Page 33 - 69 stomac-duodenum-&-small-intestine66-72_opt

CHAPTER 72

GAastrointestinal Stomas

in Children

Osarumwense David Osifo
Johanna R. Askegard-Giesmann
Benedict C. Nwomeh

Introduction Table 72.1: Categories of stomas with specific examples of common types in
children.
A stoma (or ostomy) is the deliberate creation of an opening that com-
municates between the GIT and the exterior. The purpose could be for Groups/purpose of enterostoma Specific examples
feeding, drug administration, bowel decompression, protecting distal
Stomas created without entering Nasogastric tube
anastomosis or other gut lesions, controlling faecal effluent in some through bowel wall Nasogastrojejunal tube
cases of incontinence, or a combination of these indications. The basic Nasojejunal tube
Rectal tube
types of stomas derive their names from the gastointestinal segment in
Colonic tube
which they are sited. For example, gastrostomy is sited in the stomach,
Minimally invasive stomas through Tunneled catheter
jejunostomy in the jejunum, ileostomy in the ileum, and colostomy in
bowel wall Needle catheter
the colon. Stomas may be categorised on the basis of the purpose for T-tube
their creation; specific examples of commonly used stomas in children Button, etc.
are shown in Table 72.1. Isolated jejunal loop brought to Roux-en-Y loop
The use and management of gastrointestinal stomas in children abdominal wall
has evolved since the early success with colostomy formation in the Proximal decompression with distal Nasogastric/nasojejunal tubes
1800s. Improved surgical techniques, better understanding of the loop for feeding Double-barrel jejunostomy
Double-barrel ileostomy
physiologic and psychological consequences of intestinal stomas,
and advances in stoma care have contributed to a more rational use Antegrade irrigation and Caecostomy through appendix stump
decompression Catheter placement, T-tube, etc.
by paediatric surgeons and a wider acceptance in the medical and lay
1,2
communities. . Colonic decompression, faecal/flatus End stoma, single opening
diversion or evacuation Double-barrel stomas
Although creating a stoma may be life saving and necessary to
End stoma with anastomosis below
maintain a child’s health, the affected child and the child’s family or abdominal wall.
caregivers need to understand why the surgeon is considering stoma Loop over a small rod or skin bridge.
Open loop with occluding valve,
creation and should have some input. They need to understand what T-tube device, etc.
3
a stoma is, why it is necessary, and how it will function. It is also Catheterisable pouch
important that the child and the family understand the difficulties or
complications that can be encountered. Discussions with the child’s
school during the planning phase can also be helpful, as this can Jejunostomy/Ileostomy
Stomas of the small bowel are commonly used for feeding, bowel decom-
ensure the child’s smooth reintegration after surgery. The creation
pression, or diversion of distal disease. Specific indications include
of a permanent stoma may need to be discussed openly, as some
children and their families may believe that stoma creation is only a • bypass of gastric outlet obstruction;
temporary measure. 3
• protection of distal anastomosis;
Common Types of Gastrointestinal Stomas • as a life-saving diversion procedure in clinically compromised chil-
A good stoma is best obtained by careful preoperative planning, meticu- dren with obstructive distal bowel lesions; and
lous surgical technique, and detailed attention to skin care. Different
types of stomas are created for a variety of clinical reasons. Colostomy, • to rest and/or decompress distal bowel in cases of perforation and
the most common enterostoma used in children in sub-Saharan Africa, severe enterocolitis with surgical complications.
is discussed in greater detail in this chapter. Colostomy
Gastrostomy Colostomy is a stoma of the colon with the aim of diverting faeces and
Gastrostomy is the creation of an opening between the stomach and flatus. It is the most common stoma used in children. Indications for
the skin for the purpose of feeding, drug administration, and proximal creation of a colostomy may be either congenital or acquired.
decompression of the GIT. Other clinical scenarios that may require a Congenital indications are more common and include high anorectal
gastrostomy include oesophageal obstruction due to corrosive oesopha- anomalies and Hirschsprung’s disease. More rare congenital indications
geal stricture, severe maxillofacial trauma, achalasia of the cardia, and are rectovesical/rectovaginal fistula, cloacal exstrophy, and severe spina
oesophageal carcinoma (in adults). A gastrostomy tube is most com- bifida with incontinence. Colostomy may also be beneficial for faecal
monly placed by using the standard Stamm technique, but percutaneous diversion prior to resection of large congenital intrapelvic masses.
endoscopic gastrostomy (PEG) and laparoscopic insertion are being Acquired indications include bowel perforation, high fissure-in-ano,
introduced in a few centres. severe perineal traumas, posttrauma paralysis, and to protect distal
anastomoses (such as coloanal anastomosis of pull-through procedures).