Cir Cir 2013;81:548-555.

Evidence-based improvements in elective bowel

anastomoses in children
Roberto Dvila-Prez, Eduardo Bracho-Blanchet, Emilio Fernndez-Portilla,
Jos Manuel Tovilla-Mercado, Cristian Rubn Zalles-Vidal, Jaime Nieto-Zermeo

Abstract

Background: Prior to the year 1993, the gold standard treatment in elective bowel anastomosis was two-layer anastomosis, use of
nasogastric tube for draining, and initiation of oral intake after the 5th day. These were controversial topics; therefore, we designed
several clinical trials to resolve these questions.
Results: We demonstrated that one-layer anastomosis in elective bowel anastomoses showed the same risk for complications than
two-layer anastomosis, but we used less surgical and anesthetic time to perform the one-layer procedure. We showed in an equivalence
study that the use of nasogastric tube does not confer any protective factor against surgical complications. Currently, we do not use
the nasogastric tube after an elective bowel anastomosis in our hospital. Finally, we demonstrated that enteral feeding can be safely
initiated before the 5th day after an elective bowel anastomosis. In another study we reduced the rate of surgical infections in elective
bowel anastomosis using a quality improvement model, showing that standardized perioperative surgical steps are important in the
treatment of our patients.
Discussion: Before 1993, the therapeutic gold standard in elective bowel anastomoses was based on a traditional, more than scientific
knowledge. Using clinical trials we changed the empirical-based routines instead of evidence-based improvements in pediatric bowel
anastomoses.
Conclusions: With all the evidence-based improvements, we changed our treatment protocol to benefit our patients.

Key words: Bowel anastomosis, children, evidence-based medicine.

Introduction mosis is a procedure with multiple potential complications,

Elective intestinal anastomosis is a frequently used surgical
procedure in pediatric surgery. This option is used to resto-
re intestinal continuity (ileostomy or colostomy closure),
resolve an inflammatory disease or functional or anatomic
congenital malformation of the colorectal region. In our
hospital there are ~40-60 surgical procedures performed
each year for closure of stomas. Because intestinal anasto-
Departamento de Ciruga General Peditrica, Servicio de Ciruga
Colorrectal, Hospital Infantil de Mxico Federico Gmez, Mexico, D.F.,
Mexico
Correspondence:
Dr. Roberto Dvila Prez
Hospital Infantil de Mxico Federico Gmez
Departamento de Ciruga General Peditrica
Dr. Mrquez 162
06720 Mxico, D.F., Mexico
Tel: 5552289917 ext. 2208, FAX: 5557618974
E-mail: robdape001@gmail.com
Received: 4-8-2013
Accepted: 6-28-2013
we decided to analyze the process and design a series of
investigation protocols in order to improve the technique
and its performance. This study demonstrates our experien-
ce and results in intestinal anastomosis.
In the Hospital Infantil de Mxico Federico Gmez (HI-
MFG) the therapeutic referral pattern in the pre-, intra- and
postoperative period of elective intestinal ileum and colon
anastomosis up to the year 1993 included:
Closure of the anastomosis: total preoperative in-
testinal cleansing with basic diet, enemas and crys-
talloid and povidone-iodine solutions at 10% at
both ends. There was no preparation for closure of
the ileostomy.
Broad spectrum antibiotics (clindamycin and
amikacin) therapy for 5 to 7 days, immediately af-
ter the anastomosis.
Surgical prep with povidone-iodine foam 10% in
various passes with standard technique in the intes-
tinal stomas before closure of the stoma with silk
sutures.
Anastomosis in two layers with absorbable mate-
rial in all anastomoses.
Treatment of the surgical wound with povidone-
iodine foam every 24 h in the postoperative period.

516 Ciruga y Cirujanos

Elective bowel anastomoses in children
Obligatory fast for a minimum of 5 days from the
surgery.
Obligatory gastric drainage tube during the 5 days
of fasting.
Gastric drain tube is clamped for 3 h on the fifth
day and, if no complications such as abdominal
pain, abdominal distention or vomiting are repor-
ted, it is removed and progressive oral feeding is
begun with liquids progressing to a bland diet.
