Pediatric colonic anastomosis: Can method of anastomosis and wound closure be of help?

Arindam Ghosh; Somak Krishna Biswas; Tapanjyoti Ghosh; Kalyani Saha Basu; Sumitra Kumar Biswas

doi:10.4103/jiaps.jiaps_129_22



ORIGINAL ARTICLE

Year : 2023 \| Volume : 28 \| Issue : 3 \| Page : 245-249

Pediatric colonic anastomosis: Can method of anastomosis and wound closure be of help?

Arindam Ghosh¹, Somak Krishna Biswas², Tapanjyoti Ghosh³, Kalyani Saha Basu³, Sumitra Kumar Biswas³
¹ Department of Pediatric Surgery, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
² Pediatric Surgery, ICH, Kolkata, West Bengal, India
³ Department of Pediatric Surgery, NRS Medical College and Hospital NRS Medical College and Hospital, Kolkata, West Bengal, India

Date of Submission	10-Sep-2022
Date of Decision	08-Feb-2023
Date of Acceptance	11-Feb-2023
Date of Web Publication	02-May-2023

Correspondence Address:
Sumitra Kumar Biswas
Flat C1 and C2, Shankhochil Apartment, IH – 17, Pubali, Aswini Nagar, Baguiati, Kolkata - 700 059, West Bengal
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jiaps.jiaps_129_22

Abstract

Background: Enhanced recovery after surgery (ERAS) protocols after colorectal surgery focused on reduced bowel preparation, standardized feeding schedule, earlier return of bowel function, and earlier resumption of normal activities. ERAS in pediatric surgical practice is not well established. The present study aims to present the results of two colonic anastomosis techniques of interrupted single-layered closure: Halsted (Horizontal Mattress) and Matheson (serosubmucosal or appositional extramucosal) along with two different methods of colostomy wound closure and their influence on the adoption of ERAS protocol of early feeding and early discharge.
Materials and Methods: This single institute-based randomized control study was conducted in a tertiary care facility in Kolkata for 2.4 years. Patients were chosen randomly for serosubmucosal (Group I) and full-thickness (Group II) anastomosis.
Results: Among total of 91 patients (Group I–43 and Group II–48), Return of bowel sounds and passage of bowel averaged 1.51 ± 0.51 and 1.91 ± 0.55 days in Group I and 1.91 ± 0.57 and 3.9 ± 0.66 days in Group II, respectively. Postoperative hospital stay averaged 5.88 ± 1.12 days in Group I and 8.9 ± 1.17 days in Group II. Overall 15 (16.48%) patients had complications among which SSI (Suprficial surgical site infection) and minor leaks (Group I–3 and 1 and Group II–5 and 3, respectively) which were treated conservatively (Clavien–Dindo Grade-I) and three major leaks under Group II requiring surgical intervention (Clavien–Dindo Grade-III).
Conclusion: This study concludes that the technique of colostomy closure in the form serosubmucosal closure helps in the implementation of ERAS protocol by producing early bowel movement, early initiation of food, and less postoperative complications.

Keywords: Colocolic anastomosis technique, outcome of anastomosis, pediatric enhanced recovery after surgery, serosubmucosal anastomosis

How to cite this article:
Ghosh A, Biswas SK, Ghosh T, Basu KS, Biswas SK. Pediatric colonic anastomosis: Can method of anastomosis and wound closure be of help?. J Indian Assoc Pediatr Surg 2023;28:245-9

How to cite this URL:
Ghosh A, Biswas SK, Ghosh T, Basu KS, Biswas SK. Pediatric colonic anastomosis: Can method of anastomosis and wound closure be of help?. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 May 31];28:245-9. Available from: https://www.jiaps.com/text.asp?2023/28/3/245/375517

Introduction

Enhanced recovery after surgery (ERAS) protocols are now the norm in practice, in all almost all adult surgical branches, especially gastrointestinal and hepatobiliary surgeries. The various policies adopted for ERAS, start well before the surgery itself and extends to a variable period well after discharge from the hospital. It depends on an informed, consented, and coordinated team effort including all the stakeholders, both medics and paramedics.^{[1],[2],[3],[4]}

