Journal of Pediatric Surgery 54 (2019) 1045–1048

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Bowel preparation for colostomy reversal in children☆,☆☆

Eric H. Rosenfeld, Yangyang R. Yu, Nathaniel J. Fernandes, Aleena Karediya, David E. Wesson, Monica E. Lopez,
Sohail R. Shah, Adam M. Vogel, Mary L. Brandt ⁎
Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Pediatric bowel preparation protocols used before colostomy reversal vary. The aim of this study is to
Received 18 January 2019 determine institutional practices at our institution and evaluate the impact of bowel preparations on postoperative
Accepted 27 January 2019 outcomes and hospital length of stay in children.
Methods: This was a retrospective review of children ≤18 years old undergoing colostomy reversal at Texas
Key words:
Children's Hospital (TCH) between 12/2013 and 8/2017. Preoperative bowel regimens and outcomes were
Bowel preparation
collected and analyzed using descriptive statistics, Wilcoxon Rank-Sum and Fishers Exact tests. Continuous
Colostomy reversal
Colorectal surgery
variables are presented as median [IQR].
Results: Sixty-one children underwent colostomy reversal. Thirty-eight (62%) did not receive a preoperative
bowel preparation. The two cohorts were similar in age, gender, and race. The most common indication for
colostomy was anorectal malformation for thirty-seven (61%). Time from admission to surgery (19 h [17, 23]
vs 3 [2, 3]; p b 0.01) and HLOS (6 days [5, 8] vs 5 [4, 6]; p = 0.02) were both longer in the bowel preparation
cohort. Complications (3 [13%] vs 5 [22%]; p = 0.12) and 90-day readmissions (3 [13%] vs 6 [16%]; p = 0.64)
were similar in both cohorts.
Conclusion: Foregoing bowel preparation may have the potential to improve cost and reduce morbidity in
children undergoing colostomy closure.
Level of evidence: III.
Study type: Treatment study.
© 2019 Published by Elsevier Inc.

Since the early 1970s mechanical bowel preparation has been
utilized in an effort to minimize anastomotic and infectious complications
and bowel preparation prior to elective colorectal surgery has been
standard surgical practice. Mechanical bowel preparation in young
children is typically performed in an inpatient setting, and is delivered
via a nasogastric tube, resulting in an additional cost and discomfort.
Recent adult data have questioned the benefit of this practice [1,2]. In
children, there are little data regarding the utility and benefit of a me-
chanical bowel preparation [3–5]. Despite the existing adult and pediatric
data, 96% of practicing pediatric surgeons still use mechanical bowel
preparation in their clinical practice, according to a recent survey [6–8].
Two recent meta-analyses of randomized controlled studies per-
formed in the early 2000s showed no differences in complications with
or without a mechanical bowel preparation. Slim and colleagues per-
formed a meta-analysis of trials with a total of 4859 patients and found
☆ Funding Source: This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.
☆☆ Conflicts of interest: none.
⁎ Corresponding author at: Texas Children's Hospital, Department of Pediatric Surgery,
6701 Fannin Street # 1210, Houston, TX 77030. Tel.: +1 832 822 3872.
E-mail address: MLBrandt@texaschildrens.org (M.L. Brandt).
no differences in complications or anastomotic leaks [1]. Similarly,
Guenaga and colleagues performed a meta-analysis of 18 trials with a
total of 5805 patients and found no difference in the rate of anastomotic
leaks or wound infections after colonic or colorectal surgery [2]. These
trials provided the support for the Enhanced Recovery after Surgery
guidelines for colorectal surgery, which did not recommend bowel
preparation prior to elective colorectal surgeries [9]. Studies in the
pediatric population, however, are lacking, with no large randomized
controlled trials. Retrospective studies have shown conflicting results
[10,11]. A study by Aldrink and colleagues of 44 children receiving poly-
ethylene glycol vs no bowel preparation showed no difference in the in-
cidence of infectious complications [5]. A multicenter retrospective study
by Serrurier and colleagues consisting of 272 patients showed higher
rates of surgical site infections and longer hospital length of stay
among those receiving a mechanical bowel preparation and recom-
mended against the use of these bowel preparations in children [4].
As part of an effort to create a standardized care pathway for children
undergoing colostomy reversal, we evaluated our current practices and
outcomes. The purpose of this study is to assess the current use of
bowel preparation for colostomy reversals in children at Texas Children's
Hospital (TCH) and evaluate the impact of bowel preparations on post-
operative outcomes, hospital length of stay and readmissions in children.

