Stomas of the Small and Large Intestine in Children

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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 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 and abnormalities are difficult to control.

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.

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.

Neonates with the following conditions may require a stoma:

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

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]

Levitt MA, Mathis KL, Pemberton JH. Surgical treatment for constipation in children and adults. Best Pract Res Clin Gastroenterol. 2011 Feb. 25(1):167-79. [Medline].

Mousa HM, van den Berg MM, Caniano DA. Cecostomy in children with defecation disorders. Dig Dis Sci. 2006 Jan. 51(1):154-60. [Medline].

Haut ER, Nance ML, Keller MS. Management of penetrating colon and rectal injuries in the pediatric patient. Dis Colon Rectum. 2004 Sep. 47(9):1526-32. [Medline].

Oda O, Davies D, Colapinto K, Gerstle JT. Loop versus divided colostomy for the management of anorectal malformations. J Pediatr Surg. 2014 Jan. 49(1):87-90; discussion 90. [Medline].

Ghritlaharey RK, Budhwani KS, Shrivastava DK. Exploratory laparotomy for acute intestinal conditions in children: a review of 10 years of experience with 334 cases. Afr J Paediatr Surg. 2011 Jan-Apr. 8(1):62-9. [Medline].

De Carli C, Bettolli M, Jackson CC, Sweeney B, Rubin S. Laparoscopic-assisted colostomy in children. J Laparoendosc Adv Surg Tech A. 2008 Jun. 18(3):481-3. [Medline].

Yu SC, Petty JK, Bensard DD. Laparoscopic-assisted percutaneous endoscopic gastrostomy in children and adolescents. JSLS. 2005 Jul-Sep. 9(3):302-4. [Medline].

Pini Prato A, Pio L, Leonelli L, Pistorio A, Crocco M, Arrigo S, et al. Morbidity and Risk Factors of Laparoscopic-Assisted Ileostomies in Children With Ulcerative Colitis. J Pediatr Gastroenterol Nutr. 2016 Jun. 62 (6):858-62. [Medline].

Gine C, Santiago S, Lara A, Laín A, Lane VA, Wood RJ, et al. Two-Port Laparoscopic Descending Colostomy with Separated Stomas for Anorectal Malformations in Newborns. Eur J Pediatr Surg. 2016 Oct. 26 (5):462-464. [Medline].

Kootstra G, Kamann HL, Okken A. The Bishop-Koop anastomosis-a find in pediatric surgery. Neth J Surg. 1980. 32(3):92-6. [Medline].

Cameron GS, Lau GY. The umbilicus as a site for temporary colostomy in infants. J Pediatr Surg. 1982 Aug. 17(4):362-4. [Medline].

Pearl RK, Prasad ML, Orsay CP. Early local complications from intestinal stomas. Arch Surg. 1985 Oct. 120(10):1145-7. [Medline].

Ratliff CR, Scarano KA, Donovan AM. Descriptive study of peristomal complications. J Wound Ostomy Continence Nurs. 2005 Jan-Feb. 32(1):33-7. [Medline].

Steinau G, Ruhl KM, Hörnchen H, Schumpelick V. Enterostomy complications in infancy and childhood. Langenbecks Arch Surg. 2001 Aug. 386(5):346-9. [Medline].

[Guideline] Antoniou SA, Agresta F, Garcia Alamino JM, et al. European Hernia Society guidelines on prevention and treatment of parastomal hernias. Hernia. 2017 Nov 13. [Medline]. [Full Text].

Brown H, Randle J. with a stoma: a review of the literature. J Clin Nurs. 2005 Jan. 14(1):74-81. [Medline].

Hollinworth H, Howlett S, Tallett J. Professional holistic care of the person with a stoma: online learning. Br J Nurs. 2004 Nov 25-Dec 8. 13(21):1268-75. [Medline].

O’Neil M, Teitelbaum DH, Harris MB. Total body sodium depletion and poor weight gain in children and young adults with an ileostomy: a case series. Nutr Clin Pract. 2014 Jun. 29(3):397-401. [Medline].

Na+

mEq/L

Cl

mEq/L

K+

mEq/L

HCO3

mEq/L

H+

mEq/L

Saliva

30-60

15-40

20

15-50

N/A

Gastric

60-100

90-140

10-20

N/A

30-100

Duodenal

140

80

5

50

N/A

Bile

140

100

5-10

40-50

N/A

Pancreatic

140

75

5-15

90

N/A

Jejunal

100

100

5-10

10-20

N/A

Ileal

130

110

10

30

N/A

Colonic

60

40

30

20

N/A

Diarrhea

130

30

90

N/A

N/A

Robert K Minkes, MD, PhD Medical Director of Pediatric Surgical Services, Golisano Children’s Hospital of Southwest Florida; Lee Physicians Group

Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Kim M McHard, RN, MSN, CPNP-PC Senior Advanced Nurse Practitioner, General Pediatric Surgery, Manager for Plano APS, Children’s Medical Center Plano

Kim M McHard, RN, MSN, CPNP-PC is a member of the following medical societies: Children’s Oncology Group, National Association of Pediatric Nurse Practitioners, American Pediatric Surgical Nurses Association

Disclosure: Nothing to disclose.

Mark V Mazziotti, MD Associate Professor of Surgery and Pediatrics, Baylor College of Medicine, Texas Children’s Hospital

Mark V Mazziotti, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Medical Association, American College of Surgeons, American Pediatric Surgical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Jacob C Langer, MD, FRCS 

Jacob C Langer, MD, FRCS is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, Canadian Medical Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Society for Surgery of the Alimentary Tract, Society of University Surgeons

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Andre Hebra, MD Chief Medical Officer, Nemours Children’s Hospital; Professor of Surgery, University of Central Florida College of Medicine

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Children’s Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association

Disclosure: Nothing to disclose.

Harsh Grewal, MD, FACS, FAAP Professor of Surgery and Pediatrics, Drexel University College of Medicine; Medical Director, Trauma Program and Attending Surgeon, St Christopher’s Hospital for Children

Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Children’s Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, Southwestern Surgical Congress

Disclosure: Nothing to disclose.

Kurt D Newman, MD 

Kurt D Newman, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Society of Surgical Oncology

Disclosure: Nothing to disclose.

Stomas of the Small and Large Intestine in Children

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