PPT Present

Outcome of Colostomy Closure and Influencing Factors in patients with Anorectal Malformation.

Presentator

Pawan Chansaenroj MD.

Advisor

Piyawan Chiengkriwate MD.

- Anorectal malformation includes a series of congenital lesions of the hindgut and

urogenital organs. - The reported incidence of anorectal

malformations range from 1: 3300 to 1 : 5000 live births.1

Outcome of Colostomy Closure and Influencing Factors in patients with ARM.

Background

1 : Pena, A.Migotto-Krieger, M.Levitt, M. A., Colostomy in anorectal malformations:

a procedure with serious but preventable complications, J Pediatr Surg, 2006, 748-56;

- Recent years a growing number of pediatric surgeons have begun advocating the repair of anorectal malformations in a primary fashion without a colostomy.

- Most pediatric patients with an anorectal malformation still receive a protective colostomy before the main repair to avoid contamination.


Background


Background


Background

- Many surgeon pay attention and often reveal the outcome and complication of colostomy formation.

But….- Just few studies have examined the outcome

and complications of colostomy closure and the major factors influencing the outcome.2,3


Background

2 : Chandramouli, B.Srinivasan, K.Jagdish, S.Ananthakrishnan, Morbidity and mortality of colostomy and its closure in children,J Pediatr Surg, 2004,596-9

3 : Cigdem, M. K.,Onen, A.,Duran, H.,Ozturk, H.,Otcu, S., The mechanical complications of colostomy in infants and children: analysis of 473 cases of a single center.

Pediatr Surg Int, 2006.22: 671-6

- Major complications include bleeding , anastomosis leakage , intraabdominal abscess, abdominal wall mucocele.2,3,6,10,11


Background

2 : Chandramouli, B.Srinivasan, K.Jagdish, S.Ananthakrishnan, Morbidity and mortality of colostomy and its closure in children,J Pediatr Surg, 2004,596-9

3 : Cigdem, M. K.,Onen, A.,Duran, H.,Ozturk, H.,Otcu, S., The mechanical complications of colostomy in infants and children: analysis of 473 cases of a single

center. Pediatr Surg Int, 2006.22: 671-6

6: Nour, S.Beck, J.Stringer, M. D., Colostomy complications in infants and children, Ann R Coll Surg Engl, 1996, 78: 526-30

10 : Memetoglu, M. E.Boleken, M. E.Baba, F.Kaya, M.Kanmaz, T.Yucesan, S., Abdominal wall mucocele: a late complication of colostomy closure, Int Wound J. 2008,5: 56-8

11 : Yajko, R. D.Norton, L. W.Bloemendal, L.Eiseman, B., Morbidity of colostomy closure, Am J Surg, 1976,132: 304-6

- Some factors have been found to be prognostic or influencing the colostomy closure results such as co-morbidity before stroma closure, type and location of colostomy.4,5,7,8,9


Background

4 : Gardikis, S.Antypas, S.Mamoulakis, C.Demetriades, D.Dolatzas, T.Tsalkidis, A.Chatzimicael, A.Polychronidis, A.Simopoulos, C.,

Colostomy type in anorectal malformations: 10-years experience, Minerva Pediatr, 2004,56: 425-95 : Ghorra, S. G.Rzeczycki, T. P.Natarajan, R.Pricolo, V. E.,

Colostomy closure: impact of preoperative risk factors on morbidity, Am Surg, 1999 ,65: 266-97 : Mosdell, D. M.Doberneck, R. C.,

Morbidity and mortality of ostomy closure, Am J Surg, 1991, 162: 633-6; discussion 636-78 : Demetriades, D.Pezikis, A.Melissas, J.Parekh, D.Pickles, G.,

Factors influencing the morbidity of colostomy closure, Am J Surg, 1988, 155: 594-69 : Wong, R. W.Rappaport, W. D.Witzke, D. B.Putnam, C. W.Hunter, G. C.,

Factors influencing the safety of colostomy closure in the elderly, J Surg Res, 1994,57: 289-92

What are outcome of colostomy

closure and influencing factors in patients with anorectal malformation ?


