Stomas of the small and large intestine, whether temporary or permanent, are used in the management of a wide variety of benign and malignant conditions in pediatric patients. Creation of a stoma may be required for numerous congenital or acquired diseases of the gastrointestinal tract. Intestinal stomas are used to divert fecal flow, for decompression of the proximal bowel, to reduce stool contamination of a diseased area, to protect a tenuous anastomosis during healing, and to reduce the risk of infection, obstruction and incontinence in various complex disorders of the gastrointestinal tract. In addition to diversion, proximal small intestinal stomas are used for administration long-term enteral nutrition. There are considerable differences between children and adults in terms of ongoing physical and cognitive development, and these factors should be considered as part of the decision-making process in creation and management of stomas.
Stoma originates from a Greek word, stomat, which means mouth. Technically, stomas are artificial connections between the intestine and skin. Surgeons have used stomas for more than 300 years. The index case of a colostomy was a woman whose bowel eviscerated through a ventral hernia defect and perforated spontaneously. The patient was able to live many years with her colostomy. In the early 1700s, Littre proposed creation of an abdominal colostomy and Pillore performed the first colostomy in 1776. Amussat described a lumbar and ventral colostomy to divert the fecal stream in a case of colorectal obstruction 100 years later. Stoma surgery subsequently evolved, and the use of intestinal stomas increased gradually. Although intestinal stomas are often used alone, they have also become an important part of some complex operations such as abdominoperineal resection.
Following the initial description and development of intestinal stoma techniques in adults, these techniques were adapted for children over a similar timeframe. In the pediatric surgery literature, creation of a colostomy was first performed in 1783 for a patient with anal atresia. In 1793, Duret performed an iliac colostomy for imperforate anus in an infant who survived for 45 years after the operation. Desault performed a colostomy for a case of imperforate anus, and Dumas described an infant with imperforate anus in whom surgical treatment was suggested. In addition to fecal diversion, intestinal stomas for feeding have been described in patients with high intestinal atresia and in patients who require postpyloric feeding or irrigation. There are specific stoma types designed for patients with special conditions. Bishop and Koop described a Roux-en-Y anastomosis proximal to an end ileostomy, which allows for irrigation of the bowel segment for the treatment of meconium ileus in patients with cystic fibrosis. Dr. Kock introduced the continent ileostomy as an intraabdominal reservoir for patients who required a permanent ileostomy. A portojejunostomy with a draining intestinal stoma was described by Suruga for treatment of biliary atresia to monitor bile flow.
Although the index intestinal stomas represented exteriorization of the bowel to relieve intestinal obstruction, intestinal stomas are now created for multiple indications either as part of a complex operation or as a distinct procedure. There is specific stoma equipment for pediatric patients of varying types and sizes. In addition to advances in surgical technique, stoma appliances have also evolved. Initially a leather sac was used to collect intestinal waste from the stoma site. Subsequently there were rigid containers and then soft plastic pouches of various sizes were developed by numerous manufacturers.
Support systems, patient education groups, and specialized medical personnel are other important components of the care of patients with an intestinal stoma. Rupert B. Turnbull Jr. founded the first school of enterostomal therapy with the assistance of Mrs. Norma Gill who had an intestinal stoma following surgery for colitis by Dr. Turnbull. In the modern era, enterostomal therapy has become an international nursing specialty.
Considerations for the Child with an Intestinal Stoma
In addition to limitations due to their underlying disease, having an intestinal stoma may cause both a physical and psychological burden for patients. Parents of children with an intestinal stoma are also under stress. The best stoma care starts preoperatively. The patient’s underlying condition, the possibility of future closure, and patient’s anatomy and physical status are all considered when deciding about the optimal stomal location. Pediatric patients require careful attention due to their changing physiology and expected growth. A carefully constructed stoma may provide the best quality of life for patients.
Appropriately sized appliances as well as special educational programs and support groups help to manage these patients’ issues. Norma Gill who was the first director of the Cleveland Clinic Foundation School of Enterostomal Therapy had an ileostomy in her childhood and this experience largely influenced her later career and key role in the development of appropriate enterostomal education. Although the majority of intestinal stomas are temporary, permanent stomas including an end ileostomy or a continent ileostomy can be required even in young children. In cases in which restorative bowel surgery cannot be achieved, removal of the diseased bowel segment and creation of a stoma may save the patient’s life and significantly improve the quality of life. On the other hand, intestinal stomas are associated with both short- and long-term complications. Physicians and nurses caring for patients with an intestinal stoma should be aware of how to diagnose and manage stoma–related complications. Despite sophisticated operative techniques and equipment, intestinal stoma–related issues constitute a considerable portion of our daily clinical practice.
