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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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Dantes G, Murfee J, Doll A, Weaver K, Alemayehu H. Weight at Ostomy Takedown as a Factor to Consider for Operative Timing-Is It Relevant? J Laparoendosc Adv Surg Tech A 2024; 34:855-860. [PMID: 39162564 DOI: 10.1089/lap.2024.0188] [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: 08/21/2024] Open
Abstract
Purpose: Weight thresholds have historically determined timing of enterostomy closure (EC) in premature neonates. Recent evidence suggests that neonates less than 2 kg (L2K) can safely undergo EC. We evaluate our single-center experience with performing EC in preterm neonates at L2K versus greater than 2 kg (G2K) at time of EC. Methods: A retrospective review of neonates who underwent EC from January 2018 to 2020 was performed. Neonates who were greater than 90 days at initial operation were excluded. Demographics, clinical characteristics including gestational age (GA) and birth weight (BW), operative reports, and outcomes were reviewed. We compared 30-day complications between neonates who underwent EC at L2K and G2K. We also compared time to full feeds (FF) and postoperative length of stay (LOS). Results: Twenty-four neonates were included: 11 L2K and 13 G2K. The median GA and BW was 25.9 weeks (IQR 2.89) and 805 g (IQR 327), respectively. The most common intraoperative diagnosis during index operation was spontaneous perforation (70%), followed by necrotizing enterocolitis (8.69%). There were no significant differences in GA, BW, or diagnosis, between the L2K versus G2K cohort. We found no difference in complication rates, time to FF (12 days versus 10 days, P = .89), or postoperative LOS (31 days versus 36.5 days, P = .76) between patients who underwent EC at L2K versus G2K, respectively. Conclusion: Although weight gain may be an important indicator of perioperative nutrition status, this study shows that weight alone should not preclude otherwise appropriate patients from undergoing EC.
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Affiliation(s)
- Goeto Dantes
- Department of Surgery, Division of Pediatric Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jack Murfee
- Department of Surgery, Division of Pediatric Surgery, University of South Alabama, Mobile, Alabama, USA
| | - Alissa Doll
- Department of Surgery, Division of Pediatric Surgery, University of South Alabama, Mobile, Alabama, USA
| | - Katrina Weaver
- Department of Surgery, Division of Pediatric Surgery, University of South Alabama, Mobile, Alabama, USA
| | - Hanna Alemayehu
- Department of Surgery, Division of Pediatric Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Mo I, Lapillonne A, van den Akker CHP, Khashu M, Johnson MJ, McElroy SJ, Zachariassen G. Nutritional management after necrotizing enterocolitis and focal intestinal perforation in preterm infants. Pediatr Res 2024:10.1038/s41390-024-03386-y. [PMID: 38992154 DOI: 10.1038/s41390-024-03386-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 06/04/2024] [Accepted: 06/16/2024] [Indexed: 07/13/2024]
Abstract
Nutritional management of preterm infants recovering from necrotizing enterocolitis (NEC) or focal intestinal perforation (FIP) is challenging, especially in infants managed surgically. The logistics of how, when, and what to feed are unclear and current nutritional practices are primarily based on physiological principles and consensus opinion in individual units, rather than high-quality evidence. The aim of this narrative review is to summarize the literature on nutritional management after NEC or FIP in preterm infants: when to restart enteral nutrition, type of enteral nutrition to use, and how to advance nutrition. We also discuss treatment of micronutrient deficiencies, cholestasis, replacement of stoma losses, and optimal time of stoma closure. In conclusion, there are in sufficient high-quality studies available to provide evidence-based recommendations on the best nutritional practice after NEC or FIP in preterm infants. A local or national consensus based early nutrition guideline agreed upon by a multidisciplinary team including pediatric surgeons, pediatricians/neonatologists, nurses, and nutritionists is recommended. Further studies are urgently needed. IMPACT: There is no good quality evidence or nutritional standard across neonatal units treating infants after medical or surgical NEC or FIP. With this review we hope to start providing some consistency across patients and between providers treating patients with NEC and FIP. Mother's own milk is recommended when restarting enteral nutrition after NEC or FIP. In the absence of high-quality evidence, a consensus based early nutrition guideline agreed upon by a multidisciplinary team is recommended. Nutritional research projects are urgently needed in NEC and FIP patients.
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Affiliation(s)
- Ingrid Mo
- Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark
| | - Alexandre Lapillonne
- Department of Neonatology, Necker-Enfants Malades Hospital, EHU 7328 PACT, University of Paris Cite, Paris, France
- CNRC Baylor College of Medicine, Houston, Texas, USA
| | - C H P van den Akker
- Department of Pediatrics-Neonatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Minesh Khashu
- Department of Neonatology, University Hospitals Dorset NHS Foundation Trust, Dorset, United Kingdom
| | - Mark J Johnson
- Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Steven J McElroy
- Department of Pediatrics, Division of Neonatology, University of California Davis, Sacramento, CA, USA
| | - Gitte Zachariassen
- Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark.
