Colonic stenosis in pediatric population: a retrospective study

doi:10.21203/rs.3.rs-3198346/v1

Background

Colonic stenosis is a rare disease in pediatric populations, it may lead to a serious intestinal obstruction. Necrotizing enterocolitis (NEC) is one of the reasons that lead to the non-congenital colon stenosis. In the present study, we display our experience and findings for the pediatric colonic stenosis to explore the general feathers and outcomes of the colonic stenosis are essential for surgeons to make a better choice for individual therapy.

Methods

This is a retrospective study of patients who diagnosed as colonic stenosis from January 2018 to December 2022 at Wuhan children’s hospital. We divided the patients into the NEC group, suspected-NEC group and Non-NEC group. Patients clinical characteristics including symptoms, risk factors, surgical procedure, pathology, hospital stay and postoperative outcomes were collected and analyzed. Patients were followed up for 6 months to 2 years for any gastrointestinal symptoms. Statistical analysis was performed using SPSS 28.0 software.

Results

Total of 30 patients was enrolled in this study. There were 16 patients in the NEC group, 7 patients in the suspected-NEC group, and 7 patients in Non-NEC group. The male to female ratio was higher in the NEC group. There was more premature infants in NEC group. The weight in NEC and suspected-NEC group was lower than Non-NEC group. There were more artificial feeding cases in NEC group. The hospital stay in NEC group was longer for the first administration. Next, we observed postoperation complications and found 2 patients had wound infection and 1 patient had adhesive ileus and 1 patient had anastomosis stenosis in NEC group, 1 patient had would infection in suspected-NEC group, and 1 patient had would infection in Non-NEC group. For follow up, 2 patients had intestinal obstruction and 3 patients had colitis in NEC group, 1 patient had bloody stool in suspected-NEC group, and 1 patient had an intestinal obstruction in Non-NEC group, all of them cured after conservative therapy.

Conclusions

Artificial feeding, NEC and bowel inflammation are the important risk factors for stenosis.

Necrotizing enterocolitis

colon stenosis

clinical feathers

outcomes

Artificial feeding

bowel inflammation

Colonic stenosis is a rare disease in pediatric populations, it may lead to a serious intestinal obstruction. Aganglionosis or intestinal neuronal dysplasia, which with the feathers of lack of ganglion cells or immature of ganglion cells, can lead to intestine stenosis in pediatrics [1]. In addition, ischemia during the intestinal development is another risk factors for colon stenosis [2, 3]. Beyond these congenital factors, necrotizing enterocolitis (NEC) can also lead to the non-congenital colon stenosis [3, 4]. To explore the general feathers, pathological findings and outcomes of the colonic stenosis with different pathogenesis are essential for surgeons to make a better choice for individual therapy, in the present study, we display our experience and findings for the pediatric colonic stenosis.

This is a retrospective study of patients who diagnosed as colonic stenosis from January 2018 to December 2022 at Wuhan children’s hospital. The study complied with the Declaration of Helsinki and was approved by the Review Board of Ethics Committee of Wuhan children’s hospital (Number: WCH-20180152). The children’s caregivers were informed about the study and they provided written informed consent.

Aganglionosis or Hirschsprung's disease is a common disease that leads to the colon stenosis, we exclude these cases from our study due to their specific management. Considering NEC is an important risk factor for colonic stenosis, we divided the patients into the NEC group, suspected-NEC group and Non-NEC group. Patients clinical characteristics including symptoms, risk factors, surgical procedure, pathology, hospital stay and postoperative outcomes were collected and analyzed. Patients were followed up for 6 months to 2 years for any gastrointestinal symptoms. The typical initial diagnosis of NEC complied with the Bell’s criteria and divided into suspected-NEC and NEC [5]. Abdominal signs such as abdominal distention, emesis, heme-positive stool or grossly positive stool, systemic signs including temperature instability, bradycardia, lethargy, radiographic signs such as normal or mild intestinal dilation were classified as suspected-NEC, with more and serious symptoms including but not limited to bowel sounds, abdominal tenderness, metabolic acidosis and thrombocytopenia, pneumatosis intestinalis were diagnosed as NEC.

Statistical analysis was performed using SPSS 28.0 software. The counting data was described by the rate, and the measurement data were described by the mean ± standard deviation. For independent variables, variance analysis was used for normal distribution, Krushul-Wallis rank sum test was used for non-normal distribution, chi-square test was used for counting data. The difference was statistically significant with P < 0.05.

