Risk Factors for Adverse Outcomes after Ostomy Reversal in Infants Less than Six Months Old.

The purpose of this study was to determine risk factors for 30-day complications, reoperation, and readmission after ostomy reversal in infants less than six months old. Infants aged two weeks to six months who underwent ostomy reversal were identified in the 2012 to 2016 ACS NSQIP Pediatric database. Demographics, comorbidities, and 30-day outcomes were assessed. Multivariable logistic regression was used to estimate the independent effects of clinical variables on risk of 30-day complications, reoperation, and readmission. Among 1021 infants, 163 (16%) suffered a 30-day complication. SSIs were the most common complication (5.7%), followed by unplanned reintubation (5.2%) and bleeding (3%). Mortality was 0.4 per cent. Dependence on nutritional support and hematologic disorders were independently associated with postoperative complications. Forty-five children (4.4%) required reoperation and 22 (2.2%) were readmitted for conditions related to the procedure. Younger age and preoperative dependence on oxygen or nutritional support were associated with increased length of stay. SSI, unplanned reintubation, and bleeding are the most frequent complications after ostomy takedown in infants less than six months old. Attention to risk factors predisposing to these complications, including dependence on nutritional support and hematologic disorders, may contribute to improved surgical outcomes.

Retrospective analysis of patients undergoing bowel transit reconstruction in a tertiary referral hospital of São Paulo's east side / Análise retrospectiva dos pacientes submetidos à reconstrução de trânsito intestinal em hospital terciário de referência da zona leste de São Paulo

Introduction: The morbidity and mortality of patients undergoing bowel transit reconstruction reach significant values. Perhaps this and other factors could explain why 30-60% of patients end up with definitive ostomies, even those with initially temporary ostomies, due to the procedure risks. Objective: To analyze retrospectively the medical records of patients undergoing bowel transit reconstruction in one of the SUS referral hospitals in São Paulo from October 2008 to December 2011. Results: The mean age of our patients was 53.9 years and 54% of those 100 patients studied between October 2008 and December 2011 had significant comorbidity. The indication for creating an initial ostomy was malignancy in 43%, and the mean stoma duration 14.3 months. The mortality rate was 6%. Conclusion: Although the bowel transit reconstruction is a procedure quite desired by patients, its indication should be carefully evaluated, with an appropriate consent from the patient. .

Introdução: A morbi-mortalidade de pacientes submetidos à reconstrução de trânsito intestinal alcança valores significativos e, por esse e outros fatores, talvez se explique o fato que de 30 a 60% dos portadores de ostomia intestinal terminal passam a possuí-la de maneira definitiva, apesar de, na maior parte das vezes, ela ser realizada como procedimento provisório com o argumento de maior segurança do paciente. Objetivo: Analisar retrospectivamente os dados de prontuário de pacientes submetidos à reconstrução de trânsito intestinal em um dos hospitais de referência do SUS na cidade de São Paulo no período de outubro de 2008 a dezembro de 2011. Resultados: A média de idade dos pacientes foi de 53,9 anos e 54% dos 100 pacientes estudados no período de outubro de 2008 e dezembro de 2011 padeciam de alguma comorbidade. A indicação para confecção da ostomia inicial decorreu de doença maligna em 43% e o tempo médio de permanência com o estoma foi de 14,3 meses. A taxa de mortalidade foi de 6%. Conclusão: Embora a reconstrução do trânsito intestinal seja um procedimento bastante desejado pelos pacientes, sua indicação deve ser bastante criteriosa, com consentimento adequado por parte do paciente.

Natural history of perianal Crohn's disease after fecal diversion.

BACKGROUND: Temporary fecal diversion has been used to allow severe perianal Crohn's disease (CD) to heal. Most data on intestinal reconnection rates precede the biological era with limited patient follow-up after reconnection. We, therefore, sought to evaluate the natural history of perianal CD after fecal diversion. METHODS: We identified 49 patients with CD and perianal involvement who underwent fecal diversion between 1991 and 2011 at a tertiary referral care center. Demographics, medication use, onset and extent of disease, and surgical interventions were abstracted. We determined the percentage of patients who were able to restore intestinal continuity and assessed the sustainability of this reversal. Time to intestinal reconnection and subsequent procedures were determined. We also examined temporal trends in the proportion of patients with perianal CD undergoing diversion or management with seton/EUA/fistulotomy between 2000 and 2011. RESULTS: Fifteen of 49 patients (31%) reestablished intestinal continuity during the study follow-up period. Ten of 15 patients (67%) who had reestablished intestinal continuity required an additional procedure to divert the fecal stream. Of the 5 patients who remained reconnected, 3 patients required further procedures to control sepsis. The proportion of patients with CD requiring perianal surgical interventions declined between 2000 and 2011. CONCLUSIONS: Severe perianal CD remains a challenging problem. In patients with CD with perianal disease requiring fecal diversion, the likelihood of sustained intestinal continuity remains low, despite greater biological use. However, there has been a temporal decline in the rate of surgical interventions required for perianal CD from 2000 to 2011.

Complication rates of ostomy surgery are high and vary significantly between hospitals.

