Stomas of the Small and Large Intestine

Updated: Apr 27, 2015
  • Author: Robert K Minkes, MD, PhD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
  • Print
Overview

Background

The use and management of gastrointestinal (GI) stomas in children have evolved since the early success with colostomy formation in the 1800s. 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.

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.

Several differences between adult and pediatric ostomies are recognized. Most stomas in adults are formed in the distal ileum or colon for the treatment of inflammatory bowel disease, malignant conditions, and trauma; more proximal stomas are only rarely created. In contrast, stomas in infants and children may be required anywhere along the GI tract because of the wide variety of congenital and acquired conditions that necessitate stoma formation. The effect of a stoma on physical and emotional development and on growth is an additional consideration in children.

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.

Next:

History of the Procedure

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.

Previous
Next:

Problem

Pediatric ostomies include any surgically created opening between a hollow organ and the skin connected either directly (stoma) or with the use of a tube. In infants and children, stomas are used for various purposes, including access, decompression, diversion, and evacuation. As a rule, most ostomies are for temporary use and are typically reversible in children. Certain medical conditions may dictate the need for a permanent stoma.

Previous
Next:

Epidemiology

Frequency

The frequency of intestinal stomas is difficult to determine in the pediatric population.

Previous
Next:

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]

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:

Previous
Next:

Pathophysiology

The pathophysiologic features depend on the specific disease process.

Previous
Next:

Presentation

The clinical presentation depends on the specific diagnosis and age of the patient.

Previous
Next:

Indications

Stomas are used in situations in which diversion of, decompression of, or access to the bowel lumen is needed.

Previous
Next:

Relevant Anatomy

The clinical scenario and relevant anatomy may affect the technique used for stoma creation and the location of the stoma.

Choice of technique

Several types of intestinal stomas are recognized (see the image below). The clinical scenario often dictates the segment of intestine selected, the type of stoma created, and its external location. In children, most stomas are created as an end or loop ostomy; however, it is important to be familiar with the many potential variations in their construction. Roux-en-Y construction can also be use for tube stomas (eg, feeding jejunostomy).

Diagrams illustrate pediatric stomas. (A) End stom Diagrams illustrate pediatric stomas. (A) End stoma (inset shows everting maturation); (B) double-barrel stoma: End stoma and mucous fistula are divided and brought through the same incision (inset shows closed mucus fistula sutured to abdominal wall); (C) loop stoma; (D) decompressing blowhole stoma; (E) Bishop-Koop stoma; and (F) Santulli stoma

For an end stoma (see the images below), the bowel is divided, and the proximal end is brought through the abdominal wall. The distal nonfunctioning limb can be brought out through the same abdominal wall opening as the end stoma (ie, double-barrel stoma), it can be brought out through a separate incision (ie, mucous fistula), or it can be closed and left in the peritoneal cavity (ie, Hartmann procedure).

Divided end ileostomy and ileal mucous fistula. Th Divided end ileostomy and ileal mucous fistula. The ileostomy is brought out through a separate skin incision.
End ileostomy with closed distal limb (also known End ileostomy with closed distal limb (also known as Hartman pouch).
End ileostomy with closed distal intestine after m End ileostomy with closed distal intestine after multiple resections. The segment without function is left in situ, and a stoma is used for decompression.

When the distal segment is left inside the abdomen, many surgeons fasten it to the abdominal wall adjacent to the end ostomy or tag it with a nonabsorbable suture to facilitate identification when the stoma is reversed.

A loop stoma is created by maturing a segment of bowel over a rod or tube without completely dividing the bowel. Loop stomas provide excellent decompression and have the advantage of simple closure without the need for a separate laparotomy in most cases. However, loop stomas are not completely diverting because proximal contents can spill over into the distal limb. Therefore, they should be used with caution in patients in whom stool in the distal bowel may be problematic.

A decompressing stoma, or blowhole, is created in patients in unstable condition by opening the antimesenteric border of bowel without mobilizing the entire loop of bowel.

Stomas can also be formed in association with an anastomosis for proximal or distal venting or irrigation (ie, Bishop-Koop [2] and Santulli stomas; see the images below). These stomas were initially designed for the treatment of infants with meconium ileus but have been adapted for many other purposes.

End-to-side anastomosis created in an infant with End-to-side anastomosis created in an infant with a complicated meconium ileus, with distal stoma used for irrigation (also known as the Bishop-Koop ileostomy).

In children with necrotizing enterocolitis, multiple intestinal atresia, or midgut volvulus in which multiple bowel anastomoses may be unsafe and in whom preservation of intestinal length is desired, one or more discontinuous segments of bowel may be externalized. The operating surgeon should clearly describe the anatomic configuration in the surgical notes and provide an illustration in the patient's chart.

In general, a stoma is easier to manage when it is not flush with the skin. Everting the bowel before suturing the edge to the skin (ie, Brooke technique) yields a spigot conformation that holds a stoma appliance and prevents serositis. Eversion is not always possible in neonates (whose blood supply may be tenuous) and in patients whose bowel is markedly edematous. In these cases, the bowel is left to protrude through the skin without eversion, and the stoma automatically matures as the mucosa rapidly grows over the exposed serosal surface.

Selection of stoma site

Intestinal stomas can be exteriorized on the neck, chest, or abdomen. The abdomen is by far the most common site for intestinal stomas. Enterostomies can be brought through the abdominal wall in the laparotomy incision or through a separate site. Theoretical disadvantages of bringing a stoma through a large laparotomy incision include the risk of wound infection, dehiscence, and evisceration. Nevertheless stomas are often incorporated into the incision, especially when the only goal of surgery is to create a stoma.

Whenever clinically feasible, a primary stoma site, as well as alternative sites, should be selected and marked before surgery. The ideal location for an abdominal stoma in older children and adolescents is similar to that in adults. The stoma is distant from the incision, through the midportion of the rectus muscle away from skin folds (eg, groin, flank), bony prominences (eg, rib cage, iliac spine), and umbilicus (see the image below).

Potential sites for stomas in an older child or ad Potential sites for stomas in an older child or adolescent. Ideally, a stoma is brought through the rectus muscle in a position that allows placement of a stoma appliance.

Stoma location in infants and neonates (see the image below) follows these same principles whenever possible; however, the small size of the abdominal wall in infants and the short mesentery of the bowel chosen for the stoma often limit the options.

Potential sites for neonate and infant stomas. Potential sites for neonate and infant stomas.

For temporary stomas in infants, the bowel can be brought out directly through or adjacent to the umbilicus (see the images below). [3] This site is easier for appliance placement and results in a cosmetically superior scar when the stoma is ultimately closed.

Stoma brought directly through the umbilicus. Stoma brought directly through the umbilicus.
Stoma matured through a separate inferior umbilica Stoma matured through a separate inferior umbilical incision.
Previous
Next:

Contraindications

No specific contraindications for the use of intestinal stomas are recognized, other than those for surgery in general.

Previous