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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