Timing of Stoma Closure in Neonates
Timing of Stoma Closure in Neonates
Some babies require emergency surgery on their tummy in the first few months of life. This is
 most commonly because they were born prematurely and developed a bowel problem (called NEC)
 or a blockage of the bowel. As part of this surgery, the ends of the bowel may be brought to
 the skin surface (called a stoma) to divert stool into a bag. The stoma allows time for the
 bowel to rest and recover and is intended to be temporary with reversal later on. The best
 time to reverse or "close" the stoma is unknown. Stomas may cause dehydration, poor growth
 and skin problems so earlier closure may be better; however surgery is safer when babies are
 older and bigger so later closure may be better.

 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).

 The investigators will ask parents and health professionals for their views and whether they
 would take part in a future trial and information about babies who have recently had a stoma
 to find out which factors influence the timing of closure. They will also analyse 6 years of
 data from an existing database, the National Neonatal Research Database to estimate the
 numbers of babies affected, understand current practice and outcomes for these babies to help
 decide whether a clinical trial is possible.
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.