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Risk factors for gastrointestinal complications after spinal fusion in children with cerebral palsy

Spine Deformity volume 9, pages 567–578 (2021)Cite this article

Abstract

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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References

  1. DeFrancesco CJ, Miller DJ, Cahill PJ, Spiegel DA, Flynn JM, Baldwin KD (2018) Releasing the tether: Weight normalization following corrective spinal fusion in cerebral palsy. J Orthop Surg (Hong Kong) 26(2):2309499018782556. https://doi.org/10.1177/2309499018782556

    Article  Google Scholar 

  2. Jalanko T, Helenius I, Pakarinen M, Koivusalo A (2018) Gastrointestinal complications after surgical correction of neuromuscular scoliosis: a retrospective cohort study. Scand J Surg 107(3):252–259. https://doi.org/10.1177/1457496917748223

    Article  CAS  PubMed  Google Scholar 

  3. Jalanko T, Helenius I, Pakarinen M, Puisto V, Salminen P, Peltonen J et al (2014) Effects of surgical correction of neuromuscular scoliosis on gastric myoelectrical activity, emptying, and upper gastrointestinal symptoms. J Pediatr Gastroenterol Nutr 58(1):38–45. https://doi.org/10.1097/MPG.0b013e3182a7dac4

    Article  PubMed  Google Scholar 

  4. Hasler CC (2013) Operative treatment for spinal deformities in cerebral palsy. J Child Orthop 7(5):419–423. https://doi.org/10.1007/s11832-013-0517-4

    Article  PubMed  PubMed Central  Google Scholar 

  5. Drvaric DM, Roberts JM, Burke SW, King AG, Falterman K (1987) Gastroesophageal evaluation in totally involved cerebral palsy patients. J Pediatr Orthop 7(2):187–190

    Article  CAS  Google Scholar 

  6. Nishnianidze T, Bayhan IA, Abousamra O, Sees J, Rogers KJ, Dabney KW et al (2016) Factors predicting postoperative complications following spinal fusions in children with cerebral palsy scoliosis. Eur Spine J 25(2):627–634. https://doi.org/10.1007/s00586-015-4243-0

    Article  PubMed  Google Scholar 

  7. Vande Velde S, Van Biervliet S, De Bruyne R, Van Renterghem K, Plasschaert F, Van Winckel M (2010) Gastric dysmotility following orthopaedic scoliosis surgery in patients with cerebral palsy: a case series. Neuropediatrics 41(4):182–185. https://doi.org/10.1055/s-0030-1265227

    Article  CAS  PubMed  Google Scholar 

  8. Samdani AF, Belin EJ, Bennett JT, Miyanji F, Pahys JM, Shah SA et al (2016) Major perioperative complications after spine surgery in patients with cerebral palsy: assessment of risk factors. Eur Spine J 25(3):795–800. https://doi.org/10.1007/s00586-015-4054-3

    Article  PubMed  Google Scholar 

  9. Abousamra O, Nishnianidze T, Rogers KJ, Er MS, Sees JP, Dabney KW et al (2018) Risk factors for pancreatitis after posterior spinal fusion in children with cerebral palsy. J Pediatr Orthop B 27(2):163–167. https://doi.org/10.1097/BPB.0000000000000376

    Article  PubMed  Google Scholar 

  10. Bureta C, Tominaga H, Yamamoto T, Kawamura I, Abematsu M, Yone K et al (2018) Risk factors for postoperative ileus after scoliosis surgery. Spine Surg Relat Res 2(3):226–229. https://doi.org/10.22603/ssrr.2017-0057

    Article  PubMed  PubMed Central  Google Scholar 

  11. Bendon AA, George KA, Patel D (2016) Perioperative complications and outcomes in children with cerebral palsy undergoing scoliosis surgery. Paediatr Anaesth 26(10):970–975. https://doi.org/10.1111/pan.12981

