions combined. Non-stoma related morbidity was excluded. Risk factors for major morbidity were identified using multivariable logistic regression analysis. RESULTS In total 336 young children were included with a median follow-up of 6 (IQR:2-11) years. Of these young children, 5% (n = 17/336) received a jejunostomy, 57% (n = 192/336) an ileostomy, and 38% (n = 127/336) a colostomy. Following stoma formation, 27% (n = 92/336) of the young children experienced major stoma related morbidity, mainly consisting of high output stoma, prolapse and stoma stenosis. The major morbidity rate was 23% (n = 66/292) following stoma closure, most commonly comprising anastomotic leakage/stenosis, incisional hernia and adhesive obstructions. For combined stoma interventions, major stoma related morbidity was 39% (n = 130/336). Ileostomy was independently associated with a higher risk of developing major morbidity following stoma formation (OR:2.5; 95%-CI:1.3-4.7) as well as following closure (OR:2.7; 95%-CI:1.3-5.8). CONCLUSIONS Major stoma related morbidity is a frequent and severe clinical problem in young children, both after stoma formation and closure. The risk of morbidity should be considered when deliberating a stoma.
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Affiliation(s)
- Irene Vogel
- Emma Childen's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Esmée Venema
- Emma Childen's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Karan Pandey
- Emma Childen's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Justin R de Jong
- Emma Childen's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ramon Gorter
- Emma Childen's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ernest van Heurn
- Emma Childen's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gijsbert D Musters
- Emma Childen's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Joep P M Derikx
- Emma Childen's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Coletta R, Zulli A, O’Shea K, Mussi E, Bianchi A, Morabito A. Minimizing Enterostomy Complication in Neonates, Lessons Learnt from Three European Tertiary Centres. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9020162. [PMID: 35204883 PMCID: PMC8870697 DOI: 10.3390/children9020162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Stoma formation in neonates is often a life-saving procedure across a variety of conditions but is still associated with significant morbidity. Tube stoma technique was originally described for short bowel patients, but in selected cases of neonates this approach could prevent the incidence of stoma-related complications. The aim of the study was to evaluate the safety and utility of tube stomas as an alternative to conventional enterostomy in the neonatal population. MATERIAL AND METHODS A retrospective multicentre analysis of neonates undergoing emergency laparotomy and tube stoma formation between 2005 and 2017 was performed. Tube stoma complications were analysed. The investigation focused on stricture, skin lesion, enteric fistula and prolapse. RESULTS Thirty-seven neonates underwent tube stoma fashioning during the study period. Tube-stoma complications were limited to three patients (8.1%), with two children (5.4%) requiring additional stoma surgery during the first 30 days because of an enterocutaneous fistula, and one child (2.7%) for bowel stenosis. CONCLUSIONS In select neonates, such as those with proximal enteric stomas, the tube stoma avoids some of the commonly encountered complications (prolapse, skin excoriation). Further prospective studies are needed to validate these findings in order for us to recommend this technique as superior.
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Affiliation(s)
- Riccardo Coletta
- Department of Paediatric Surgery, Meyer Children’s Hospital, 50139 Florence, Italy; (A.Z.); (A.M.)
- School of Environment and Life Science, University of Salford, Salford M5 4NT, UK
- Correspondence:
| | - Andrea Zulli
- Department of Paediatric Surgery, Meyer Children’s Hospital, 50139 Florence, Italy; (A.Z.); (A.M.)
- Department of Neurofarba, University of Florence, Viale Pieraccini 6, 50121 Florence, Italy
| | - Kathryn O’Shea
- Department of Paediatric Surgery, Royal Manchester Children’s Hospital, Manchester M13 9WL, UK;
| | - Elisa Mussi
- Department of Industrial Engineering, University of Florence, 50139 Florence, Italy;
| | - Adrian Bianchi
- Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK;
| | - Antonino Morabito
- Department of Paediatric Surgery, Meyer Children’s Hospital, 50139 Florence, Italy; (A.Z.); (A.M.)