https://doi.org/10.1016/j.jpedsurg.2019.01.037
0022-3468/© 2019 Published by Elsevier Inc.
1046 E.H. Rosenfeld et al. / Journal of Pediatric Surgery 54 (2019) 1045–1048

1. Methods Table 2
Indications for Colostomy.

The study cohort consisted of patients 18 years or younger who Indications for Colostomy
underwent elective colostomy closure between January 2014 and Bowel No Bowel All
August 2017 at TCH. Records were retrospectively reviewed. Data preparation preparation Patients
collected included demographic data, primary disease diagnoses, pre- (n = 23) (n = 38) (n = 61)
operative bowel regimen, time from admission to bowel preparation Imperforate 57% (13) 63% (24) 61% (37)
time to order placement and time to bowel preparation administration, Anus/Cloaca
delays in surgery start times, operative time, hospital length of stay, post- Hirschsprung's Disease 13% (3) 11% (4) 11% (7)
operative complications and readmissions within 90 days. For analysis, Bowel Perforation 13% (3) 0% (0) 5% (3)
Other 17% (4) 26% (10) 23% (14)
children were divided into two cohorts: those who received an inpatient
mechanical bowel regimen, and those who did not undergo a preopera-
tive bowel preparation. Surgical site infections were diagnosed according The median time from admission to surgery was longer in the bowel
to the guideline for the prevention of surgical site infection [2]. preparation group [19 h (17–23) vs 3 (2–3); p b 0.01). The median time
Chi-Square and Fisher's exact tests were used to evaluate the cate- from admission until the orders for a bowel preparation were placed
gorical data which are reported as frequencies and proportions. was 1.3 h (0.7–2.2). The median time from order placement to medica-
Wilcoxon rank-sum tests were used to evaluate the continuous data tion administration was 2.3 h (2.0–3.6) (Fig. 1). Reasons for delay to
which are reported as median and interquartile range (IQR). A single receiving bowel preparation included nursing staff confusion regarding
patient who had received their bowel preparation at home was orders, difficulty in placing a nasogastric (NG) tube and displacement
excluded for the preoperative and postoperative length of stay calcula- of an NG tube requiring replacement. Time from receiving the bowel
tions as we sought to evaluate children admitted to the hospital pre- preparation to the initiation of surgery was 15.7 h (13.3–17.2). Three
operatively for a bowel preparation. An alpha b 0.05 was considered patients (14%) required additional doses owing to incomplete bowel
statistically significant. All data management and statistical analysis preparation. Postoperative stay was similar despite the lack of a bowel
were performed using SAS version 9.4 (Statistical Analytics Software preparation (5 days [−6] vs. 5 [4–7]; p = 0.40).
Institute, Cary, NC). IRB approval was obtained for this study. The most common complication within 90 days was a wound infec-
tion, which occurred in 3 (13%) of children who had a bowel preparation
and 1 patient (3%) who did not receive a bowel preparation (p = 0.36).
2. Results There was one child with an anastomotic leak in the bowel preparation
group. Total complications were similar in the two cohorts (23% vs 8%;
A total of 61 colostomy closures were performed during the study pe- p = 0.12). Readmissions were also similar in the two cohorts, 3 (13%)
riod. Thirty-eight patients (62%) were male. Thirty-eight patients (62%) in the bowel preparation group and 6 (16%) in the non-bowel prepara-
underwent same day admission without any bowel preparation. Of the tion group (p = 0.64). Four patients were readmitted for infectious com-
23 (38%) who received a bowel preparation, 18 (78%) were admitted plications (2 children with upper respiratory infections, a child with a
one-day prior surgery and 4 (17%) were admitted 2 days prior to surgery. wound infection and a child with a urinary tract infection), 2 with nausea
One patient in the bowel preparation group also received oral antibiotics. and vomiting, 1 with constipation requiring fecal disimpaction, 1 with an
The two cohorts were similar in age, gender and race (Table 1). The most intraabdominal abscess and 1 with bowel dehiscence. (Table 3). Hospital
common indication for colostomy was anorectal malformations (61%)
(Table 2). All had left sided colostomies aside from one patient with a
transverse colostomy, 44 (72%) were end (Hartman's) colostomies and
50 (82%) had handsewn anastomosis. There was no difference in their
distribution between the cohorts (Table 1).