Hospital discharge after tolerance to oral feeding is
demonstrated.
Is Intestinal Anastomosis in Two Layers Necessary?
According to Kerr, intestinal anastomoses in a single layer
were described for the first time by Lembert in 1826. In
1881 Czemy described the need to perform a second layer
with sutures on the grounds of at least two possibilities of
anastomotic leaks. Since that time, intestinal anastomosis
in two layers is considered adequate.1 In 1973, Irving et al.2
showed in a methodologically adequate study that there is
no difference in performing an intestinal anastomosis in one
layer or two in adult patients. Until 1992, intestinal anasto-
mosis in two layers was considered to be the therapeutic
technique of choice in children, without any experimental
clinical trials to demonstrate this.
The authors of this paper inquired about the need for all
intestinal anastomoses to be done in two layers. For this,
Ordorica Flores et al.3developed, at the HIM, a prospecti-
ve, controlled, randomized and comparative research pro-
tocol between 1993 and 1996, which included all pediatric
patients requiring elective intestinal anastomosis. High-
risk patients were excluded (neonates, duodenal or rectal
anastomosis, those who required enteroplasty or who had
bypass proximal to the anastomosis). Once in the operating
room, patients were randomly assigned via sealed envelope
to an experimental group (in one plane with simple sutures)
and to a control group (two planes, the first with Connel-
Mayo sutures and the second with Lembert sutures), both
with polyglactin910, 4-0 or 5-0. Follow-up was done by a
physician who was blind to the type of intestinal anastomo-
sis done. All patients were treated in a standardized manner
with obligatory fasting and gastric drain tube for 5 days and
clindamycin and amikacin for 7 days. When fasting was
completed, the gastric drain tube was removed and feeding
was progressively begun. After hospital discharge, patients
were scheduled for follow-up each month.3
Demographic variables and pre-, intra-, and evolution
were analyzed. There were 86 patients included in the study
(42 in the experimental group and 44 in the control group).
Both groups were statistically comparable in terms of de-
Volume 81, No. 6, November-December 2013 517
mographic and preoperative variables (age, nutritional sta-
tus, severity of disease, bowel prep, segment of intestine
anastomosed, baseline diagnosis).3
The average surgical time was significantly shorter in
the experimental group (26 vs. 43 min). No patient expe-
rienced stenosis of the anastomosis and the incidence of
intestinal fistulas was 5.8% (1-35% in the scientific litera-
ture) without showing a statistically significant difference
between groups. On stratifying the patients with fistulas vs.
confounding variables (urgent surgery, malnutrition, bowel
prep, severity of the disease and location of the anastomo-
sis) there was also no statistically significant difference.3
In conclusion, this study demonstrates that intestinal
anastomosis in one layer in a controlled population has
the same percentage of complications as the technique in
two layers. The advantage of a one plane technique is that
it is carried out faster, with less consumption of surgical
supplies and exposure to anesthetic.3
Is the Routine Use of Gastric Drainage Tube after
Elective Intestinal Anastomosis Necessary?
The gastric drainage tube was described for the first time
in 1821 by Levine as a method of decreasing abdominal
distention caused by air and secretions during the postope-
rative period of abdominal surgeries.4 Since that time and
until some years ago it was routinely used after abdomi-
nal surgeries in children and adults so as to prevent nau-
sea, vomiting, pulmonary complications and to decrease
the possibilities of fistulas, wound complications and days
of hospital stay. Since the mid-20th century, reports exis-
ted in the world literature against this routine, especially
in adult patients. With clinical studies that were well done
methodologically, including a meta-analysis, it was de-
monstrated that the gastric drainage tube is not only un-
necessary, but potentially harmful.5-10 For this reason many
general surgeons worldwide have changed its routine use,
whether to shorten the time it remains in place or to elimi-
nate its use.11,12 The routine use of the gastric drainage tube
in the postoperative period of abdominal surgery has been
little explored in children and the few studies reported in
the scientific literature are methodologically inadequate to
assess its usefulness in preventing postoperative complica-
tions in children. It is traditionally believed that pediatric
patients ingest large quantities of air during the immediate
postoperative period due to crying and that the gastric dra-
inage tube prevents complications secondary to gastric or
intestinal overdistention.12,13
For this reason, until the year 2000 our therapeutic refe-
rence pattern in the postoperative period of elective intes-
tinal anastomosis was to leave a gastric drainage tube for

a minimum of 5 days. To evaluate the role of the gastric
drainage tube in the prevention of abdominal complications
in pediatric patients who underwent intestinal anastomosis,
we performed a surgical clinical trial (prospective, rando-
mized and controlled).
