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Stomas of the Small and Large Intestine

Michael W. L. Gauderer

Historical Note
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The word stoma originates from the Greek stomoun (to provide with an opening or mouth). Intestinal
1–4
stomas, considered basic surgical procedures, have a long and colorful history.​ As a method of

treating intestinal obstruction, colostomies date back to the latter part of the eighteenth century and
5–7
some of the first survivors of this procedure were children with an imperforate anus.​ Despite

sporadic early successes, the use of stomas in the large intestine and later the small intestine in
children evolved slowly. Surgeons were understandably reluctant and even strongly opposed to
performing these drastic procedures, which were associated with major complications. However, as
the experience of surgeons increased toward the end of the nineteenth century and beginning of the
twentieth century, colostomies and occasionally jejunostomies were used to man- age a few pediatric
conditions. With the advent and the devel- opment of pediatric surgical practice in the mid to late
1900s and survival of children with conditions that were formerly likely to be fatal, the need for
8–12
stomas increased. Enterostomal construction techniques, originally developed for adults,​ were

modified and adapted for use in children, particularly newborns with congenital intestinal
obstruction.​13–18 ​New techniques that combined proximal decompression and distal

19,20 ​
feeding for neonates with atresia of the duodenum or high jejunum were introduced next.​ In the
past 3 decades, endo- scopic, laparoscopic, and various image-guided approaches have been
added to established open techniques continuously foster- ing the creation of feeding, venting,
decompressing, irrigating, and special-purpose stomas. Understanding of stomal physiol- ogy and of
specialized enteral and parenteral nutrition, as well as the diagnosis and management of
stoma-related complica- tions, have paralleled the advances in technique significantly improving
outcome.
Several other factors have contributed to the safety, effec- tiveness, and ease of care of stomas in
adults and children. Paramount among these is the advent of enterostomal therapy, which has
21,22
evolved into a specialty in its own right.​ Enter- ostomal therapists are now an integral part of

health care teams in most medical institutions. Major national and inter- national ostomy
associations​23 ​foster the dialogue among professionals and provide a wealth of information through
traditional and web-based material including publications for parents, caregivers, and teenage
patients.​24,25
Regional and local chapters are involved in establishing non- medical support systems and
guidance to access resources.​26 ​Greater awareness and acceptance of ostomates, as well as the
recognition of their needs and rights among the lay popu- lation, has also helped to improve their
quality of life. The knowledge and experience derived from enterostomal care has led to the creation
of appliances in a wide variety of types and sizes, manufactured of well-tolerated biomaterials and
27 ​
complemented by numerous stoma care products.​ Not sur- prisingly, at times, parents, caregivers,
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or ostomates contribute innovative ideas to the established management techniques.​ In the

contemporary clinical setting, primarily because of earlier diagnosis of certain gastrointestinal
anomalies such as Hirschsprung disease, improved surgical approaches, and peri- operative care,
pediatric surgeons were able to safely perform more single-stage procedures, thereby decreasing
29–33
the need for preliminary decompressing enterostomies (ileostomies and co- lostomies).​
Conversely, due to an ever-increasing number of children with a variety of complex surgical and
nonsurgical pathologies, there has been a greater demand for upper gastro- intestinal access for
34–38 ​
long-term enteral feeding (gastrostomies and jejunostomies),​ as well as lower intestinal access
39–43
for antegrade enemas (appendicostomies, tube cecostomies, and tube sigmoidostomies).​ Often

requiring a team approach, the creation, care, and closure of enterostomas continue to occupy a
substantial portion of pediatric surgical practice.

Child with a Stoma


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An enterostoma in a child is a major disruption of normality and frequently leads to substantial


psychologic trauma for the child and parents. However, most decompressing intestinal stomas in the
pediatric age group are temporary and correc- tion of the underlying problem often leads to closure
of the diverting opening. Although pediatric surgeons continuously search for alternatives to
intestinal exteriorization, an appro- priately indicated, properly constructed temporary stoma is
frequently unavoidable and lifesaving. Moreover, in several in- stances of noncorrectable and
crippling pathologic conditions of the lower intestinal tract, a permanent, well-functioning stoma
44,45
contributes to an improved quality of life.​
Despite many advances related to enterostomas, their placement, care, and closure are still
46–70 ​
associated with a surpris- ingly high rate of both early and late complications.​ These facts present
the surgeon, the enterostomal therapist, the nurses, the parents, and the child with major challenges.
Therefore when the need for a stoma arises, the best results are achieved by carefully evaluating the
child’s pathologic condition and health status, weighing the pros and cons of diversion, planning ahead
(for eventual closure) whenever possible, and considering both construction and takedown as major
interventions.
In addition to the well-defined guidelines for stomal place- ment established for adult patients,
pediatric factors including anatomic and physiologic differences, delicate structures, growth, and
physical and emotional maturity, as well as preoperative preparation, whenever possible, need to be
con- sidered.​24,25,71 ​The surgeon and members of the surgical team must always keep in mind that the
quality of life of a patient with a stoma is largely related to the quality of that stoma.

Types of Enterostomas
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The four basic types of enterostomas, primary purposes, and technique options are listed in ​
Table 98-1​
.
Examples of these methods are illustrated in ​
Figures 98-1 ​to ​98-3​
. Options for bringing the proximal
stoma through the abdominal wall and handling the distal stoma are listed in ​ Table 98-2​ . Examples
are found in ​Figures 98-3 to 98-5​.

