When is enterostomy closure performed in the surgery for necrotizing enterocolitis (NEC)?

Updated: Dec 27, 2017
  • Author: Shelley C Springer, JD, MD, MSc, MBA, FAAP; Chief Editor: Muhammad Aslam, MD  more...
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Answer

Timing of enterostomy closure to restore intestinal continuity is the principal follow-up issue for infants who are surgically treated for NEC. This procedure is generally performed 1-2 months after the original operation, depending on weight gain and ostomy output, among other factors. The argument against early ostomy closure is the difficulty of operating in a peritoneal cavity replete with adhesions and resolving inflammation; the ideal time is approximately 8 weeks.

If goal enteral feeds can be accomplished, there is some benefit in discharging the patient home and performing a reanastamosis after several months. This gives the infant a chance to grow and better tolerate an additional laparotomy.

Abnormally high ostomy output may indicate a need for early ostomy closure. A patient with a high jejunostomy may have substantial loss of fluid and electrolytes, with consequences such as failure to thrive and peristomal skin injury. These patients may benefit from early ostomy closure with attendant colonic water absorption.

However, infants with a high ostomy and extensive ileal resection who undergo ostomy closure may have considerable secretory diarrhea after the colon comes in contact with unabsorbed bile salts. They may require treatment with a bile salt–binding agent, such as cholestyramine. Sodium chloride supplementation (1-3 mcg/kg/day) has been recommended to optimize growth in infants with small-bowel stomas.

All patients who have any remaining large intestine after an initial operation for NEC must be examined with contrast-enhanced enema of the colon to identify any areas of stricture before the ostomy is closed. If any such areas are present, they are resected when the enterostomy is closed. In addition, some advocate a screening contrast enema study approximately 30 days after recovery in infants who have been nonoperatively treated for NEC. Symptomatic colonic strictures require treatment, whereas asymptomatic strictures may be observed.


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