Journal of pediatric surgery · 2025
Comparative outcomes of proximal stoma versus primary anastomosis in pediatric colorectal trauma.
СтатьяСравнительное исследованиеНазвание и аннотация: Перевод пока не подготовлен
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Giron Andreina, Flyer Zoe E, Dumitru Ana Maria, Ahmad Hira, Goodman Laura F, Nahmias Jeffry, Yu Peter T, Schomberg John
Аннотация
INTRODUCTION: Historically, fecal diversion via proximal stoma (PS) was an accepted option for pediatric colorectal trauma, but recent studies have suggested primary anastomosis (PA) to be safe. This study aimed to compare outcomes between PS and PA for pediatric colorectal trauma, hypothesizing PS will be associated with increased complications but lower mortality compared to PA in this population.
METHODS: A retrospective study using the National Trauma Data Bank (2018-2022) was conducted. Patients ≤18 years old with colon and/or rectal injury who underwent either PS or PA were included. PS was defined as fecal diversion using a stoma proximal to the colorectal injury; PA was defined as any colon and/or rectal anastomosis without proximal fecal diversion. Descriptive statistics, Kaplan-Meier curves and logistic regression were performed to compare outcomes.
RESULTS: A total of 3511 pediatric patients met inclusion criteria; 548 (15.6 %) underwent PS and 2963 (84.4 %) underwent PA. Demographics were similar between groups, though PS patients had higher median ISS (17 vs. 16, p = 0.0003) and more rectal injuries (46.7 % vs. 8.2 %, p < 0.0001). PS was associated with longer ICU (median 5 vs. 4 days, p < 0.0001) and total hospital stays (median 12 vs. 8 days, p < 0.0001), and higher rates of deep space SSI (2.4 % vs. 1.6 %, p = 0.05), return to OR (8.8 % vs. 4.7 %, p = 0.003), and mechanical ventilation use (41.9 % vs. 35.7 %, p = 0.006). Unadjusted mortality was lower with PS (2.6 % vs. 5.4 %, p = 0.0007), but multivariable analysis showed no mortality difference by diversion type; instead, colonic resection/excision independently increased mortality risk (OR 1.02, 95 % CI 1.00-1.05, p = 0.04). Kaplan-Meier analysis demonstrated higher survival with PS only in rectal injuries and in patients without resection, with no survival difference in other anatomic sites or among resection cases.
CONCLUSIONS: Despite longer hospitalizations and higher complication rates, PS patients demonstrated lower unadjusted mortality compared to PA. However, after adjustment, diversion type was not independently associated with mortality, and the need for colonic resection/excision emerged as a more important predictor of death. These findings suggest that previously observed survival advantages with PS may be driven by underlying injury severity and operative factors rather than diversion status alone. Prospective studies are warranted to clarify optimal surgical management for pediatric colorectal trauma, particularly in high-risk subgroups.
LEVEL OF EVIDENCE: III.
METHODS: A retrospective study using the National Trauma Data Bank (2018-2022) was conducted. Patients ≤18 years old with colon and/or rectal injury who underwent either PS or PA were included. PS was defined as fecal diversion using a stoma proximal to the colorectal injury; PA was defined as any colon and/or rectal anastomosis without proximal fecal diversion. Descriptive statistics, Kaplan-Meier curves and logistic regression were performed to compare outcomes.
RESULTS: A total of 3511 pediatric patients met inclusion criteria; 548 (15.6 %) underwent PS and 2963 (84.4 %) underwent PA. Demographics were similar between groups, though PS patients had higher median ISS (17 vs. 16, p = 0.0003) and more rectal injuries (46.7 % vs. 8.2 %, p < 0.0001). PS was associated with longer ICU (median 5 vs. 4 days, p < 0.0001) and total hospital stays (median 12 vs. 8 days, p < 0.0001), and higher rates of deep space SSI (2.4 % vs. 1.6 %, p = 0.05), return to OR (8.8 % vs. 4.7 %, p = 0.003), and mechanical ventilation use (41.9 % vs. 35.7 %, p = 0.006). Unadjusted mortality was lower with PS (2.6 % vs. 5.4 %, p = 0.0007), but multivariable analysis showed no mortality difference by diversion type; instead, colonic resection/excision independently increased mortality risk (OR 1.02, 95 % CI 1.00-1.05, p = 0.04). Kaplan-Meier analysis demonstrated higher survival with PS only in rectal injuries and in patients without resection, with no survival difference in other anatomic sites or among resection cases.
CONCLUSIONS: Despite longer hospitalizations and higher complication rates, PS patients demonstrated lower unadjusted mortality compared to PA. However, after adjustment, diversion type was not independently associated with mortality, and the need for colonic resection/excision emerged as a more important predictor of death. These findings suggest that previously observed survival advantages with PS may be driven by underlying injury severity and operative factors rather than diversion status alone. Prospective studies are warranted to clarify optimal surgical management for pediatric colorectal trauma, particularly in high-risk subgroups.
LEVEL OF EVIDENCE: III.