Applications and Considerations for Enterostomas


Administration of Feedings, Medication, or Both
Without entering the jejunal wall: nasojejunal tube, gastrostomy- jejunostomy tube​34
Direct access through the jejunal wall: tunneled catheter,​9​ ​needle catheter, T-tube,​82​ ​button,​100​ ​other
Isolated jejunal loop brought directly to abdominal wall: Roux-en-Y​108–110
Proximal Decompression and Distal Feedings
Gastrostomy and distal feeding tube, same stoma or separately​20,34​ ​Double-lumen tube in dilated proximal jejunum with feeding end
across an anastomosis​19​; or two single-lumen tubes inserted
separately into divided, closed loops of small intestines​81​ ​Divided intestinal segments brought directly to skin level, with
pouch applied to proximal stoma and feeding catheter inserted
into distal one
Access for Antegrade Irrigation
Appendix or other intestinal conduit brought to abdominal wall for intermittent catheterization​5,52,85
Catheter, T-tube, skin level device placed in intestinal ​lumen​37,41,81,88

Decompression, Diversion, or Evacuation


End stoma, single opening​11​ ​Double-barrel stoma​10,17
End stoma with an anastomosis below the abdominal wall​13,15​ ​Loop over a small rod or skin bridge​8,14
Closed loop with catheter​81​ ​or open loop with occluding valve-type device allowing controlled egress
Special stomas such as a catheterizable pouch​36,47

Indications for Enterostomas in Children


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Temporary and occasionally permanent stomas of the small and large intestine are used in the
management of a wide variety of surgical and nonsurgical pathologic conditions in neonates,
infants, and children. With the exception of feeding and antegrade enema access, more than one
half of all stomas are placed in the neonatal period and another one fourth in infants younger than 1
year of age.​51,52,54,59

JEJUNOSTOMIES
Indirect access to the jejunum via naso-jejunal or gastro- jejunal route is adequate for short- or
36
intermediate-length nutritional support.​ Direct access to the proximal small bowel is most

commonly used for long-term enteral alimenta- tion as an alternative to a gastrostomy, which is the
preferred route.​34,72 ​The majority of patients requiring a feeding jeju- nostomy are neurologically
impaired children, usually with complex medical problems associated with foregut dysmoti- lity.
Some of these may require both a gastrostomy and a jejunostomy in their management. Jejunal
access can also be useful in the care of patients with acute surgical problems benefiting from early
enteral nutrition (e.g., major trauma or burn victims, children needing long-term supplemental
feedings). Various types of exteriorized jejunal segments were once used in the management of
infants with biliary atresia, in an attempt to reduce ascending cholangitis. However, this approach is
no longer used, in part because of secondary prob- lems such as bleeding from stomal varices
associated with por- tal hypertension​50 ​and because the stoma adds complexity to a future liver
transplantation.
On the other hand, the use of a segment of intestine or drainage device interposed between the
gallbladder and the abdominal wall for partial drainage of bile has been helpful in the management
73–76 ​
of children with some types of genetic cholestatic syndromes.​ As with other segments of the
55,77–80 81
intestine, exteriorization​ ​or tube decompression​ ​ is indicated following bowel resection when
a primary anasto- mosis is unsafe or impossible (e.g., necrotizing enterocolitis, midgut volvulus).

ILEOSTOMIES
These stomas are essential in the management of neonates with certain types of distal intestinal
obstruction (e.g., long- segment Hirschsprung disease, complex meconium ileus, gastroschisis with
atresia).​13,52,54,82 ​Ileostomies are com- monly placed to divert bowel contents when reestablishing
bowel continuity is precluded by peritonitis, ischemia, or hemodynamic instability ( e.g., neonatal
77–79,82 ​
necrotizing enteroco- litis) (​Figs. 98-6 ​and ​
98-7​).​ Ileal diversion has tradi- tionally been used
in the surgical approach to colonic pathology (e.g., ulcerative colitis, familial polyposis) as tem-
3,4,11,83,84
porary, protective, or, at times, permanent stomas.​ Less common indications include other

forms of inflammatory bowel disease, rare manifestations of colonic dysmotility, and monitoring of
the intestinal graft in patients with small bowel transplantation.
FIGURE 98-1 ​Diagrams of select-feeding and decompressing-feeding jejunostomies. A, Tunneled catheter.​9 ​B, Needle catheter. C, T-tube.​82
D, Button.​100 ​E, Proximal decompression and distal feeding across an anastomosis.​19 ​F, Temporary decompression feeding using
catheters when primary anastomosis is unsafe and intestinal exteriorization is undesirable or not possible.​81

APPENDICOSTOMIES, TUBE CECOSTOMIES, AND TUBE SIGMOIDOSTOMIES


The main indication for these interventions is to provide long-term access sites for antegrade
intestinal irrigation in children with colonic motility, anal sphincter problems, and
myelodysplasia.​39–42,85–91

COLOSTOMIES
Stomas of the large bowel have the longest history, and exten- sive experience with these
enterostomies has accrued.​1–7 ​Diversion of fecal stream is essential in the treatment of several
5,6,67
congenital hindgut pathologies (e.g., high forms of imperfo- rate anus,​ late diagnosis or

68 92
complicated Hirschsprung disease,​ ​ complex pelvic malformations,​ ​ colonic atresia​93​). Colostomies
32,94,95 ​ 96
are also used in patients with severe colonic, anorectal or perineal trauma,​ perineal burns,​
58,97
and complications of malignant conditions.​ ​ Unlike in the adult population, in which colorectal
cancer is the most com- mon indication, colostomies are rarely permanent in children.

UROSTOMIES
Exteriorized segments of ileum or colon have been used as conduits in the management of urinary
tract pathologies, although these diversions are seldom used today. However, the mobilized
appendix, interposed between the bladder and the abdominal wall surface, is used in children with
FIGURE 98-2 ​Roux-en-Y feeding jejunostomy with a balloon-type skin-level access device.​108

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