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Risk factors for gastrointestinal complications after spinal fusion in children with cerebral palsy
Bram P Verhofste1, Jay G Berry1, Patricia E Miller1
1Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
Insights
Gastrointestinal complications like pancreatitis and ileus occur in 16.2% of children with cerebral palsy (CP) after spinal fusion (SF). Higher complication severity correlated with longer hospital stays, validating the modified Clavien-Dindo-Sink classification.
Area of Science:
- Pediatric Orthopedics
- Gastroenterology
- Surgical Outcomes
Background:
- Perioperative gastrointestinal (GI) complications after spinal fusion (SF) in children with cerebral palsy (CP) increase length of stay (LOS) and morbidity.
- Objective classification systems for analyzing GI complications are lacking.
Purpose of the Study:
- To evaluate the incidence and risk factors of GI complications in CP patients undergoing SF.
- To investigate the validity of the modified Clavien-Dindo-Sink classification for grading GI complications.
Main Methods:
- A prospective, multicenter study reviewed 425 children with CP who underwent SF.
- GI complications were categorized using the modified Clavien-Dindo-Sink classification (Grades I-II minor, Grades III-V major).
- Patients with and without GI complications were compared.
Main Results:
- 16.2% of patients (69/425) experienced 87 GI complications, most commonly pancreatitis and ileus.
- Preoperative G-tube feeding and higher normalized estimated blood loss (nEBL) were significant risk factors.
- Patients with GI complications had longer LOS and ICU admissions, with LOS correlating to complication severity.
Conclusions:
- Gastrointestinal complications are common after SF in children with CP.
- The modified Clavien-Dindo-Sink classification appears valid for assessing GI complication severity and its impact on LOS.
- Further research into enteral feeding protocols is warranted.
Design:
Prospective cerebral palsy (CP) registry review.
Objectives:
(1) Evaluate the incidence/risk factors of gastrointestinal (GI) complications in CP patients after spinal fusion (SF); and (2) investigate the validity of the modified Clavien-Dindo-Sink classification.
Background:
Perioperative GI complications result in increased length of stay (LOS) and patient morbidity/mortality. However, none have analyzed the outcomes of GI complications using an objective classification system.
Methods:
A prospective/multicenter CP database identified 425 children (mean, 14.4 ± 2.9 years; range, 7.9-21 years) who underwent SF. GI complications were categorized using the modified Clavien-Dindo-Sink classification. Grades I-II were minor complications and grades III-V major. Patients with and without GI complications were compared.
Results:
87 GI complications developed in 69 patients (16.2%): 39 minor (57%) and 30 major (43%). Most common were pancreatitis (n = 45) and ileus (n = 22). Patients with preoperative G-tubes had 2.2 × odds of developing a GI complication compared to oral-only feeders (OR 2.2; 95% CI 0.98-4.78; p = 0.006). Similarly, combined G-tube/oral feeders had 6.7 × odds compared to oral-only (OR 6.7; 95% CI 3.10-14.66; p < 0.001). The likelihood of developing a GI complication was 3.4 × with normalized estimated blood loss (nEBL) ≥ 3 ml/kg/level fused (OR 3.41; 95% CI 1.95-5.95; p < 0.001). Patients with GI complications had more fundoplications (29% vs. 17%; p = 0.03) and longer G-tube fasting periods (3 days vs. 2 days; p < 0.001), oral fasting periods (5 days vs. 2 days; p < 0.001), ICU admissions (6 days vs. 3 days; p = 0.002), and LOS (15 days vs. 8 days; p < 0.001). LOS correlated with the Clavien-Dino-Sink classification.
Conclusion:
Gastrointestinal complications such as pancreatitis and ileus are not uncommon after SF in children with CP. This is the first study to investigate the validity of the modified Clavien-Dindo-Sink classification in GI complications after SF. Our results suggest a correlation between complication severity grade and LOS. The complexity of perioperative enteral nutritional supplementation requires prospective studies dedicated to enteral feeding protocols.
Level Of Evidence:
Therapeutic-level III.
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