Although ERAS has rooted itself in adult surgical practice, the picture is different in pediatric surgical practice. There are sporadic reports of individual teams from different institutes worldwide but there is still the lack of procedure specific universally agreed-upon protocols or guidelines; however, there is a emerging evidence to adapt ERP (Enhance recovery protocol) where it is available.^[5],[6]

The early feeding protocol after colostomy closure has shown that early feeding was superior to traditional feeding (only after bowel movement) with improved outcome in terms of complications, hospital stay, and patients and parents' satisfaction.^[7]

We examined whether the technique of colonic anastomosis or avoidance of intra-abdominal drains and wound closure techniques influence the adoption of ERAS protocol of early feeding and early discharge from the hospital. In the present study, we compared between two techniques of interrupted single-layered closure: Halsted (Horizontal Mattress) and Matheson (serosubmucosal or appositional extra-mucosal)^[8] with different methods of wound closure.

Materials and Methods

This single institute-based randomized control study was performed in the department of pediatric surgery, in a tertiary care facility in Kolkata during the period of 2.4 years (November 2016 to February 2019). Children with colostomy for anorectal malformation who completed definite surgery at least 12 weeks ago with adequate neoanus were chosen for the study. Patients with associated comorbidities such as seizure disorders, congenital cardiac anomalies, dense pericolostomy adhesions, and gross luminal disparity were excluded from the study. In one group (Group I), Matheson (serosubmucosal or appositional extramucosal) anastomotic technique has been used, and in another group (Group II), Halsted (Horizontal Mattress) technique used for colostomy closure. The sample size was estimated by clinical superiority model as the variables are dichotomous (not continuous). In our study, the sample size is 91. All patients after being prepared for surgery were chosen randomly for both groups. The technique of interrupted serosubmucosal anastomosis was performed in one unit only (Group I) and the other two units in the department used the through-and-through interrupted single-layer technique (Group II).

After choosing the patients proper consent from parents or caregivers in vernacular language is taken. Along with distal colonic washes, proximal bowel preparation was done using nonresidue diet for 2 days, clear liquids for 1 day, and low molecular weight polyethylene glycol (0.4–0.8 Gm/Kg, maximum 17Gm/day) a day prior surgery until the effluent was clear. If the effluent was not clear, mechanical bowel wash with warm saline was given before surgery. All children received combination of cefotaxime, amikacin, and metronidazole for 72 h after getting first dose preoperatively. The procedure time for both groups was comparable (1 h to 1.15 h) and performed by consultants only to rule out confounding factors of experience of surgeons. Postoperatively NG (Naso Gastric ) tube was removed after 24 h; however, feeding was started only after passage of flatus or feces. Suture materials used were polyglactin in all the cases to nullify any suture-related difference in outcome. Postoperatively in all patients, feeding was initiated only after bowel movement; to start with clear fluids like ORS (Oral rehydration solution ) for three feeds as per demand and quickly changing to nonresidues such as curd or ice cream or breast milk as seemed appropriate. A mixed diet was introduced when these children were craving for it and observed for a day. In all the patients of Group I, no intra-abdominal drain was given; after muscle and sheath closure by far and near mattress suture, the wound was thoroughly washed with warm saline till clean and closed with absorbable subcutaneous suture and was discharged after initiation of a mixed diet. In Group II patients, the policy was to keep corrugated sheet drain intra-abdominally, to remove it after a mixed diet was tolerated for at least 2–3 days and discharge the patient; the subcutaneous drain was removed on the 3^rd postoperative day; the colostomy closure wounds were closed by removable mattress or simple stitches, which were removed in the next outpatient department (OPD) date. Surgical complications had been taken care as per need. After discharge, all patients were followed in the next OPD date within a week and then after 4 weeks for any delayed SSI. Prior permission from ethical committee was taken (IEC No/NMC/502 dated January 28, 2016). Data were tabulated and calculated for age, sex, anastomotic technique, appearance of peristaltic sound, first bowel movement, anastomotic leak, infective complications immediate and delayed, and postoperative hospital stay. Statistical analysis was done by Microsoft Excel 2010 software.