    Article  PubMed  Google Scholar 

  12. Borkhuu B, Nagaraju D, Miller F, Moamed Ali MH, Pressel D, Adelizzi-Delany J et al (2009) Prevalence and risk factors in postoperative pancreatitis after spine fusion in patients with cerebral palsy. J Pediatr Orthop 29(3):256–262. https://doi.org/10.1097/BPO.0b013e31819bcf0a

    Article  PubMed  Google Scholar 

  13. El Bouyousfi M, Leveque C, Miladi L, Irtan S, Hamza J, Oualha M (2016) Acute pancreatitis following scoliosis surgery: description and clinical course in 14 adolescents. Eur Spine J 25(10):3316–3323. https://doi.org/10.1007/s00586-016-4595-0

    Article  PubMed  Google Scholar 

  14. Tsirikos AI, Chang WN, Dabney KW, Miller F (2003) Comparison of one-stage versus two-stage anteroposterior spinal fusion in pediatric patients with cerebral palsy and neuromuscular scoliosis. Spine (Phila Pa 1976) 28(12):1300–1305. https://doi.org/10.1097/01.BRS.0000065572.10824.AB

    Article  Google Scholar 

  15. Lipton GE, Miller F, Dabney KW, Altiok H, Bachrach SJ (1999) Factors predicting postoperative complications following spinal fusions in children with cerebral palsy. J Spinal Disord 12(3):197–205

    CAS  PubMed  Google Scholar 

  16. Master DL, Son-Hing JP, Poe-Kochert C, Armstrong DG, Thompson GH (2011) Risk factors for major complications after surgery for neuromuscular scoliosis. Spine (Phila Pa 1976) 36(7):564–571. https://doi.org/10.1097/BRS.0b013e3181e193e9

    Article  Google Scholar 

  17. Jevsevar K (1993) The relationship between preoperative nutritional-status and complications after an operation for scoliosis in patients who have Cerebral-Palsy. J Bone Jt Surg Am 75a(8):1256

    Google Scholar 

  18. Pesenti S, Blondel B, Peltier E, Launay F, Fuentes S, Bollini G et al (2016) Experience in perioperative management of patients undergoing posterior spine fusion for neuromuscular scoliosis. Biomed Res Int 2016:3053056. https://doi.org/10.1155/2016/3053056

    Article  PubMed  PubMed Central  Google Scholar 

  19. Dodwell ER, Pathy R, Widmann RF, Green DW, Scher DM, Blanco JS et al (2018) Reliability of the modified Clavien–Dindo–Sink complication classification system in pediatric orthopaedic surgery. JB JS Open Access 3(4):e0020. https://doi.org/10.2106/JBJS.OA.18.00020

    Article  PubMed  PubMed Central  Google Scholar 

  20. Katayama H, Kurokawa Y, Nakamura K, Ito H, Kanemitsu Y, Masuda N et al (2016) Extended Clavien–Dindo classification of surgical complications: Japan Clinical Oncology Group postoperative complications criteria. Surg Today 46(6):668–685. https://doi.org/10.1007/s00595-015-1236-x

    Article  PubMed  Google Scholar 

  21. Khanna K, Berven SH (2017) Mesenteric ischemia following the correction of adult spinal deformity: case report. J Neurosurg Spine 26(4):426–429. https://doi.org/10.3171/2016.8.SPINE16571

    Article  PubMed  Google Scholar 

  22. Lipton GE, Letonoff EJ, Dabney KW, Miller F, McCarthy HC (2003) Correction of sagittal plane spinal deformities with unit rod instrumentation in children with cerebral palsy. J Bone Jt Surg Am 85(12):2349–2357. https://doi.org/10.2106/00004623-200312000-00012

    Article  Google Scholar 

  23. Tsirkos AI, Spielmann P (2007) Spinal deformity in paediatric patients with cerebral palsy. Curr Orthopaed 21(2):122–134. https://doi.org/10.1016/j.cuor.2007.01.001