- Department of Neurofarba, University of Florence, Viale Pieraccini 6, 50121 Florence, Italy
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Vinit N, Rousseau V, Broch A, Khen-Dunlop N, Hachem T, Goulet O, Sarnacki S, Beaudoin S. Santulli Procedure Revisited in Congenital Intestinal Malformations and Postnatal Intestinal Injuries: Preliminary Report of Experience. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9010084. [PMID: 35053709 PMCID: PMC8774359 DOI: 10.3390/children9010084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/28/2021] [Accepted: 01/05/2022] [Indexed: 11/16/2022]
Abstract
In our experience, the Santulli procedure (SP) can improve bowel recovery in congenital intestinal malformations, necrotizing enterocolitis (NEC), and bowel perforation. All cases managed at our institution using SP between 2012 and 2017 were included in this study. Forty-one patients underwent SP (median age: 39 (0-335) days, median weight: 2987 (1400-8100) g) for intestinal atresia (51%, two gastroschisis), NEC (29%), midgut volvulus (10%), Hirschsprung's disease (5%), or bowel perforation (5%), with at least one intestinal suture below the Santulli in 10% of cases. The SP was performed as a primary procedure (57%) or as a double-ileostomy reversal. Anal-stool passing occurred within a median of 9 (2-36) days for 95% of patients, regardless of the diversion level or the underlying disease. All three patients requiring repeated surgery for Santulli dysfunction had presented with stoma prolapse (p < 0.01). Stoma closure was performed after a median of 45 (14-270) days allowing efficient transit after a median of 2 (1-6) days. After a median follow-up of 2.9 (0.7-7.2) years, two patients died (cardiopathy and brain hemorrhage), full oral intake had been achieved in 90% of patients, and all survivors had normal bowel movement. Whether used as primary or secondary surgery, the SP allows rapid recovery of intestinal motility and function.
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Affiliation(s)
- Nicolas Vinit
- Department of Pediatric Surgery and Urology, Necker-Enfants Malades Hospital, APHP, 75015 Paris, France; (N.V.); (V.R.); (A.B.); (N.K.-D.); (S.S.)
- Faculté de Médecine Paris Centre, Université de Paris, 75006 Paris, France;
| | - Véronique Rousseau
- Department of Pediatric Surgery and Urology, Necker-Enfants Malades Hospital, APHP, 75015 Paris, France; (N.V.); (V.R.); (A.B.); (N.K.-D.); (S.S.)
| | - Aline Broch
- Department of Pediatric Surgery and Urology, Necker-Enfants Malades Hospital, APHP, 75015 Paris, France; (N.V.); (V.R.); (A.B.); (N.K.-D.); (S.S.)
| | - Naziha Khen-Dunlop
- Department of Pediatric Surgery and Urology, Necker-Enfants Malades Hospital, APHP, 75015 Paris, France; (N.V.); (V.R.); (A.B.); (N.K.-D.); (S.S.)
- Faculté de Médecine Paris Centre, Université de Paris, 75006 Paris, France;
| | - Taymme Hachem
- Department of Neonatology, Necker-Enfants Malades Hospital, APHP, 75015 Paris, France;
| | - Olivier Goulet
- Faculté de Médecine Paris Centre, Université de Paris, 75006 Paris, France;
- Department of Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades Hospital, APHP, 75015 Paris, France
| | - Sabine Sarnacki
- Department of Pediatric Surgery and Urology, Necker-Enfants Malades Hospital, APHP, 75015 Paris, France; (N.V.); (V.R.); (A.B.); (N.K.-D.); (S.S.)
- Faculté de Médecine Paris Centre, Université de Paris, 75006 Paris, France;
| | - Sylvie Beaudoin
- Department of Pediatric Surgery and Urology, Necker-Enfants Malades Hospital, APHP, 75015 Paris, France; (N.V.); (V.R.); (A.B.); (N.K.-D.); (S.S.)
