Original Article
231
Timing of Ostomy Reversal in Neonates with Necrotizing Enterocolitis Kartheek Nagappala2
Logan Danielson1
1 Department of Pediatric Surgery, Children’s Hospital of Michigan,
Detroit, Michigan, United States 2 Department of Surgery, Detroit Medical Center, Detroit, Michigan, United States 3 School of Medicine, Wayne State University, Detroit, Michigan, United States
Michael Klein1,2,3
Address for correspondence Michelle Veenstra, MD, Department of Pediatric Surgery, Children’s Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI 48202, United States (e-mail: [email protected]).
Eur J Pediatr Surg 2015;25:231–235.
Abstract
Keywords
► necrotizing enterocolitis ► ostomy reversal ► neonatal disease
Introduction Most neonates with necrotizing enterocolitis (NEC) requiring laparotomy have bowel resection and intestinal diversion. At present, there is no consensus regarding the best time for enterostomy reversal. Our aim is to determine if there is any difference in outcomes of infants whose enterostomy was reversed early versus late. Materials and Methods We retrospectively reviewed medical records of patients with NEC admitted to the neonatal intensive care unit at a large urban children’s hospital from 2002 to 2010. The patients underwent operative intervention with creation and subsequent reversal of stomas. Patient characteristics, operative characteristics, and postoperative care were recorded. Results A total of 206 neonates were diagnosed with NEC and 44 met the inclusion criteria. Seven had ostomies reversed within 8 weeks, 20 underwent reversal 8 to 12 weeks after initial operation, and 17 underwent ostomy reversal greater than 12 weeks from creation. Early reversal did not affect the incidence of total parenteral nutrition–associated cholestasis (p ¼ 0.16), length of parenteral nutrition (p ¼ 0.12), or ability to reach full enteral nutrition (p ¼ 0.30). Ventilator days were not different (p ¼ 0.08). We found no difference in contamination at laparotomy (p ¼ 0.61) or adhesions at reversal (p ¼ 0.73). Mortality rate (p ¼ 0.15) and complications following reversal (p ¼ 0.25) were not different. Conclusion There is no advantage to early or late enterostomy reversal in the endpoints studied.
Introduction Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in newborn infants.1 Operation is indicated in 20 to 40% of patients when there is evidence of gangrenous intestine such as pneumoperitoneum or erythema and edema of the abdominal wall.2,3 Most neonates
received October 11, 2013 accepted after revision February 3, 2014 published online May 2, 2014
undergoing laparotomy have a resection of gangrenous bowel and intestinal diversion, subsequently requiring enterostomy reversal. At present, there exists no consensus regarding the best time for enterostomy reversal. Our aim in conducting this study was to determine if there was any difference in the outcomes of infants whose enterostomy was reversed earlier than 8 weeks or longer than 12 weeks from the initial surgery.
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1372460. ISSN 0939-7248.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Michelle Veenstra1
Timing of Ostomy Reversal in Neonates with NEC
Veenstra et al.
Patients/Material and Methods Patient Selection We retrospectively reviewed the medical records of all patients admitted to the neonatal intensive care unit (NICU) at a large urban children’s hospital. The pediatric surgical team managed all patients’ perioperative care. We used generally accepted indications for operative intervention for NEC, presumed to indicate necrotic intestine: pneumoperitoneum, erythema, and edema of the abdominal wall, tenderness, and guarding, a fixed loop of intestine on serial plain abdominal radiographs, and clinical deterioration including persistent acidosis and thrombocytopenia. Patients who received only nonoperative treatment for NEC were excluded. Most patients undergoing operative intervention were treated with resection of the nonviable segment(s) of bowel with exteriorization of the viable end(s). Patients with diversion only without bowel resection and patients who had percutaneous placement of intraperitoneal drains or whose abdomen was closed after finding panintestinal necrosis were excluded. Patients that underwent placement of intraperitoneal drains and subsequent laparotomy with intestinal diversion, however, were included within the study cohort. Operations for ostomy closure were limited laparotomies if possible.
Database Formation Total parenteral nutrition–associated cholestasis (TPNAC) was said to be present if direct hyperbilirubinemia levels exceeded 2.0 mg/dL at any point during the hospitalization.4 Vasopressor use was also defined as use at any point during the patient’s hospitalization. The degree of contamination at initial laparotomy and extent of adhesions at reversal were noted from dictated operative reports as mild, moderate, or severe. High output stoma was defined as > 30 mL/kg/d.
