Childhood colostomies: patterns, indications and outcomes in a Nigerian University Teaching Hospital

Background: Most childhood colostomies are done for decompression or diversion in gastrointestinal tract congenital anomalies.Colostomy may be sited in the transverse or sigmoid colon as loop or defunctioning (divided) colostomies. Current pattern seems towards construction of more sigmoid and defunctioning colostomies. Aims: To evaluate the patterns, indications and outcomes of childhood colostomies. Patients and Methods: Retrospective chart review of all colostomies performed in children below 15 years from September 2010 to August 2020. Results: There were 104 colostomies (55males; 49females; 65 sigmoid; 39 transverse colostomies; 3 loop; 101 defunctioning colostomies. Anorecatal Malformation (ARM)was indication in 32 males and 41 females; age range 2 days to 13 years. Hirschsprung’s Disease (HD) was indication in 18 males and 4 females; age range 6 weeks to 15 years.In HD there were three loop colostomies (3/22) in transverse colon and 19 defunctioning colostomies (8 sigmoid, 11 transverse) while in ARM all 73 were defunctioning colostomies(P=0.01) In HD there were 14/22 transverse colostomies and 8/22 sigmoid colostomies while ARM had 24/73 transverse and 49/73sigmoid colostomies (P =0.013) In HD 91% colostomies were done beyond infancy while in ARM 93% were before one year(P<0.0001). Mortalities were notedin 1.9% patients. Conclusion: Commonest indication for colostomy is ARM. There are more defunctioning than loop colostomies, and more sigmoid than transverse colostomies. of most colostomies in ARM were during infancy while mostly beyond infancy in HD. Keywords: Childhood colostomies; oatterns; indications; outcomes

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030