Research question

Title : Outcome of Colostomy Closure and Influencing Factors in patients with Anorectal Malformation.


Study Design : Title

Primary outcome - First feeding time , Length hospital stay ,

Complication rate

Secondary outcome - Relationship about suspected influencing

factor* and outcome

* : ( 1.Adhesion 2. Quality of bowel preparation 3.Intra-operative Fecal contamination 4. Co- Morbidity prior surgery 5.Ganglion cell number 6.Colostomy type )


Study Design : Material and Method

Design - A retrospective descriptive – analytic study



Patient - All patients with anorectal malformation who

were admitted between January 1997 and December 2007 and receive a closure colostomy at Songklanagarind Hospital in Hadyai, Thailand.



Exclusion criteria -



Data collection • prior operation

Demographic data •Sex •Parent religious •Age at stoma formation•Age at stoma closure•Weight at colostomy closure •Type of ARM •Associated abnormally •Type of colostomy •Co-morbidity

Factor and Outcome•Operative finding •Soiling during surgery •Operative times•Estimate blood loss •Hospital stay •First feeding time •Complication•Follow up after Discharge •Colon histopathology





Statistical study - Data collected and calculated by manual input

with Microsoft Excel 2007 ® - Numerical data were compared with Student ‘s t-test CI 95%



Result


Result

Table 1 : Demographic dataNumber (101) Percent

Sex Male Female

7526

74.26%25.74%

Religious BuddhaIslamic

4853

47.53%52.47%

Type of Ano-Rectal Malformation (by Wingspread classification)

LowIntermediateHigh

263540

VACTERL association 9 8.9%

Down Syndrome 12 11.88%


Result

Table 2 : Colostomy closure detail

Number of colostomy closure

107

Age at 1st colostomy formation :

*** Body weight at 1st colostomy formation[kg]-no data

Range [day] Low Intermediated High Total 0 – 1 5 14 15 342 – 3 11 10 12 33 4 – 7 [8] 4 1 3 88 – 30 [5] 0 2 3 5>30 [21] 6 8 7 21 101


Result


Age at colostomy closure : Month< 11-2> 2-3> 3-12> 12

1st [101] 2nd[6] 1 0 1 0 3 0 50 0 46 6 101 6

Range [day] 17 – 9030 531 - 1844Mean 761.13 1070Median 337 853.5


Result


Weight at colostomy closure [kg] Range < 3 3-5 > 5-10 > 10-15 > 15Total

1st[101] 2nd[6] 1.12 - 41.00 9.05 - 16.60 6 0 5 0 65 3 17 2 8 1 101 6


Result


Type of colostomy before closure - Loop colostomy - Transverse end colostomy - Other eg. End hepatic or splenic colostomy End sigmoid colostomy

89108

83.18%9.35%7.47%


Result


Co-morbidity prior surgery

- Unstable heart disease

- Anemia - Severe Malnutrition - Gastroenteritis- Parasitic infection - Urinary tract infection- NEC - Hypothyroid - Gut obstruction

*some patient had more than 1 co-morbidity

1st [101] 16 15.84% 4 5 2 2 2 1 1 2 -

2nd [6] 1 16.67% - - - - - - - - 1


Result

Table 3 : Outcome of colostomy closure

1st 2nd Number

Number of colostomy closure 101 6 107

Operative time : Mean Mode

130 min 120 min

Estimate blood loss (ml) : Range Mean

0 – 200 cc41.69

First feeding time : Range Mean Median Mode

1 - 11 d2.04 d

5 d2 d


Result


Hospital stay : Range Mean Median Mode

3 – 24 d5.85 d

5 d4 d


Result


Number Percent

Complication : - Acute ( Present with in 1 mo )- Late ( Present after 1 mo )

12 11.21% 16 14.95%

Follow up post operation : Longest Shortest

132 months 1 week

Adequacy of Follow up : ≥ 1 yr

69 89.6%(n=77)

6 mo – 1 yr

4 5.2%(n=77)

