Early ileostomy closure in necrotizing enterocolitis

doi:10.1016/S0022-3468(87)80432-3

Journal of Pediatric Surgery

Volume 22, Issue 2, February 1987, Pages 140-143

https://doi.org/10.1016/S0022-3468(87)80432-3 Get rights and content

The nutritional and metabolic complications following intestinal resection and ileostomy for necrotizing enterocolitis (NEC) in low birth weight preterm infants often necessitate repeated prolonged hospitalization for salt and water imbalance and reliance on total parentaral nutrition (TPN). The traditional concerns about anesthetic and anastomotic complications delays the restoration of intestinal continuity until the infant has attained a weight of about 5 kg, but recent nutritional balance studies in our unit have shown a combination of nutrient and mineral malabsorption in neonates with ileostomies. Beginning 4 years ago, a prospective study of early closure of the ileostomy was undertaken in infants weighing as low as 2 kg to examine the effect on surgical morbidity, infant growth, and gastro-intestinal function using the preclosure infant as his/her own control. Ten infants with birthweights ranging from 670 to 2,000 g developed NEC requiring ileostomy at age three days to 11 weeks. In addition to partial ileal resection, the cecum was resected in 10 patients, ascending colin in 7, transverse in 4, descending colon in 1 patient. Postoperative treatment, including short-term TPN and elemental diet, preceded closure of ileostomy at a mean age of 18 weeks (range 5 to 36 weeks). Mean weight at time of closure was 3,052±994 g. There were no short-term complications of early closure in this series, nor was there any incidence of anastomotic dysfunction, colon stricture, or recurrent NEC. Bowel function was restored between the third and seventh postoperative day with infants tolerating full-strength formula shortly thereafter. Weight gain for 4 to 6 weeks before closure was 132 g/wk (±57) v 186 g/wk (±56) for a similar period beginning 2 weeks following ileostomy closure (P<.03). None of these patients have been readmitted because of short gut complications. We conclude that (1) elective ileostomy closure at weights as low as 1.9 kg can be accomplished with excellent results and low operative morbidity; (2) normal bowel function and accelerated growth is readily achieved following restoration of intestinal continuity; and (3) the potential metabolic and nutritional complications of ileostomies in neonates can be minimized by early restoration of intestinal continuity.

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Cited by (37)