We conducted an equivalence study that included all pe-
diatric patients who required intestinal anastomosis (ileum
and colon), those at high risk were excluded such as infants,
biliodigestive or rectal anastomosis, immunosuppressed,
and with bypass proximal to the anastomosis, chronic intes-
tinal obstruction or those who required an enteroplasty (ta-
pering) and who did not meet with a minimum of 1 month
postoperative follow-up. Demographic and intraoperative
variables were analyzed (age, weight, gender, nutritional
status and diagnosis and surgeon category, surgical time
and location of the anastomosis).
Based on the prior study,3 all intestinal anastomoses were
performed in one suture layer. The follow-up variables to
consider the equivalencies were start of peristalsis, bowel
movements, complete oral diet and postoperative hospital
stay. Variable complications were mild or persistent vomi-
ting, persistent abdominal distention, wound infection and
wound dehiscence or of the intestinal anastomosis, gas-
trointestinal bleeding and gastrointestinal problems in pa-
tients who were neurologically competent to report it.14
Because it was a controlled study, all patients were
routinely treated preoperatively with a double scheme of
antibiotics (clindamycin and amikacin), total intestinal
cleansing with a solution of ethylene glycol in case of a
colonic anastomosis, and baseline measurement of ab-
dominal circumference in the operating room prior to the
onset of anesthesia. All patients received general balanced
anesthesia. All had a gastric drainage tube placed during
the surgical procedure. Patients were randomly assigned to
two groups as designated in the sealed envelope opened at
the time the intestinal anastomosis was completed: 1) expe-
rimental group that included patients without gastric drai-
nage tube, which was removed at the time of coming out
of anesthesia and of aspiration of gastric contents, and 2)
control group that included patients with gastric drainage
tube in whom its adequate placement was corroborated with
a plain radiograph. Both groups were treated in an identi-
cal manner postoperatively, except for the gastric drainage
tube. All remained at a minimum 5-day fast and were trea-
ted with H2 blockers and analgesics. No antiemetics were
given. At the completion of the fast, the gastric drainage
tube was clamped and removed in the control group. In both
groups a progressive diet was begun and patients were dis-
charged when diet was tolerated and scheduled for a 30-day
follow-up.14
Of a total of 107 patients operated on for intestinal
anastomosis, 47 were excluded due to being high risk. The-
518 Ciruga y Cirujanos
Dvila-Prez R et al.
re were 60 patients admitted to the study (the majority for
closure of the ileostomy or colostomy because of anorectal
malformations or Hirschsprung disease). There were 31 pa-
tients in the experimental group and 29 in the control group.
Both groups were comparable with respect to the demogra-
phic variables. In the analysis of the follow-up variables,
an equivalency was shown because each of the confidence
intervals of each variable was found within the margin of
expected equivalency (delta), except for the beginning of
ambulation where we only demonstrated that the equiva-
lency was suggested according to the criteria of Williams
et al.15 With respect to the complication variables, we could
not conclude equivalencies with tests of differences or of
equivalencies, but there were no clinical differences bet-
ween groups with respect to the postoperative period. Mild
vomiting was more frequent in the group without gastric
drainage tube, but arose during the first 24 h postoperati-
vely and was persistent in only one case and was associated
with abdominal distention that required placement of gas-
tric drainage tube (therapeutic failure of 3.2%). Digestive
tract bleeding was clearly more frequent in the group with
gastric drainage tube and was interpreted as being secon-
dary to local trauma and stress generated by this. In the 23
patients who were neurologically competent to report their
problems, the main problem reported was the gastric drai-
nage tube in the experimental group and pain the control
group. Although it is a very subjective parameter, it su-
ggests that the problem generated by the gastric drainage
tube is clearly greater than that generated by the surgical
wound itself. There was no difference between groups with
regard to dehiscence of the anastomosis or fistulas, reope-
rations or deaths.14
Based on this, we conclude that there were no significant
differences in the variables of follow-up that traditionally
were thought to be influenced by a gastric drainage tube.