Statistical Analysis Data were analyzed using analysis of variance with Bonferroni significance and chi-square test with SPSS statistics standard (IBM Corporation, Somers, NY) and a statistician. A p-value of < 0.05 was considered statistically significant.
Overall 44 patients that had undergone stoma reversal within the study period met inclusion criteria. Seven patients had their ostomies reversed within 8 weeks of the first operation (group 1), 20 patients underwent ostomy reversal between 8 and 12 weeks from ostomy creation (group 2), and 17 patients had ostomy reversal greater than 12 weeks after creation (group 3). The average time, between ostomy creation and reversal for group 1 was 7 weeks, 9.9 weeks for group 2, and 16.3 weeks for group 3 (p < 0.01). As shown in ►Table 1, the gestational age and weight at birth between the two groups was similar, but the age and weight at reversal were significantly different (p < 0.01 and p ¼ 0.02, respectively). Patients in group 1 were reversed 5 weeks younger than those in group 2 and 10 weeks younger than group 3. The average weight at reversal was 2,266 g for patients in group 1 up to 4,076 g for group 3 patients (►Table 1). Only one patient underwent revision at a weight less than 2 kg.
Stoma Characteristics At the time of initial operation, the most common indication to operate was bowel perforation. Among enteral diversions performed, ileostomy was performed most commonly (64%), followed by jejunostomy (32%) and colostomy (4.5%). Complications related to enterostomy were high-output enterostomy (54%), stomal stenosis (22%), peristomal skin excoriation (20%), and ostomy prolapse (4%). High-output enterostomy and stomal stenosis were initially managed with decreasing or stopping enteral feeds and use of parenteral nutrition until the time of reversal per surgeon preference. Peristomal skin excoriation was managed with wound care initially. Those patients that did not respond to these measures required reversal of stomas at an earlier date. Indications for stoma reversal, in addition to elective (89%), were highoutput enterostomy (7%), stomal prolapse (2%), or peristomal skin excoriation (2%). In group 1, six stomas were closed electively and one was closed due to prolapse. In group 2, 17 stomas were closed electively and 3 closed due to high output, and group 3 had 1 stoma closed due to peristomal skin excoriation and 16 closed electively.
Patient Outcomes
Results Patient Demographics A total of 206 neonates with a diagnosis of NEC were treated at our institution from January 2002 to December 2010.
►Table 2 displays all data points collected and analyzed between groups. TPN was administered to all patients at some point during their hospitalization. TPNAC was said to be present if direct hyperbilirubinemia levels exceeded 2.0 mg/dL.4 Early reversal of enterostomy did not significantly
Table 1 Comparison of age and weight at birth and ostomy reversal between groups Gestational age (wk) (mean SD)
Birth weight (g) (mean SD)
Age at reversal (wk) (mean SD)
Weight at reversal (g) (mean SD)
Reversal < 8 wk
29.0 3.4
1,315 457
9.8 3.2
2,266 556
Reversal 8–12 wk
29.1 3.8
1,273 1,066
14.7 4.7
3,559 1,575
Reversal > 12 wk
29.7 5.0
1,425 867
19.2 6.3
4,076 1,337
p-Value
0.89
0.88
< 0.01
0.02
Abbreviation: SD, standard deviation. European Journal of Pediatric Surgery
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Reversal < 8 wk
Reversal 8–12 wk
Reversal > 12 wk
p-Value
TPNAC
4/7 (57%)
17/20 (85%)
10/17 (59%)
0.16
Stoma-related complication
7/7 (100%)
13/20 (65%)
9/17 (53%)
0.08
TPN days
60 22
120 50
75 64
0.12
Ventilator days
29 31
65 42
41 42
0.08
Vasopressor use
3/7 (43%)
9/20 (45%)
6/17 (35%)
0.83
Contamination at laparotomy
7
20
16a
0.61
Mild
4/7 (57%)
6/20 (30%)
4/16 (25%)
Moderate
1/7 (13%)
7/20 (35%)
5/16 (31%)
Severe
2/7 (29%)
7/20 (35%)
7/16 (44%)
7
20
17
Adhesions at reversal
0.73
Mild
2/7 (29%)
5/20 (25%)
2/17 (12%)
Moderate
2/7 (29%)
3/20 (15%)
4/17 (24%)
Severe
3/7 (43%)
12/20 (60%)
11/17 (65%)
Length of stay (days)
93 56
141 48
93 70
0.03
Mortality rate
0/7 (0%)
3/20 (15%)
0/17 (0%)
0.15
Abbreviation: TPN, total parenteral nutrition; TPNAC, TPN-associated cholestasis. Note: Stoma-related complications include high-output stomas. a Degree of contamination missing from one operative report.
