|Year : 2023 | Volume
| Issue : 3 | Page : 187-193
Retrospective analysis of the outcome of stoma closure in children without preoperative mechanical bowel preparation
Rahul Saxena1, Somya Bhatt1, Manish Pathak1, Akhil D Goel2, Kirtikumar J Rathod1, Arvind Sinha1, Shubhlaxmi R Nayak1, Avinash S Jadhav1
1 Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Community Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
|Date of Submission||16-Sep-2022|
|Date of Decision||16-Nov-2022|
|Date of Acceptance||18-Dec-2022|
|Date of Web Publication||02-May-2023|
Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
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.
Keywords: Children, mechanical bowel preparation, stoma closure
|How to cite this article:|
Saxena R, Bhatt S, Pathak M, Goel AD, Rathod KJ, Sinha A, Nayak SR, Jadhav AS. Retrospective analysis of the outcome of stoma closure in children without preoperative mechanical bowel preparation. J Indian Assoc Pediatr Surg 2023;28:187-93
|How to cite this URL:|
Saxena R, Bhatt S, Pathak M, Goel AD, Rathod KJ, Sinha A, Nayak SR, Jadhav AS. Retrospective analysis of the outcome of stoma closure in children without preoperative mechanical bowel preparation. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Jun 2];28:187-93. Available from: https://www.jiaps.com/text.asp?2023/28/3/187/375518
| Introduction|| |
Stoma closure is one of the most frequently performed surgical procedures by pediatric surgeons worldwide. There are various indications for temporary stomas in children, including anorectal malformations (ARMs), Hirschsprung's disease (HD), necrotizing enterocolitis, and intestinal atresia. Preoperative mechanical bowel preparation (MBP) in colonic and rectal surgeries has been the standard of care for decades. MBP can be used in combination with preoperative oral antibiotics (OAB) and intravenous antibiotics. However, recent studies on adult patients have deemed these procedures to be nonbeneficial and thus unnecessary. According to Bischoff et al., clear fluids need to be used through the mouth and repetitive proximal stoma washes need to be performed 24 h before the scheduled surgery. MBP usually necessitates the nasogastric tube (NGT) insertion in children due to noncompliance with the standard method which increases the patient's discomfort. The complications of the stoma closure procedure include wound infection, incisional hernia, anastomotic leaks, and death and there is considerable variation in the practices of antibiotic usage, abdominal closure methodology, and the time frame for NG tube removal and oral feeding initiation after stoma closure.
Slim et al. in their meta-analysis of trials involving 4859 patients did not find any significant difference in complication rate and anastomotic leaks in patients with or without MBP. Similarly, Güenaga et al. in their meta-analysis of 18 trials involving 5805 patients did not find a significant difference in the rates of wound infection and anastomotic leaks and suggested that the usage of bowel cleaning can be completely eradicated in cases of colonic surgery. There are very few research papers that have looked into the use of MBP in children, so more research is needed, especially regarding its discontinuity.,
Therefore, based on the clear existing gap in knowledge in this critical field, we performed this study to evaluate the postoperative outcomes of stoma closure with the research hypothesis that the outcome of patients undergoing stoma closure without MBP is comparable to the surgeries performed after MBP.
| Materials and Methods|| |
After receiving approval from the Institution's Ethics Committee (AIIMS/IEC/2019-20/796), the observational study was conducted at the Department of Paediatric Surgery, All India Institute of Medical Sciences, Jodhpur, India. The study aimed to assess the outcome of stoma closure in children, without undergoing a preoperative MBP and to compare the outcome of colostomy closure patients with ileostomy closures. The primary outcome variables were the incidence of the surgical site (wound) infection, wound dehiscence, anastomotic leak, and mortality.
For purpose of the study superficial surgical site infection (superficial SSI) was diagnosed in presence of any one of the followings: purulent discharge from the incision; organism cultured from wound tissue or fluid; the presence of any one of the local signs and symptoms, for example, pain or tenderness, localized swelling, redness, heat, and the superficial incision gaping. Deep SSI was diagnosed when the infection involved deep fascia and muscle layers. SSI was diagnosed according to the guideline for the prevention of SSI. The wound dehiscence was considered to have occurred when all the layers of the wound got separated.
The patients who underwent stoma closure (ileostomy or colostomy) from 2017 to 2021 were included in the study. However, patients with immunocompromised status and those with major congenital heart disease were excluded from the study group. Only one patient was excluded from the study based on the exclusion criteria who was severely malnourished and had tetralogy of fallot. The surgeries were performed by one of the five consultant pediatric surgeons in our department or the residents who were at least in the 4th year of their training.