Table 1
Demographics and preoperative characteristics.

Demographics and Preoperative Characteristics

Bowel No Bowel P-Value

preparation preparation
(n = 23) (n = 38)

Agea 1.2 (0.7–5.4) 1.5 (0.5–6.8) 0.98

Gender, Male 50% (12) 68% (26) 0.20
Race 1.00
Asian 5% (1) 8% (3)
Black/African American 27% (6) 28% (11)
Unable to Obtain 5% (1) 3% (1)
White 64% (14) 62% (24)
Ethnicity 0.48
Hispanic 27% (6) 38% (15)
Non-Hispanic 64% (14) 59% (23)
Unable to Obtain 9% (2) 3% (1)
End colostomy 70% (16) 74% (28) 0.23
Hand-sewn anastomosis 87% (20) 79% (30) 0.51
Inadequate Bowel preparation 5% (1) 0% (0) x
(per operative notes)
Bowel preparation Medications x
Polyethylene Glycol 100% (23) 0% (0)
Sodium Phosphate 5% (1) 0% (0)
Fig. 1. Flow chart for children undergoing bowel preparation (one patient who underwent
a
Median (IQR). a home bowel preparation was excluded for these calculations).
 E.H. Rosenfeld et al. / Journal of Pediatric Surgery 54 (2019) 1045–1048
Table 3
Outcomes of bowel preparation vs. no bowel preparation.
Outcomes of bowel preparation vs. no bowel preparation
Bowel No Bowel
preparation preparation
(n = 23) (n = 38)
Hospital Length of Stay (days)a,b 6 (5–8) 5 (4–6)
Post-operative Length of Stay (days)a,b 5 (4–7) 5 (4–6)
Time from Admission to Surgery 19 (17–23) 3 (2–3)
(hours)a,b
Complications (within 60 days)
Wound Infections 13% (3) 5% (2)
Deep Abscess 0% (0) 3% (1)
Anastomotic Leak 4% (1) 0% (0)
SBO 4% (1) 0% (0)
Hospital Readmissions 13% (3) 16% (6)
Need for Additional Surgeries 4% (1) 3% (1)
a
Median (IQR).
b
One patient who received a home bowel regimen was excluded.
length of stay was one day shorter in those who did not receive a pre-
operative bowel preparation (5 vs 6 days; p = 0.02).
3. Discussion
In our review of a large tertiary care children's hospital we have
shown significant variation in the administration of a mechanical
bowel preparation in children undergoing a colostomy reversal. Pre-
operative admissions for bowel preparation frequently led to operative
delays owing to delays in the placement of orders, difficulty placing
nasogastric tubes, confusion of staff or the need for additional doses of
bowel preparations. Patients undergoing a bowel preparation also had
a longer hospital length of stay. Despite the longer preoperative length
of stay in the bowel preparation cohort, the non-bowel preparation
cohort had a similar postoperative hospital length of stay. We did not
observe an increase in complications in those who did not receive a
mechanical bowel preparation.
Prior studies in adults have challenged the utility of mechanical
bowel preparation for colonic operations and have shown that bowel
preparation does not decrease the rate of anastomotic and wound com-
plications and may, in fact, increase the risk of anastomotic leak, wound
infection, and extraabdominal morbidity [2,12–16]. In this study of
children undergoing colostomy reversal, we similarly, failed to show
any short-term benefits in those receiving a bowel preparation in
terms of complications, infection rates or readmissions. In addition,
mechanical bowel preparation in young children requires the expense
of an additional hospital day, placement of a nasogastric tube, and addi-
tional laboratory tests and intravenous fluids to ensure adequate hydra-
tion all of which increase costs and stress on the family and child. The
longer hospital length of stay in the bowel preparation group would
add an estimated two thousand dollars in costs [17].
In a recent survey by the American Pediatric Surgical Association on
bowel preparation practices prior to elective colorectal surgeries among
pediatric surgeons, 31% reported utilizing a mechanical bowel prepara-
tion alone, 27% utilized diet modification only, 20% utilized a mechanical
bowel preparation with oral antibiotics, and 12% did not utilize any pre-
