What is the risk of leakage after stoma closure in children using full thickness closure versus extra mucosal (peripheral mucosectomy) closure techniques?

Risk of Leakage After Stoma Closure in Children: Full Thickness vs. Extra Mucosal Closure

Full thickness closure technique has a lower risk of leakage after stoma closure in children compared to extra mucosal closure (peripheral mucosectomy), with evidence suggesting early closure (before 8 months) further reduces complication rates.

Comparison of Closure Techniques

Full Thickness Closure

• Involves closing all layers of the intestinal wall in a single procedure
• Associated with lower overall complication rates compared to extra mucosal techniques
• Primary closure does not increase infection rates compared to delayed primary closure 1
• Provides better structural integrity of the anastomosis

Extra Mucosal Closure (Peripheral Mucosectomy)

• Involves removal of the mucosal layer before closure
• May be associated with higher risk of leakage due to compromised tissue integrity
• More technically challenging, potentially leading to longer operative times
• Longer operative times (>105 minutes) independently predict higher surgical site infection rates 2

Risk Factors for Leakage and Complications

Patient-Related Factors

• Age: Older children have increased risk of surgical site infection (SSI) 2
• Underlying conditions:
  • Hirschsprung disease increases SSI risk 2
  • Cardiac risk factors independently predict SSI 2
  • Inflammatory bowel disease associated with higher readmission rates 3

Procedure-Related Factors

• Operative time >105 minutes significantly increases SSI risk 2
• Timing of closure: Closure before 8 months after primary surgery results in lower overall complication rates 4
• Male sex is associated with increased odds of major morbidity and reoperation 3

Complication Rates and Outcomes

• Overall complication rates after stoma closure range from 0% to 40% 2
• Most common complications include:
  • Postoperative ileus (10%) 4
  • Wound infection (5-6.2%) 4, 3
  • Anastomotic leakage
• Mortality rates are approximately 1.0-1.8% 4, 3

Prevention Strategies

Preoperative Considerations

• Optimize nutritional status before closure
• Ensure adequate bowel preparation
• Administer appropriate prophylactic antibiotics

Intraoperative Techniques

• Minimize operative time (aim for <105 minutes) 2
• Use full thickness closure technique when possible
• Ensure tension-free anastomosis
• Consider using a glycerin hydrogel or glycogel dressing for stoma site protection 5

Postoperative Management

• Monitor for signs of leakage: fever, abdominal pain, distension, or wound drainage
• Empty any pouches frequently to reduce pressure and potential leakage 5
• Apply zinc oxide-based skin protectants to the peristomal area to protect from leakage and irritation 5
• Consider early oral feeding to stimulate bowel function

Special Considerations

• For patients with ulcerative colitis, rectal mucosectomy with hand-sewn ileoanal anastomosis provides good functional results 6
• Eliminating routine diverting ileostomy in selected cases can avoid complications from the stoma and its closure 6
• For persistent irritation, apply stomal powder followed by skin sealant on the peristomal skin 5

Common Pitfalls to Avoid

• Delaying closure beyond 8 months after primary surgery 4
• Prolonged operative times increasing infection risk 2, 3
• Improper appliance fitting leading to leakage 5
• Inadequate protection during periods of increased output 5

By following these guidelines and selecting the appropriate closure technique based on patient characteristics, the risk of leakage after stoma closure in children can be minimized.