We follow standard operative procedure steps for stoma closure which included the administration of IV antibiotics at induction of anesthesia. The patients are admitted one day before surgery. The patients are kept fasting for 6 h for food and formula, 4 h for breast milk, and 2 h for clear fluid. The surgery commences by taking multiple stay sutures at the mucocutaneous junction of the stomas to provide uniform traction. The bowel wall is dissected carefully avoiding any fecal contamination. This is achieved by packing the wound all around the bowel with sterile pads. Adhesions are released whenever found necessary by the operating surgeon. An end-to-end anastomosis with interrupted absorbable sutures is done in the single or double layer as per the surgeon's preference. We close the peritoneum and fascia in a single layer with interrupted absorbable sutures. The wound is closed in separate layers of subcutaneous tissue and skin.
The NGTs are not used routinely after colostomy closures, while it is used in most cases of ileostomy closures. The clear fluids are started on the 1st postoperative day if they do not have ileus and the patients are discharged when they are tolerating feeds and have passed stools.
The demographic data, primary diagnoses, and indication of stoma, level, and type of stoma, were retrieved from the hospital information system, and primary endpoints such as SSI, wound dehiscence/incisional hernia, anastomotic leak, and mortalities were recorded. Furthermore, secondary endpoints such as the length of surgery, the requirement of NG tube insertion and time of its withdrawal, time to the first postoperative stool passage, time taken to start oral feeds, and the length of hospital stay (LOS) were also studied. The categorical data are expressed in percentages and the continuous data are expressed in medians and interquartile ranges (IQR). The nonparametric data were analyzed using the Mann–Whitney U-test and categorical data were analyzed used using the Chi-square test. The results were analyzed using IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, N.Y., USA).
| Results|| |
A total of 89 patients were identified during the study's timeframe. There were 46 males (51.7%) and 43 females (48.3%) with a slight male preponderance and the median age at surgery was 18 months (IQR = 36 months). The most common indication for stoma formation was ARM (68.5%) followed by HD. There were 73 colostomies and 16 ileostomies which were reversed during the study.
The median duration for which patients had been on a stoma was 11.5 months (IQR = 10.5 months), ranging from 25 days to 18 years. The child of 25 days underwent early ileostomy closure which was done for ileal atresia. There were two children of 18 years; one had a sigmoid colostomy at neonatal age for ARM and the other one was operated case of Duhamel's procedure with an anastomotic stricture. Out of the sample size, nearly 83.14% of patients were on distal washes at the time of closure. All of our patients received a single prophylactic dose of intravenous antibiotics and none of the patients underwent any MBP based on the department's protocol.
The closure was done in a single layer in 41 (46%) and double layer fashion in 35 (39%) patients as per the surgeon's preference while the information was missing in the operative notes of thirteen patients. Intraoperative adhesiolysis was required in 34 patients (38%), ceco-transverse anastomosis and ileocolic anastomosis were required in one patient each, and four patients had some degree of stomal prolapse at the time of closure. The NGT was inserted as and when required after colostomy closures and the majority of our patients (74%) did not require an NG tube. On the other hand, NGT was inserted in most of the ileostomy closures (12/16) [Table 1].
The incidence of SSI was not related to age at surgery, duration of stoma, or duration of surgery. Furthermore, the incidence of SSI in ileostomy and colostomy closure was 25% and 27.4%, respectively, which was not statistically significant [Table 2].
The decision to start the feeds was based on the clinical assessment of the child. In 18 patients (20%) feeds were started on the day of surgery while feeds were established on postoperative days 1 and 2 in 16 (18%) and 17 (19%) patients, respectively. The median duration to start the feeds was 2 days (IQR = 2.5 days). Moreover, most of the patients passed stools within a median duration of 3 days (IQR = 1 day). The median duration to establish full feeds was 5 days (IQR = 3 days). The median length of surgery was 120 min (IQR = 30 min, however, duration was not mentioned in 26 patients) and the length of hospital stay was 7 days (IQR = 3 days) [Table 4] The Spearman's correlation of the duration of surgery with the time taken to pass first stools, NGT removal, initiation of the feeds, and LOS was not significant.