Primary Anastomosis Versus Stoma for Surgical Necrotizing Enterocolitis in US Children's Hospitals
2024, Journal of Surgical Research
Multiple studies have documented the safety of intestinal anastomosis after resection for necrotizing enterocolitis (NEC). We sought to evaluate a large population of infants with surgical NEC and assess outcomes after primary anastomosis versus enterostomy.
The Pediatric Health Information System database was used to identify infants with Bell Stage 3 NEC who underwent an intestinal resection for acute disease between 2016 and 2021. Demographics and preoperative physiology were assessed, and nutritional, infectious, and surgical outcomes were analyzed.
Two hundred twenty-two infants at 38 children's hospitals were included. Thirty-five (15.8%) were managed with a primary anastomosis. Among infants who underwent a resection within 10 d of their first operative intervention and survived for at least 3 d, a primary anastomosis was used in 26 (13.7%). These patients were older but had similar weight and physiological status at the time of resection as those managed with an enterostomy. The incidence of wound and infectious complications, duration of parenteral nutrition and length of stay were similar after anastomosis or enterostomy.
In a large, geographically heterogenous population of infants with NEC, only 15.8% were managed with a primary anastomosis after intestinal resection. Survivors who underwent resection within 10 d were demographically and physiologically comparable to those who underwent enterostomy and had similar surgical outcomes. While there are clearly indications for enterostomy in some infants with NEC, these data confirm the conclusions of smaller, single-center studies that a primary anastomosis should be considered more frequently.
Surgical Necrotizing Enterocolitis – Can We Predict the Need for Gastrostomy Tube Placement?
2024, Journal of Surgical Research
Necrotizing enterocolitis (NEC) is a significant cause of morbidity and mortality among extremely premature infants. Approximately 50% of cases progress to surgery, frequently resulting in resection of necrotic bowel and ostomy creation. Premature neonates are at risk for bronchopulmonary dysplasia and feeding failure; surgery in these patients is higher risk. We evaluated the incidence of gastrostomy tube (GT) placement after ostomy reversal in surgical NEC to define a subset of patients who would benefit from concurrent ostomy reversal and GT placement.
A single-center retrospective study of infants with surgical NEC requiring ostomy creation between 2007 and 2021 was performed.
Eighty patients met inclusion criteria. A GT was placed in 45/80 (56.3%), of which 3/45 (6.7%) were placed before, 20/45 (44.4%) concurrently with, and 22/45 (48.9%) after ostomy reversal. Between those who did and did not require GT placement, there were no significant differences in gestational age (27 versus 27 wk, P = 0.94) or birth weight (830 g versus 1055 g, P = 0.36). Hospital length of stay was longer in the GT group (128.2 versus 70.9 d, P < 0.0001). Time from ostomy reversal to hospital discharge was shorter when performed concurrently with GT (56 versus 77 d, P = 0.02). There were no differences in short-term or long-term GT related complications based on timing of GT placement.
GT placement occurred in approximately 50% of patients with surgical NEC and GT may be accomplished safely at the time of ostomy reversal thus reducing the need for an additional procedure.
Enterostomy closure timing for minimizing postoperative complications in premature infants
2014, Pediatrics and Neonatology
Citation Excerpt :
Because there are wide ranges of weights and PMAs at the time of enterostomy creation, and the infants are growing after bowel exteriorization, the maturation status at the time of the closure surgery, as with PMA or weight, would be more important than stoma duration. Early enterostomy closure is indicated for premature infants with proximal stomas that are complicated by high output (i.e., proximal jejunostomies).9,18,25 Aside from this clear indication for early repair, in the case of elective EC, we need to be careful not to perform the repair operation too early in preterm infants with systemic immaturities.
For premature infants with advanced acute abdomen, creating a temporary enterostomy is believed to be an appropriate surgical management. However, there is no consensus regarding the timing of enterostomy reversal. The aim of this study was to determine the optimal timing for enterostomy closure (EC) by analyzing EC-related complications.
This was a retrospective study of preterm infants who underwent enterostomy for suspected acute abdomens and subsequent closure.
EC-related complications occurred in 35 of 54 infants (65%). A univariate analysis determined the following risk factors for EC-related complications: lower weight and younger age at the time of EC and a shorter stoma duration. In a multiple logistic regression analysis, the only significant risk factor was a weight under 2660 g at the time of the closure operation. Infants with EC-related complications were ventilated longer, were administered more vasopressors, and were more likely to undergo reoperation. Additionally, these infants required parenteral nutrition for a longer duration, had a longer length of hospital stay after EC, and had a significantly lower weight and height at a corrected age of 7–10 months than infants without EC-related complications.
Body weight may be one of the most important factors to consider for minimizing EC-related complications.
Current concepts in the surgical approach to necrotizing enterocolitis
2014, Pathophysiology
Citation Excerpt :
Stoma specific complications include retraction, stricture, prolapse, obstruction, and skin/wound issues [35]. A second anesthetic is also required for stoma takedown typically when the patient's weight is over 2 kg and at least 4 weeks after stomas maturation to avoid encountering vascular intra-abdominal adhesions [36]. Laparotomy with resection and primary anastomosis is another option that eliminates the mandatory need for a second operative intervention to reestablish intestinal continuity [37].
Necrotizing enterocolitis (NEC) is the most common surgical emergency occurring in neonatal intensive care unit (NICU) patients. Among patients with NEC, those that require surgery experience the poorest outcomes and highest mortality. Surgical intervention, while attempting to address the intestinal injury and ongoing mulitfactorial physiologic insults in NEC is associated with its own stresses that may compound the ongoing physiologic derangement. Surgery is thus reserved for those patients with clear indication for intervention such as pneumoperitoneum, confirmed stool or pus in the peritoneal cavity, or worsening clinical status. The purpose of this review is to briefly describe the physiologic stress induced by surgical intervention in the preterm, low birth weight patient with NEC and to provide a contemporary overview of available surgical management options for NEC. The optimal surgical plan employed is strongly influenced by clinical judgment and theoretical benefits in terms of minimizing physiologic stressors while providing temporary and/or definitive treatment in a timely fashion. While the choice of operation has not been shown to have a significant effect on any clinically important outcomes, ongoing investigations continue to study both short and long-term outcomes in patients with NEC.
Late vs early ostomy closure for necrotizing enterocolitis: Analysis of adhesion formation, resource consumption, and costs
2012, Journal of Pediatric Surgery
Citation Excerpt :
In a study conducted by Gertler et al [20], the same conclusion was drawn in 10 patients with NEC who underwent closure of ileostomy at a mean age of 18 weeks (range, 5-36 weeks). However, the weight gain per week in this group significantly improved after closure [20]. Elective restoration of intestinal continuity within 4 weeks in 27 neonates who had a temporary exteriorization of the small intestine after laparotomy demonstrated no mortality, a leakage rate of 10%, and full enteral nutrition after a mean of 8 days [21].
Surgeons prefer to close ostomies at least 6 weeks after the primary operation because of the anticipated postoperative abdominal adhesions. Limited data support this habit. Our aim was to evaluate adhesion formation—together with an analysis of resource consumption and costs—in patients with necrotizing enterocolitis who underwent early closure (EC), compared with a group of patients who underwent late closure (LC).
Chart reviews and cost analyses were performed on all patients with necrotizing enterocolitis undergoing ostomy closure from 1997 to 2009. Operative reports were independently scored for adhesions by 2 surgeons.
Thirteen patients underwent EC (median, 39 days; range, 32-40), whereas 62 patients underwent LC (median, 94 days; range, 54-150). Adhesion formation in the EC group (10/13 patients, or 77%) was not significantly different (P = 1.000) from the LC group (47/59 patients, or 80%). No differences were found in the costs of hospital stay, surgical interventions, and outpatient clinic visits.
Ostomy closure within 6 weeks of the initial procedure was not associated with more adhesions or with changes in direct medical costs. Therefore, after stabilization of the patient, ostomy closure can be considered within 6 weeks during the same admission as the initial laparotomy.
Stomas of the Small and Large Intestine
2012, Pediatric Surgery, 2-Volume Set: Expert Consult - Online and Print

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¹: From the Section of Pediatric Surgery, Department of Surgery, Yale University School of Medicine, and the Yale-New Haven Hospital, New Haven, CT.

View full text

Early ileostomy closure in necrotizing enterocolitis

Am J Surg

J Pediatr Surg

Neonatal necrotizing enterocolitis. Evolution of new principles in management

Arch Surg

Indications for operation in acute necrotizing enterocolitis of the neonate

Surgery

Surgical experience with neonatal necrotizing enterocolitis (NNE)

Ann Surg