improve the incidence of TPNAC in neonates versus late reversal (p ¼ 0.16), nor did it significantly reduce the number of days that TPN was administered (p ¼ 0.12). In further evaluation of days on TPN, there was a significant difference in patients reversed 8 to 12 weeks after initial operation and the other two groups (p ¼ 0.04). In addition, the ability to reach full enteral nutrition by discharge date was not significantly different (p ¼ 0.30) nor the number of patients discharged home on TPN (p ¼ 0.97). Total ventilator days between the two groups were also not statistically different (p ¼ 0.08). Neonates who had congenital anomalies/conditions that required prolonged ventilator support were evenly distributed between the groups. Contamination of the peritoneal cavity at the initial laparotomy for treatment of NEC was noted in the operative report of the operating surgeon in all but one of the cases, and the extent of adhesions at reversal was noted in all cases. These were expressed as mild, moderate, and severe in each case. We found no statistical difference with the extent of contamination at laparotomy (p ¼ 0.61) or the severity of adhesions at reversal (p ¼ 0.73) between groups. All patients did not undergo ostomy reversal during the same hospitalization as ostomy creation. One patient in group 2 and 11 patients in group 3 were discharged home and returned for ostomy reversal at a later date. Patients who were transferred to another hospital and returned for reversal but did not go home were not considered to be discharged. Cumulative length of stay (LOS), that is, days of hospitalization surrounding the ostomy creation as well as ostomy reversal, was recorded and found to be significantly higher in patients reversed 8 to 12 weeks after initial operation compared with the early and late groups (p ¼ 0.03). However,
when comparing group 2 patients with those in group 1 and 3 independently, this loses significance (p ¼ 0.19 and p ¼ 0.05, respectively). The mortality rate was not different between groups, however all deaths occurred in patients reversed 8 to 12 weeks after initial operation (p ¼ 0.15). Complications following ostomy reversal were found to be similar between groups (p ¼ 0.25). Only three patients required reoperation, however these were all reversed at 8 to 12 weeks following ostomy creation. Two patients underwent reexploration following ostomy closure, both in group 2. One patient had a negative exploratory laparotomy for possible hematoma and the other was explored for abdominal compartment syndrome. Two patients had an anastomotic stricture causing a partial small bowel obstruction, managed conservatively in the patient in group 1 and requiring reoperation in a patient in group 2.
Discussion Literature Review The appropriate timing for ostomy reversal in neonates with NEC has been debated. Some advocate stoma reversal at 3 to 6 weeks from the time of creation or at the time the neonate attains a weight of at least 2,000 g, whichever emanates first.5,6 Recently, the recommended parameters are similar, with reversal done at 4 to 8 weeks from ostomy creation or at a weight of 2,000 g. In 2009, Al-Hudhaif et al found longer duration to full enteral nutrition and longer duration of TPN in those neonates reversed before 10 weeks.7 Even after this study, a systematic review was unable to provide recommendations on ostomy closure before or after 8 weeks due to European Journal of Pediatric Surgery
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Table 2 Comparison of variables between groups
Timing of Ostomy Reversal in Neonates with NEC
Veenstra et al.
