Published online Dec 26, 2018. doi: 10.12998/wjcc.v6.i16.1101
Peer-review started: September 24, 2018
First decision: November 1, 2018
Revised: November 12, 2018
Accepted: November 14, 2018
Article in press: November 15, 2018
Published online: December 26, 2018
Infants with intestinal disorders often require surgical treatment consisting of enterostomy creation. However, enterostomy formation as well as its reversal frequently seem to lead to complications. Past studies have reported complication rates as high as 68% following enterostomy formation. Reported rates after enterostomy reversal are similarly high with up to 64.8% of neonates affected. Possible complications of the enterostomy range from skin excoriation and prolapse to enterostomy necrosis or mechanical ileus.
In some cases of patients with enterostomy-related complications further medical treatment or even reoperations can be necessary. Furthermore the nutrition and therefore growth of the infant can be impacted by occurring complications. This poses the question whether enterostomy formation is an appropriate surgical treatment for newborns with intestinal disorders. It also has to be evaluated for whom enterostomy formation should be deemed the right treatment.
The aim of this study was to assess the frequency, severity and impact of enterostomy complications in infants. We furthermore wanted to examine whether neonates with necrotizing enterocolitis (NEC), a life threating disease with mortality rates ranging up to 30%, have a higher risk for developing enterostomy-related complications than children with other intestinal disorders.
A 10-year retrospective cohort study (2008-2017) investigated newborns who underwent enterostomy formation and reversal for different intestinal disorders. Only infants less than 28 d old at the time of enterostomy creation were included in the study (corrected age was applied in the cases of preterm neonates). The patients were divided into two groups according to their underlying diseases. Group 1 included infants suffering from NEC, whereas Group 2 included newborns diagnosed with intestinal disorders other than NEC, such as meconium obstruction, anorectal malformation, focal intestinal perforation, ileus, intestinal atresia and volvulus. The primary outcome measure was enterostomy-related morbidity. The data were analyzed statistically and to evaluate the severity of the occurring complications, the Clavien-Dindo-Classification was applied, which allows the ranking of surgical complications.
In total, 76 infants met the inclusion criteria and were evaluated for enterostomy-related complications. Neither group showed significant differences regarding gender, gestational age, weight at birth or weight at enterostomy formation. The overall rate of one or more complications in patients of both groups after enterostomy formation was 80.3%, with rates of 86.3% in Group 1 and 68.0% in Group 2 (P = 0.073). Following enterostomy closure, at least one complication was observed in 26.0% of the patients (30.6% in Group 1 and 16.7% in Group 2, P = 0.321). 65.8% of patients required no treatment or only pharmacological treatment for the complications that occurred (Clavien-Dindo-Classification < III), while 34.2% required surgery to address the complications (CDC ≥ III). Early reversal of the enterostomy was performed significantly more often (P = 0.003) and the time to full enteral nutrition after closure was significantly longer (P = 0.006) in infants with a CDC grading ≥ III than in infants with a CDC grading < III.
Enterostomy treatment is associated with a high frequency of minor complications (CDC < III) and only a few major (CDC ≥ III) complications. The major complications do have an impact on the infant’s clinical course and lead to prolonged parenteral nutrition or a need for reoperation and early reversal. However, in the majority of cases, infants do not need to undergo surgical treatment to address the enterostomy-related complications. Regarding the underlying disease of the infants a clear trend could be observed that neonates suffering from NEC have a higher risk for developing enterostomy complications than those without NEC. This may be explained by the fact that bowel integrity in those infants is typically very low.
Enterostomy creation frequently leads to complications, but nevertheless can be deemed an appropriate surgical treatment for most infants suffering from intestinal disorders. It needs to be further evaluated though, whether an alternative treatment such as primary anastomosis might be a more feasible option in some cases. Especially the right treatment of children with NEC should be studied further in the future.