Early Versus Late Stoma Reversal in Children Presenting with Acute Abdomen

By Abdullah Khan, Muhammad Bilal Mirza, Nabila Talat

Affiliations

1. Department of Paediatric Surgery Unit II, The Children's Hospital and University of Child Health Sciences, Lahore, Pakistan

doi: 10.29271/jcpsp.2025.08.1036

ABSTRACT
Objective: To determine the morbidity e.g., anastomotic leakage and wound infections, in children enduring early (same-admission) vs. late (routine-interval) stoma reversal.
Study Design: A quasi-experimental study.
Place and Duration of the Study: Department of Paediatric Surgery Unit II, The Children’s Hospital and University of Child Health Sciences, Lahore, Pakistan, from February 2022 to March 2023.
Methodology: This study enrolled 60 patients with an emergency temporary stoma, using a non-probability consecutive sampling technique. Among them, half of the patients (n = 30) underwent early stoma reversal (Group A), while the remaining half underwent the procedure after a routine interval of 2 months or more (Group B). The frequencies of anastomotic leakage and surgical site infection were compared using the Chi-square test.
Results: In this study, 60 temporary ileostomy stomas were reversed. The group that underwent same-admission reversal compromised comparatively younger patients (median: 12 vs. 66 months). Both groups had mostly male patients. Operative time was also comparable in both groups. No cases of anastomotic leakage were observed in either group. The overall wound infection rate was similar in both groups; however, more patients in the routine-interval stoma reversal group experienced minor wound infections, Southampton Grade I and II.
Conclusion: Stoma reversal during the same admission has shown a comparable rate of anastomotic leakage, surgical site infection, and operative time. Patients with an emergency temporary stoma can undergo stoma reversal in the early postoperative period without any major risk of complications.

Key Words: Early stoma reversal, Routine interval stoma reversal, Surgical site infection, Anastomotic leak.

INTRODUCTION

In operations for acute abdominal emergencies, the creation of intestinal stomas may be required when primary anastomosis is unsafe.¹ Stoma creation is linked to a considerable morbidity, and stoma-related complications are reported in over 25% of patients with a stoma, including bleeding (2%), skin excoriation (5%), stoma retraction (7%), prolapse (42%), parastomal hernia (2%), and stenosis (12%). Moreover, factors such as the uses and expenses of stoma devices and social and psychological issues significantly impact the patient's quality of life.^1,2

Principally, the stoma should be closed as soon as the indication of its formation is over; however, its closure during the first few weeks of formation needs to be elucidated, especially in children with an acute abdomen.³

Some recommend its closure after a conventional period of 2-3 months, while others close them after a few days of their creation.^3-6 No specific guidelines are available on when to close these temporary stomas in children, as available literature largely addresses the adult population.^3-5 This study was carried out to determine the outcome of early versus delayed stoma reversal in patients with a temporary stoma, based on the hypothesis that a temporary stoma can be reversed in the early postoperative period without causing additional harm.

METHODOLOGY

This quasi-experimental study was conducted at the Department of Paediatric Surgery Unit II, The Children's Hospital and University of Child Health Sciences, Lahore, Pakistan, from February 2022 to March 2023. Ethical approval was obtained from the Institutional Review Board of the Children’s Hospital, Lahore, Pakistan. The study was also approved by the Advanced Studies and Research Board (ASRB) of the University of Health Sciences (UHS), Lahore, Pakistan. Informed written consent was obtained from the parents of the patients.

The study included a total of 60 cases. Out of these, 30 cases in Group A underwent stoma reversal during the same admission (early). In comparison, the remaining 30 cases in Group B had their stoma reversed at least two months after its formation (late). The inclusion criteria for Group A were children aged between 1 month and 14 years, for whom a primary anastomosis was considered risky by the emergency paediatric surgery team, and a stoma was formed due to acute abdominal conditions such as intestinal perforation or intestinal gangrene. In Group B, children were enrolled if a routine interval of two months or more had passed since stoma formation for the same indications as in Group A. Children in whom the stomas were formed for congenital anomalies (Hirschsprung’s disease, anorectal malformations), anal sphincter injury, severely malnourished, as well as those who are haemodynamically unstable, had septicaemia, or experienced iatrogenic serosal tears during the first surgery were excluded from the study. Patients who developed wound infections after the first surgery in Group A were also excluded.