- Faculté de Médecine Paris Centre, Université de Paris, 75006 Paris, France;
- Correspondence: ; Tel.: +33-(0)1-7119-6297
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11
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Sakamoto R, Vossler J, Woo R. Predictors of Morbidity Following Enterostomy Closure in Infants: An American College of Surgeons Pediatric National Surgical Quality Improvement Program Database Analysis. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2021; 80:27-30. [PMID: 34820632 PMCID: PMC8609193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Optimal timing of enterostomy closure in infants is poorly defined, and clinical practice is based mainly on surgeon preference. This study aims to determine the predictors of morbidity in infants < 365 days old undergoing enterostomy reversal. A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP Peds) database was conducted from 2012-2017, including all laparoscopic and open enterostomy reversals in patients < 365 days old. Predictors of overall morbidity were analyzed by bivariate and multivariate logistic regression analysis with statistical significance at P < .05. We identified 2415 cases with an overall morbidity rate of 30.5%. Bivariate analysis identified that younger age, lower weight, prematurity, pulmonary disease, previous cardiac surgery, preoperative nutritional support, preoperative steroids, and preoperative transfusion were associated with overall morbidity for enterostomy closure. On multivariate analysis, prematurity < 30 weeks at birth (odds ratio [OR], 1.49; 95% confidence interval [CI]; 1.07-2.08), pulmonary disease (OR, 1.31; 95% CI, 1.01-1.71), and preoperative nutritional support (OR, 2.46; 95% CI 1.99-3.05) were independently associated with overall morbidity. Age and weight at the time of enterostomy closure were not independently associated with overall morbidity on multivariate analysis. Prematurity < 30 weeks at birth, presence of pulmonary disease, and preoperative need for nutritional support were independent predictors of overall morbidity in patients < 365 days old undergoing enterostomy reversal. Given the high rate of overall morbidity in this population, further research into the matter is warranted.
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Affiliation(s)
- Reid Sakamoto
- Department of Surgery, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - John Vossler
- Department of Surgery, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Russell Woo
- Department of Surgery, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
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12
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Cassey JG, Liebenberg PH, Nightingale S, Gupta SK. Bowel scintigraphy identifies segmental dysmotility prior to stoma closure. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2020.101695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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13
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Bonasso PC, Dassinger MS, Mehl SC, Gokun Y, Gowen MS, Burford JM, Smith SD. Timing of enterostomy closure for neonatal isolated intestinal perforation. J Pediatr Surg 2020; 55:1535-1541. [PMID: 31954555 DOI: 10.1016/j.jpedsurg.2019.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE No consensus guidelines exist for timing of enterostomy closure in neonatal isolated intestinal perforation (IIP). This study evaluated neonates with IIP closed during the initial admission (A1) versus a separate admission (A2) comparing total length of stay and total hospital cost. METHODS Using 2012 to 2017 Pediatric Health information System (PHIS) data, 359 neonates with IIP were identified who underwent enterostomy creation and enterostomy closure. Two hundred sixty-five neonates (A1) underwent enterostomy creation and enterostomy closure during the same admission. Ninety-four neonates (A2) underwent enterostomy creation at initial admission and enterostomy closure during subsequent admission. For the A2 neonates, total hospital length of stay was calculated as the sum of hospital days for both admissions. A1 neonates were matched to A2 neonates in a 1:1 ratio using propensity score matching. Multivariate models were used to compare the two matched pair groups for length of stay and cost comparisons. RESULTS Prior to matching, the basic demographics of our study population included a median birthweight of 960 g, mean gestational age of 29.5 weeks, and average age at admission of 4 days. Eighty-seven pairs of neonates with IIP were identified during the matching process. Neonates in A2 had 91% shorter total hospital length of stay compared to A1 neonates (HR: 1.91; 95% CI for HR: 1.44-2.53; p < .0001). The median length of stay for A1 was 95 days (95% CI: 78-102 days) versus A2 length of stay of 67 days (95% CI: 56-76 days). Adjusting for the same covariates, A2 neonates had a 22% reduction in the average total cost compared A1 neonates (RR: 0.78; 95% CI for RR: 0.64-0.95; p-value = 0.014). The average total costs were $245,742.28 for A2 neonates vs. $315,052.21 for A1 neonates (p < 0.001). CONCLUSION Neonates with IIP have a 28 day shorter hospital length of stay, $75,000 or 24% lower total hospital costs, and a 22 day shorter post-operative course following enterostomy closure when enterostomy creation and closure is performed on separate admissions. TYPE OF STUDY Prognosis Study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Patrick C Bonasso