Depending on the severity of the primary disease and the patient’s general condition, the overall complication rates can exceed 50% in some series of pediatric patients with intestinal stomas. The major short-term complications are primarily surgical including evisceration, or herniation of the small bowel at the stoma site, wound infection, intestinal obstruction or metabolic complications such as respiratory distress syndrome, deep venous thrombophlebitis, and persistent acidosis. Skin excoriation is the most common complication observed in children with an intestinal stoma. Skin issues usually heal with topical treatment and appropriate stoma care. Although perioperative mortality is usually related to the patient’s underlying disease and poor general condition, abdominal evisceration and intestinal obstruction have been reported as stoma complications which may result in death.
Prolapse, stenosis, colocutaneous fistula, retraction, peristomal wound hernia, bleeding, and the development of a sinus are potential long-term complications. Stoma revision may overcome the aforementioned surgical complications. The requirement for stoma revision may also relate to technical errors at the index operation such as poor location of the stoma. Stma complications are similar in patients with a loop or end colostomy. However, creation of a sigmoid colostomy is associated with a lower complication rate than a transverse colostomy based on the experience of Mollitt et al.
Jejunostomies are usually created to administer enteral feeding in patients with feeding problems, cystic fibrosis, and neurologic impairment. Due to their high output, jejunostomies are not the preferred site for diversion in routine practice. The overall complication rate varies between 38% to 64% in patients with a jejunostomy. Obstruction requiring surgical repair is the most common complication these patients. In addition, patients with a jejunostomy are prone to systemic and wound infections. Patients with neurologic impairment are at high risk for associated morbidity and the incidence of jejunostomy complications is less in neonates who undergo this procedure.
Takedown of an intestinal stoma is also associated with certain complications that occur in approximately 15% of patients. Common complications associated with intestinal stoma closure are wound infection, intestinal obstruction, bowel infarction, and volvulus.
Types of Intestinal Stomas and Technical Aspects in the Pediatric Population
Intestinal stomas are used for enteral feeding, administration of medications, decompression, access for antegrade irrigation, diversion of fecal contents, and evacuation. Basic operative principles should be considered during the creation of any type of intestinal stoma based on the specific indications for stoma creation and patients’ characteristics.
Basic Technical Steps
Hemostasis should be achieved before stoma maturation and there should be a 2- to 3-cm protrusion above the level of the skin in order to reduce the risk of epidermal irritation ( Figures 59-1 and 59-2 ) in patients with an end ileostomy. Marking the proximal and distal bowel segment is helpful for orientation ( Figure 59-3 ). The active side of the ileostomy constitutes two-thirds of the stoma orifice circumferentially ( Figure 59-4 ). Reciprocal suturing facilitates stabilization of stoma ( Figure 59-5 ). The intestinal wall is everted during suturing ( Figure 59-6 ). Colotomy is performed on the antimesenteric teniae when creating a loop colostomy ( Figure 59-7 ), and the colostomy is stabilized with cutaneous sutures ( Figure 59-8 ).
Because creation of a gastrostomy has a lower complication rate compared to performing a simple jejunostomy. The use of Roux-en-Y button jejunostomy is preferred when a long-term jejunostomy is indicated. A balloon button may block the intestinal lumen in a simple feeding jejunostomy. The Roux-en-Y technique is performed to overcome the limitations of a simple jejunostomy ( Figure 59-9 ). A skin-level button tube is advantageous ( Figure 59-10 ). In selected cases, a percutaneous endoscopic jejunostomy (PEJ) can be performed without creation of a Roux limb.
Feeding pumps are frequently used for patients with a jejunostomy, especially in those with limited mobility. Small jejunal lumen may not be suitable for bolus feedings. Most common complications of simple jejunostomies are enterocutaneous fistula and skin ulceration Retrograde flow of formula can be prevented with creation of a Roux-en-Y limb. This helps to reduce skin irritation due to leakage of intestinal contents. A tunneled catheter is rarely used with a loop jejunostomy. Creation of a Witzel tunnel can cause obstruction due to the reduced size of the bowel lumen. A Roux-en-Y button jejunostomy can also be performed laparoscopically.
After dividing the jejunum 15 cm distal to the ligament of Treitz, an end-to-side anastomosis is performed approximately 20 cm distal to the tube jejunostomy site ( Figure 59-10 ). For construction of a tube jejunostomy, two purse-string sutures of 4-0 polyglycolic acid are placed in the antimesenteric border of the jejunum, proximal to the terminal end of the Roux limb ( Figure 59-11 ). A 12 French “gastrostomy” button is placed in the left upper abdominal quadrant in the jejunum. Following inflation of the balloon and tying the purse strings, the tube jejunostomy is fixed to the abdominal wall ( Figure 59-12 ).
Other Intestinal Stomas and Special Considerations
Necrotizing enterocolitis (NEC) is seen in infants, often as a complication of prematurity. NEC can be severe in extent and can be associated with severe intestinal necrosis. If possible at the time of surgery, the surgeon should try to limit the length of intestinal resections for NEC in order to prevent the subsequent development of short-gut syndrome. In this setting, creation of multiple stomas can be required to preserve bowel length ( Figure 59-13 ).