The median duration for NGT removal was 3 days and there was no significant difference in the median duration of NGT removal and LOS between ileostomy and colostomy closure patients. Furthermore, the duration of passage of first stools, NGT removal, initiation and establishment of feeds, and LOS was not significantly altered by the need for adhesiolysis during surgery [Table 3].
| Discussion|| |
MBP is commonly used before colorectal surgery. It is commonly believed to decrease the complications that are related to fecal contamination including anastomotic dehiscence, wound infection, and sepsis. The administration of MBP is an unpleasant experience in young children as it often involves NGT insertion and preoperative admission. It can be performed by oral polyethylene glycol (PEG), oral sodium phosphate, sodium picosulfate/magnesium citrate, normal saline, and phosphate enemas. A systematic review investigating the optimum agent for MBP found all of them equivocal for adequacy of bowel preparation but in comparison, sodium picosulfate and magnesium citrate are better tolerated in children and PEG has the least tolerability with a lot of patients requiring NGT insertion. MBP is also used along with a combination of oral or IV antibiotics. It is done as it is assumed that it would reduce the complications that arise due to stool bacterial infections. A large series of colostomy closures advocates clear liquids by mouth and repeated proximal stomal irrigations, 24 h before surgery. The validity and efficacy of the procedure have been questioned for a significant amount of time, but most of the data against the use of MBP is associated with adult patients.
MBP is frequently associated with issues like poor acceptance and tolerance which frequently necessitates NG tube insertion. Other minor adverse events include abdominal distension, bloating, fecal incontinence, nausea, vomiting, headaches, and anal irritation. Very few studies have challenged the usage of MBP in children. There are no established guidelines for the use of preoperative MBP in children and usually, practices are driven by surgeon's preferences.
Hence, this study was conducted to evaluate the outcome of stoma closure surgeries without preoperative MBP.
The most common indications of stoma were ARMs and HD which were similar to previous studies,,, while the median age for stoma reversal in our series was 18 months.,,, The median operating time for surgery was 120 min which was comparable to the time mentioned in other studies.,
There is no consensus on the routine use of NGT drainage and resumption of oral feeds postoperatively. Many surgeons use NGT considering it to be helpful in the early resumption of bowel function, prevention of anastomotic leaks, and prevention of aspiration. We inserted NGT in the postoperative period, only when there was abdominal distension or vomiting, and only 35% of patients required postoperative NGT insertion in our cohort of colostomy closures. The time taken to pass first stools and start feeds was significantly shorter in the patients with colostomy closure as compared to ileostomy closure. The median duration for NGT removal was 3 days while the duration for initiation of feeds and passage of first stools were 2 and 3 days, respectively [Table 4]. Furthermore, the durations to remove NGT and start oral feeds were shorter while the time taken to pass the first stool was comparable to those studies where the NGT was routinely inserted and MBP was performed.,, In the comparison of the MBP group with no MBP group, Leys et al. and Aldrink et al. did not find any significant difference in the duration of NGT removal, time taken to start full feeds, the passage of first stools, operative duration, and length of stay, [Table 4]. The median LOS was 7 days which was also comparable to those mentioned in the literature.,,,,,
The patients in our cohort received prophylactic IV antibiotics (Ceftriaxone) in the operating room at the time of induction and metronidazole is added and followed for 48 h postoperatively. The antibiotics were continued or restarted if the wound infection occurred according to the sensitivity of the organism grown in the pus culture. The median duration of antibiotics in our cohort was 2 days (IQR = 3 days, range 2–20 days).
In our cohort of stoma closures without MBP, the superficial SSI occurred in 23% of patients, deep incisional SSI occurred in 2.2% of cases, while wound dehiscence and the anastomotic leak occurred in 1 patient each. These are comparable to the data on the complication rates in the patients undergoing stoma closure with preoperative bowel preparation.,,,,,,,
The rate of wound infection in the present literature ranges from 0% to 45%, anastomotic leak/fecal fistula ranges from 0% to 12%, and incisional hernia from 0% to 2.6%.,,,,,
Furthermore, the rate of adhesive obstruction is up to 9%.,, Breckler et al. 2010 reported a wound infection rate of 14% in their cohort of colostomy closures of patients with ARMs while no infection occurred in eight patients who received only IV antibiotics without any MBP. In a retrospective study of 2110 children undergoing stoma closure, the rate of SSI was 7.6% and the SSI was found to be related to longer operative duration (>105 min), increasing age, cardiac risk factors, and HD on univariate regression analysis.
The retrospective comparative studies for the outcomes of colostomy closure with and without MBP did not suggest any significant difference in rates of wound infection, anastomotic leak, incisional hernia, and adhesive bowel obstruction.,, Serrurier et al. found that the rate of wound infection in patients who received MBP (4.4%) was significantly higher than in those without MBP (5.8%) with a P = 0.04. The retrospective study of colostomy closures by Rosenfeld et al. found that patients who did not receive MBP had a significantly shorter hospital stay than those who received the MBP while the rate of complications such as wound infection and anastomotic leaks were not different. Liang et al. found that the hospitalization of MBP had a significantly higher cost than the no MBP group. However, there is no difference in the complication rates between the two groups.