- Division of Pediatric Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - M Sidney Dassinger
- Division of Pediatric Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Steven C Mehl
- Division of Pediatric Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Yevgeniya Gokun
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Marie S Gowen
- Division of Pediatric Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeffrey M Burford
- Division of Pediatric Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Samuel D Smith
- Division of Pediatric Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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14
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Kauffman JD, Danielson PD, Chandler NM. Risk Factors for Adverse Outcomes after Ostomy Reversal in Infants Less than Six Months Old. Am Surg 2020. [DOI: 10.1177/000313481908501132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to determine risk factors for 30-day complications, reoperation, and readmission after ostomy reversal in infants less than six months old. Infants aged two weeks to six months who underwent ostomy reversal were identified in the 2012 to 2016 ACS NSQIP Pediatric database. Demographics, comorbidities, and 30-day outcomes were assessed. Multivariable logistic regression was used to estimate the independent effects of clinical variables on risk of 30-day complications, reoperation, and readmission. Among 1021 infants, 163 (16%) suffered a 30-day complication. SSIs were the most common complication (5.7%), followed by unplanned reintubation (5.2%) and bleeding (3%). Mortality was 0.4 per cent. Dependence on nutritional support and hematologic disorders were independently associated with postoperative complications. Forty-five children (4.4%) required reoperation and 22 (2.2%) were readmitted for conditions related to the procedure. Younger age and preoperative dependence on oxygen or nutritional support were associated with increased length of stay. SSI, unplanned reintubation, and bleeding are the most frequent complications after ostomy takedown in infants less than six months old. Attention to risk factors predisposing to these complications, including dependence on nutritional support and hematologic disorders, may contribute to improved surgical outcomes.
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Affiliation(s)
- Jeremy D. Kauffman
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Paul D. Danielson
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Nicole M. Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
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15
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Chong C, van Druten J, Briars G, Eaton S, Clarke P, Tsang T, Yardley I. Neonates living with enterostomy following necrotising enterocolitis are at high risk of becoming severely underweight. Eur J Pediatr 2019; 178:1875-1881. [PMID: 31522315 PMCID: PMC6892362 DOI: 10.1007/s00431-019-03440-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 05/30/2019] [Accepted: 08/06/2019] [Indexed: 11/26/2022]
Abstract
Necrotising enterocolitis (NEC) is often managed with a temporary enterostomy. Neonates with enterostomy are at risk of growth retardation during critical neurodevelopment. We examined their growth using z-score. We identified all patients with enterostomy from NEC in two neonatal surgical units (NSU) during January 2012-December 2016. Weight-for-age z-score was calculated at birth, stoma formation and closure, noting severely underweight as z < - 3. We compared those kept in NSU until stoma closure with those discharged to local units or home (LU/H) with a stoma. A total of 74 patients were included. By stoma closure, 66 (89%) had deteriorated in z-score with 31 (42%) being severely underweight. There was no difference in z-score at stoma closure between NSU and LU/H despite babies sent to LU/H having a more distal stoma, higher birth weight and gestational age. Babies in LU/H spent a much shorter period on parenteral nutrition while living with their stoma for longer, many needing readmission.Conclusion: Growth failure is a common and severe problem in babies living with enterostomy following NEC. z-score allowed growth trajectory to be accounted for in nutrition prescription and timing of stoma closure. Care during this period should be focused on minimising harm.What is Known:• Necrotising enterocolitis (NEC) is a life-threatening condition affecting predominately premature and very low birth weight neonates. Emergency treatment with temporary enterostomy often leads to growth failure.• There is no consensus on the optimal timing for stoma reversal, hence prolonging impact on growth during crucial developmental periods. Both malnutrition and surgical NEC are independently associated with poor neurodevelopment outcome.What is New:• Our study found growth in 89% of babies deteriorated while living with a stoma, with 42% having a weight-for-age z-score < - 3, meeting the WHO criteria of being severely underweight, despite judicial use of parenteral nutrition. Applying z-score to weight measurements will allow growth trajectory to be accounted for in clinical decisions, including nutrition prescription (both enteral and parenteral), and guide timing of stoma closure.• Surgeons who target stoma closure at a certain weight risk waiting for an indefinite period of time, during which babies' growth may falter.