Result

In this study, we recruited a total of 91 patients, 43 in Group I and 48 in Group II. Fifty-six patients were boys and the rest 35 were girls [Table 1]. Age for surgery ranged from 1 year to 12 years with an average of 3.8 years. About 73.86% (65) patients operated were within 4 years of age [Figure 1].

Table 1: Age, sex, postoperative bowel movement and passage of flatus/stool, postoperative complications, and hospital stay in Group I and II

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Figure 1: Age distribution of patients in the study

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Return of bowel sounds averaged 1.5 days in Group I and 1.9 days in Group II (not statistically significant). However, passage of bowel averaged 1.9 days in Group I, whereas the average was 3.9 days in Group II which is statistically significant [Table 1].

Initiation of feeding was thus 2 days earlier in Group I with achievement to solid food early. This was reflected in hospital stay which averaged 5.9 days in Group I (range 5–10 days), which averaged 8.9 days in Group II (range 7–18 days). Values are again statistically significant [Table 1].

In our study, three patients had major complications (Clavien–Dindo Grade-III) in Group II-2 had major leak detected on fifth POD (Post operative day) and 1 had adhesive obstruction due to a sealed leak found on exploration on eighth POD. No patient in Group I suffered from such major complication. Twelve patients had acceptable complications (Clavien–Dindo Grade-I) and were treated conservatively. Group I had three late minor SSIs at follow-up period, whereas Group II had five minor SSIs within hospitalized period, which delayed discharge, and this might have skewed up the results of hospital stay in Group II. One patient in Group I and three patients in Group II had minor leaks on D5 and D7/8, respectively. These closed spontaneously after conservative treatment on D10 in Group I and D16 in Group II. Clearly, this has also affected the hospital stay results. Overall, 15 (16.48%) patients had complications out of total 91 patients in this study [Table 1].

Discussion

Methods of colonic or intestinal anastomosis are many. Traditional hand-sewn methods still prevail over mechanical methods, for example, staples in colostomy closures. However, a lot of hand-sewn techniques had been described in the literature.^{[9],[10],[11]} In case of colonic anastomosis, we as a fraternity had abandoned two layered closure techniques and continuous suture closure techniques. Hence, the present study compared between two techniques of interrupted single-layered closure: Halsted (Horizontal Mattress) and Matheson (serosubmucosal or appositional extramucosal).^[8] The hallmark difference between the two is that in Matheson's technique suture is never in contact with fecal stream and will theoretically never produce microabscesses and so resultant leak. Moreover, apposed mucosa will seal the luminal circular wound line within 24 h by epithelialization and bowel will move earlier.^{[12],[13],[14]} This along with (1) avoidance of intraperitoneal and parietal drains,(2) subcutaneous fat closure with absorbable sutures after thorough saline wash, and (3) subcuticular closure of skin, (instead of traditional vertical mattress/simple nonabsorbable suture closure which increase hospital stay) were done to assess whether these new practices are safe or not, in terms of incidence of SSI.^[15] The idea was to put traditional ideas of wound closure to acid tests and to promote ERAS protocol, even for the uninitiated. The objective of the present study was to seek answer to all these presumptions. If a technique consistently and conclusively provided data that return of bowel function was significantly earlier after it, then it would be an armamentarium for ERAS protocol. It should also be safe, i.e., rate of complications should be comparable or superior. It also sought answer to the question, whether subcuticular closure of this wound (potentially contaminated) would be safe or not. This would further strengthen the ERAS protocol.

Our study was performed in the department of pediatric surgery in a tertiary care facility in Kolkata. Out of total 91 patients, appositional extramucosal or serosubmucosal interrupted colonic anastomosis (that do not transgress the lumen) was done in 43 (47.3%) patients. Through-and-through interrupted colonic anastomosis (that transgresses the lumen) was done in 48 (52.7%) patients.

