Stoma is the Greek word meaning opening or mouth. Formation management and subsequent closure of bowel stomas represents a considerable volume of the work of a paediatric surgical service. Since the first successful colostomy was performed in 1793 by Duret on a 3-day-old infant for an anorectal malformation, stomas were slow in gaining professional and social acceptance. In contrast to stomas performed in adults, most of the stomas in infants and children are temporary. There are two general indications for stomas: to defunction the distal bowel and as access to the gastrointestinal tract.
Stoma formation is often considered a simple operation with few hazards. However, a number of reports have suggested a substantial morbidity associated with stoma formation, management and subsequent closure. With meticulous technique and comprehensive stoma therapy these can be reduced to a minimum.
CLASSIFICATION
The anatomical site of stoma formation is determined by the indication or the anatomical part of the gut to which access is required.
Cervical oesophagostomy
This is usually performed for long gap oesophageal atresia and occasionally for distal oesophageal obstruction or perforation. Gastrostomy for initial decompres- sion and subsequent feeding is an essential additional procedure.
Gastrostomy
Gastrostomy is an increasingly used form of stoma. Most gastrostomies are per- formed as a means of access to the gastrointestinal tract for supplementary feeding, sometimes in conjunction with an antireflux procedure. A further indication is the use of gastrostomy tubes for a transoesophageal string for safe antegrade or pro- grade oesophageal dilatation after caustic injury or severe reflux-associated stricture.
Initially all gastrostomies were open operations and the majority in children were performed using the Stamm technique with double inversion purse string sutures around a De Pezzer catheter or one of the newer commercial devices such as the Mickey or Bard gastrostomy buttons. Surgically placed gastrostomies, particularly those done for oesophageal atresia, have been associated with a high incidence of gastro-oesophageal reflux. Percutaneously placed endoscopic gastrostomy (PEG) was pioneered in the early 1980s by Gauderer and has become a routine proce- dure with little morbidity. Complications which may be seen after any method of performing a gastrostomy include bowel perforation, bleeding and separation of the gastrostomy from the anterior abdominal wall with leakage of gastric contents into the peritoneal cavity. More recently laparoscopically assisted gastrostomy placement is favoured, and visual localisation of a gastrostomy site along with additional U sutures from the gastric wall through the anterior sheath provides a secure gastrosto- my with a very low incidence of complications. Separation of the stomach from the A NUMANOGLU
FCS (SA)
Senior Specialist
Department of Paediatric Surgery Red Cross Children’s Hospital and University of Cape Town
A J W MILLAR FRCS, FRACS, DCH Head
Paediatric Liver Transplantation Birmingham Children’s Hospital UK
R A BROWN
DCH, FRCS (Edin), FCS (SA), MPhil (Ancient Cultures) Honorary Consultant Red Cross Children’s Hospital Cape Town
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anterior abdominal wall occurs more frequently in premature infants, patients with HIV/AIDS infection and severely malnourished neurologically impaired children as a result of impaired healing.
Two specific complications with gastros- tomy tubes may occur: The first is that a tube may dislodge and fall out, in which case it should be re-inserted immediately otherwise the tract will tend to rapidly close spontaneously. If tube replacement is delayed a surgical pro- cedure under anaesthesia may be required for re-insertion. The second complication relates to a gastrostomy tube, which may slip into the stomach and be carried by peristalsis into the duodenum, causing obstruction.
Patients with these complications usually present with non-bile-stained vomiting.
Clearly marked numbers on the outside of the catheter indicating the length of catheter within the stomach are a reli- able and simple means of confirming the correct position of the tip. The haz- ard of this complication is that forceful traction on the tube, particularly when a Foley's catheter has been used and the bulb has not been deflated, may result in retrograde intussusception of the duo- denum with infarction of gut. It is also important to be aware that although it is acceptable adult practice when remov- ing PEGs to divide the tube at skin level and allow the intragastric portion to fall back into the stomach to be passed along the gastrointestinal tract, in chil- dren this has the potential for intralumi- nal obstruction by the device.
Endoscopic removal of the retaining intragastric flange is thus advised.
Ileostomy and colostomy
With small-and large-bowel stomas, the anatomical site of formation is again determined by the patient's specific indi- cation. For those with long-term or per- manent stomas, the site of the stoma becomes an essential feature of the sur- gery performed. A poorly sited stoma can make life a misery. The stomathera- pist in conjunction with the surgeon should choose and mark the most suit- able site prior to the operation. In the
neonatal period this is more difficult because of abdominal distension and the frequent urgency of surgery.
Most small-bowel stomas are fashioned for necrotising enterocolitis in the neona- tal period and occasionally in older chil- dren for small-bowel obstruction, perfo- ration, and necrosis associated with intraperitoneal sepsis. We do not favour the use of loop stomas. They tend to have a higher incidence of complica- tions, do not fully defunction the distal bowel and are more difficult to pouch.
To minimise the chances of retraction of the stoma and parastomal herniation, the following basic surgical manoeuvres are employed. Stomas are usually divided stomas and are brought out at least 2 cm apart. The peritoneal edges, the rectus sheath and skin are approxi- mated with interrupted sutures between the stomal orifices. The peritoneum and rectus sheath are sutured circumferen- cially to the seromuscular layers of each stoma with interrupted fine absorbable or polydiaxonone sutures. Care is taken not to enter the bowel lumen to avoid later fistula formation.
T-tube jejunostomy and ileostomy
T-tubes of latex rubber have been very useful for both access and decompres- sion in paediatric surgical practice.
Feeding jejunostomy with a tunnelled T- tube has been used to good effect after complex upper gastrointestinal surgery or major abdominal trauma where gas- tric ileus can be expected. Enteral feed- ing can be instituted early and pro- longed parenteral nutrition can be avoided. The T-tube is also less easily pulled out than other catheters. A T-tube inserted into the small bowel can be a
‘damage control’ lifesaving measure as a decompression stoma in postoperative anastomotic dehiscence of bowel, intra- abdominal sepsis and extensive adhe- sion of bowel loops. We have also used a T-tube in meconium ileus as decompression and access for irrigation of the bowel lumen to loosen the inspis- sated meconium of infants with cystic fibrosis.
Large-bowel stomas for anorectal malfor- mations are usually placed in the proxi- mal sigmoid or descending colon and those with Hirschsprung's disease are placed in ganglionic bowel confirmed by frozen section biopsy at the time of surgery and as close as possible to the distal aganglionic segment. With anorectal malformations the stoma is sited in the proximal part of the sigmoid loop or distal descending colon to allow for adequate length for the reconstruc- tive anorectoplasty. The cut end of the proximal limb is everted and sutured to the surrounding skin whereas the distal limb is deliberately made tight with inversion plication if necessary and sutured flush to the skin in an attempt to avoid prolapse and allowing for easier pouching of the proximal stoma. With neonatal operations, stomas can be placed within the laparotomy wound, each end being separated by 2 cm.
This method has an acceptably low inci- dence of complications in our hands and has the advantage of requiring only one incision at the time of closure.
Stomas brought out separately from the wound are just as effective although slightly more difficult to secure and have an increased incidence of stomal steno- sis, although associated with a slightly lower incidence of wound sepsis. Two other frequent indications for sigmoid colostomy are in full-thickness perineal and buttock burns and with severe per- ineal or rectal trauma.
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