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Affiliation(s)
- Clara Chong
- Department of Paediatric Surgery, Evelina Children’s Hospital, Westminster Bridge Rd, Lambeth, London, SE1 7EH UK
- Department of Paediatric Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY UK
| | - Jacqueline van Druten
- Department of Nutrition and Dietetics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Colney Lane, Norwich, NR4 7UY UK
| | - Graham Briars
- Department of Paediatric Gastroenterology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY UK
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
| | - Simon Eaton
- UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH UK
| | - Paul Clarke
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
- Neonatal Intensive Care Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY UK
| | - Thomas Tsang
- Department of Paediatric Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY UK
| | - Iain Yardley
- Department of Paediatric Surgery, Evelina Children’s Hospital, Westminster Bridge Rd, Lambeth, London, SE1 7EH UK
- Faculty of Life Sciences & Medicine, King’s College London, Strand, London, WC2R 2LS UK
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16
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Wolf L, Gfroerer S, Fiegel H, Rolle U. Complications of newborn enterostomies. World J Clin Cases 2018; 6:1101-1110. [PMID: 30613668 PMCID: PMC6306644 DOI: 10.12998/wjcc.v6.i16.1101] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 11/12/2018] [Accepted: 11/15/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To evaluate the occurrence and severity of enterostomy complications in newborns suffering from different intestinal disorders.
METHODS A 10-year retrospective cohort study (2008-2017) investigated newborns that underwent enterostomy formation and reversal for different intestinal disorders. Only infants less than 28 d old at the time of enterostomy creation were included in the study (corrected age was applied in the cases of preterm neonates). The patients were divided into two groups according to their underlying diseases. Group 1 included infants suffering from necrotizing enterocolitis (NEC), whereas Group 2 included newborns diagnosed with intestinal disorders other than NEC, such as meconium obstruction, anorectal malformation, focal intestinal perforation, ileus, intestinal atresia and volvulus. The primary outcome measure was enterostomy-related morbidity. The data were analyzed statistically using Pearson’s χ2 test or Fisher’s exact test for categorical variables and the Wilcoxon-Mann-Whitney U-Test for continuous variables.
RESULTS In total, 76 infants met the inclusion criteria and were evaluated for enterostomy-related complications. Neither group showed significant differences regarding gender, gestational age, weight at birth or weight at enterostomy formation. Infants suffering from NEC (Group 1) were significantly older at enterostomy formation than the neonates of Group 2 [median (range), 11 (2-75) d vs 4 (1-101) d, P = 0.004)]. Significantly more ileostomies were created in Group 1 [47 (92.2%) vs 16 (64.0%), P = 0.007], whereas colostomies were performed significantly more often in Group 2 [2 (3.9%) vs 8 (32.0%), P = 0.002]. The initiation of enteral nutrition after enterostomy was significantly later in Group 1 infants than in Group 2 infants [median (range), 5 (3-13) vs 3 (1-9), P < 0.001]. The overall rate of one or more complications in patients of both groups after enterostomy formation was 80.3%, with rates of 86.3% in Group 1 and 68.0% in Group 2 (P = 0.073). Most patients suffered from two complications (23.7%). Four or more complications occurred in 21.6% of the infants in Group 1 and in 12.0% of the infants in Group 2 (P = 0.365). Following enterostomy closure, at least one complication was observed in 26.0% of the patients (30.6% in Group 1 and 16.7% in Group 2, P = 0.321). The occurrence of complications was not significantly different between neonates with NEC and infants with other intestinal disorders. 48 (65.8%) patients required no treatment or only pharmacological treatment for the complications that occurred [Clavien-Dindo-Classification (CDC) < III], while 25 (34.2%) required surgery to address the complications (CDC ≥ III). Early reversal of the enterostomy was performed significantly more often (P = 0.003) and the time to full enteral nutrition after closure was significantly longer [median (range), 7 (3-87) d vs 12 (5-93) d, P = 0.006] in infants with a CDC grading ≥ III than in infants with a CDC grading < III.