Bowel preparation, antibiotic uses, and suture materials used were uniform in all patients so that external components of causality were minimized particularly for complications like leaks, which may affect hospital stay. Colostomy closure wounds are potentially infected/clean contaminated wounds. The age-old surgical tradition is to put both intra-abdominal and parietal drains to detect leak and to drain contaminated collection in the subcutaneous fat layer (both practices are subject to controversies).^[15] No doubt these practices hinder an ERAS protocol as intra-abdominal drains are removed variably from the 7^th to 10^th postoperative day depending on the individual practice. Parietal drains are usually removed on the 3^rd postoperative day. We had followed this traditional practice in Group II of 48 patients. However, in Group I of 43 patients, we altogether replaced this practice with: (1) no drains anywhere, (2) subcutaneous fat apposition by absorbable suture, and (3) subcuticular closure of the wound.

It is clear from our results that serosubmucosal technique of bowel anastomosis is superior to through-and-through anastomosis in terms of early bowel movement by 2 days which is significant. In terms of complications like minor leak, the serosubmucosal technique is again superior (1/43, 2.32% leak rate) compared to through-and-through technique (leak rate 12.5%, 6/48) including three major leaks requiring surgical exploration and three minor leak. The presence of intra-abdominal drain did not help to detect the minor leaks earlier in Group II as probably we depended more on the presence of drainage rather than clinical vigilance of subtle leak. The one patient with leak in Group I presented as wound swelling on POD5 and diagnosed with collection draining which revealed the actual situation. However, in Group II three major leaks which were detected early by drain output, other three minor leaks manifested after intra-abdominal drain removal. Hence, function of drain does not answer the question of our study proposal.

When we compare wound closure techniques, we found that there is no immediate minor SSI in Group I. However, in Group II, all minor SSI (5/48 patients 10.4%) manifested within the hospitalized period of minimum of 7 days. Hence, placement of parietal drains rather hindered smooth healing by preventing proper apposition of fat layer which is relatively avascular. This rather increased the hospital stay, whereas in Group I without parietal drain, there was no immediate SSI. This helped early discharge of these patients. The delayed SSI in Group I, (3/43 patients, 6.97%) occurred when braided absorbable material was used for wound closure in early part of the study. Later we changed to nonbraided absorbable material with no further incidence. It is clear from this study that colostomy closure wounds can be closed cosmetically with no increased incidence of SSI and is probably better than traditional closure.

Overall complications were found in 15 (16.48%) patients had complications; 4 (4.4%) had minor leaks, and 8 (8.8%) had minor SSIs classified as Clavien–Dindo Grade I and three major leaks requiring surgical intervention which can be defined under Clavien–Dindo Grade III. Clavien–Dindo classification system is used to rank a surgical complication in an objective and reproducible manner and the basis is the therapy used to correct the complication.^[16] Serosubmucosal technique had a leak rate of 2.32% and full thickness through-and-through technique had leak rate of 12.5%. SSI with serosubmucosal technique was 6.97%, and with full thickness, it was 10.4%. This is corroborating with study of Mittal et al.^[9] wound infection rate ranged from 8% to 16% and leak rate of 2%–6% was reported from different studies.^{[9],[10],[17],[18],[19],[20]}

Different studies had previously stated the superiority of serosubmucosal closure technique^[21],[22] and our study further reinforce those statements. It has the least complication rate. This technique consistently produces early bowel movement, with early initiation of feed and hence earlier discharge. Postoperative hospital stay is 5.9 days in serosubmucosal group compared to 8.9 days in full-thickness group. This is comparable to another study by Paul et al. where post of stay average was 7.5 days.^[23]

Judicious cosmetic closure of colostomy closure wounds is also superior in terms of safety. At least it is no less safe than the traditional practice. Hence, it is time to change the traditional practice so that ERAS protocol is not hindered.

Our study bears a moderate sample size which needs rectification in future studies for an increased number of study population and prospective study.

Conclusion

This controlled study concludes that the technique of colostomy closure in the form serosubmucosal closure helps in the implementation of ERAS protocol by producing early bowel movement, early initiation of food, and less complications. Along with bowel closure techniques, the other armamentariums are omission of all forms of drains along with closure of fat and skin by absorbable nonbraided suture material to expedite ERAS further.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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