eMedicine Specialties > Pediatrics: Surgery > General Surgery

Stomas of the Small and Large Intestine

Author: Robert K Minkes, MD, PhD, Professor of Surgery, University of Texas Southwestern; Chief of Surgical Services, Children's Medical Center of Dallas-Legacy
Coauthor(s): Mark V Mazziotti, MD, Assistant Professor of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital; Jacob C Langer, MD, Professor, Department of Surgery, University of Toronto Faculty of Medicine
Contributor Information and Disclosures

Updated: Oct 1, 2008

Introduction

The use and management of 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 Media file 1), especially when the anatomy is not clear and the fluid and electrolyte abnormalities are difficult to control.

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 require 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.

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. Intestinal stomas were considered a drastic procedure and were avoided because of the high incidence of complications and mortality. With improvements in surgical technique and practice, the need for stomas increased as children with formerly fatal conditions survived.

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.

Frequency

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

Etiology

Many diseases may require 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, although 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.

Children with severe perineal burns or trauma (see Media file 2) often require a temporary colostomy to allow the injury to heal.

Patients with the following conditions may require a stoma:

• Neonatal conditions
  • Necrotizing enterocolitis
  • Hirschsprung disease
  • Meconium ileus
  • Imperforate anus
  • Complex hindgut anomalies
  • Intestinal malrotation
  • Intestinal volvulus
  • Intestinal atresia, stenosis, and webs
  • Esophageal atresia with or without tracheoesophageal fistula
  • Trauma
• Childhood and adolescent conditions
  • Trauma
  • Inflammatory bowel disease
  • Intestinal malrotation
  • Intestinal volvulus
  • Gardner syndrome and other intestinal polyposis syndromes
  • Typhlitis
  • Intestinal pseudo-obstruction

Pathophysiology

The pathophysiologic features depend on the specific disease process.

Presentation

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

Indications

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

Relevant Anatomy

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

Technique

Several types of intestinal stomas are recognized (see Media file 3). 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, be familiar with the many potential variations in their construction. Roux-en-Y construction can also be performed for tube stomas such as feeding jejunostomy.

For an end stoma (see Media files 3-6), 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). 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-Koop¹ and Santulli stomas [see Media file 3 and Media file 7]). These stomas were initially designed for the treatment of infants with meconium ileus but have been adapted for many other purposes. 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 prior to suturing the edge to the skin (ie, Brooke technique) produces a spigot conformation that holds a stoma appliance and prevents serositis (see Media file 3, inset in part A). Eversion is not always possible in neonates (in whom the blood supply may be tenuous) and in situations in which the 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.

Stoma location

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 Media files 8-9).

Stoma location in infants and neonates 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. For temporary stomas in infants, the bowel can be brought out directly through or adjacent to the umbilicus (see Media files 10-11).² This site is easier for appliance placement and results in a cosmetically superior scar when the stoma is ultimately closed.

Contraindications

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

• Search for CME/CE on This Topic »