insufficient studies, but there was no indication that early closure was harmful.8 Studies evaluating cost have also found no difference in direct medical costs related to either approach.9
Discussion of Results We found a statistical difference in age at reversal as well as in weight at reversal of the neonates between groups. The patients in group 1 may have been generally healthier and with less risk than the neonates in group 2 or 3. Simply put, the less comorbidity, the earlier it was safe for stoma reversal. The lack of statistical difference between groups, however, in the overall ventilator days and use of vasopressors would indicate that the severity of associated disease(s) was evenly distributed between them. Still, there may have been comorbidities that we did not measure which influenced the operating surgeon in timing the stoma reversal. Most of the ostomy reversals in our study were performed on an elective basis. Several variables were noted to have come into play during the surgeon’s decision-making process as to the optimal time for the neonate to undergo stoma reversal. Some surgeons felt that repeat laparotomy any time before 10 weeks increased the difficulty of the operation, while others felt that reversal should occur once a neonate had all other comorbidities stabilized. Our rate of ostomy complications including skin excoriation (20%), prolapse (4%), and stenosis (22%) are congruent with previous literature reports.10,11 Between the groups, the severity of adhesions at reversal did not statistically improve by delaying stoma reversal, even when there was severe contamination at initial operation. Adhesiolysis was as difficult (or as easy) whether reversal was performed early or late. Still, our surgeons may have delayed ostomy closure longer in patients with more significant contamination at the initial operation feeling that this would increase the adhesions at the time of stoma closure. This is congruent with reported findings of no difference in adhesions at time of ostomy reversal in the early or late closure groups.9 Reinstating intestinal continuity to improve the absorption of enteral nutrients has been an important impetus for early reversal of enterostomies. The ability to reach full enteral feeds before discharge was not different between the groups. Moreover, enteral nutrition has important implications such as reducing TPNAC in this population. Patients that were reversed between 8 and 12 weeks after stoma creation had the largest number of days on TPN, however, in comparison of groups, this was not significant. We found no statistical significance in the incidence of TPNAC between groups. This indicates earlier reversal of enterostomy does not improve the incidence of TPNAC in neonates with NEC, and that simply reinstating enteral continuity does not equate to fewer days spent on TPN. LOS was affected by the timing of reversal between groups. Patients in group 2 had the longest LOS, while patients in group 1 and 3 had very similar LOS. This may be because the majority of patients in group 3 were discharged home and returned for ostomy reversal at a later date. European Journal of Pediatric Surgery
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This study and previous ones evaluate the natural division between early and late closure, indicating that some surgeons are closing stomas later than the textbook recommendations. Al-Hudhaif et al found benefit to late closure, while other studies find no difference between the two groups.5,7–9 Our data indicates that there is no disadvantage to any timing of closure, however patients reversed between 8 and 12 weeks after reversal had slightly higher LOS and longer days on TPN. This suggests that it is reasonable to close stomas during the same hospitalization, but not unreasonable to discharge the patients and have them return at a later date.
Study Limitations We acknowledge several limitations to this study. The data were collected retrospectively in a relatively small cohort of patients that was not of a uniform range of gestational age/ weight. Selection bias was also likely present due to the nature of this study. Some of our patients underwent percutaneous drain placement before undergoing laparotomy. Reported LOS was cumulative since some patients underwent reversal as outpatients with subsequent discharge upon return of bowel function. We therefore cannot say that earlier ostomy reversal meant earlier discharge, however; in patients maintained in the hospital until reversal, earlier reversal was related to earlier discharge. LOS may have been further confounded by the presence of associated comorbidities in our patients. Determination of contamination at initial laparotomy and extent of adhesions at stoma closure were subjective measures based on operative dictations.
Conclusion Patients undergoing early reversal within 8 weeks of stoma creation or late reversal after being discharged and brought back as an outpatient were found to have slightly improved LOS and decreased days on TPN when compared with patients undergoing reversal 8 to 12 weeks from creation. However, early reversal does not decrease the incidence of TPNAC or the number of patients discharged home on TPN. In addition, it does not entail a more challenging operative procedure at reversal and it does not affect the incidence of stoma-related complications.
Conflict of Interest None.