    Article  Google Scholar 

  24. Sponseller PD, Jain A, Shah SA, Samdani A, Yaszay B, Newton PO et al (2013) Deep wound infections after spinal fusion in children with cerebral palsy: a prospective cohort study. Spine (Phila Pa 1976) 38(23):2023–2027. https://doi.org/10.1097/BRS.0b013e3182a83e59

    Article  Google Scholar 

  25. Islek A, Sayar E, Yilmaz A, Artan R (2013) Percutaneous endoscopic gastrostomy in children: is early feeding safe? J Pediatr Gastroenterol Nutr 57(5):659–662. https://doi.org/10.1097/MPG.0b013e3182a0d171

    Article  PubMed  Google Scholar 

  26. Morinville VD, Husain SZ, Bai H, Barth B, Alhosh R, Durie PR et al (2012) Definitions of pediatric pancreatitis and survey of present clinical practices. J Pediatr Gastroenterol Nutr 55(3):261–265. https://doi.org/10.1097/MPG.0b013e31824f1516

    Article  PubMed  PubMed Central  Google Scholar 

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Funding

This study was supported in part by grants to the Setting Scoliosis Straight Foundation in support of the Harms Study Group, research from DePuy Synthes Spine, EOS Imaging, K2M, Medtronic, NuVasive, and Zimmer Biomet.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA

    Bram P. Verhofste, Jay G. Berry, Patricia E. Miller, Charis N. Crofton & Brigid M. Garrity

  2. Department of Orthopaedic Surgery, Children’s Healthcare of Atlanta, Atlanta, GA, USA

    Nicholas D. Fletcher

  3. Setting Scoliosis Straight Foundation, San Diego, CA, USA

    Michelle C. Marks

  4. Department of Orthopaedic Surgery, A. I. DuPont Institute, Wilmington, DE, USA

    Suken A. Shah

  5. Department of Orthopaedic Surgery, UC San Diego University of California, San Diego, CA, USA

    Peter O. Newton

  6. Department of Orthopaedic Surgery, Shriner’s Hospital for Children, Philadelphia, PA, USA

    Amer F. Samdani

  7. Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA

    Mark F. Abel

  8. Department of Orthopaedic Surgery, John Hopkins Hospital, Baltimore, MD, USA

    Paul D. Sponseller

  9. Department of Orthopaedic Surgery, University Hospital Cleveland Medical Center, Rainbow Babies and Children’s Hospital, 201 Adelbert Road, Cleveland, OH, 44106, USA

    Michael P. Glotzbecker

Authors
  1. Bram P. Verhofste
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  2. Jay G. Berry
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Consortia

Harms Study Group

Contributions

BPV, JGB, PEM, CNC, BMG, NDF, MCM, SAS, PON, AS, MFA, PDS, Harms Study Group, MPG: substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work. BPV, JGB, PEM, CNC, BMG, NDF, MCM, SAS, PON, AS, MFA, PDS, Harms Study Group, MPG: drafting the work or revising it critically for important intellectual content. BPV, JGB, PEM, CNC, BMG, NDF, MCM, SAS, PON, AS, MFA, PDS, Harms Study Group, MPG: final approval of the version to be published.

Corresponding author

Correspondence to Michael P. Glotzbecker.