Patients in Group A were initially cared for in the postoperative area. Once they were stable, had resumed stoma function, and could tolerate a full diet, discussions regarding the reversal option held with their legal guardians. For patients residing in the nearby locality, a temporary leave was granted without formal discharge, accompanied by vigilant monitoring. Subsequently, these individuals were contacted after a few days to ensure their inclusion in the elective list.

Outcome variables included anastomotic leakage and surgical site infection (SSI). Anastomotic leakage was suspected clinically and was confirmed with an x-ray and ultrasound of the abdomen. Surgical site infection was graded with the Southampton wound grading system.

Patients were transferred to the surgical wards following the surgery, and postoperative care was initiated based on the hospital guidelines. The patients were evaluated daily for complications and discharged once they became orally free and started passing stools normally.
 

Demographic information, indication and operative findings of the first surgery, and variables of stoma reversal, including operative time, length of stay, rate of SSI, and anastomotic leaks, were recorded on a proforma.

Data were analysed using the SPSS version 26. The quantitative variables, such as age and weight, were summarised using the median (IQR: Interquartile range). Qualitative variables, including gender, wound infection, and anastomotic leak, were presented as frequency and percentage. The Chi-square test was applied to compare the categorical outcome variables. Whereas, the Mann-Whitney U test was used to compare continuous outcome variables, as the data were non-normally distributed according to the Shapiro-Wilk test. A p-value of ≤0.05 was considered statistically significant.

RESULTS

The patients undergoing stoma reversal during the same admission (Group A) were significantly younger with male pre-ponderance compared to those in whom stomas were reversed after a routine interval (Group B), as illustrated in Table I.

The most common causes of stoma formation were intussusception (53.3%) and band obstruction (18.3%). Table II depicts the indication of stoma formation in both groups.

In 47 patients, divided ileostomy stomas and 13 loop ileostomy stomas were reversed. In all cases, the operation of stoma reversal was performed through the stoma wound, and in only a few cases the laparotomy incision was reopened.

The median postoperative day for stoma reversal in the same admission group was 18 days (IQR: 2). The median interval between stoma formation and stoma reversal in the routine-interval group was 124 days (IQR: 217). 

Operative time was comparable in both groups, and no unusual difficulties were encountered in patients of either group (median operative time: 90 minutes vs. 91.5 minutes, p = 0.882). No anastomotic leakage was observed in either group.

Table I: Comparison of variables in both groups.
 

Study variables	Same-admission reversal group (Group A)	Routine-interval reversal group (Group B)	p-values
Median age (months)	12 months, IQR: 32.25	66 months, IQR: 96	<0.005*
Median weight (kgs)	9 kg, IQR: 7.25	15 kg, IQR: 12	0.010*
Gender distribution (male, female)	22 (73.3%), 8 (26.7%)	23 (76.7%), 7 (23.3%)	>0.99**
Median operative time (min)	90 minutes, IQR: 9	91.5 minutes, IQR: 10.5	0.882*
Anastomotic leakage (frequency)	Nil	Nil	NA
SSI (frequency)	21 (70%)	30 (100%)	0.016**
Significant grade SSI#	9 (30%)	8 (26.7%)	>0.05**
*Mann-Whitney U test, **Chi-square test, #Southampton grade IIA to V.

Table II: Aetiology of stoma formation.

Diagnoses	Study groups		Total
	Same-admission stoma reversal	Conventional stoma reversal
Intussusception Band obstruction Perforated Meckel’s diverticulum Blunt abdominal trauma Obstructed hernia Perforated appendix	20	12	32
	3	8	11
	3	5	8
	2	4	6
	1	1	2
	1	0	1
Total	30	30	60

In this study, the routine interval stoma reversal group exhibited a higher incidence of minor wound infections (Southampton SSI grades I and II). Nevertheless, the occurrence of more severe grades of wound infections was comparable in both groups, with frequencies of SSI Southampton grades IIA-V recorded as 9 in the same-admission group versus 8 in the routine-interval group (Table I).

All patients with wound infections were successfully managed with wound care and dressings, and no additional major surgical interventions were deemed necessary for any of the cases.