References 1 Henry MC, Moss RL. Neonatal necrotizing enterocolitis. Semin
Pediatr Surg 2008;17(2):98–109 2 Raval MV, Hall NJ, Pierro A, Moss RL. Evidence-based prevention
and surgical treatment of necrotizing enterocolitis-a review of randomized controlled trials. Semin Pediatr Surg 2013;22(2): 117–121 3 Abdullah F, Zhang Y, Camp M, et al. Necrotizing enterocolitis in 20,822 infants: analysis of medical and surgical treatments. Clin Pediatr (Phila) 2010;49(2):166–171
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8 Struijs MC, Sloots CE, Hop WC, Tibboel D, Wijnen RM. The timing of
treatment of parenteral nutrition-associated cholestasis and intestinal failure-associated liver disease in infants and children: a systematic review. JPEN J Parenter Enteral Nutr 2014;38(1):70–85 PubMed 5 Musemeche CA, Kosloske AM, Ricketts RR. Enterostomy in necrotizing enterocolitis: an analysis of techniques and timing of closure. J Pediatr Surg 1987;22(6):479–483 6 Gertler JP, Seashore JH, Touloukian RJ. Early ileostomy closure in necrotizing enterocolitis. J Pediatr Surg 1987;22(2):140–143 7 Al-Hudhaif J, Phillips S, Gholum S, Puligandla PP, Flageole H. The timing of enterostomy reversal after necrotizing enterocolitis. J Pediatr Surg 2009;44(5):924–927
ostomy closure in infants with necrotizing enterocolitis: a systematic review. Pediatr Surg Int 2012;28(7):667–672 9 Struijs MC, Poley MJ, Meeussen CJ, Madern GC, Tibboel D, Keijzer R. Late vs early ostomy closure for necrotizing enterocolitis: analysis of adhesion formation, resource consumption, and costs. J Pediatr Surg 2012;47(4):658–664 10 O’Connor A, Sawin RS. High morbidity of enterostomy and its closure in premature infants with necrotizing enterocolitis. Arch Surg 1998;133(8):875–880 11 Aguayo P, Fraser JD, Sharp S, St Peter SD, Ostlie DJ. Stomal complications in the newborn with necrotizing enterocolitis. J Surg Res 2009;157(2):275–278
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4 Lauriti G, Zani A, Aufieri R, et al. Incidence, prevention, and
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231
Timing of Ostomy Reversal in Neonates with Necrotizing Enterocolitis Kartheek Nagappala2
Logan Danielson1
1 Department of Pediatric Surgery, Children’s Hospital of Michigan,
Detroit, Michigan, United States 2 Department of Surgery, Detroit Medical Center, Detroit, Michigan, United States 3 School of Medicine, Wayne State University, Detroit, Michigan, United States
Michael Klein1,2,3
Address for correspondence Michelle Veenstra, MD, Department of Pediatric Surgery, Children’s Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI 48202, United States (e-mail: [email protected]).
Eur J Pediatr Surg 2015;25:231–235.
Abstract
Keywords
► necrotizing enterocolitis ► ostomy reversal ► neonatal disease
Introduction Most neonates with necrotizing enterocolitis (NEC) requiring laparotomy have bowel resection and intestinal diversion. At present, there is no consensus regarding the best time for enterostomy reversal. Our aim is to determine if there is any difference in outcomes of infants whose enterostomy was reversed early versus late. Materials and Methods We retrospectively reviewed medical records of patients with NEC admitted to the neonatal intensive care unit at a large urban children’s hospital from 2002 to 2010. The patients underwent operative intervention with creation and subsequent reversal of stomas. Patient characteristics, operative characteristics, and postoperative care were recorded. Results A total of 206 neonates were diagnosed with NEC and 44 met the inclusion criteria. Seven had ostomies reversed within 8 weeks, 20 underwent reversal 8 to 12 weeks after initial operation, and 17 underwent ostomy reversal greater than 12 weeks from creation. Early reversal did not affect the incidence of total parenteral nutrition–associated cholestasis (p ¼ 0.16), length of parenteral nutrition (p ¼ 0.12), or ability to reach full enteral nutrition (p ¼ 0.30). Ventilator days were not different (p ¼ 0.08). We found no difference in contamination at laparotomy (p ¼ 0.61) or adhesions at reversal (p ¼ 0.73). Mortality rate (p ¼ 0.15) and complications following reversal (p ¼ 0.25) were not different. Conclusion There is no advantage to early or late enterostomy reversal in the endpoints studied.
Introduction Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in newborn infants.1 Operation is indicated in 20 to 40% of patients when there is evidence of gangrenous intestine such as pneumoperitoneum or erythema and edema of the abdominal wall.2,3 Most neonates
received October 11, 2013 accepted after revision February 3, 2014 published online May 2, 2014
undergoing laparotomy have a resection of gangrenous bowel and intestinal diversion, subsequently requiring enterostomy reversal. At present, there exists no consensus regarding the best time for enterostomy reversal. Our aim in conducting this study was to determine if there was any difference in the outcomes of infants whose enterostomy was reversed earlier than 8 weeks or longer than 12 weeks from the initial surgery.
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1372460. ISSN 0939-7248.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Michelle Veenstra1
Timing of Ostomy Reversal in Neonates with NEC
Veenstra et al.