Ethics declarations

Conflict of interest

Bram P. Verhofste: nothing to disclose; Jay G. Berry: JAMA Pediatrics: editorial or governing board; Patricia E. Miller: nothing to disclose; Charis N. Crofton: nothing to disclose; Brigid M. Garrity: nothing to disclose; Nicholas D. Fletcher: Medtronic: paid presenter or speaker; Medtronic Sofamor Danek: paid consultant; Nuvasive: paid presenter or speaker; Orthopaediatrics: paid presenter or speaker; unpaid consultant; Pediatric Orthopaedic Society of North America: board or committee member; Scoliosis Research Society: board or committee member; Zimmer: paid presenter or speaker; Michelle C. Marks: Pediatric Orthopaedic Society of North America: board or committee member; Scoliosis Research Society: board or committee member; Setting Scoliosis Straight Foundation (FKA Harms Study Group Foundation): board or committee member; Suken A. Shah: AAOS: board or committee member; DePuy Synthes Spine: IP royalties; paid consultant; DePuy Synthes Spine via Setting Scoliosis Straight Foundation: research support. Electrocore: stock or stock options; Globus Medical: paid consultant; Innovative Surgical Designs, Inc.: stock or stock options; K2M: IP royalties; K2M via Setting Scoliosis Straight Foundation: research support; NuVasive via Setting Scoliosis Straight Foundation: research support; Pediatric Orthopaedic Society of North America: board or committee member; Scoliosis Research Society: board or committee member; Setting Scoliosis Straight Foundation: board or committee member; Springer: publishing royalties, financial or material support; Peter O. Newton: DePuy Synthes Spine via Setting Scoliosis Straight Foundation: research support; DePuy Synthes Spine, A Johnson & Johnson Company: IP royalties; ElectroCore: stock or stock Options; EOS Imaging via Setting Scoliosis Straight Foundation: research support; Harms Study Group: board or committee member; International Pediatric Orthopedic Think Tank: board or committee member; K2M via Setting Scoliosis Straight Foundation: research support; MAZOR Surgical Technologies: Research support; Medtronic via Setting Scoliosis Straight: Research support; Nuvasive via Setting Scoliosis Straight Foundation: Research support; Scoliosis Research Society: Board or committee member; Setting Scoliosis Straight Foundation: Board or committee member; Stryker K2M: IP royalties; Paid consultant; Theime Publishing: Publishing royalties, financial or material support; Zimmer Biomet via Setting Scoliosis Straight Foundation: Research support; Amer Samdani: Children's Spine Study Group: Board or committee member; DePuy, A Johnson & Johnson Company: paid consultant; Ethicon: paid consultant; Globus Medical: paid consultant; Nuvasive: IP royalties; PAID consultant; Setting Scoliosis Straight Foundation: board or committee member; Stryker: paid consultant; Zimmer Biomet: IP royalties; paid consultant; Mark F. Abel: nothing to disclose; Paul D. Sponseller: DePuy, A Johnson & Johnson Company: IP royalties; paid consultant; research support; Globus Medical: IP royalties; Journal of Bone and Joint Surgery: editorial or governing board; Journal of Bone and Joint Surgery-American: publishing royalties, financial or material support; Orthpediatrics: other financial or material support; Scoliosis Research Society: board or committee member; Harms Study Group: Biomet: research support; CHU Sainte-Justine: research support; DePuy Synthes Spine, a Johnson & Johnson Co.: research support; DePuy, A Johnson & Johnson Company: other financial or material support; EOS Imaging: research support; Globus Medical: other financial or material support; Hanger Clinic: other financial or material support; K2M: research support; Medicrea: research support; Medtronic: research support; Medtronic Sofamor; Danek: other financial or material support; Misonix: other financial or material support; Nuvasive: other financial or material support; research support; RPR Surgical Corporation: other financial or material support; Scoliosis Research Society: research support; Sea Spine: other financial or material support; Thieme Publishing: publishing royalties, financial or material support; UNYQ: other financial or material support; Washington University: research support; Zimmer: research support; Michael P. Glotzbecker: Biomet: paid presenter or speaker; DePuy, A Johnson & Johnson Company: paid presenter or speaker; Medtronic: paid presenter or speaker; Member of CSSG: research support; Member of GSSG: research support; Member of HSG: research support; Nuvasive: paid consultant; paid presenter or speaker; Orthobullets: publishing royalties, financial or material support.

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. Boston Children’s Hospital IRB approval number: IRB-P00030792.

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Verhofste, B.P., Berry, J.G., Miller, P.E. et al. Risk factors for gastrointestinal complications after spinal fusion in children with cerebral palsy. Spine Deform 9, 567–578 (2021). https://doi.org/10.1007/s43390-020-00233-y

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