operative prep. They identified a trend towards no preoperative bowel
regimens as the strategy of choice [18]. Utilization of bowel prepara-
tions in our study was comparable to this survey, with the exception
of the use of oral antibiotics which is rare in our institution. Our study
was in agreement with retrospective institutional data from Aldrink
and colleagues, who prospectively evaluated the incidence of infectious
complications including anastomotic leak, intraabdominal abscess,
and wound infection in patients who received a mechanical bowel
preparation with those who did not and found no difference in compli-
cations. Similarly, in our cohort, we found that the children who did not
1047
have a mechanical bowel preparation did not have a higher rate of com-
plications [5].
In the adult population, institution of Enhanced Recovery after
P-Value
Surgery (ERAS) protocols has used evidence-based recommendations
which cover the entire perioperative period to reduce the time to full re-
covery after major abdominal surgery [9]. The ERAS pathway reduces
0.02 surgical stress, maintains postoperative physiological function, and
0.40 encourages early mobilization after surgery which has resulted in re-
b0.01 duced rates of morbidity, faster recovery and shorter hospital length
of stay [19,20]. In children, Raval and colleagues used a modified Delphi
0.12
0.36
process to create a list of ERAS interventions and have shown their
1.00 feasibility and safety [21–25]. We intend to build on their work and
0.38 use our data to create a perioperative care pathway for children under-
038 going colostomy reversal which eliminates mechanical bowel prepara-
0.64
tion and standardizes all aspects of the care of these children.
1.00
Our study is limited by the retrospective design. Additionally,
we only captured readmissions and postdischarge complications of
children managed at our institution. Children presenting to other insti-
tution with complications were not captured. Colostomy reversals are
performed in a very similar manner by all operating surgeons in this
study, with only minor variations in technique. We believe this makes
our results more generalizable as one would expect similar variation
in technique by pediatric surgeons across the country.
4. Conclusion
Most children at our institution undergo colostomy reversal without
receiving a preoperative mechanical bowel preparation and have a
shorter hospital length of stay than children who undergo a bowel
preparation, without increasing postoperative complications. These
data suggest that eliminating mechanical bowel preparation before
colostomy reversal is beneficial, although prospective randomized trials
will be needed to definitively answer this question.
References
[1] Slim K, Vicaut E, Launay-Savary MV, et al. Updated systematic review and meta-
analysis of randomized clinical trials on the role of mechanical bowel preparation
before colorectal surgery. Ann Surg 2009;249(2):203–9.
[2] Guenaga KF, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective
colorectal surgery. The Cochrane database of systematic reviews. 2011;9:Cd001544.
[3] Leys CM, Austin MT, Pietsch JB, et al. Elective intestinal operations in infants and
children without mechanical bowel preparation: a pilot study. J Pediatr Surg 2005;
40(6):978–81 [discussion 82].
[4] Serrurier K, Liu J, Breckler F, et al. A multicenter evaluation of the role of mechanical
bowel preparation in pediatric colostomy takedown. J Pediatr Surg 2012;47(1):
190–3.
[5] Aldrink JH, McManaway C, Wang W, et al. Mechanical bowel preparation for
children undergoing elective colorectal surgery. J Pediatr Gastroenterol Nutr 2015;
60(4):503–7.
[6] Smith RL, Bohl JK, McElearney ST, et al. Wound infection after elective colorectal