We did not observe that the gastric drainage tube prevents
the incidence of postoperative complications because the
frequency of vomiting or persistent abdominal distention,
infection or surgical wound dehiscence or fistulas and
reoperations occurred with the same frequency in both
groups. This clearly demonstrates that there is no added be-
nefit in using a gastric drainage tube in children operated
with elective intestinal anastomosis of the ileum or colon
and, therefore, should not be used routinely, but only when
necessary.14
When Should Enteral Feeding in a Patient Operated
for Intestinal Anastomosis Begin?
Once the above is demonstrated, the pattern of therapeutic
reference continued to keeping the patients in a fasting state
Elective bowel anastomoses in children
for at least 5 days postoperatively, justifying it according
to the perception that fasting would protect the intestinal
anastomosis from any complication such as abdominal dis-
tention, vomiting, ileus, dehiscence or leak of the anasto-
mosis, infection, and surgical wound dehiscence and would
allow for a hermetic closure of the intestinal anastomosis
before starting the enteral route, without any scientific basis
to substantiate this.16-18
There were well-based fundamentals for assuming that
it was functionally possible to initiate early feeding (before
the 5th postoperative day):
Clinical and electrophysiological studies that show
that the small intestine recovers its function in the
first 4 to 8 h and the colon in the first 24 postopera-
tive hours.
The ability of the intestinal mucosa to absorb elec-
trolytes, glucose and nutrients is not affected after
intestinal anastomosis.
The intestinal epithelium is perfectly sealed after 24
h of intestinal anastomosis.
Early feeding speeds up healing of the anastomosis
and surgical wound in animal models.
Early feeding is clearly related with a lower inciden-
ce of nosocomial infections, liver disorder, posto-
perative stay, bacterial translocation, secondary
malnutrition as well as promoting peristalsis, bowel
movements and early ambulation in adult patients
who are operated.17-24
Until 2012, there was only one study in pediatric pa-
tients operated on for colostomy closure, which suggested
that early feeding was safe and shortened the hospital stay.
However, it was a retrospective study and with a historical
control group that detracted from the strength of their con-
clusions.25
From the year 2003 we began a new controlled and ran-
domized clinical surgical trial to evaluate the tolerance
and safety of early feeding in pediatric patients who were
postoperative from elective intestinal anastomosis with
the same exclusion criteria as in the previous protocol.
Once again, demographic variables were considered (age,
weight, gender, nutritional status, diagnosis) and intraope-
rative variables (surgeon category, surgical time and site of
the anastomosis), as well as variables of tolerance (need to
place a gastric drainage tube, beginning of peristalsis and
bowel movements, time to tolerate complete diet and posto-
perative hospital stay), and safety variables (mild and per-
sistent vomiting, persistent abdominal distention, surgical
wound infection and dehiscence, dehiscence of the intesti-
nal anastomosis, fistulas, reoperations and death).26
All patients were treated in a routine and standardized
manner preoperatively with a double scheme of antibiotics
(clindamycin and amikacin), which was started on the same
Volume 81, No. 6, November-December 2013 519
day of surgery, bowel prep with an ethylene glycol solution
in cases of closure of colostomy and measurement of base-
line abdominal circumference before the start of anesthe-
sia. General balanced anesthesia and placement of gastric
drainage tube exclusively during anesthesia was removed
in all patients at the end of anesthesia. All intestinal anasto-
moses were done in a single plane with sutures of 4-0 and
5-0 polyglactin910. Randomization was done with sealed
envelopes at the end of the surgery in two groups:
1) Experimental group with early feeding after an obli-
gatory 24-h fast. Conditions of the abdomen were evaluated
periodically and enteral feeding was begun when there was
adequate peristalsis and flatus or when there was a bowel
movement, without having abdominal distention, nausea or
vomiting. Once enteral feeding was begun, the patient was
maintained on clear liquids for 24 h as a precaution before
initiating the soft diet.