Patients/Material and Methods Patient Selection We retrospectively reviewed the medical records of all patients admitted to the neonatal intensive care unit (NICU) at a large urban children’s hospital. The pediatric surgical team managed all patients’ perioperative care. We used generally accepted indications for operative intervention for NEC, presumed to indicate necrotic intestine: pneumoperitoneum, erythema, and edema of the abdominal wall, tenderness, and guarding, a fixed loop of intestine on serial plain abdominal radiographs, and clinical deterioration including persistent acidosis and thrombocytopenia. Patients who received only nonoperative treatment for NEC were excluded. Most patients undergoing operative intervention were treated with resection of the nonviable segment(s) of bowel with exteriorization of the viable end(s). Patients with diversion only without bowel resection and patients who had percutaneous placement of intraperitoneal drains or whose abdomen was closed after finding panintestinal necrosis were excluded. Patients that underwent placement of intraperitoneal drains and subsequent laparotomy with intestinal diversion, however, were included within the study cohort. Operations for ostomy closure were limited laparotomies if possible.
Database Formation Total parenteral nutrition–associated cholestasis (TPNAC) was said to be present if direct hyperbilirubinemia levels exceeded 2.0 mg/dL at any point during the hospitalization.4 Vasopressor use was also defined as use at any point during the patient’s hospitalization. The degree of contamination at initial laparotomy and extent of adhesions at reversal were noted from dictated operative reports as mild, moderate, or severe. High output stoma was defined as > 30 mL/kg/d.
Statistical Analysis Data were analyzed using analysis of variance with Bonferroni significance and chi-square test with SPSS statistics standard (IBM Corporation, Somers, NY) and a statistician. A p-value of < 0.05 was considered statistically significant.
Overall 44 patients that had undergone stoma reversal within the study period met inclusion criteria. Seven patients had their ostomies reversed within 8 weeks of the first operation (group 1), 20 patients underwent ostomy reversal between 8 and 12 weeks from ostomy creation (group 2), and 17 patients had ostomy reversal greater than 12 weeks after creation (group 3). The average time, between ostomy creation and reversal for group 1 was 7 weeks, 9.9 weeks for group 2, and 16.3 weeks for group 3 (p < 0.01). As shown in ►Table 1, the gestational age and weight at birth between the two groups was similar, but the age and weight at reversal were significantly different (p < 0.01 and p ¼ 0.02, respectively). Patients in group 1 were reversed 5 weeks younger than those in group 2 and 10 weeks younger than group 3. The average weight at reversal was 2,266 g for patients in group 1 up to 4,076 g for group 3 patients (►Table 1). Only one patient underwent revision at a weight less than 2 kg.
Stoma Characteristics At the time of initial operation, the most common indication to operate was bowel perforation. Among enteral diversions performed, ileostomy was performed most commonly (64%), followed by jejunostomy (32%) and colostomy (4.5%). Complications related to enterostomy were high-output enterostomy (54%), stomal stenosis (22%), peristomal skin excoriation (20%), and ostomy prolapse (4%). High-output enterostomy and stomal stenosis were initially managed with decreasing or stopping enteral feeds and use of parenteral nutrition until the time of reversal per surgeon preference. Peristomal skin excoriation was managed with wound care initially. Those patients that did not respond to these measures required reversal of stomas at an earlier date. Indications for stoma reversal, in addition to elective (89%), were highoutput enterostomy (7%), stomal prolapse (2%), or peristomal skin excoriation (2%). In group 1, six stomas were closed electively and one was closed due to prolapse. In group 2, 17 stomas were closed electively and 3 closed due to high output, and group 3 had 1 stoma closed due to peristomal skin excoriation and 16 closed electively.
Patient Outcomes
Results Patient Demographics A total of 206 neonates with a diagnosis of NEC were treated at our institution from January 2002 to December 2010.
