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Journal of Pediatric Surgery (2013) 48, 111–117

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Probiotic prophylaxis after pullthrough for Hirschsprung disease to reduce incidence of enterocolitis: A prospective, randomized, double-blind, placebo-controlled, multicenter trial☆,☆☆,★
Mohamed El-Sawaf b,1 , Sabina Siddiqui a,1 , Moustafa Mahmoud b , Robert Drongowski a , Daniel H. Teitelbaum a,⁎
a b

Section of Pediatric Surgery , Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA Pediatric Surgery Unit, Department of Surgery, Tanta University, Tanta, Egypt

Received 25 September 2012; accepted 13 October 2012

Key words:
Hirschsprung disease; Enterocolitis; Probiotics; Aganglionosis

Abstract Objective: Hirschsprung-associated enterocolitis (HAEC) is one of the most troublesome problems encountered after a pullthrough. We hypothesized that prophylactic administration of probiotics after a pullthrough procedure would decrease the incidence of HAEC. Study Design: A prospective, double-blind, placebo-controlled, randomized trial was conducted at 2 children's hospitals. Infants undergoing pullthrough were randomized to probiotic or placebo for a period of 3 months post-pullthrough. Primary outcome was incidence of post-operative HAEC. Other outcomes included severity of HAEC by clinical grade, number of HAEC episodes and extent of aganglionosis. Pearson Chi Square analysis, as well as logistic regression, was used for statistical analysis. Results: Sixty-two patients were recruited (Sites: A=40; B=22). One was lost to follow up and one immediate post-op death was not included in final analysis. Probiotics were administered to 32 patients. Distribution of placebo/probiotics was equal between sites (P=0.858). Mean age at pullthrough was 6.5±8.1(±SD) months. The incidence of HAEC was 28.3%. The incidence of HAEC was not statistically different between probiotic and placebo study groups. Conclusions: Incidence of HAEC was not reduced with prophylactic probiotics. Future studies are needed to better determine the etiology and possible ways of preventing this complex condition. © 2013 Elsevier Inc. All rights reserved.

☆ Study Funded and Placebo and Probiotics provided by: VSL Pharmaceuticals Inc., Sigma-Tau Pharmaceuticals, Inc, Townson, MD. The corporation had no influence on the reporting of our results. ☆☆ Registered with: ClinicalTrials.gov, identifier: NCT00630838. ★ Presented at the American Pediatric Surgical Association, San Antonio, TX, May, 2012. ⁎ Corresponding author. Section of Pediatric Surgery, University of Michigan Hospitals, Mott F3970, Box 0245, Ann Arbor, Michigan 48109. Tel.: +1 734 936 8464; fax: +1 734 936 9784. E-mail address: dttlbm@umich.edu (D.H. Teitelbaum). 1 Both the first and second authors contributed equally to the production of this manuscript.