Total of 30 patients aged from 2 days to 9 months was enrolled in this study. There were 16 patients in the NEC group, 7 patients in the suspected-NEC group, and 7 patients in Non-NEC group. Demographic data and preoperative characteristics were presented in Table 1 and Fig. 1. The male to female ratio was higher in the NEC group than that of suspected-NEC and Non-NEC group. There was more premature infants in NEC group as compared with suspected-NEC and Non-NEC group. The weight in NEC and suspected-NEC group was lower than Non-NEC group. As feeding patterns are important factors that may affect infants intestinal function, we found that there were more artificial feeding cases in NEC group, while more breast feeding in suspected-NEC group.

As showed in Table 2, a total of 15 patients experienced surgery in the NEC group including 7 patients accepted staged operation, the other one accepted conservation therapy. 5 patients had surgery in suspected-NEC group, 2 patients accepted conservation therapy. 3 patients had surgery in Non-NEC group with 1 patient accepted staged operation, 4 patients accepted conservation therapy. Pictures of surgical stenosis specimen were shown in Fig. 2, ascending colon and descending colon were identified as the most common stenosis sites in the NEC patients. In suspected-NEC and Non-NEC group, the most common stenosis sites located in transverse colon. The average bowel resection length from long to short ranged as NEC, suspected-NEC group and Non-NEC group, respectively. The hospital stay in NEC group was longer than suspected-NEC group and Non-NEC group for the first administration, but there was no difference between the NEC group and Non-NEC group for the second admission. For the operation time, there was no difference between the NEC group and suspected-NEC group, while both of them were higher than Non-NEC group, there was no difference between NEC group and Non-NEC group for the second operation. The pathological findings were shown in Fig. 3, 14 patients had normal ganglion cell and 1 patient with neuronal dysplasia in NEC group, 4 patients had normal ganglion cell and 1 patient with neuronal dysplasia in suspected-NEC group, 3 patients had normal ganglion cell in Non-NEC group. We found that 15 patients, 4 patients and 3 patients had bowel inflammation in the NEC group, suspected-NEC group and Non-NEC group respectively. Next, we observed postoperation complications and found 2 patients had wound infection and 1 patient had adhesive ileus and 1 patient had anastomosis stenosis in NEC group, 1 patient had would infection in suspected-NEC group, and 1 patient had would infection in Non-NEC group.

For follow up, 2 patients had intestinal obstruction and 3 patients had colitis in NEC group, 1 patient had bloody stool in suspected-NEC group, and 1 patient had an intestinal obstruction in Non-NEC group, all of them cured after conservative therapy.

Gastrointestinal tract is an important system with complex organization structure, any structural and functional abnormalities may affect body healthy [6]. Colonic stenosis is a serious disease that can destroy the intestine structure and lead to serious outcomes including ileus, shock, and even death. In this study, we found that NEC and suspected-NEC are the major causes for pediatric colon stenosis, surgical resection is the main treatment for colonic stenosis.

Colonic atresia and stenosis are rare disease in pediatric with 1 in 20,000 live births and comprise about 1.8–15% of intestinal atresias [7]. Mesenteric vascular accidents during fetal development is an acceptable explanation for colonic stenosis, failure of recanalization, cystic fibrosis, aganglionosis, and neuronal dysplasia can also lead to congenital stenosis [7, 8]. NEC, congenital cytomegalovirus infection, antibiotic-related colitis, inflammatory bowel disease are the risk factors that may cause non-congenital colon stenosis [9–12]. We identified that more than half stenosis patients suffered from NEC, the lower age and weight, premature infants and artificial feeding are the risk factors in those NEC related stenosis. The artificial feeding (pH, bacterial counts, host defense factors and nutrients) is apt to affect gut environment and may destroy intestinal barrier [13].We observed much more artificial feeding in Non-NEC patients. Collectively, in our observation, the NEC and artificial feeding may be risk factors for non-congenital colon stenosis.

Gastrointestinal symptom such as abdominal distension, vomiting, and constipation are highly suspected for colon stenosis[10, 14], in our study, nearly all patients had above symptoms. Except mild colon stenosis or Non-NEC stenosis patient who would accept conservative therapy, most patients need surgical treatment. While in these serious infection or multiple stenosis, staged operation should be considered, during reoperation, the distal free bowel can recurrence stenosis, so the surgeons should pay more attention and carefully exam the bowel condition. The hospital stay, operation time and bowel resection length are longer in NEC associated stenosis, and more patients had postoperative complications in NEC associated stenosis, suggesting that the outcomes in the NEC related stenosis are more serious.

