Stomas of the Small and Large Intestine in Children

Updated: Jun 26, 2017
  • Author: Robert K Minkes, MD, PhD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
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Overview

Background

Pediatric ostomies include any surgically created opening between a hollow organ (eg, the small or large intestine) and the skin connected either directly (stoma) or with the use of a tube.

Colostomies were used in the late 1800s to treat intestinal obstruction. Some of the earliest survivors were children with an imperforate anus. Creation of an intestinal stoma was considered a drastic procedure and was avoided because of the high incidence of complications and mortality. With improvements in surgical technique and practice, the need for stomas increased as more children with formerly fatal conditions survived.

Since the early success with colostomy formation in the 1800s, the use and management of gastrointestinal (GI) stomas in children have evolved. Improved surgical techniques, better understanding of the physiologic and psychological consequences of intestinal stomas, and advances in stoma care have contributed to more rational use of ostomies by pediatric surgeons and a wider acceptance in the medical and lay communities (though the frequency of intestinal stomas in the pediatric population is difficult to determine).

Nevertheless, treating a child with multiple abdominal stomas can be intimidating and challenging (see the image below), especially when the anatomy is not clear and the fluid and electrolyte abnormalities are difficult to control.

Multiple stomas in the abdomen of a 3-year-old chi Multiple stomas in the abdomen of a 3-year-old child who underwent surgery as an infant for high imperforate anus. A divided colostomy was performed to divert the stool. The other end was brought out through the skin (mucous fistula) to allow evacuation of mucus and gas. A vesicostomy was performed because of a neurogenic bladder.

Although great advances have been made with regard to stoma formation and management, both early and late complications are common. Fortunately, most pediatric stomas are temporary, and many of the complications associated with intestinal stomas are eliminated when the stoma is closed. Understanding enterostomal construction and physiology is essential for providing these children with optimal care.

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Etiology

Many diseases may necessitate formation of a stoma or placement of a tube within the bowel. Small-bowel stomas are used for patients with intestinal perforation or ischemia in whom an anastomosis is considered unsafe. A proximal ileostomy is often used to protect the distal anastomosis after restorative proctocolectomy for familial polyposis or ulcerative colitis.

Similarly, colostomy is often used both before and after a pull-through procedure for imperforate anus or Hirschsprung disease, though many surgeons are now performing primary pull-through procedures without colostomy for both of these conditions. Tube cecostomy or Malone appendicocecostomy have been used for antegrade bowel irrigation in children with intractable constipation and various medical conditions. [1, 2]

Children with severe perineal burns or trauma (see the image below) often require a temporary colostomy to allow the injury to heal.

Severe injury to the perineum and anal sphincter ( Severe injury to the perineum and anal sphincter (caused by a lawn mower) in a 9-year-old boy. A diverting colostomy was performed. Several weeks later, a skin graft was placed over the defect. After reconstruction of the anal sphincter, the colostomy was reversed.

Neonates with the following conditions may require a stoma:

Children and adolescents with the following conditions may require a stoma:

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Prognosis

Outcome for pediatric patients with intestinal stomas depends on the underlying condition. Fortunately, most stomas in infants and children are reversible. Reestablishing bowel continuity depends on factors such as the underlying disease, the general medical condition of the child, and the presence of stoma-related complications. Understanding the anatomy prior to stoma closure is crucial. In most instances, a preoperative distal contrast-enhanced study should be performed.

In general, the prognosis for patients with intestinal stomas is good. The exception is in patients with stomas and short-bowel syndrome. In such cases, reversal of the stoma should be attempted as soon as possible in order to maximize the absorptive capacity of the intestines. However, in many cases of short-bowel syndrome, ostomy reversal is not possible because of other associated comorbid conditions. The most common cause of short-bowel syndrome in North America is necrotizing enterocolitis.

In a retrospective cohort study intended to compare clinical outcomes of loop and divided colostomies in patients with anorectal malformations, Oda et al found that the former, because of the higher incidence of prolapse, carried a higher total complication rate than the latter but that the rates of other complications (eg, megarectum and urinary tract infection) did not differ significantly between the two stoma types. [4]

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