Leys et al. in their study of comparison of outcome of elective intestinal surgeries with and without MBP did not find any significant difference in complication rates. Similarly, Shah et al. and Aldrink et al. in their respective prospective randomized control trials (RCTs) did not find significant differences in rates of wound infection, anastomotic leak, intra-abdominal abscess, sepsis, bowel obstruction in comparing MBP with no MBP in pediatric patients undergoing stoma closures or elective bowel surgeries., On the contrary, the research works have also highlighted that bowel preparation by MBP alone can cause a significant increase in the possibility of anastomotic leaks, wound infections,, and other complications in the patients. These increased complication rates with MBP can be due to difficulty in handling liquid stools after MBP and hence leading to wound contamination. Moreover, MBP does not decrease the bacterial concentration in the residual stools.,
There is Class I evidence that the addition of enteral antibiotics with MBP reduces SSI in the adult population but data are limited for the safety and efficacy of the same in children., There was no difference in the rate of SSI among the children who received MBP or MBP with OAB in the retrospective review of Breckler et al. Besides, the use of OAB is challenging in children due to poor palatability and their use may increase nausea, vomiting, and growth of other bacteria. In a retrospective study of 1581 patients undergoing colonic anastomosis, a comparison of patients with no MBP, with MBP, and MBP + OAB was done and found that the aggregate surgical complication was significantly more in patients undergoing surgery without MBP while the rates of wound infection, anastomotic leak and wound dehiscence were not significantly different.
The choice of preoperative bowel preparation among pediatric surgeons is variable and a survey by the American Pediatric Surgical Association in 2015 by Feng et al. for the practices of bowel preparation revealed that nearly fifty percent of the surgeons still use MBP (MBP alone by 31.1% and MBP with OAB by 19.6). This was followed by dietary modification by 26.8 percent, no preparation by 12.2%, and OAB alone by 5.4% of respondents. However, there is a downtrend in the use of MBP alone or in combination with OAB, and younger surgeons preferred either no preparation or just dietary modifications. The prevalence of the practice of MBP among pediatric surgeons can be due to the need of decompressing the long-standing dilated bowels to make the surgery easier and shorter.
A recent systematic review of two randomized controlled trials, and four retrospective analyses,,, included 2178 patients undergoing colorectal surgeries (1011 received MBP and 1167 did not receive MBP). Among the patients in two RCTs, the wound infection, anastomotic leakage, and intra-abdominal abscess rates in the MBP group and no MBP group were 16.7%, 4.8%, 7.1% and 14.7%, 2.9%, 5.9%, respectively, and there was no significant difference found between the two groups. Furthermore, among the two groups of patients in retrospective studies the rates of wound infection, anastomotic leakage, and intra-abdominal abscess in MBP versus no MBP were 6.6%, 3.2%, 0.7%, and 3.9%, 4.7%, 0.8%, respectively, with no statistically significant difference.
The complication rates of our study group are comparable to the other studies where bowel preparation was done, and only two patients had Clavien–Dindo Grade III complications. Only one-third of the patients required NGT and the duration of nasogastric drainage, and time to start oral feeds were shorter than those mentioned in the previous studies.,, In addition, the unpleasant experience of preoperative NGT insertion and problems such as nausea and vomiting were also avoided.
Our study has the limitation of having a retrospective design where we have analyzed the outcome of the patients who underwent stoma closure without preoperative bowel preparation. Due to the retrospective collection of data, all patients with documented redness and induration were also considered to have SSI and it gives the impression of a high infection rate in our cohort but actually, the intervention was required in two patients only. Moreover, there is no comparative group of patients in our study and the availability of patient data was not complete. The data on the length of surgery were missing in the records of 26 patients due to which we could not find any significant correlation between the length of surgery and time taken to pass first stools, NGT removal, initiate oral feeds, and the LOS. The patients were operated on by different surgeons which adds to the confounding factors in the study. The results of our study need further validation by large-size RCTs.
| Conclusion|| |
The results of our study suggest that MBP can safely be omitted before stoma closures in children. The preclusion of MBP will render the surgical procedure more convenient and cost-effective. The rates of various complications such as wound infection, anastomotic leak, and incisional hernia are not altered with the use of MBP. The recent literature suggests that stoma closures without MBP are associated with lesser complications, earlier return of bowel function, feed establishment, recovery, and discharge from the hospital. The practice of preoperative bowel preparation among pediatric surgeons is an individual preference and there is a need for laying the standard guidelines with quality of care initiatives.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]