►Table 2 displays all data points collected and analyzed between groups. TPN was administered to all patients at some point during their hospitalization. TPNAC was said to be present if direct hyperbilirubinemia levels exceeded 2.0 mg/dL.4 Early reversal of enterostomy did not significantly
Table 1 Comparison of age and weight at birth and ostomy reversal between groups Gestational age (wk) (mean SD)
Birth weight (g) (mean SD)
Age at reversal (wk) (mean SD)
Weight at reversal (g) (mean SD)
Reversal < 8 wk
29.0 3.4
1,315 457
9.8 3.2
2,266 556
Reversal 8–12 wk
29.1 3.8
1,273 1,066
14.7 4.7
3,559 1,575
Reversal > 12 wk
29.7 5.0
1,425 867
19.2 6.3
4,076 1,337
p-Value
0.89
0.88
< 0.01
0.02
Abbreviation: SD, standard deviation. European Journal of Pediatric Surgery
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233
Reversal < 8 wk
Reversal 8–12 wk
Reversal > 12 wk
p-Value
TPNAC
4/7 (57%)
17/20 (85%)
10/17 (59%)
0.16
Stoma-related complication
7/7 (100%)
13/20 (65%)
9/17 (53%)
0.08
TPN days
60 22
120 50
75 64
0.12
Ventilator days
29 31
65 42
41 42
0.08
Vasopressor use
3/7 (43%)
9/20 (45%)
6/17 (35%)
0.83
Contamination at laparotomy
7
20
16a
0.61
Mild
4/7 (57%)
6/20 (30%)
4/16 (25%)
Moderate
1/7 (13%)
7/20 (35%)
5/16 (31%)
Severe
2/7 (29%)
7/20 (35%)
7/16 (44%)
7
20
17
Adhesions at reversal
0.73
Mild
2/7 (29%)
5/20 (25%)
2/17 (12%)
Moderate
2/7 (29%)
3/20 (15%)
4/17 (24%)
Severe
3/7 (43%)
12/20 (60%)
11/17 (65%)
Length of stay (days)
93 56
141 48
93 70
0.03
Mortality rate
0/7 (0%)
3/20 (15%)
0/17 (0%)
0.15
Abbreviation: TPN, total parenteral nutrition; TPNAC, TPN-associated cholestasis. Note: Stoma-related complications include high-output stomas. a Degree of contamination missing from one operative report.
improve the incidence of TPNAC in neonates versus late reversal (p ¼ 0.16), nor did it significantly reduce the number of days that TPN was administered (p ¼ 0.12). In further evaluation of days on TPN, there was a significant difference in patients reversed 8 to 12 weeks after initial operation and the other two groups (p ¼ 0.04). In addition, the ability to reach full enteral nutrition by discharge date was not significantly different (p ¼ 0.30) nor the number of patients discharged home on TPN (p ¼ 0.97). Total ventilator days between the two groups were also not statistically different (p ¼ 0.08). Neonates who had congenital anomalies/conditions that required prolonged ventilator support were evenly distributed between the groups. Contamination of the peritoneal cavity at the initial laparotomy for treatment of NEC was noted in the operative report of the operating surgeon in all but one of the cases, and the extent of adhesions at reversal was noted in all cases. These were expressed as mild, moderate, and severe in each case. We found no statistical difference with the extent of contamination at laparotomy (p ¼ 0.61) or the severity of adhesions at reversal (p ¼ 0.73) between groups. All patients did not undergo ostomy reversal during the same hospitalization as ostomy creation. One patient in group 2 and 11 patients in group 3 were discharged home and returned for ostomy reversal at a later date. Patients who were transferred to another hospital and returned for reversal but did not go home were not considered to be discharged. Cumulative length of stay (LOS), that is, days of hospitalization surrounding the ostomy creation as well as ostomy reversal, was recorded and found to be significantly higher in patients reversed 8 to 12 weeks after initial operation compared with the early and late groups (p ¼ 0.03). However,
when comparing group 2 patients with those in group 1 and 3 independently, this loses significance (p ¼ 0.19 and p ¼ 0.05, respectively). The mortality rate was not different between groups, however all deaths occurred in patients reversed 8 to 12 weeks after initial operation (p ¼ 0.15). Complications following ostomy reversal were found to be similar between groups (p ¼ 0.25). Only three patients required reoperation, however these were all reversed at 8 to 12 weeks following ostomy creation. Two patients underwent reexploration following ostomy closure, both in group 2. One patient had a negative exploratory laparotomy for possible hematoma and the other was explored for abdominal compartment syndrome. Two patients had an anastomotic stricture causing a partial small bowel obstruction, managed conservatively in the patient in group 1 and requiring reoperation in a patient in group 2.