- Hans Christian Andersen Children's Hospital, Department of Neonatology, Odense University Hospital, 5000, Odense, Denmark.
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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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Okten EI, Frankl M, Wu S, Gamaty H, Thompson H, Yardley IE. Factors affecting neurodevelopmental outcome following surgical necrotising enterocolitis: a systematic review. Pediatr Surg Int 2024; 40:71. [PMID: 38446238 PMCID: PMC10917837 DOI: 10.1007/s00383-024-05651-x] [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: 02/04/2024] [Indexed: 03/07/2024]
Abstract
Surgically treated necrotising enterocolitis (sNEC) is associated with significantly worse neurodevelopmental outcomes than that seen in premature infants without NEC. We aim to review the association between factors involved in the surgical treatment of NEC and subsequent neurodevelopmental outcomes to identify potential areas for improvement. The PubMed and Embase databases were interrogated for articles reporting neurodevelopmental outcomes in babies treated surgically for NEC using key terms including: "Infant", "Necrotising enterocolitis", "Surgical", "Neurodevelopmental" and "Outcomes". The search strategy yielded 1170 articles and after applying inclusion and exclusion criteria 22 studies remained and formed the review. A diverse range of neurodevelopmental outcomes were reported. Extreme prematurity and lower birth weight were associated with worse neurodevelopmental outcomes. The use of peritoneal drains and enterostomies were associated with worse outcomes. Modifications to surgical strategies in NEC may improve neurodevelopmental outcomes but the effect of confounding factors remains unclear. Further large scale studies are required to define the optimum strategies for treating NEC surgically and to develop a core outcome set for research into NEC.
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Affiliation(s)
- E I Okten
- GKT School of Medical Education, King's College London, London, UK
| | - M Frankl
- GKT School of Medical Education, King's College London, London, UK.
| | - S Wu
- GKT School of Medical Education, King's College London, London, UK
| | - H Gamaty
- GKT School of Medical Education, King's College London, London, UK
| | - H Thompson
- Department of Paediatric Surgery, Evelina London Children's Hospital, London, UK
| | - I E Yardley
- GKT School of Medical Education, King's College London, London, UK
- Department of Paediatric Surgery, Evelina London Children's Hospital, London, UK
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Davidson JR, Omran K, Chong CKL, Eaton S, Edwards AD, Yardley IE. Exploring Growth Failure in Neonates With Enterostomy. J Pediatr Surg 2024; 59:211-215. [PMID: 37940463 DOI: 10.1016/j.jpedsurg.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/07/2023] [Indexed: 11/10/2023]
Abstract
AIM OF THE STUDY Neonatal enterostomy is a known risk for growth failure. We hypothesized that episodes of inflammation may drive a catabolic state, exploring this by assessing serum biochemistry alongside growth trajectory in enterostomy patients. METHODS A retrospective analysis of infants with histologically confirmed NEC from 01/2012-07/2021 in a tertiary neonatal surgical centre was performed. Change in weight-for-age Z-score (ΔZ) between stoma formation and closure was calculated. Serum CRP (C-reactive protein), urea, and creatinine levels were recorded and duration of elevated levels calculated as Area Under Curve (AUC). We examined for trends of serum levels rising together using intersecting moving averages. Spearman's correlation analysis was performed, while multivariable linear regression examined factors associated with ΔZ. RESULTS 79 neonates were included. At stoma formation, median Z-score was -1.42 [range -4.73, +1.3]. Sixty-two patients (78 %) had a fall in Z-score during their time with a stoma, 16 (20 %) had a ΔZ less than -2. Urea AUC was significantly univariably correlated with ΔZ and remained statistically significant in a multivariable model (Exp(B) x 100 = -0.57[-1, -0.09]; p = 0.022). The number of biomarker peaks correlated significantly with ΔZ for urea (r = -0.25; p = 0.025) and CRP (r = -0.35; p = 0.0017) but not Creatinine (r = -0.21; p = 0.066). Analysing the number of peaks of any combination of variables coinciding was consistently significantly correlated negatively with ΔZ (r = -0.29 to -0.27; p ≤ 0.016 for all). CONCLUSION Our data shows that infants who were more severely affected by growth failure had more frequent and severe uremia while they had a stoma (suggesting a catabolic state). Disturbances in urea were commonly associated with CRP, suggesting that inflammation is a significant factor in growth failure in these infants. These findings promote aggressive management of sepsis in these infants, as well as suggesting an earlier closure of stoma to minimise their "at-risk"' period.