2) Control group in which the patient remained on an
obligatory fast for 5 days, with diet being progressively ad-
vanced when the fasting period was completed. Treatment
in the postoperative period was identical except for the en-
teral route in both groups and antibiotics, H2 blockers, and
analgesics were included without antiemetics. The varia-
bles of tolerance and safety were evaluated every 8 h. When
patients tolerated a complete diet, they were discharged and
scheduled for a follow-up in 1 month.26
Between 2003 and 2004, a total of 92 intestinal anasto-
moses were carried out, of which 32 were considered high
risk and 60 were admitted to the study, 30 in each group.
Both groups were comparable in all demographic and in-
traoperative variables with a homogeneous distribution.
None of the patients had vomiting nor did they require pla-
cement of a gastric drainage tube; 13% experienced mild
abdominal distention, 18% had fever secondary to superfi-
cial surgical wound infection that healed with treatment and
6% had a mild enterocutaneous fistula that closed with con-
servative treatment. None of the patients required reopera-
tion. In a comparative analysis of the variables of tolerance
and safety, start of peristalsis, flatus and bowel movements
there was no significant difference between groups. Inci-
dence of complications including fistulas was low and was
equally distributed between groups. The time for reaching a
complete diet resulted, as expected, significantly earlier in
the experimental group (second day vs. fifth postoperative
day). Postoperative stay was also less in the experimental
group (6 2.9 vs. 9.8 4.1days) without reaching statisti-
cal significance, but did reach clinical significance.26
With this we demonstrated that obligatory fasting for
5 postoperative days from elective intestinal anastomosis
does not provide any protective role in avoiding complica-
tions such as abdominal distention, vomiting, wound infec-
tion, dehiscence of the intestinal anastomosis or fstulas and

reoperations. This allows for early feeding to be safely star-
ted in these cases, provided the right abdominal conditions
are met. Initiation of feeding should be progressive and a
24-h liquid diet should be maintained before beginning a
bland diet in case a complication should arise. This leads
to a shorter hospital stay and, together with prior studies,
improves the quality of the postoperative period in our pa-
tients.14,26
How to Reduce the Surgical Infection Rate in Patients
Operated for Intestinal Anastomosis?
From the point of view of surgical site infections, the type
of wound in surgeries for closure of stomas are considered
to be clean-contaminated because the fecal material is in
contact with the skin surface at the time of surgery (intes-
tinal and bacterial content), despite efforts to decrease the
bacterial load with the intestinal cleansing and, therefore,
are wounds with a high risk of surgical site infections. Fre-
quencies of 4-42.8% have been reported for surgical site
infections with closures of stomas, according to the study
reviewed. There were reports of very high incidences in our
institution before 2003.27,28
Hernandez Porras et al.28 carried out a study in our insti-
tution to evaluate the effectiveness of implementing a stan-
dardized process of perioperative care to control the high
rate of surgical site infections in our patients. The authors
included all pediatric patients who were admitted for clo-
sure of stomas at any anatomic site from the jejunum to
the colon between 2003 and 2005. We performed a before/
after study to analyze the effect of the standardized process
of perioperative care in our patients. The before phase
encompassed 40 weeks from 2003 to 2004 and the after
phase lasted 56 weeks from 2004 to 2005.28
All variables considered for 30 days after surgery were
collected prospectively and included demographic variables
(age, gender, weight, height, baseline diagnosis, location of
the stoma, preoperative ASA evaluation, use of bowel pre-
paration, condition of the peristomal skin 1 week after the
surgery and on the day of surgery, and use of prophylactic
antibiotics), operative variables (type of surgery, surgeon
category, type of surgical wound, surgical time, bleeding,
technical complications and use of drains), postoperative
variables (duration of antibiotics, duration of postopera-
tive coverage, personnel who performed postoperative
treatments, postoperative hospital stay, medical condition at
discharge, and presence of surgical site infections). If there
was edema, erythema or maceration at a distance 3 mm
around the mucocutaneous junction it was considered to be
inflammation of the peristomal skin. Asepsis and antisep-
sia of the preoperative peristomal area was done in all ca-
520 Ciruga y Cirujanos
Dvila-Prez R et al.
