Timing of Stoma Closure in Neonates

Neonates undergoing emergency abdominal surgery frequently require stoma formation. Reversing (closing) these stomas with a second operation is an essential part of the infant's recovery. The timing of this closure is highly variable around the United Kingdom (UK) and the best time remains unclear. Current evidence is of low methodological quality and presents mixed conclusions: determining the best time has significant potential benefits for: (i) infant health outcomes (short-term e.g. avoiding complications and long-term e.g. growth and neurodevelopment); ii) families (e.g. reduced Neonatal Intensive Care Unit (NICU) stay); and iii) healthcare providers (e.g. reduced costs). Ideally, a clinical trial to compare early and late closure would be conducted but this is likely to be challenging and may not be feasible or acceptable to parents and clinicians.

Aims and objectives:

This study aims to answer the question, 'is it feasible to conduct a clinical trial comparing 'early' vs. 'late' stoma closure in neonates?' It has a series of specific objectives which incorporate: (i) describing current UK practice; (ii) establishing whether or not a clinical trial (and exactly what form of trial) is acceptable to parents and clinicians; and (iii) establishing the design of a potential trial, including defining the intervention ('early vs. late') and the population of infants to be included, how infants should be recruited and what information should be collected (outcomes).

Methods:

The study will use a mixed-methods approach comprising three parallel workstreams (WS). WS 1 will be a national survey of clinician perspectives of neonatal stoma closure. WS 2 will use an observational cohort study, interviews, questionnaires and focus groups. WS 3 will analyse three existing large databases (National Neonatal Research Database (NNRD), Health Episode Statistics (HES) and British Association of Paediatric Surgeons Congenital Anomalies Surveillance System (BAPS-CASS)).

The findings of these WS will be combined and presented at a final, trial design meeting where conclusions about trial feasibility will be reached and if appropriate, an outline of a trial protocol agreed.

Anticipated impact and dissemination:

The principal impact will be determining whether or not a definitive trial can go ahead: if the study demonstrates that a trial is feasible then the investigators will use their findings to design a trial that is acceptable to parents and clinicians; that includes the most appropriate infants; that measures outcomes important to parents and clinicians and ultimately, answers the question: when is the best time to close an infant's stoma? Findings will be disseminated at national meetings of relevant professionals, through social media (including patient groups), to funding bodies and in open access publications.

Workstream 1

Inclusion criteria

• Neonatologists in surgical NICUs, neonatal surgeons, neonatal dieticians and neonatal surgical nurses.

Workstream 2.1

Inclusion criteria

• Infants having a stoma as part of emergency surgery before 44 weeks post-conceptual age: Group A preterm infants who have stomas formed for necrotising enterocolitis, spontaneous intestinal perforation or other intestinal pathology, and Group B infants (usually born closer to term) who have congenital anomalies that lead to bowel obstruction (e.g. intestinal atresias; meconium ileus and other conditions such as complicated gastroschisis).

Exclusion criteria

• Cases where a stoma is part of a planned treatment pathway e.g. for an anorectal malformation or Hirschsprung's disease.
• Infants who have a stoma formed after 44 weeks post-conceptual age.

Workstream 2.2

Inclusion criteria

• Lead surgeons and neonatologists caring for infants recruited to WS 2.1.

Workstream 2.3

Inclusion criteria

• Parents of premature and term infants who have had an stoma in the last three years (including parents of infants recruited to WS 2.1).
• Clinicians in participating surgical units, who are involved in the treatment of infants requiring emergency stoma closure.

Exclusion criteria

• Parents who do not speak English.