0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2012.10.028

we hypothesized that prophylactic administration of probiotics after a pullthrough procedure would decrease the incidence of HAEC. hemodynamically unstable. Study participants were administered either VSL#3 or maize starch orally twice a day. Patient recruitment The study was performed with IRB approval (IRB HUM00000684) at the University of Michigan. thereby increasing transepithelial resistance [12]. as well as having parents bring in empty sachets at the time of their clinic visit. HAEC is a significant source of morbidity and potential mortality in this patient population.2. Dosing of the probiotic was based on body weight. probiotics can promote mucin production. FL) is a probiotic preparation containing 90 billion viable lyophilized bacteria (per packet) composed of four strains of Lactobacillus. One patient was dropped from the final study analysis due to early post-pullthrough death from unrelated causes (pneumonia and sepsis. Ft. Tanta. and one strain of Streptococcus salivarius subsp. Ann Arbor (defined as Site B) as well as by the Ethical Committee at Tanta University. emergency room or hospital admissions.112 Hirschsprung-associated enterocolitis (HAEC) is one of the most troublesome problems encountered after a pullthrough. identifier: NCT00630838. The complete preparation lactic acid bacteria and bifidobacteria. 62 families consented to participation and underwent randomization.10]. 3.3. Methods 1.1.. 1. HAEC is the most common cause of death in children with HD [2.7. Further. Children b 5 kg received 90 billion bacteria (one 0. The coordinators were able to approach 67 families. As well. Lauderdale. confer a health benefit to the host. including alterations in mucosal cytokine expression. thermophilus. Randomization tables and envelopes were generated by the Department of Biostatistics at the University of Michigan and were distributed to each site. which is deranged in HAEC [16]. The dispensed medication was coded related to the patient ID and these codes were kept from the treating physicians and patient's parents. including feeding intolerance and incidence.gov. Although the exact etiology of HAEC is unknown.The study was registered with ClinicalTrials. The rate may reach as high as 55% in patients with total colonic aganglionosis Hirschsprung disease (HD) [6]. The patients were evaluated on a routine post-operative visit schedule of 1. three strains of Bifidobacterium. including the alteration of intestinal mucins [11]. At the time of pullthrough parents/guardians were approached for study enrollment. Compliance was measured by questioning the parents at post-operative follow-up. Adequate function of the intestinal mucosal barrier is also thought to play a major role in the prevention of HAEC. masking and randomization 1. frequency and severity . an alteration in the gut microbiome or loss of intestinal epithelial barrier has been hypothesized to play a mechanistic role [5. Prospective data were collected. when administered in adequate amounts. Probiotics are live microbes that. one week postpullthrough) and one was dropped due to complete noncompliance (Fig. Of these.9. Based on this previous knowledge on the beneficial effects of probiotics during pro-inflammatory conditions of the gastrointestinal tract. microcrystalline cellulose. and silicon dioxide in a vegetable capsule have been shown to be safe in children and neonates.8]. 1). competing with intestinal pathogens for mucosal receptors. major congenital anomalies with markedly The study was a double blinded and randomization was conducted by the Investigational Drug Service in the Department of Pharmacy who was responsible of dispensing either probiotic or placebo. Study design. shortened life expectancy. active septicemia. this was another exclusion in the postpullthrough period. 6 and 12 months post pullthrough procedure as well as during unanticipated clinic. The diagnosis of HD was confirmed by suction rectal biopsy results prior to surgical pullthrough. Block randomization with a randomly chosen block size of 2 or 4 within center was used. Exclusion criteria were children N 48 months of age at time of pullthrough. The placebo consisted of identical bags containing only maize starch. The drug was delivered to the families in individual packets with maize starch as a filler. Probiotics have been suggested to be efficacious in the prevention and treatment of viral diarrhea [13]. 1. and those over 5 kg received 180 billion bacteria (two sachets/dose) twice a day. necrotizing enterocolitis [14] and pouchitis [15].25 g sachet/dose) twice a day. Study medication VSL#3 (VSL Pharmaceuticals. The probiotic was diluted in 2 to 4 oz of expressed human milk or formula. All data were available and collected for 60 patients. El-Sawaf et al. which may allow for the translocation of pathogens through the mucosa triggering the start of the inflammatory process. The study coordinator at each site evaluated new hospital admissions for potential candidates during the recruitment period of 1/2006 to 12/2009. Thirty-two patients were randomized to the probiotic group. stearic acid. Egypt (defined as Site A). Both compounds were indistinguishable in appearance. HAEC may occur through a defect in this barrier. magnesium stearate. Inclusion criteria consisted of all patients suffering from HD at an age of 48 months or younger. Probiotics potentially play a protective role in maintaining intestinal mucosal integrity through a number of different interactions. with a reported incidence of 17% to more than 40% during the postoperative course after pullthrough procedure [1–5]. as children on parenteral nutrition have been reported to translocate many probiotics into the blood stream. or an inability to tolerate or take the oral probiotics. Inc. M.