3 mo – 6 mo

1 1.3%(n=77)

< 3 mo 3 3.9%(n=77) Lost OPD card

30


Result

Table 4 : Complication Number Percent

Acute complication (Present at < 1 mo )- Sepsis- Urinary tract infection- Wound infection- Bleeding per rectum- Acute gastroenteritis- Pneumonia

12 11.2%

1 2 1.87 % 4 3.74 %

1 3 2.8 %

1

Late complication (Present at > 1mo - Fecal impact- Rectal prolapsed- Gut obstruction- Entero - Urinary tract fistula

168242


Result

Table 5 : Factor Detail Quality bowel prep :

Good

Fair

Poor Not

describe

13 81.25%(n=16)

3 18.75%(n=16)

0

91Fecal contamination during surgery : No

LittleModerate

Too much Not describe

23 92%(n=25)1 4%(n=25)0 0%(n=25)

1 4%(n=25)

82Adhesion :

No Minimal

Moderate Severe

70 65.42%(n=107)

13 12.15%(n=107)

14 13.08%(n=107)

10 9.35%(n=107)


Result : Factor detail

Table 5 : Factor Detail

Ganglion cell number (n=80) Range of average cell 0 – 9 Cell / HPF

Mean 5.45 Cell / HPF

Median 5.33 Cell / HPF

Mode 5 Cell / HPF

Maximum Cell / HPF 17 Cell / HPF


Result : Factor detail : Ganglion cell

Table 6 : Influencing factor analysis

Factor Outcome Comparative factor P value

Adhesion

Adhesion

Non adhesion

Mean First feeding time

2.2 1.85 0.065

Mean Hospital stay 5.15 4.9 0.51


Result : Influencing factor analysis : Adhesion



Quality of bowel preparation Fair , Poor Good


2.33 2 0.45



Result : Influencing factor analysis : Bowel preparation



Intra-operative

Fecal contamination

Contamination

Non Contaminatio

n Mean First feeding time

2.5 1.91 0.376



Result : Influencing factor analysis : Fecal contamination



Co-Morbidity prior surgery

Co-morbidity present

Non Co -morbidity


2.43 1.96 0.485


Number of Acute Complication

4/17 (23.53%)

8/90 (8.88%)


Result : Influencing factor analysis : Co-morbidity



Ganglion cell number ≤ 5 Cell/HPF ≥ 6 Cell/HPF


1.92 2.07 0.77



Result : Influencing factor analysis : Ganglion cell



Colostomy type Sigmoid loop colostomy

Transverse End Colostomy

Mean First Feeding time

1.93 2.12 0.48


Complication rate 8/89 (8.98%) 4/10 (40%)


Result : Influencing factor analysis : Colostomy type

• • Colostomy still was a necessary operation that

helped ARM patient for defecation ,waiting for total correction.

• Complication of colostomy closure have had a little collected and described.


Discussion

• • Some factors had impact of their outcome such

as colostomy type, co-morbidity prior surgery and adhesion during surgery.

• And some suspected factors was proven that (Intra-operative fecal contamination ,bowel preparation quality ,ganglion cell number )their weren't related with colostomy closure outcome.


Discussion

• • Nevertheless, our detail were too little too

decided some factor was influencing or not furthermore long term complication and other outcome were needed more study.


Discussion

•

• Some factors (Fecal contamination and bowel preparation quality ) had too little data too calculated for significance relationship.

• Some outcome and complication may be reflect that impact of both colostomy closure and surgical correction,eg. PSARP , anoplasty, such as fecal impactation ,rectal prolapse gut obstruction.


Limitation

•

• Even through each surgeon in this institute used same protocol and practical method to take care their patient ,many aspect still be different such as surgical skill , decision to start feeding and decision to discharge patient are upon their experience.


Limitation

• The factors that had impact of closure colostomy outcome included colostomy type, co-morbidity prior surgery, and adhesion during surgery.

• But the intra-operative fecal contamination, bowel preparation quality, and ganglion cell number had not related with the outcome.


Conclusion


Thank you for your attension

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