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Affiliation(s)
- Joseph R Davidson
- Department of Paediatric Surgery, Evelina London Children's Hospital, London, UK; Stem Cells and Regenerative Medicine Section, GOS-UCL Institute of Child Health, London, UK; Prenatal Cell and Gene Therapy, Elizabeth Garrett Anderson UCL Institute for Women's Health, London, UK
| | - Kareem Omran
- Department of Neonatology, Evelina London Children's Hospital, London, UK
| | - Clara K L Chong
- Department of Paediatric Surgery, Evelina London Children's Hospital, London, UK
| | - Simon Eaton
- Stem Cells and Regenerative Medicine Section, GOS-UCL Institute of Child Health, London, UK
| | - A David Edwards
- Department of Neonatology, Evelina London Children's Hospital, London, UK; Centre for the Developing Brain, King's College London, London, UK
| | - Iain E Yardley
- Department of Paediatric Surgery, Evelina London Children's Hospital, London, UK; Department of Neonatology, Evelina London Children's Hospital, London, UK.
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Solís-García G, Jasani B. Mucous fistula refeeding in neonates: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2023; 108:523-529. [PMID: 36858828 DOI: 10.1136/archdischild-2022-324995] [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: 10/11/2022] [Accepted: 02/16/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND AND OBJECTIVE Mucous fistula refeeding (MFR) aims to maximise bowel function when an ostomy is active after abdominal surgery, by introducing the proximal ostomy effluent into the distal mucous fistula to maintain intestinal physiology. The aim of the study was to assess the effectiveness and complications of MFR in neonates following abdominal surgery. DESIGN, SETTING AND INTERVENTIONS Systematic review and meta-analysis of randomised controlled trials and observational studies. PubMed, Embase, Cochrane and CINAHL were searched until June 2022 for studies including neonates with ostomy receiving MFR compared with neonates with ostomy without MFR. OUTCOMES The primary outcome was duration of parenteral nutrition. Secondary outcomes were time to full enteral feeds, rates of cholestasis, peak total serum bilirubin, sepsis, time to reanastomosis and length of hospital stay. RESULTS A total of 16 observational studies were included (n=623). Compared with comparator group, neonates who received MFR had fewer days of parenteral nutrition (mean difference 37.17 days, 95% CI -63.91 to -10.4, n=244, 5 studies, GRADE: low). In addition, neonates who received MFR had lower rates of cholestasis, shorter time to reach full feeds and shorter hospital stay. CONCLUSION Low certainty of evidence suggests that MFR is associated with shorter duration of parenteral nutrition in neonates following abdominal surgery and stoma creation. Results of ongoing and future randomised trials may help to corroborate these findings.
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Affiliation(s)
- Gonzalo Solís-García
- Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
- Neonatology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Bonny Jasani
- Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Montalva L, Incerti F, Qoshe L, Haffreingue A, Marsac L, Frérot A, Peycelon M, Biran V, Bonnard A. Early laparoscopic-assisted surgery is associated with decreased post-operative inflammation and intestinal strictures in infants with necrotizing enterocolitis. J Pediatr Surg 2023; 58:708-714. [PMID: 36585304 DOI: 10.1016/j.jpedsurg.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 10/12/2022] [Accepted: 11/13/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In 2015, a protocol including early laparoscopy-assisted surgery in the treatment of necrotizing enterocolitis (NEC) was implemented at our institution. Carbon dioxide insufflation during laparoscopy may have an anti-inflammatory effect. We aimed to compare post-operative outcome after early laparoscopy-assisted surgery and classical laparotomy for NEC. MATERIAL AND METHODS Charts of premature infants undergoing surgery for NEC (2012-2021) were reviewed. Cases operated by early laparoscopy-assisted surgery (2015-2021) were compared to infants operated for NEC between 2012 and 2015 (laparotomy-NEC). Outcomes were post-operative CRP, need for reintervention, mortality, and the occurrence of post-NEC intestinal strictures. CRP was measured on the day of surgery (POD-0), 2 days (POD-2), and 7 days after surgery (POD-7). Data were compared using contingency tables for categorical variables and Student t-test or Mann-Whitney test for continuous variables. RESULTS Infants with NEC operated by early laparoscopy (n = 48) and laparotomy (n = 29) were similar in terms of perforation (60% vs 58%, p = 0.99) and POD-0 CRP (139 vs 124 mg/L, p = 0.94). Delay between first signs of NEC and surgery was shorter in the laparoscopy group (3 vs 6 days, p = 0.004). Early laparoscopy was associated with a lower CRP on POD-2 (108 vs 170, p = 0.005) and POD-7 (37 vs 68, p = 0.002), as well as a lower rate of post-operative intestinal stricture (34% vs 61%, p = 0.04). CONCLUSIONS In addition to being safe and feasible in premature infants, early laparoscopic-assisted surgery was associated with decreased NEC-related post-operative inflammation and strictures. A prospective, randomized study is needed in order to evaluate short and long-term effects of laparoscopy in infants with NEC. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Louise Montalva
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France.
