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430  Gastrointestinal Stomas in Children
                    Classifications of Stomas                      Complications of Gastrointestinal Stomas
        Stomas may be classified by using temporal, anatomical, or construc-  Major complications could occur in up to 75% of children following
        tional criteria.                                       colostomy or ileostomy, with an overall revision rate of approximately
        Temporal Stomas                                        15% (Table 72.2). Skin complications, such as dermatitis, granuloma,
        Temporal  classification  is  based  on  the  anticipated  duration  of  the   and  ulceration,  are  the  most  frequent  problems  with  ostomies.  Most
        stoma and is either temporary or permanent. Most stomas in children   surgeons  in  Africa  will  not  have  access  to  dedicated  enterostomal
        are temporary and are reversed as soon as possible. Permanent stomas   therapists, and therefore they need to be knowledgeable in the care of
        may  be  necessary  for  patients  with  spinal  cord  injury  and  resultant   stomas and in the prevention and management of skin problems and
        paralysis or severe spina bifida.                      other complications.
                                                                 Stomas  made  in  the  small  intestine  (enterostomas)  are  associated
        Anatomical Stomas                                      with  more  complications  than  colostomies.  In  addition,  transverse
        Anatomical  classification  is  based  on  the  anatomical  portion  of  the   colostomies  cause  more  problems  than  sigmoid  colostomies.  With
        colon in which the stoma is sited. Examples include sigmoid colostomy,   temporary  stomas,  the  occurrence  of  complications  should  prompt
        when sited in the sigmoid colon; transverse colostomy, when sited in   consideration for closure of the ostomy, rather than revision.
        the transverse colon, which can be further subdivided into right-trans-
        verse, mid-transverse, and left-transverse colostomy; and caecostomy,   Table 72.2: Stoma complications in children.
        when sited in the caecum.                               Complication                     Incidence (%)
        Constructional Stomas                                   Ischaemia/necrosis                   <1
        Constructional classification is based on how the stoma is constructed,
        and is of two major types: loop colostomy and divided colostomy.  Stenosis/stricture        3–6
        Loop colostomy                                          Retraction                          2–4
        An opening is made on the antimesenteric border of the colon without   Prolapse             12–24
        completely dividing it. A loop colostomy does not interrupt colon con-
        tinuity and allows faecal material to pass beyond the stoma. Because   Parastomal hernia     1
        some  enteric  material  still  enters  the  distal  bowel,  it  is  in  essence  a   Skin excoriation  20–30
                           1
        non-defunctioning  stoma.   The  stoma  may  be  looped  over  a  rod  to
        prevent retraction. Loop colostomies are easy to create and are quite   Bleeding            1–10
        useful in clinically compromised children when prolonged anaesthesia   Obstruction          1–6
        is undesirable. Loop ostomies are associated with a higher rate of com-
        plications; therefore, most paediatric surgeons prefer divided stomas. 4  Source: Nwomeh B. Reoperation for Stoma Complications. In: Teich S, Caniano DA, eds.
                                                               Reoperative Pediatric Surgery. Humana Press, 2008, Pp 279–285.
        Divided colostomy
        In the divided stoma, the bowel is completely divided and the bowel
        continuity interrupted. Because intestinal content does not enter the dis-  Skin Excoriation
        tal bowel, divided stomas are also called defunctioning stomas. Divided   Skin excoriation is one of the most common complications following
        stomas may be further subclassified based on what the surgeon does   colostomy  creation.  It  usually  occurs  due  to  (1)  continuous  wetting
        with the proximal and distal limbs. The most common variations are   of the surrounding skin by effluent, which results in maceration; (2)
        the double-barrel, Devine, and end stomas.             allergic reaction to effluent; (3) enzymatic digestion of macerated tis-
           Stomas in which the distal limb is brought to the surface permit the   sues;  and  (4)  bacterial and  fungal  growth  on  the  macerated  exposed
        release of secreted mucus, and provide access for contrast studies for   tissues. It is graded from 1 to 4, depending on the depth of excoriation.
        the diagnosis of distal lesions and to assess the patency and integrity of   Management includes using a properly fitted colostomy bag, applying
        the distal bowel before stoma closure. With end stomas, care must be   zinc oxide paste to the skin (or petroleum jelly when zinc oxide paste is
        taken to avoid leaving a Hartmann’s pouch in which complete drainage   not available), and keeping the skin dry as much as possible. In severe
        through the anus is prevented by an obstructing lesion within the distal   cases, it may be necessary to revise or relocate the stoma.
        bowel. In such cases, mucous distention of bowel above the obstruction   Wound Infection
        may lead to perforation of the Hartmann’s pouch.       Wound infection is most common when the stoma is sited within the
        Double-barrel stoma                                    main incision. To reduce the incidence of postoperative infection, the
        Both the proximal and distal limbs may or may not be plicated together   stoma should be placed at a separate location. Treatment is usually with
        but are brought out side-by-side through the same wound like a double-  antibiotics and good peristomal skin care. Drainage may be necessary
        barrel gun. The proximal limb discharges faeces and flatus, and the distal   if an abscess develops.
        limb discharges mucus. If the two ends are brought too close together,   Retraction
        or are included in a single stoma pouch, enteric contents may pass into
                                                               Retraction occurs when the stoma retracts back to the peritoneal cavity. It
        the distal bowel, and such a stoma may not be completely defunctioning.
        Devine stoma                                           is important to identify the cause of stomal retraction. The most common
                                                               problem is undue tension on the stoma because the proximal bowel and
        In  a  Devine  stoma,  both  proximal  and  distal  limbs  are  brought  out
                                                               its mesentery had not been adequately mobilised. Anchoring the bowel
        separately, sometimes through different incisions, and are separated by
                                                               to the fascia with sutures cannot be relied upon to prevent retraction of
        a skin bridge. When complete diversion of stool from the distal bowel
                                                               the stoma because it does not mitigate the tension in the bowel. A second
        is desired, this type of stoma is preferred over the double-barrel variety.
        End stoma                                              cause is stomal necrosis. Also, retraction may be due to prolonged sero-
                                                               sitis with subsequent shortening of bowel when the stoma has not been
        Here the proximal limb is brought out to evacuate faeces and flatus,
                                                               matured. The retracted stoma causes leakage of intestinal contents, which
        and the distal limb is closed or oversewn and returned to the peritoneal
                                                               may interfere with the secure application of the appliance.
        cavity. The blind distal bowel, the Hartmann’s pouch, opens distally
                                                                  Revision  of  the  retracted  stoma  is  usually  required.  The  retracted
        into the anus.
                                                               stoma  is  often  fixed  in  position  and  the  goal  is  to  mobilise  sufficient
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