We next found that the stenosis site located mainly in ascending colon and descending colon in NEC patients. Anatomically, the ascending and descending colon are separately supplied by the superior and inferior mesenteric artery, any mesenteric vascular accidents may easy affect the colon blood supply[15]. Moreover, nearly all NEC related stenosis had bowel inflammation, indicated that blood supply and inflammation events may contribute to the NEC related stenosis. While in suspected-NEC and Non-NEC patients, the stenosis site happened mainly in transverse colon, this colon has double blood supply from superior mesenteric artery and inferior mesenteric artery, and can maintain sufficient oxygen and nutrition [15]. We also found the majority patients had bowel inflammation, which is line with previous study that a colon stricture coexisting with active inflammation, indicating that intestine inflammation is highly correlated with colon stenosis [10].

Colonic stenosis seriously threatened the pediatrics health. Artificial feeding, NEC and bowel inflammation are the important risk factors for stenosis. Even if surgery can treat colon stenosis, choosing the best operative way and pay attention to every detail in the operation could reduce the complications of the colon stenosis.

NEC, Necrotizing enterocolitis

Ethics approval and consent to participate: The study complied with the Declaration of Helsinki and was approved by the Review Board of Ethics Committee of Wuhan children’s hospital (Number: WCH-20180152). The children’s caregivers were informed about the study and they provided written informed consent.

Consent for publication: Not applicable

Availability of data and materials: All data generated or analysed during this study are included in this published article.

Competing interests: The authors declare that they have no competing interests

Funding: Children's Hepatobiliary and Pancreatic Diseases Research Laboratory Fund (2022FEYJS004)

Authors' contributions: XC, XY and NZ collected the data, conceived and drafted the initial manuscript. HL, QY, XQ and XD co-designed the project. XC revised the manuscript. All authors approved the final manuscript as submitted.

Acknowledgements: Not applicable

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Table 1. Patients clinical characteristic.

Characteristics	NEC	suspected-NEC	Non-NEC	P
Cases	6 (53.3%)	7 (23.3%)	7 (23.3%)
Male:Female	9:6	4:3	3:4	0.000
Age (days)	47.5±58.0	62.8±30.0	77.8±59.4	0.000
Pregnancy (< 37 weeks)	6 (37.5%)	2 (28.5%)	2 (28.5%)	0.000
Weight (kg)	2.74±0.84	2.64±0.94	3.12±0.66	0.000
Feeding patterns Artificial feeding Mix feeding Breast feeding	9(56.3%) 5(31.2%) 2(12.5%)	1(14.3%) 2(28.6%) 4(57.1%)	3(42.8%) 2(28.6%) 2(28.6%)	0.000

Table 2. Operation and pathological findings.

Characteristics

NEC

suspected-NEC

Non-NEC

P

Stenosis location

Ascending colon

Transverse colon

Descending colon

Sigmoid colon

Multiple stenosis

6

1

6

1

2

1

3

2

0

1

2

3

1

0

0.000

Conservation treatment

Surgery treatment

1

15

2

5

4

3

0.000

Readmission patients

7(43.75%)

0(0%)

1(14.28%)

0.000

Hospital stay(days)

First admission

Second admission

21.2±8.3

17.5±9.4

19.4±8.0

-

16.4±13.1

150

0.054

0.000

Operation time(minutes)

First admission

Second admission

116.7±46.0

151.4±55.9

125±47.7

-

98.3±7.6

150

0.000

Bowel resection length(cm)

12.4±5.3

9.6±3.6

7.0±2.6

0.000

Pathological findings

Ganglion cell

Normal

Dysplasia

Bowel inflammation

Mucosal ulcer

14

1

15

3

4

1

4

3

-

3

1

0.014

0.000

Complications

Would infection

Adhesive ileus

Anastomosis stenosis

2

1

-

1

-

0.094

0.000

No competing interests reported.

Colonic stenosis in pediatric population: a retrospective study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Results

Discussion

Conclusions

List of abbreviations

Declarations

References

Tables

Additional Declarations

Status:

Version 1