80. Multivariate regression was performed to analyze for contributing covariates predisposing to HAEC (e. and age at pullthrough procedure).1. and did not identify any significant adverse events between study groups (e. Based on this. sepsis. weight loss. we modeled the study anticipating that probiotic prophylaxis would Table 1 Grade I Clinical grading of HAEC. 1. Demographics Sixty patients had completed charts and were used in the final analysis.6. A model that tests the equality of two binomial probabilities was used. Power analysis Based on previous published series of HAEC. length of aganglionosis. and the fact that a predicted additional 8 patients into each study would not influence the statistical outcome of the study..4. anorexia. (Site: A =40. Data safety monitoring An independent data safety monitoring board was established which examined data halfway through the recruiting process. [17]. Evaluation and clinical grading of HAEC To facilitate the diagnosis and objectively classify the severity of HAEC. A common definition was based on previous diagnostic criteria at both centers [2]. 2. Fig. gender. and associated contributing factors predisposing to HAEC (e. Specifically. 1. Probiotic therapy was administered to 32 patients. of post-operative HAEC. HAEC was clinically diagnosed and documented by the treating physician. 1 Consort assignment of patients. and age at pullthrough procedure).g. B=20).05. 1. based on the estimated treatment effect and a power of 0. or severe diarrhea or feeding problems that were possibly associated with either treatment arm). it was elected to terminate the study at a somewhat earlier point. Results 2. gender. the clinical severity of HAEC. a diagnosis of Trisomy 21. The number of excluded patients included those who did not meet eligibility criteria and those whose parents or guardians refused to participate or secondarily dropped out of the study within the first 5 days after randomization.g. this power analysis showed that we can achieve the desired power with sample sizes of 40 per group using a one-sided test with α =0. age at diagnosis. Distribution of the patients assigned to placebo versus probiotic groups was 1.5. tachycardia) Moderate explosive diarrhea Moderate to severe abdominal distention Associated with mild to moderate systemic manifestations Explosive diarrhea Marked abdominal distention Hypotension/shock or impending shock . Statistical analysis T-test was used for comparison between groups for the primary outcome measure. (Table 1). Comparison of demographics between study sites is shown in Table 2. length of aganglionosis. death. Grade II Grade III Mild explosive diarrhea Mild to moderate abdominal distension No significant systemic manifestations (fever. an inspection of the data demonstrated an actual bias towards more HAEC in the probiotics group.7. the diagnosis was stratified into three grades (mild. age at diagnosis. During the course of these experiments. Primary outcome measure was the occurrence of HAEC. Secondary outcome measures included number of HAEC episodes.. moderate or severe) according to the previously described grading system by Elhalaby et al.g.Probiotic prophylaxis after pull through for HD 113 reduce the incidence of Hirschsprung-associated enterocolitis from 40% in the placebo group to 10% in the treatment group. a diagnosis of Trisomy 21.