Discussion Literature Review The appropriate timing for ostomy reversal in neonates with NEC has been debated. Some advocate stoma reversal at 3 to 6 weeks from the time of creation or at the time the neonate attains a weight of at least 2,000 g, whichever emanates first.5,6 Recently, the recommended parameters are similar, with reversal done at 4 to 8 weeks from ostomy creation or at a weight of 2,000 g. In 2009, Al-Hudhaif et al found longer duration to full enteral nutrition and longer duration of TPN in those neonates reversed before 10 weeks.7 Even after this study, a systematic review was unable to provide recommendations on ostomy closure before or after 8 weeks due to European Journal of Pediatric Surgery
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Table 2 Comparison of variables between groups
Timing of Ostomy Reversal in Neonates with NEC
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insufficient studies, but there was no indication that early closure was harmful.8 Studies evaluating cost have also found no difference in direct medical costs related to either approach.9
Discussion of Results We found a statistical difference in age at reversal as well as in weight at reversal of the neonates between groups. The patients in group 1 may have been generally healthier and with less risk than the neonates in group 2 or 3. Simply put, the less comorbidity, the earlier it was safe for stoma reversal. The lack of statistical difference between groups, however, in the overall ventilator days and use of vasopressors would indicate that the severity of associated disease(s) was evenly distributed between them. Still, there may have been comorbidities that we did not measure which influenced the operating surgeon in timing the stoma reversal. Most of the ostomy reversals in our study were performed on an elective basis. Several variables were noted to have come into play during the surgeon’s decision-making process as to the optimal time for the neonate to undergo stoma reversal. Some surgeons felt that repeat laparotomy any time before 10 weeks increased the difficulty of the operation, while others felt that reversal should occur once a neonate had all other comorbidities stabilized. Our rate of ostomy complications including skin excoriation (20%), prolapse (4%), and stenosis (22%) are congruent with previous literature reports.10,11 Between the groups, the severity of adhesions at reversal did not statistically improve by delaying stoma reversal, even when there was severe contamination at initial operation. Adhesiolysis was as difficult (or as easy) whether reversal was performed early or late. Still, our surgeons may have delayed ostomy closure longer in patients with more significant contamination at the initial operation feeling that this would increase the adhesions at the time of stoma closure. This is congruent with reported findings of no difference in adhesions at time of ostomy reversal in the early or late closure groups.9 Reinstating intestinal continuity to improve the absorption of enteral nutrients has been an important impetus for early reversal of enterostomies. The ability to reach full enteral feeds before discharge was not different between the groups. Moreover, enteral nutrition has important implications such as reducing TPNAC in this population. Patients that were reversed between 8 and 12 weeks after stoma creation had the largest number of days on TPN, however, in comparison of groups, this was not significant. We found no statistical significance in the incidence of TPNAC between groups. This indicates earlier reversal of enterostomy does not improve the incidence of TPNAC in neonates with NEC, and that simply reinstating enteral continuity does not equate to fewer days spent on TPN. LOS was affected by the timing of reversal between groups. Patients in group 2 had the longest LOS, while patients in group 1 and 3 had very similar LOS. This may be because the majority of patients in group 3 were discharged home and returned for ostomy reversal at a later date. European Journal of Pediatric Surgery
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This study and previous ones evaluate the natural division between early and late closure, indicating that some surgeons are closing stomas later than the textbook recommendations. Al-Hudhaif et al found benefit to late closure, while other studies find no difference between the two groups.5,7–9 Our data indicates that there is no disadvantage to any timing of closure, however patients reversed between 8 and 12 weeks after reversal had slightly higher LOS and longer days on TPN. This suggests that it is reasonable to close stomas during the same hospitalization, but not unreasonable to discharge the patients and have them return at a later date.
Study Limitations We acknowledge several limitations to this study. The data were collected retrospectively in a relatively small cohort of patients that was not of a uniform range of gestational age/ weight. Selection bias was also likely present due to the nature of this study. Some of our patients underwent percutaneous drain placement before undergoing laparotomy. Reported LOS was cumulative since some patients underwent reversal as outpatients with subsequent discharge upon return of bowel function. We therefore cannot say that earlier ostomy reversal meant earlier discharge, however; in patients maintained in the hospital until reversal, earlier reversal was related to earlier discharge. LOS may have been further confounded by the presence of associated comorbidities in our patients. Determination of contamination at initial laparotomy and extent of adhesions at stoma closure were subjective measures based on operative dictations.
Conclusion Patients undergoing early reversal within 8 weeks of stoma creation or late reversal after being discharged and brought back as an outpatient were found to have slightly improved LOS and decreased days on TPN when compared with patients undergoing reversal 8 to 12 weeks from creation. However, early reversal does not decrease the incidence of TPNAC or the number of patients discharged home on TPN. In addition, it does not entail a more challenging operative procedure at reversal and it does not affect the incidence of stoma-related complications.
Conflict of Interest None.
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