BACKGROUND: Ostomy surgery is common and has traditionally been associated with high rates of morbidity and mortality, suggesting an important target for quality improvement. OBJECTIVE: The purpose of this work was to evaluate the variation in outcomes after ostomy creation surgery within Michigan to identify targets for quality improvement. DESIGN: This was a retrospective cohort study. SETTINGS: The study took place within the 34-hospital Michigan Surgical Quality Collaborative. PATIENTS: Patients included were those undergoing ostomy creation surgery between 2006 and 2011. MAIN OUTCOME MEASURES: We evaluated hospital morbidity and mortality rates after risk adjustment (age, comorbidities, emergency vs elective, and procedure type). RESULTS: A total of 4250 patients underwent ostomy creation surgery; 3866 procedures (91.0%) were open and 384 (9.0%) were laparoscopic. Unadjusted morbidity and mortality rates were 43.9% and 10.7%. Unadjusted morbidity rates for specific procedures ranged from 32.7% for ostomy-creation-only procedures to 47.8% for Hartmann procedures. Risk-adjusted morbidity rates varied significantly between hospitals, ranging from 31.2% (95% CI, 18.4-43.9) to 60.8% (95% CI, 48.9-72.6). There were 5 statistically significant high-outlier hospitals and 3 statistically significant low-outlier hospitals for risk-adjusted morbidity. The pattern of complication types was similar between high- and low-outlier hospitals. Case volume, operative duration, and use of laparoscopic surgery did not explain the variation in morbidity rates across hospitals. LIMITATIONS: This work was limited by its retrospective study design, by unmeasured variation in case severity, and by our inability to differentiate between colostomies and ileostomies because of the use of Current Procedural Terminology codes. CONCLUSIONS: Morbidity and mortality rates for modern ostomy surgery are high. Although this type of surgery has received little attention in healthcare policy, these data reveal that it is both common and uncommonly morbid. Variation in hospital performance provides an opportunity to identify quality improvement practices that could be disseminated among hospitals.

Ostomy creation in neonates with acute abdominal disease: friend or foe?

BACKGROUND: An ostomy seems a safe alternative in neonates with an acute abdomen when immediate restoration of bowel continuity is deemed undesirable. Faced with several complications in our center, and the feeling we are not the only center with these complications, we decided to assess the rate and type of complications after both ostomy creation and closure. METHODS: All data regarding neonates (<30 days of age) who underwent a laparotomy for a suspected abdominal emergency in the period 2000 to 2010 were retrospectively analyzed. These data included demographics such as gender, gestational age, and birth weight. Disease etiology was defined and various features of the enterostomy were analyzed. These features included type, location, time to ostomy take down, and complications and mortality directly related to both creation and closure of the ostomy. RESULTS: A total of 155 patients who underwent a laparotomy for suspect acute abdomen were identified. Median gestational age was 33 weeks (range 25 to 40) and median birth weight was 1926 g (range 560 to 4380). Median age at laparotomy was 8 days (range 0 to 30). Indications for surgery were necrotizing enterocolitis (n = 38), spontaneous intestinal perforation (n = 11), intestinal atresia (n = 9) or obstruction (n = 5), and volvulus (n = 4). An ostomy was created in 67 patients (67/155: 43%): 38 boys and 29 girls. There were 8 jejuno-, 49 ileo-, and 10 colostomies created. In almost all cases (94%), a mucous fistula was also constructed.In 23 patients (23/67: 34%) ostomy-related complications occurred. Most frequent were high output ostomy (n = 10) and necrosis of the enterostomy (n = 7). Due to either one of the complications, nine patients (9/67: 13%) needed a reoperation.In this study, 11 patients died before ostomy closure could occur. In 53 patients, the ostomy was closed after a median of 107 days (range 4 to 299).After ostomy closure, complications occurred in 13 cases (13/53: 25%). Seven patients (7/53: 13%) needed another reoperation because of anastomotic leakage (n = 4), adhesions (n = 2), or incisional hernia (n = 1). There was no closure-related mortality. CONCLUSION: Although creating a temporary ostomy in newborns is preferable in certain situations, there is a considerable occurrence of complications and reoperations.

Biliary atresia in Canada: the effect of centre caseload experience on outcome.

OBJECTIVES: : Biliary atresia (BA) is a leading cause of end-stage paediatric liver disease. Standard BA treatment is sequential surgery with an initial Kasai procedure (KP) followed by liver transplant (LT) for patients who progress to liver failure. A key determinant for the post-KP patient survival with their native liver is patient age at KP (older age, poorer outcome). Recently, European studies have reported that caseload experience influences prognosis with centres managing <5 cases per year (UK) or <2 cases per year (France) having worse survival. Our study investigates the effect of caseload experience on outcomes of Canadian patients with BA. PATIENTS AND METHODS: : A national database of cases with BA, born from 1992 to 2002, was examined. Patients were grouped according to treatment centre size (A: on average <1 case per year; B: 1 to 3 cases per year; and C: >3 cases per year). Overall patient, post-KP native liver, and LT survivals were compared between centres. Outcome parameters were reevaluated for patients grouped by the largest Canadian centre (>5 cases per year) and all other centres (<5 cases per year). RESULTS: : Two-hundred thirty patients were identified among 6 group A, 4 group B, and 2 group C centres. The overall median age at KP was 64 days. There were no significant differences in patient, post-KP native liver, or LT survivals between the sized centres and even the largest centre, with the overall 4-year post-KP native liver survival being 39%. CONCLUSIONS: : Caseload experience does not importantly affect the outcomes for Canadian children with BA. Although outcomes in Canada are comparable to those elsewhere, national policies directed towards timely referral and earlier age at KP rather than centralisation of care are needed.

Ostomías en Iquique: características epidemiológicas / Ostomias in Iquique: epidemiologic characteristics

Se analiza el perfil biodemográfico de los pacientes ostomizados en el Hospital de Iquique durante los últimos 5 años, el grado de conocimiento de su patología y características en el auto cuidado. El perfil y las características encontradas muestran algunos aspectos deficitarios en el cuidado integral de estos pacientes, así como también aspectos sociales específicos, los cuales deben tomarse en consideración, tanto por los profecionales de la salud como las instituciones encargadas o que prestan el apoyo a dichos pacientes. Se refuerza la idea de euqipos o programas especializados para manejo de éstos.