resection. Ann Surg 2004;239(5):599–605 [discussion − 7].
[7] Silvestri M, Dobrinja C, Scomersi S, et al. Modifiable and non-modifiable risk factors
for surgical site infection after colorectal surgery: a single-center experience. Surg
Today 2017;48:338–45.
[8] Breckler FD, Fuchs JR, Rescorla FJ. Survey of pediatric surgeons on current practices
of bowel preparation for elective colorectal surgery in children. Am J Surg 2007;
193(3):315–8 [discussion 8].
[9] Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in
elective colonic surgery: Enhanced Recovery After Surgery (ERAS(R)) Society
recommendations. Clin Nutr 2012;31(6):783–800.
[10] Rangel SJ, Islam S, St Peter SD, et al. Prevention of infectious complications after elec-
tive colorectal surgery in children: an American Pediatric Surgical Association
Outcomes and Clinical Trials Committee comprehensive review. J Pediatr Surg
2015;50(1):192–200.
[11] Pennington EC, Feng C, St Peter SD, et al. Use of mechanical bowel preparation and
oral antibiotics for elective colorectal procedures in children: is current practice
evidence-based? J Pediatr Surg 2014;49(6):1030–5 [discussion 5].
[12] Harris LJ, Moudgill N, Hager E, et al. Incidence of anastomotic leak in patients under-
going elective colon resection without mechanical bowel preparation: our updated
experience and two-year review. Am Surg 2009;75(9):828–33.
[13] Miettinen RP, Laitinen ST, Makela JT, et al. Bowel preparation with oral polyethylene
glycol electrolyte solution vs. no preparation in elective open colorectal surgery:
prospective, randomized study. Dis Colon Rectum 2000;43(5):669–75 [discussion
75-7].
1048 E.H. Rosenfeld et al. / Journal of Pediatric Surgery 54 (2019) 1045–1048
[14] Burke P, Mealy K, Gillen P, et al. Requirement for bowel preparation in colorectal
surgery. Br J Surg 1994;81(6):907–10.
[15] Zmora O, Mahajna A, Bar-Zakai B, et al. Colon and rectal surgery without mechanical
bowel preparation: a randomized prospective trial. Ann Surg 2003;237(3):363–7.
[16] Bucher P, Mermillod B, Morel P, et al. Does mechanical bowel preparation have a
role in preventing postoperative complications in elective colorectal surgery?
Swiss Med Wkly 2004;134(5–6):69–74.
[17] Witt Whitney P, Weiss Audrey J, Elixhauser Anne. Overview of hospital stays for
children in the United States. Agency for Healthcare Research and Quality; 2012.
[18] Feng C, Sidhwa F, Anandalwar S, et al. Contemporary practice among pediatric
surgeons in the use of bowel preparation for elective colorectal surgery: a survey
of the American Pediatric Surgical Association. J Pediatr Surg 2015;50(10):1636–40.
[19] Serclova Z, Dytrych P, Marvan J, et al. Fast-track in open intestinal surgery: prospec-
tive randomized study (Clinical Trials Gov Identifier no. NCT00123456). Clin Nutr
2009;28(6):618–24.
[20] Muller S, Zalunardo MP, Hubner M, et al. A fast-track program reduces complications
and length of hospital stay after open colonic surgery. Gastroenterology 2009;136
(3):842–7.
[21] Heiss KF, Raval MV. Patient engagement to enhance recovery for children undergoing
surgery. Semin Pediatr Surg 2018;27(2):86–91.
[22] Raval MV, Heiss KF. Development of an enhanced recovery protocol for children
undergoing gastrointestinal surgery. Curr Opin Pediatr 2018;30(3):399–404.
[23] Short HL, Taylor N, Piper K, et al. Appropriateness of a pediatric-specific enhanced
recovery protocol using a modified Delphi process and multidisciplinary expert
panel. J Pediatr Surg 2018;53(4):592–8.
[24] Short HL, Taylor N, Thakore M, et al. A survey of pediatric surgeons' practices
with enhanced recovery after children's surgery. J Pediatr Surg 2018;53(3):
418–30.
[25] Short HL, Heiss KF, Burch K, et al. Implementation of an enhanced recovery protocol
in pediatric colorectal surgery. J Pediatr Surg 2018;53(4):688–92.