Pediatrics and Neonatology (2014) 55, 333e334

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The Optimal Timing of Enterostomy Closure in Preterm Infants Enterostomy is an alternative procedure during laparotomy for advanced acute abdomen, and in particular for necrotizing enterocolitis (NEC) in premature infants.1 Choosing either enterostomy or primary anastomosis is usually dependent on the surgeon’s experience and extent of disease. The benefits and adverse effects of both procedures remain under debate.1 If the ostomy has been established, it will be useful to establish the optimal timing of closure. Early (within 42 days after ostomy formation) ostomy closure has been reported to be preferential due to potentially reducing medical costs and improving the quality of life of patients.2 By comparison, the benefits of late closure are to avoid adhesion during reoperation and to reduce postoperative complications. Well-designed studies focusing on the comparison of early and late stoma closure in premature infants are rare. Struijs et al2 compared the adhesion rate in repeat surgery and costs in infants with NEC between early and late stoma closure. Their results showed that early stoma closure was not associated with more adhesions or changes in direct medical costs. By contrast, Al-Hudhaif et al3 reported that early stoma closure in NEC infants led to longer mechanical ventilation, postoperative hospital stay, total days of parenteral nutrition, and time to full enteral nutrition. They suggested that, unless seriously indicated, stoma closure should be deferred until at least 10 weeks after stoma creation. These differences may be due to the younger gestational age (40 weeks vs. 51.7 weeks) and lower weight (2662 g vs. 3967 g) in the infants with early closure compared to late closure at stoma reversal. Struijs et al4 also published a meta-analysis review article addressing the complications after stoma closure in infants with NEC. The results are controversial, as only four retrospective articles and one prospective case series (10 cases) were included, indicating that randomized clinical

trials are necessary to determine the optimal timing of stoma closure. In this issue, Lee et al5 report that stoma closurerelated complications occurred in 65% of 54 preterm infants who underwent enterostomy. They also investigated the risk factors for the development of complications after stoma closure. Among them, only a weight < 2660 g at the time of reversal was a significant factor to predict stoma closure-related complications in multiple logistic regression analysis. Weber et al6 reported that a lower albumin level and poor weight gain after stoma formation were risk factors for anastomotic dehiscence in infants with NEC after stoma closure. These results suggest that not only the duration after stoma formation, but also body weight and nutritional status of infants should be taken into consideration when determining the timing of stoma closure to minimize postoperative complications in preterm infants. Failure to thrive is one of the long-term complications in preterm infants after stoma closure. Miserez et al7 reported that 33% of very-low-birth-weight preterm infants with functionally isolated small bowel obstructions and idiopathic gastrointestinal perforations developed failure to thrive after stoma closure. Lee et al5 further report that infants with stoma closure-related complications had significantly lower weight and height growth compared to those without complications at a corrected age of 10 months. These results clearly show that choosing an optimal timing for stoma closure can prevent stoma closure-related complication and preserve long-term infantile growth. Both pediatricians and surgeons should be consulted for whether early stoma closure can avoid massive fluid loss and electrolyte imbalance in infants with enterostomy.6 The optimal timing of stoma closure in infants with enterostomy remains unknown. However, a stable medical 1875-9572/Copyright ª 2014, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.



condition and good nutritional status in preterm infants are mandatory before stoma closure. 2.

Conflicts of interest The author declares no conflicts of interest.


Yao-Jong Yang* Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan * Department of Pediatrics, National Cheng Kung University Hospital, 138 Sheng Li Road, Tainan 704, Taiwan. E-mail address: [email protected]




Jun 3, 2014 7.

References 1. Downard CD, Renaud E, St Peter SD, Abdullah F, Islam S, Saito JM, et al. Treatment of necrotizing enterocolitis: an American Pediatric Surgical Association Outcomes and Clinical

Trials Committee systematic review. J Pediatr Surg 2012;47: 2111e22. 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;47:658e64. Al-Hudhaif J, Phillips S, Gholum S, Puligandla PP, Flageole H. The timing of enterostomy reversal after necrotizing enterocolitis. J Pediatr Surg 2009;44:924e7. Struijs MC, Sloots CE, Hop WC, Tibboel D, Wijnen RM. The timing of ostomy closure in infants with necrotizing enterocolitis: a systematic review. Pediatr Surg Int 2012;28: 667e72. Lee J, Kang MJ, Kim HS, Shin SH, Kim HY, Kim EK, et al. Enterostomy closure timing for minimizing postoperative complications in premature infants. Pediatr Neonatol 2014;55: 363e8. Weber TR, Tracy Jr TF, Silen ML, Powell MA. Enterostomy and its closure in newborns. Arch Surg 1995;130:534e7. Miserez M, Barten S, Geboes K, Naulaers G, Devlieger H, Penninckx F. Surgical therapy and histological abnormalities in functional isolated small bowel obstruction and idiopathic gastrointestinal perforation in the very low birth weight infant. World J Surg 2003;27:350e5.

The optimal timing of enterostomy closure in preterm infants.

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