CONCLUSION Complications occur in almost all infants with enterostomies. The majority of these complications are minor and do not require surgical treatment. There is a clear trend that neonates with NEC have a higher risk for developing complications than those without NEC.
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Affiliation(s)
- Lea Wolf
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe-University Frankfurt am Main, Frankfurt 60590, Germany
| | - Stefan Gfroerer
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe-University Frankfurt am Main, Frankfurt 60590, Germany
| | - Henning Fiegel
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe-University Frankfurt am Main, Frankfurt 60590, Germany
| | - Udo Rolle
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe-University Frankfurt am Main, Frankfurt 60590, Germany
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17
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Yang HB, Han JW, Youn JK, Oh C, Kim HY, Jung SE. The Optimal Timing of Enterostomy Closure in Extremely Low Birth Weight Patients for Acute Abdomen. Sci Rep 2018; 8:15681. [PMID: 30356166 PMCID: PMC6200749 DOI: 10.1038/s41598-018-33351-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 09/24/2018] [Indexed: 11/25/2022] Open
Abstract
There are few reports on enterostomy closure (EC) timing for acute abdomen in extremely low birth weight (ELBW) patients. We retrospectively reviewed ELBW patients who underwent enterostomy formation (EF) and subsequent EC. We investigated baseline characteristics, surgical outcomes, and follow-up data of 55 patients and analyzed optimal timing by age at EC, enterostomy duration, and body weight (Bwt) at EC. The minimum p-value approach (MPA) using the Chi-squared test was used to determine each cut-off value. Mean gestational age was 25+3 weeks, while mean age and Bwt at EF were 10 days and 660 g. Enterostomy duration and Bwt at EC were 102 days and 2400 g. Fourteen surgical complications were related to EC. The MPA identified a cut-off of 2100 g (p = 0.039) at EC but no significant cut-off age or enterostomy duration. The 18 patients <2100 g had more enterostomy-related problems at EC than the >2100 g group (66.7% vs 10.8%, p < 0.001). No other characteristics were significantly different. Operation time, ventilator period, hospital stay, parenteral nutrition duration, and full feeding day were significantly longer in <2100 g patients. Follow-up Bwt did not differ (11.55 kg vs 13.95 kg, p = 0.324). Our findings suggest EC can be safely performed when Bwt is over 2100 g.
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Affiliation(s)
- Hee-Beom Yang
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Ji-Won Han
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Joong Kee Youn
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Chaeyoun Oh
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University, College of Medicine, Seoul, Korea.
| | - Sung Eun Jung
- Department of Pediatric Surgery, Seoul National University, College of Medicine, Seoul, Korea
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18
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Lucas DJ, Gosain A. Association of Comorbidities With Adverse Outcomes After Enterostomy Closure in Premature Neonates. JAMA Surg 2018; 153:776-778. [PMID: 29799909 DOI: 10.1001/jamasurg.2018.0880] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Donald J Lucas
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis
| | - Ankush Gosain
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis.,Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis
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19
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Outcome of stoma closure in babies with necrotising enterocolitis: early vs late closure. Pediatr Surg Int 2017; 33:783-786. [PMID: 28434039 DOI: 10.1007/s00383-017-4084-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2017] [Indexed: 01/26/2023]
Abstract
UNLABELLED Newborns undergoing surgery for necrotizing enterocolitis (NEC) often require a stoma. Currently, there is no consensus regarding the best time for stoma closure (SC). Our aim was to determine the outcomes of early versus late closure. METHODS Retrospective analysis of patients who underwent SC following stoma formation for NEC between Jan 2009 and July 2015 was done. Early (EC) versus late closure (LC) was defined as less than 10 weeks versus at or after 10 weeks of stoma formation. RESULTS Of 36 patients, M:F was 23:13. Indications for laparotomy were pneumoperitoneum (30) and gangrene (6). Postoperatively, 9/15 (60.0%) of EC group required ventilator support versus none in LC group (p < 0.05). It took longer to establish full feeds following EC (12 days) versus LC (8 days). Median duration of postoperative hospital stay following EC was 31 days (18-35) versus 7 days (4-54) following LC. Three patients were re-operated for intestinal obstruction (two following EC, one following LC). Three patients developed incisional hernia after EC versus none after LC (p < 0.05). One patient died after EC due to staphylococcus septicaemia. CONCLUSION Early closure before 10 weeks of formation for NEC patients is associated with significant morbidity, increased ventilator requirements and chances of developing incisional hernia.