ses with 10% povidone-iodine. All patients were evaluated
daily up the time of discharge and scheduled for assessment
at 7 and 30 days from discharge as an outpatient.28
The process of standardized perioperative care was de-
signed after an analysis of the possible causes of the high
incidence of surgical site infections through brainstorming
sessions with experts and a construction of a cause-effect
diagram, Pareto graphs, and statistical analysis of risk fac-
tors.28
Between 2003 and 2005, there were 71 stoma closures
performed and all patients were admitted to the study and
met the agreed upon follow-up. There were 12 surgical site
infections in 28patients (42.8%) operated in the before
phase and 6/43 patients operated (13.9%) once the standar-
dized process was implemented (p = 0.006, RR 3.1; 95%
CI 1.3-7.2). Patients operated on in both periods did not
demonstrate differences with regard to baseline clinical
characteristics. Only patients with colostomy had a total
intestinal cleansing protocol performed. The control graph
demonstrated that the incidence of surgical site infections
were well above the statistical control limits in the befo-
re phase. After the introduction of the standardized pro-
cess of perioperative care there were only three peaks of
surgical site infections present that reached or went above
the control limits in the after phase, two of which were
explained by intraoperative complications and the last one
due to prolonged surgical time (>180min). During the be-
fore phase, nine surgical site infections were superficial
and the others were organ-spatial, whereas in the after
period, five were superficial and one was organ-spatial. Sur-
gical site infection presented itself on the average at 5 days
(range 2-20 days) and four were diagnosed after the patient
was discharged.28
In the univariate analysis, weight 10kg (p =0.05, OR
= 5; 95% CI 0.8-37.5) and the presence of peristomal in-
flammation 3 mm from the mucocutaneous junction (p
=0.08, OR4.3, 95% CI 0.6-33.8) showed a tendency to be
related with surgical site infections in the before phase
of the study, whereas in the after phase the intraopera-
tive complications (p <0.001, OR 72, 95% CI 3.9-315.3),
surgical time >180 min (p = 0.01, OR 13.5, 95% CI 1.2-
346.9) and not receiving prophylactic antibiotics (p =0.01,
OR17.5, 95% CI 1.5-278) showed an association with sur-
gical site infections. Based on the Pareto graph, 80% of the
surgical site infections were secondary to intrinsic factors
of the patients and to factors related with the surgical proce-
dure. The multivariate analysis identified the after phase
as a protective factor against infections in the surgical site:
peristomal inflammation 3mm and intraoperative compli-
cations such as perforation of the stoma during dissection
and severe acute bleeding with hemodynamic effect. Pro-
longed surgical time (>180 min) presented a marginal risk
Elective bowel anastomoses in children
for surgical site infections (p = 0.06). The direct cost of
introducing the standardized perioperative care for patients
with stoma closure was $800 USD and the estimated saving
from preventing 12 episodes of surgical site infections du-
ring the after phase was ~$10,500 USD.28
Our study definitely demonstrated that we were able to
decrease the percentage of surgical site infections after im-
plementing the process of standardized perioperative care
and that the intrinsic constitutional factors play a lesser role
in the development of surgical site infections in children,
whereas standardized perioperative care proved to be of
great importance (prevention of peristomal inflammation
>3mm and intraoperative complications).
Finally, we recovered an acceptable rate of surgical site
infections of 9% in closures of the jejunum or ileum and
of 15.6% in colostomy closures.28 We demonstrated that
the three fundamental points for decreasing the frequency
of surgical site infections is stoma closures are as follows:
condition of the peristomal skin before closure, extremely
careful surgical technique, and the application of point to
point standardized perioperative care.28
In conclusion, based on the previous information, we mo-
dified throughout 20 years the usual routines in elective
intestinal anastomoses based on clear evidences such as obli-
gatory performance of anastomosis in two layers or always
leaving a gastric drainage tube and waiting a minimum of 5
days before initiating enteral feeding. On the other hand, we
demonstrated that a standardized program of perioperative
management in intestinal anastomosis manages to keep the
rate of surgical site infections within the acceptable interna-
tional range. With this we have definitively and convincingly
improved the quality of the postoperative period in pediatric
patients operated for elective intestinal anastomosis.
