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Gastrointestinal Stomas in Children 433
Other Complications applied over the stoma results in spontaneous closure in most cases.
Peritonitis may be a caused by early stoma retraction or wound infec- However, if a persistent gastrocutaneous fistula develops, surgical
tion and may lead to intraperitoneal abscess, particularly in neonates. closure is indicated.
Antibiotic treatment or operative drainage may be indicated. Bowel Stomas should be closed when the underlying condition has
obstruction may occur due to improper alignment and twisting at the resolved. Although there is no urgency to the timing of stoma closure,
time of stoma construction. This requires urgent surgical correction to the psychological stress and cost of providing stoma care should be
prevent necrosis and resection and possible sepsis. considered. A contrast study (distal loopogramme) and/or endoscopic
Exteriorisation of the wrong bowel segment may occur. For assessment of the distal bowel may be done to ascertain normalcy
example, the small intestine may be mistakenly used instead of the (and patency) before closure. In cases of Hirschsprung’s disease and
colon, or the distal limb of the colon may be used as the stoma while anorectal anomalies, a stoma is usually in place at the time of definitive
the proximal limb is closed and returned to the peritoneal cavity as pull-through. After the anastomosis has healed, it is helpful to begin
the Hartmann’s pouch. When performing a left-sided colostomy, it anal dilatation for up to a week before stoma closure. As mentioned
is recommended to place a rectal tube to aid the identification of the previously, the occurrence of complications in temporary stomas should
colon. The problem usually manifests as a complete bowel obstruction prompt consideration for closure of the ostomy rather than revision.
and requires immediate surgical correction. Complications of closure include:
Other, less serious complications include granulation and/or polyp 1. wound infection;
formation and ulceration. These are typically managed with local 2. anastomotic leak;
cauterisation therapies and observation. Psychological trauma, which
may be a serious problem for families and school-age children, can be 3. enterocutaneous fistula;
mitigated by adequate preoperative counselling and constant support. 4. stenosis/stricture at the site of anastomosis;
Stoma Care 5. intestinal obstruction; and
In most African hospitals, specialised nurses, such as enterostomal ther- 6. abdominal scars.
apists, are not available. The paediatric surgeon is therefore the primary Evidence-Based Research
source of care and support for children with stomas and their families.
Table 72.3 presents a retrospective review of colostomy complications
Management at Home in children.
Children and their families adapt to stomas in various ways. Adequate
planning by families is needed, and older children should be incorpo- Table 72.3: Evidence-based research.
rated into care planning for their stomas. The use of an adequate size Title Colostomy complications in children
stoma bag is important to prevent the effluent from making contact with Authors Mollittt DL, Malangoni MA, Ballantine TV, Grosfeld JL
the skin. The nonavailability of stoma bags for children with colostomy
Institution James Whitcomb Riley Hospital for Children, Indianapolis,
is a major problem in this subregion. Some innovation may be needed, Indiana, USA
given the resources available locally. For example, a cut-off leg por-
Reference Arch Surg 1980; 115:455–458
tion of a thick cotton pant slid over a soft napkin can be applied over
6
the stoma. This must be cleaned regularly to reduce offensive odour, Problem Intestinal stomas.
Comparison/ Single institution retrospective review.
and zinc oxide paste or petroleum jelly should be applied to protect the
control
peristomal skin.
(quality of
Management at School evidence)
The psychological effect on the school-age child is important. Some
children will be open and discuss the stoma with their friends and class- Outcome/ Analysis of 146 paediatric patients with colostomies,
specifically related to formation, management, and
effect
mates, but others may choose to conceal it. In some cases, however, the subsequent closure of colostomies. The majority of the
whole class and schoolmates may be told about the child’s stoma so as colostomies were performed for congenital diseases
to avoid subjecting the child to manual labour and overzealous play and (Hirschsprung’s and imperforate anus). There were more
loop colostomies than divided colostomies, but also more
physical contact in the playground. The child should be taught how to complications noted with loop versus divided colostomies.
change the stoma bag and clean it regularly, even at school, to reduce No deaths were related to colostomy closure. Sigmoid
offensive odour. colostomies were associated with the lowest rate of
complications.
Stoma Closure Historical This study underscores the importance of location and type
In temporary stomas, closure is imperative to restore bowel continuity significance/ of colostomy (specifically sigmoid colostomy), attention
as the last step in the treatment of the child. Provided there is no distal comments to technical details, principles of stoma care, and proper
instruction for parents in minimising complications from
obstruction, the majority of tube stomas require no surgical closure. colostomies.
Removal of the tube (e.g., gastrostomy tube) with pressure dressing