The type of pullthrough operation. The most common indication for colostomy creation was active enterocolitis (n=4). it was important to note that the distribution of children with long vs.796 Long segment was defined as proximal to the rectosigmoid region. Site A (Tanta) (N=40) 29 (73%) 9 (23%) 4 (10%) 32. The overall incidence of post-operative Table 3 Type of procedure performed by randomization group. approach and existence of pre-pullthrough stomas were also noted to be evenly distributed (Table 3). followed by poor general condition (n=2) and severe abdominal distention (n=2).001 b 0. 2.5 months old (range 2 days–4 months).967 0. Of the 28 patients randomized to the placebo group. Six of these seven patients went on to have recurrent episodes of HAEC (19%). male) Prematurity (n) Diagnosis of Trisomy 21 (n) Age at diagnosis (months) Long segment aganglionosis a Incidence of Postoperative HAEC Recurrent episodes of HAEC a Probiotic group (N=28) 25 (89%) 6 (21%) 1 (3. Probiotic Group (n) Placebo Group (n) 5 14 7 3 3 1 p-value p=0. Seven children had an associated diagnosis of Trisomy 21.235 0.5%) Site B (Ann Arbor) (N=20) 14 (70%) 2 (10%) 3 (15%) 7.336 p=1. Six were classified as clinical grade I. Gender distribution.068 0.929 0.236 Presence of Pre-Pullthrough Colostomy Type of Pullthrough operation Trans-anal pullthrough Open Soave Swenson's Lap Soave Other 4 16 8 3 3 0 .839 0. Three cases were classified as clinical grade I. six as grade II and one as grade III.238 0.570 0. Length of aganglionosis was defined as ‘standard’ — involving the rectosigmoid junction versus ‘long segment’ — involving colon proximal to the rectosigmoid junction.3%. none as grade II and one as grade III (Table 3).2. This was thought to reflect the fact that long segment disease. the length of aganglionosis was significantly longer in the Ann Arbor (B) group. a known risk factor for postoperative HAEC [18]. was encountered more frequently in Site B.5%) 32±7. some significant differences between the two study sites. Of the 32 patients randomized to probiotic treatment.491 0. Demographic Variable Gender (n.4 ±2. and this was not significantly different from the findings in the placebo group. Despite these differences. and the incidence of Trisomy 21 were similar between study centers. The mean age of colostomy creation was 1.001 Demographic Distribution by Randomization Group Demographic Variable Gender (n. Finally. El-Sawaf et al. 7 were diagnosed with post-operative HAEC (25%). HAEC The overall incidence of HAEC was 28. Second.6 7 (25%) 10 (36%) 6 (21%) Placebo group (N=32) 18 (56%) 5 (16%) 6 (18%) 28±4.9± 6. Six of these ten patients went on to have recurrent episodes of HAEC (21%). equal between sites (p=0. male) Prematurity (n) Diagnosis of Trisomy 21 (n) Age at diagnosis (months±SD) Long segment aganglionosis a Incidence of Postoperative HAEC Recurrent Episodes of HAEC p-value 0.009 b 0. the age at diagnosis and at time of pullthrough procedure was significantly older in the Egypt group. The incidence of postoperative HAEC was noted to be more prevalent at Site B (Ann Arbor). 10 were diagnosed with post-operative HAEC (31%).114 Table 2 Demographic distribution by site of study. First.9 6 (19%) 7 (22%) 6(19%) p-value 0. number of premature patients.4 3 (8%) 5 (13%) 3 (7. standard segment aganglionosis was similar between the placebo and probiotic groups (Table 2). including ‘total colonic’ Hirschsprung.592 0. There were however.001 b 0.6 10 (50%) 12 (60%) 9 (45%) M.858). the incidence of post-pullthrough HAEC was higher in the Ann Arbor group (Table 2).