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20
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Bethell G, Kenny S, Corbett H. Enterostomy-related complications and growth following reversal in infants. Arch Dis Child Fetal Neonatal Ed 2017; 102:F230-F234. [PMID: 27671835 DOI: 10.1136/archdischild-2016-311126] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 08/10/2016] [Accepted: 09/06/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Infant enterostomies are used to manage various neonatal surgical conditions where it is not suitable or safe to form a primary anastomosis. Complications are common and there is no consensus regarding optimal timing of enterostomy reversal. Stoma reversal is thought to allow patients to thrive; however, this has not been demonstrated robustly. AIM The study aimed to identify risk factors for enterostomy-related complications and to determine the relationship between enterostomy complications, enterostomy reversal and weight gain in infants with enterostomies. METHODS A retrospective case note review of 58 infants who underwent enterostomy formation and reversal during a 6-year period was undertaken; demographic data, diagnosis, enterostomy complications and serial weights were noted. Standardised growth charts were used to calculate z scores. RESULTS Enterostomy complications were documented in 24 infants (41%). Infants of low birth weight and low gestational birth age were significantly more likely to have an enterostomy-related complication (1110 vs 2125 g, 28.5 vs 35 weeks, respectively); they were more likely to have longer inpatient stays and remain dependent on parenteral nutrition prior to closure (median 92.5 vs 52 days, 40% vs 16%, respectively). Irrespective of diagnosis, gestation and presence of an enterostomy complication, the mean z score prior to enterostomy closure was -0.747 vs +0.892 following closure. CONCLUSIONS Around 40% of infants with an enterostomy will have an enterostomy-related complication. Whatever their weight, gestation or underlying pathology, most infants thrive after enterostomy closure and this should be considered when planning the optimal timing for this procedure.
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Affiliation(s)
- George Bethell
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.,University of Liverpool Institute of Translational Medicine, Liverpool, UK
| | - Simon Kenny
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.,University of Liverpool Institute of Translational Medicine, Liverpool, UK
| | - Harriet Corbett
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
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Mochizuki K, Hayakawa M, Urushihara N, Miyake H, Yokoi A, Shiraishi J, Fujinaga H, Ohashi K, Esumi G, Ohfuji S, Amae S, Yanai T, Furukawa T, Tazuke Y, Minagawa K, Okuyama H. Timing and outcome of stoma closure in very low birth weight infants with surgical intestinal disorders. Surg Today 2017; 47:1001-1006. [PMID: 28247106 DOI: 10.1007/s00595-017-1498-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 12/25/2016] [Indexed: 12/01/2022]
Abstract
PURPOSE Very low birth weight infants (VLBWIs) are at risk of surgical intestinal disorders including necrotizing enterocolitis (NEC), focal intestinal perforation (FIP), and meconium-related ileus (MRI). We conducted this study to verify whether the timing of stoma closure and that of enteral nutrition establishment after stoma closure in VLBWIs differ among the most common disorders. METHODS A retrospective multicenter study was conducted at 11 institutes. We reviewed the timing of stoma closure and enteral nutrition establishment in VLBWIs who underwent stoma creation for intestinal disorders. RESULTS We reviewed the medical records of 73 infants: 21 with NEC, 24 with FIP, and 25 with MRI. The postnatal age at stoma closure was 107 (28-359) days for NEC, 97 (25-302) days for FIP, and 101 (15-264) days for MRI (p = 0.793), and the postnatal age at establishment of enteral nutrition was 129 (42-381) days for NEC, 117 (41-325) days for FIP, and 128 (25-308) days for MRI (p = 0.855). The body weights at stoma closure were 1768 (620-3869) g for NEC, 1669 (1100-3040) g for FIP, and 1632 (940-3776) g (p = 0.614) for MRI. There were no significant differences among the three groups. CONCLUSIONS The present study revealed that the time and body weights at stoma closure and the postoperative restoration of bowel function in VLBWIs did not differ among the three diseases.