| | - Filippo Incerti
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
| | - Livia Qoshe
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; Princeton Internships in Civic Service, Princeton University, Princeton, NJ, USA
| | - Aurore Haffreingue
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Lucile Marsac
- Department of Pediatric Anesthesia, Intensive Care and Pain Management, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alice Frérot
- Neonatal Intensive Care Unit, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Matthieu Peycelon
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
| | - Valérie Biran
- Neonatal Intensive Care Unit, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Arnaud Bonnard
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
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11
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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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12
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Honoré KD, Johansen MN, Rasmussen L, Zachariassen G. Stoma Closure Improves Head Circumference Growth in Very Preterm Infants after Necrotizing Enterocolitis. Eur J Pediatr Surg 2021; 31:504-508. [PMID: 33080629 DOI: 10.1055/s-0040-1718407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Very preterm infants (VPIs) surgically treated for necrotizing enterocolitis (NEC) are at risk of growth retardation. The aim of this study was to demonstrate and compare growth during the first 6 years of life in VPIs with stoma after NEC surgery with VPIs without NEC surgery. MATERIALS AND METHODS We included all VPIs surgically treated due to NEC at the Odense University Hospital from August 1, 2004, to July 31, 2008. Outcome on growth was compared with a group of VPIs without NEC. The VPIs with NEC were identified searching the local database using the International Classification of Diseases, 10th Revision diagnosis of NEC (DP77.9). Data on growth were collected from medical files and if not present, the parents reported the data. RESULTS Nineteen VPIs, surgically treated due to NEC, survived to 6 years of age. Median gestational age was 283/7 weeks (245/7-313/7). Median age at NEC surgery and stoma formation was 2.3 weeks (0.1-6.3) and median age at stoma closure was 2.5 months corrected age (CA) (postmenstrual age 36 weeks to CA 6.7 months). Compared with the non-NEC group, VPIs with NEC and stoma demonstrated poor growth, especially in head circumference (HC) with no increase in growth velocity before the time of stoma closure between 2.5- and 3-month CAs. CONCLUSION Our findings demonstrate poor growth in VPIs after NEC surgery and improved HC growth after stoma closure.
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Affiliation(s)
| | | | - Lars Rasmussen
- Department of Surgery, Odense University Hospital, Odense, Denmark
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13
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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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14
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Woods SD, McElhanon BO, Durham MM, Figueroa J, Piazza AJ. Mucous Fistula Refeeding Promotes Earlier Enteral Autonomy in Infants With Small Bowel Resection. J Pediatr Gastroenterol Nutr 2021; 73:654-658. [PMID: 34347677 DOI: 10.1097/mpg.0000000000003272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Infants requiring intestinal resection because of necrotizing enterocolitis (NEC) or small bowel atresia (SBA) may benefit from mucous fistula refeeding (MFR) of enterostomy output to improve nutrition and bowel adaptation before reanastomosis. Previous series demonstrated improved outcomes with MFR but did not account for varied patient characteristics as potential sources of bias. We performed a cohort analysis using multivariable adjusted models to compare outcomes of patients with and without MFR. METHODS Retrospective chart review was performed for patients with NEC or SBA and small bowel resection with enterostomy and MF. Demographic and outcome data was compared between MFR and non-MFR groups using adjusted multivariable analysis for potential confounding variables. RESULTS MFR was performed in 65 of 101 patients (64%), including 45 of 75 patients with NEC and 20 of 26 patients with SBA. Reasons for not receiving MFR included bowel stricture, technical limitation, or not otherwise specified. NEC patients receiving MFR had 14 fewer days to achieve full enteral feeds after intestinal reconnection, 22 fewer days of parenteral nutrition, lower peak direct bilirubin by 2.4 mg/dL, and 77% less odds of ursodiol use (all P < 0.01). SBA patients had similar trends not reaching statistical significance. Growth parameters were improved in MFR groups. There were no complications or increased infections from MFR. CONCLUSIONS This study suggests that MFR safely improves nutritional outcomes in infants with intestinal resection, related to decreased total parenteral nutrition (TPN) dependence and earlier enteral autonomy.
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Affiliation(s)
- Sean D Woods
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University - Children's Healthcare of Atlanta at Egleston
| | | | | | - Janet Figueroa
- Department of Pediatrics, Pediatrics Biostatistics Core, Emory University School of Medicine, Atlanta, GA
| | - Anthony J Piazza
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University - Children's Healthcare of Atlanta at Egleston
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15
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Letter to the editor: NICU costs are not the whole story. J Pediatr Surg 2020; 55:2246. [PMID: 32703625 DOI: 10.1016/j.jpedsurg.2020.05.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 11/24/2022]
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