We next stratified HAEC by patients with standard length aganglionosis versus those with longsegment aganglionosis and found no differences in patients receiving placebo or probiotics (p=0.053 0. either due to the release of immunoglobulins in the aganglionic colon [7. and extent of aganglionosis (standard versus long segment) (p=0.508 p-value 0.648). third and fourth episodes. Some hypothesize that stasis due to a partial mechanical obstruction by the remaining aganglionic segment or spastic internal sphincter may be the inciting cause [1. gender (p=0.702–1. with several groups showing that there is a loss of normal mucosal immune defense.842–13. Discussion The overall objective of this study was to test our hypothesis that prophylactic administration of probiotics after a pullthrough procedure would decrease the incidence of Hirschsprung-associated enterocolitis.159–7. We first stratified the study groups by severity of HAEC (See Table 3). further stratification of the patients was then performed.295–2. Placebo Site A Site B Y N Grade I Grade II Grade III Grade I Grade II Grade III HAEC Y HAEC N HAEC Y HAEC N 11 19 7 23 6 0 1 7 12 1 2 15 4 19 3 5 Probiotic 12 21 10 23 3 6 1 10 11 10 1 22 6 19 4 4 p value p=0. The loss of normal mucosal immune defense is another possibility. Our study demonstrated that prophylactic treatment with probiotic therapy was ineffective in the prevention of HAEC. The exact etiology of HAEC remains unclear.778 3. The prevailing model for the development of HAEC suggests a multifactorial etiology. due to a combination of normal mucosal defense loss followed by an invasion of pathogens into the intestinal wall with subsequent development of an Table 5 Covariates Relative risk of HAEC based on several influencing covariates.072).150 2. severity of HAEC and length of aganglionosis.515 0.925 HAEC was not significantly different between the patients receiving placebo or probiotic therapy (p=0. age at diagnosis (b or N 1 week) (p= 0.604 0. altered microbiome [10] or a deficiency in the transfer of secretory IgA [7.23] within the gastrointestinal mucosa resulting in a propensity towards infection. showed a trend toward Trisomy 21 predisposing to HAEC and longer lengths of aganglionosis as a predisposing factor. N) HAEC Severity (Second.20. Multivariate logistic regression models for HAEC using treatment arms (p=0.693) or with a recurrence rate of HAEC (p=0. regression analysis further demonstrated no significant influence on the effect of treatment with probiotics and its impact on the incidence of HAEC. Hosmer–Lemeshow goodness-of-fit demonstrated no significant difference between the predicted and actual distribution.648 Standard Length Aganglionosis (N) Long-Segment Aganglionosis (N) p=0.21].925). Because of differences in the rate of HAEC between sites.951 0.373 95% Confidence intervals 0. Treatment with probiotics did not affect severity or clinical grade of HAEC experienced both for the first incidence of HAEC (p=0. and thus the model was a good fit (Tables 4 and 5).592 0.3.604).22] as well as aberrant mucosal mucins [11. Table 3).897 0. despite advances in the diagnosis and management of HD.Probiotic prophylaxis after pull through for HD Table 4 115 Stratification of patients with and without HAEC based on randomization.198).19].858 p=0.897 p=0.18.693 HAEC (N) HAEC Severity (First episode. as well as differences between the extent of aganglionosis. diagnosis of Trisomy 21 (0.598 0.474–7.364 0.072 Probiotic Therapy Long segment aganglionosis Age at Pull Through (N 1 year old) Diagnosis of Trisomy 21 Female Gender Use of Antacid therapy . Relative risk 1.381–1.592).653 1.021 0. 3.117 0. However.21.067 0.883 1.021).897. N) p=0.