DISCUSSION

This study investigated the outcomes of stoma reversal in patients with a temporary ileostomy, comparing cases where the reversal occurred within a few days of its creation to those where it was performed after a routine interval. The study revealed no discernible differences in terms of anastomotic and wound complications between the two stoma reversal strategies, as no anastomotic leakage occurred in either group, and the frequency of significant wound infections (Southampton Grade IIA to V) was also comparable (9:8, Table I).

Temporary stomas are often created in cases of acute abdomen, and numerous factors prompt surgeons to favour a stoma over primary anastomosis.⁶ Additionally, in the emergency settings, where a significant proportion of emergency surgical procedures are performed by trainees, the choice of creating a stoma over a primary anastomosis may also be influenced. Regardless of the initial indication, these stomas should be reversed once the patients' clinical conditions stabilise. In the present study, over half of the patients had temporary stomas due to intussusception. While this may indicate a delayed presentation or referral, these patients generally exhibit good health post-stoma formation. Therefore, early stoma reversal is advisable to mitigate potential issues associated with stoma maintenance.

How early a stoma can be reversed is not well-established. Various authors closed temporary stomas as early as one week to four weeks after the creation of the stoma.^7-11 However, a conventional duration before stoma reversal is considered to be 8-12 weeks. The same admission reversal refers to the closure of the stoma during the admission for stoma creation.^4,5 Early reversals in this study were considered as the same-admission reversal, as patients were granted temporary leave rather than being discharged before stoma reversal. In this study, stomas were typically reversed to a median of 18 days after stoma creation in the same-admission reversal group.

While early reversal holds promise in reducing stoma-related complications,^5,6 it is crucial to ensure its safety, especially in children, as existing literature on early or same-admission reversal primarily focuses on adults.^3-5,7 The absence of proper paediatric studies underscores the importance of the present research, which contributes valuable data on the safety and outcomes of early stoma reversal in children with temporary stomas.

Most available studies on early or same-admission reversal documented comparable complication rates with the conventional duration stoma reversal.^3,5,7 Only a few studies documented more wound infections in the early reversal group.⁴ The present study did not encounter any anastomotic leakage in either group. Interestingly, in this study, the overall wound infection rate was higher in the routine- interval group, however, on comparing the significant grade infection as per the Southampton wound grades (IIA-V), the wound infection rate was comparable.

The question of whether all cases of temporary stoma can be reversed early lacks a definitive answer in the available literature. However, to ensure patient safety, the practice of early stoma reversal during the same admission should be approached with caution. In this study, a more cautious approach was adopted, and early stoma reversal was avoided in patients with signs of sepsis and those with poor nutritional status (Hb <8g/dl, albumin <2.5 g/dl). Additionally, a more conservative approach was adopted by not performing early stoma reversal in patients who had undergone another anastomosis or repair of multiple serosal tears. It is worth noting that some authors have reported the early closure of covering stomas without raising additional safety concerns.^3,4,12

A small sample size, short study duration, single-centre study, and non-randomised experimental design are the main limitations of the present study. Only a limited number of studies have focused on early stoma closure in children—in cases with necrotising enterocolitis (NEC).^13-15 Furthermore, only one reported case involves a temporary stoma created for intestinal gangrene resulting from internal herniation of the small bowel in a child.⁶ The authors recommend conducting multicentre randomised controlled trials (RCTs) on the early reversal of temporary stomas in children. Despite its limitations, the strength of this study lies in its contribution of valuable data on the early closure of temporary stomas in paediatric patients.

CONCLUSION

The outcomes for children undergoing stoma reversal within the same admission are comparable to those undergoing reversal after a routine interval. Study outcomes such as operative time, anastomotic leakage, and significant wound infection grades show no significant differences between the two groups. Early stoma reversal is therefore recommended in carefully selected patients who are in good health and deemed fit for stoma reversal during the early postoperative period.

ETHICAL  APPROVAL:
Ethical approval was obtained from the Institutional Review Board of the Children’s Hospital, Lahore, Pakistan.

PATIENTS’  CONSENT:
Informed written consent was obtained from the parents of the patients.

COMPETING  INTEREST:
The authors declared no conflict of interest.

AUTHORS’  CONTRIBUTION:
AK: Conception, design of the work, analysis, interpretation of data, drafting, and revision of work.
MBM: Conception of work and drafting.
NT: Designing and revision of the work.
All authors approved the final version of the manuscript to be published.

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