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Affiliation(s)
- Kyoko Mochizuki
- Department of Surgery, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, 232-0066, Japan.
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hiromu Miyake
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Akiko Yokoi
- Department of Pediatric Surgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Jun Shiraishi
- Department of Neonatology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Hideshi Fujinaga
- Division of Neonatology, Center for Maternal-Fetal and Neonatal Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kensuke Ohashi
- Department of Pediatric Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Genshiro Esumi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Satoko Ohfuji
- Department of Public Health, Osaka University Faculty of Medicine, Osaka, Japan
| | - Shintaro Amae
- Department of Pediatric Surgery, Miyagi Children's Hospital, Sendai, Japan
| | - Toshihiro Yanai
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, Japan
| | - Taizo Furukawa
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kyoko Minagawa
- Department of Pediatrics, Hyogo College of Medicine, Hyogo, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
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22
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Talbot LJ, Sinyard RD, Rialon KL, Englum BR, Tracy ET, Rice HE, Adibe OO. Influence of weight at enterostomy reversal on surgical outcomes in infants after emergent neonatal stoma creation. J Pediatr Surg 2017; 52:35-39. [PMID: 27916444 DOI: 10.1016/j.jpedsurg.2016.10.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/20/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE Neonates after emergent enterostomy creation frequently require reversal at low weight because of complications including cholestasis, dehydration, dumping, failure to thrive, and failure to achieve enteral independence. We investigated whether stoma reversal at low weight (< 2.5kg) is associated with poor surgical outcomes. METHODS Patients who underwent enterostomy reversal from 2005 to 2013 at less than 6months old were identified in our institutional database. Only patients who underwent emergent enterostomy creation (i.e. for necrotizing enterocolitis or spontaneous perforation) were included. Demographics, disease process, comorbidities, stoma type, reversal indication, operative details, and complications were examined. Patients were categorized by weight at reversal of less than 2kg, 2.01-2.5kg, 2.51-3.5kg, and greater than 3.5kg. Data were analyzed using univariable and multivariable regression with significance level of p<0.05. The primary outcome examined was major morbidity, defined as the presence of anastomotic leak, obstruction, hernia, EC fistula, perforation, wound infection, sepsis, or death. RESULTS Eighty-nine patients met inclusion criteria. Demographics (sex, ethnicity, surgical disease process, reversal indication, and ASA score) were similar. The lowest weight group had lower gestational age (p<0.001) and birth weight (p=0.005), and contained a higher proportion of jejunostomies to ileostomies (p=0.013). On univariable analysis, only incisional hernia was significantly different as a complication between weight groups. On multivariable analysis controlling for gestational age and ASA, there was no significant difference in odds of major operative morbidity between groups. CONCLUSIONS Enterostomy reversal at lower weight may not be associated with increased risk of perioperative complications. Early stoma reversal may be acceptable when required for progression of neonatal care. LEVEL OF EVIDENCE Level III, Treatment Study (Retrospective comparative study).
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Affiliation(s)
| | - Robert D Sinyard
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kristy L Rialon
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian R Englum
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Elizabeth T Tracy
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, USA
| | - Henry E Rice
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, USA
| | - Obinna O Adibe
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, USA
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23
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Yang YJ. The optimal timing of enterostomy closure in preterm infants. Pediatr Neonatol 2014; 55:333-4. [PMID: 25042477 DOI: 10.1016/j.pedneo.2014.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2014] [Indexed: 11/30/2022] Open
Affiliation(s)
- Yao-Jong Yang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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