Therefore, our updated standardized protocol in elective
intestinal anastomosis is the following:
Before surgery
1. Evaluation of the condition of the peristomal skin by
the enterostomal nurses before surgery
2. Training of the childs parents regarding peristomal
skin care and on the application of the stoma bag in
order to prevent skin lesions
3. Total intestinal cleansing in case of colostomy closu-
re, which includes a solution based on polyethylene
glycol, diluting the content of an envelope in 1 liter
of water, a dose of 25ml/kg/h with maximal dose of
1l/h, whether via nasogastric tube or orally. The same
dose is repeated the following day in case the residue
in the colostomy drainage is not eliminated. After this,
the diet remains based on clear liquids.
Volume 81, No. 6, November-December 2013 521
4. Regional cleansing: enema of both ends of the colos-
tomy with physiological solution at a dose of 10ml/kg/
dose each 8h
5. In case of ileostomy closure, steps 3 and 4 are unneces-
sary
6. Fast 8 h prior to the surgery
Day of surgery
1. Preoperative antibiotics: clindamycin (20 mg/kg IV)
(maximum 600mg) + amikacin 15mg/kg/dose (maxi-
mum 500mg) 40min before surgery. Maintain thera-
peutic dosage in the postoperative period (clindamycin
10mg/kg/dose every 6h and amikacin 22mg/kg/dose
every 24h)
2. Aspiration of the stoma contents with nelaton 12 Fr
tube starting with the distal stoma
3. Packing of the ends of the stomas with linen tape
soaked with povidone/iodine introducing ~15 cm in
each stoma and leaving the end of the tape in sight
4. Closure of both stomas with nonabsorbable suture (3-0
silk) with round needle and anchored stitch fixing the
end of the linen tape with sutures.
5. Antisepsia with clorhexidine 2% and isopropyl alco-
hol70% in a circumferential manner starting 3 cm from
the stomal margin and in a centripetal direction toward
the stomas. Once they are touched, the device or the
gauze is disposed of, repeating the process three times.
Then, from the same 3 cm of the stomal margin, but
now in centrifugal direction (towards the periphery) on
three occasions, without approaching the stomas once
again.
6. Once the patient is dressed with surgical clothing,
the 4-0 silk sutures are taken with a round needle in
the entire circumference of the stomas at the level
of the mucocutaneous junction, leaving them tied as
reference.
7. Circumferential dissection of both stomas, starting with
the distal using fine point monopolar electrocautery.
8. Dissection very close to the intestinal serosa in both
ends, avoiding perforations and unexpected bleeding,
until reaching the peritoneal cavity, freeing ~5 to 7 cm
of each loop.
9. Resection of both stomas
10. Intestinal anastomosis in one layer with simple po-
lyglactin910, 4-0 or 5-0 sutures
11. Cleaning under pressure of the surgical wound before
closure with 20ml saline solution.
12. Surgical team and instrumentalist change gloves and
change of surgical instruments and isolating compres-
ses from the surgical field before wound closure.

13. Once the skin is closed, the wound is covered with a
semipermeable polyurethane adhesive cover and sterile
gauze.
After surgery
1. No patient is managed with gastric drainage tube unless
deemed high-risk or with abdominal distention (3cm
from baseline during 8h consecutively) and persistent
vomiting (more than three episodes of vomiting in 8h)
2. The patient is sponge bathed during the first 48 h
without removing the covering gauze.
3. The wound is uncovered only in the following cases:
a)fever, b)erythema and local pain, c)abundant drainage
from the surgical wound, d)yellowish secretion from the
surgical wound, e)detachment of the covered bandages.
4. In case where the wound is not infected, change the
bandages on the day the patient is discharged.
5. In case of wound infection, obtain fluid for culture by
puncture and begin treatment of the wound with banda-
ge changes every 8 to 12 h until day of discharge.
6. After the first 24 obligatory hours of fasting, verify that
the patient is not high risk. At any time where the pa-
tient is passing flatus or has a bowel movement and is
without vomiting or abdominal distention, oral feeding
with clear liquids exclusively is started for 24 h and, if
tolerated, a bland diet including dairy products is be-
gun. Once diet is tolerated, the patient is discharged
without antibiotics.
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