et al. Bere P. et al. Filler RM. Enterocolitis.23:237-42. Children who have experienced delayed diagnosis of HD have been shown to have increased incidence of enterocolitis [4]. J Pediatr Surg 2003. Caniano D. Teitelbaum D. Pediatr Surg Int 1992. Enterocolitis associated with Hirschsprung's disease: a clinical–radiological characterization based on 168 patients. It was interesting that the age at presentation was quite older in the Tanta. Pediatr Surg Int 2010. inflammatory bowel disease [25] and the prevention of necrotizing enterocolitis [14]. J Pediatr Surg 1995. et al. The treatment of HAEC consists of rectal decompression along with oral antibiotics. References [1] Caneiro P. randomized. although VSL#3 contains a broad range of probiotic strains and one of the highest concentrations of probiotics commercially available. . MUC-2 mucin production in Hirschsprung's disease: possible association with enterocolitis development. [10] De Filippo C.7:162-9. El-Sawaf et al. [6] Wildhaber BE. [7] Fujimoto T. Genomics approach to the analysis of bacterial communities dynamics in Hirschsprung's disease-associated enterocolitis: a pilot study. Coran AG. this may have influenced the comparative rates of HAEC seen between sites. Based on these previous studies. Teitelbaum DH. Coran AG. Coran AG. our hypothesis that probiotics would reduce the incidence of HAEC seemed quite plausible.[see comment]. Hirschsprung's disease. J Pediatr Surg 2009. The period of treatment varies from patient to patient. The use of these medications may have put the Ann Arbor cohort at further risk of developing enterocolitis and may have even played a role as a confounding factor influencing the outcome. [12] Khan MW. The adult literature describes the use of antacid therapy as an independent risk factor for the development of M. Qualman S. Other practice differences existed between study sites that may have played a role. it is difficult to draw conclusions as to why this modality of treatment was unable to diminish the incidence or severity of HAEC in patients post-pullthrough procedure. Osman F. 6:81-94. Egypt site. community acquired colitis and is posited to be due to an alternation in the microbiome of the gastrointestinal tract [26].4. The higher recurrence rate may be attributed to the persistence of the mucosal histopathological changes for long periods even after the performance of decompressive colostomy or even following successful pullthrough procedure [2].40:203-6 [discussion 206-207]. our outcomes were not markedly different. et al. While this was a prospective. intestinal inflammation and probiotics. Microbes.33:830-3. Enterocolitis in Hirschsprung's disease. Ann Surg 1988. J Pediatr Surg 1988. Pearl RH. As long segment disease has been associated with higher rates of HAEC [2].7:356-60. Semin Pediatr Surg 1998. our study showed that despite our two centers being geographically quite distinct. [Review] [59 refs]. Drake D. controlled trial. Currently there is no single strategy identified for prophylaxis from this major complication. [9] Teitelbaum DH. Coran A.44:251-6. However.30:76-83. Blane C. Identification of risk factors for enterocolitis. especially in patients with long-segment aganglionosis. In very ill patients intravenous antibiotics are used. These include. yet the overall rate of enterocolitis was lower than the Ann Arbor group. Brereton R. Enterocolitis associated with Hirschsprung's disease: a clinical histopathological correlative study. Further. usually 1 to 2 weeks of treatment is required. Refractory and repetitive enterocolitis is a common and serious problem in pediatric surgical patients.9]. It is possible that other formulations of probiotics may have had a more positive effect. pouchitis [24]. [2] Elhalaby E. including suppressive antibiotics and anti-reflux therapy. First. As the exact mechanism of action of probiotic therapy is yet to be understood. Kale AA. In addition children who develop HAEC are prone to recurrent episodes. Teitelbaum DH. Development of a standardized definition for Hirschsprung's-associated enterocolitis: a Delphi analysis. It is of utmost importance that the treatment of enterocolitis is started early and pursued vigorously to prevent the condition from becoming chronic or spreading systemically. Other risk factors include increased length of the aganglionic segment. It was interesting that the Ann Arbor group was more likely to treat these children with antacid therapy while the Tanta group did not have any of its patients treated with either H2 blockers or proton pump inhibitors. Total colonic Hirschsprung's disease: a 28-year experience. Of which long segment aganglionosis. Enterocolitis after the surgical treatment of Hirschsprung's disease: risk factors and financial impact.38:417-21 [discussion 417-421]. Expert Rev Gastroenterol Hepatol 2012. Teitelbaum DH. there were some potential confounding factors that may have influenced the results. J Pediatr Surg 1998. Mattioli G. [3] Hackam DJ. We may benefit from repeating the study with a more stringent control over concurrent medical regimens. Pini-Prato A.30:1023-6 [discussion 1026-1027]. [11] Mattar AF. et al. [5] Pastor A. female sex. Further analysis showed that the Ann Arbor site had a higher incidence of long segment disease. In conclusion. and neither center found probiotics to be able to prevent the development of enterocolitis. [8] Elhalaby EA. Natural history and pathophysiology of enterocolitis in the piebald lethal mouse model of Hirschsprung's disease.26:465-71. an increasing body of literature supports the use of probiotics to prevent or treat a number of pro-inflammatory conditions of the gastrointestinal tract.207:240-4. Many risk factors have been identified and help support the current model for the pathophysiology of HAEC.116 enterocolitic process. [4] Teitelbaum D. Coran AG. J Pediatr Surg 2005. we do not anticipate any probiotic having a positive impact on reducing HAEC. Trisomy 21 and the presence of other associated congenital anomalies [2. et al. the results of this study indicate that the use of probiotic bacterial therapy was ineffective in reducing either the incidence or severity of post-pullthrough HAEC. and possibly age > 1 year at time of pullthrough and Trisomy 21 were predisposing factors for HAEC in the present study. because HAEC occurred more frequently in infants in the probiotic group. 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