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432 Gastrointestinal Stomas in Children

hours. If mucosal necrosis is limited to the portion superficial to the
fascia, an expectant approach may be employed, but the stoma should
be monitored closely for progressive necrosis or subsequent develop-
ment of stenosis, stricture, or retraction.
4
Haemorrhage
Bleeding may occur from the mucosa or the stoma edge itself.
Haemorrhage may occur postoperatively due to dislodgement of a
clot or suture following crying or an increase in blood pressure when
adequate haemostasis was not achieved in the operating room. Pressure
with a gauze pad is usually sufficient to control the bleeding, but
(A) endoscopy or operative intervention may be necessary. Areas of the
(A)
(A) (A) abdominal wall with major vessels, such as epigastric vessels, should
be avoided when choosing the stoma site.
Stoma Stenosis or Stricture
Stenosis or stricture of the stoma may occur at the skin or fascial level
and is clinically apparent as reduced stoma output or frank bowel
obstruction. This may occur when the skin or fascial opening is tight,
leading to ischaemia at the mucocutaneous junction. If the stoma had
not been matured, prolonged serositis with subsequent fibrosis may
also lead to stenosis. Serial dilatation with anal (or Hegar) dilators may
resolve the obstruction, but this procedure carries the risk of bowel per-
foration. In many cases, a formal surgical revision is needed.
High Stoma Output
Excessive stoma output occurs in more proximal stomas. Stoma losses
can cause profound fluid and electrolyte derangement. Adequate moni-
toring and replacement of losses are important.
(B) Faecal Impaction
(B)
(B) Faecal impaction should prompt the evaluation for stomal stenosis. It may
(B) be relieved with enemas administered through the stoma or by manual
disimpaction, which should be done under sedation or general anaesthesia.
Parastomal Hernia
A parastomal hernia is a herniation that occurs at the site of the colos-
tomy (Figure 72.4). Parastomal hernia appears to occur less frequently
in children than in adult patients, with an incidence of less than 1%.
The most likely cause is the creation of a fascial aperture relatively
larger than the bowel used for the ostomy. Other factors predisposing to
parastomal hernia include wound infection, malnutrition, and obesity.
Fortunately, more serious complications, such as intestinal obstruction
and strangulation, are rare. The stoma appliance is more difficult to
retain, and persistent leakage may occur. In such cases, operative repair
(C) should be considered. The simplest procedure is to mobilise the stoma,
(C)
repair the hernia snugly around the bowel, and then mature the ostomy
(C)

at the same site. Alternatively, the hernia could be repaired and the

stoma relocated to another site. It is often best to relocate or close the

(C) stoma because recurrence is frequent after local revision. 4
Source: Nwomeh BC. Reoperation for stoma complications. In: Teich S, Caniano DA, eds.
Reoperative Pediatric Surgery. Humana Press, 2008. Reproduced with permission.
Figure 72.3: An alternative technique for temporary control of prolapse of one
limb of a looped ostomy. See text for procedure.
Colostomy Dehiscence
When prolapse occurs before the colostomy is matured (a minimum of
2 weeks after formation), it may detach from the skin and allow evis-
ceration of the intraabdominal content. This is a serious complication
that requires emergency revision.
Ischaemia or Necrosis
The complication of significant ischaemia or frank necrosis is apparent
early in the postoperative period. The cause is devascularisation from
excessive stripping of the mesentery, venous congestion due to ten- Source: Nwomeh BC. Reoperation for stoma complications. In: Teich S, Caniano DA, eds. Reop-
sion on the bowel, or a tight fascial opening. Some degree of oedema erative Pediatric Surgery. Humana Press, 2008. Reproduced with permission.
and venous congestion normally occurs with new stomas, especially if Figure 72.4: Parastomal hernia, with a bulge in the abdominal wall to one side
of the stoma.
previously distended bowel is used, but this usually resolves within 48