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418 Cataldo
Figure 4 End loop stoma. Fully matured Brooke ileostomy and noneverted, pri-
marily matured distal colotomy.
The Difficult Stoma 419
with only one intestinal stoma and (2) laparotomy is not required for subse-
quent stoma take-down.
At the time of second surgery, an incision is made around the stoma
site; then the proximal transverse colon and the terminal ileum are brought
through the wound and mobilized appropriately. An intestinal anastomosis
is created and dropped into the peritoneal cavity. The wound is closed ap-
propriately. Thus, the intestinal continuity can be restored without the need
for laparotomy.
This can similarly be done at other sites in the colon or small bowel
as appropriate. The only criteria for performing this type of end loop stoma
is that both the proximal and distal ends will reach the same, appropriate
stoma site on the anterior abdominal wall. Creation of these end loop sto-
mas may be slightly more difficult at the time of the primary operation but
will avoid the need for repeat laparotomy and often extensive adhesiolysis
at the time of stoma take-down and re-establishment of the intestinal conti-
nuity.
CREATING DIFFICULT STOMAS
Aside from finding the appropriate stoma site in patients with multiple sto-
mas or with complex anterior abdominal walls, nearly all difficulty occur-
ring in creating intestinal stomas results from the need to create a well-
perfused stoma that reaches and protrudes through the anterior abdominal
wall. The following factors predispose to difficult stoma creation:
1. Emergency surgery
2. Obstructed/dilated bowel
3. Thickened short mesentery
4. Thick, fat-laden abdominal wall
In these difficult situations, maintaining perfusion and creating a
stoma without tension are often at odds. Extensive mobilization of the
bowel with resection and thinning of the mesentery can nearly always lead
to the creation of a protruding stoma with no tension whatsoever. Unfortu-
nately, this comes at a price. Mobilization and particularly mesenteric re-
section often result in subsequent ischemia of the terminal stoma. The tech-
nical difficulty lies in creating an appropriate compromise, thereby producing
a well-perfused stoma without undue tension. The following paragraphs
hopefully illustrate several “tricks” to achieve this goal.
THE DIFFICULT COLOSTOMY
In most obese individuals, the abdominal wall is substantially thicker below
the umbilicus, consistent with the characteristic American panis or “beer
420 Cataldo
belly.” Often, the abdominal wall above the umbilicus is relatively free of
extensive adipose tissue. This discrepancy can be used to the surgeon’s
advantage for creating a stoma in obese individuals. Further, stomas created
below the umbilicus are often difficult for obese individuals to care for.
Upon standing and sitting, they often disappear below the abdominal panis,
making visual stoma care nearly impossible, while stomas above the umbi-
licus stay upright are easily visualized and cared for. For these reasons
supraumibical stomas are often the ostomies of choice in obese individuals
(see Fig. 5).
The classic scenario leading to the creation of a difficult stoma is as
follows. An extremely obese male requires emergency surgery for compli-
cated diverticular disease. The abdominal wall is muscular and is covered
with a large apron of adipose tissue. The sigmoid mesentery is thickened
and short due to inflammation associated with the diverticulitis. These fac-
tors make creation of end sigmoid colostomy or end descending colostomy
difficult.
The following factors should be considered in order to achieve the
desired results:
1. Is there any safe alternative to colostomy creation? That is, in
some individuals a primary anastomosis may in fact be safer than
creation of a difficult left-sided colostomy (a diverting ileostomy
can be considered following creation of an anastomosis if neces-
sary).
2. All inflamed sigmoid colon should be excised.
3. The segment of colon used for the colostomy should be free of
inflammation, thickening, or edema.
4. The lateral peritoneal reflection should be taken down com-
pletely, leaving the left colon attached only by its midline mes-
entery.
5. Medial peritoneal attachments at the base of the colonic mesen-
tery should be transected in order to increase mobility.
6. The splenic flexure should be fully mobilized.
7. The inferior mesenteric artery proximal to the takeoff of the left
colic artery can be ligated, if necessary, to provided additional
length.
8. “Windows” can be created in the medial and lateral aspects of
the mesocolon in order to increase length.
9. The mesentery adjacent to the terminal left colon can be
trimmed provided that a 1-cm segment of mesentery containing
the marginal artery is left attached to the colon wall.
10. An oversized abdominal trephine will often allow passage of a
thick colonic mesentery, preventing venous congestion and sub-
sequent stomal ischemia.
The Difficult Stoma 421
Figure 5 Supraumbilical stoma placement is often ideal in obese individuals.
11. A stoma site above the umbilicus, as previously mentioned, will
decrease the thickness of the abdominal wall through which the
colon must pass and will often further decrease tension, as mobi-
lized left colon reaches most easily to the abdominal wall above
the umbilicus.
Use of these tips or tricks will nearly always result in a well-profused
end colostomy reaching the abdominal wall without undue tension. In rare
circumstances, despite all these maneuvers, it will be impossible to create
422 Cataldo
a well-profused sigmoid colostomy. In this circumstance, although rare, a
“pseudoloop” colostomy can be created using the antimesenteric border of
the left colon (see Fig. 6). After all the previously mentioned maneuvers
have been performed, the distal aspect of the left colon is “stapled closed”
and left in the peritoneal cavity. The anitmesenteric border of the colon just
proximal to its terminal end is then brought to the anterior abdominal wall.
A colotomy is made in the antimesenteric border and is matured primarily
to the abdominal wall. This situation is less than ideal but often results
in a functional left-sided colostomy, allowing the patient to recover from
emergency surgery. The stoma can either be revised later, if necessary, or
taken down if appropriate.
THE DISTENDED COLON
In the obstructed colon, distention creates two problems: (1) the distended
colon is less likely to reach the anterior abdominal wall without tension and
(2) a distended colon can cause compressive venous obstruction as it passes
through the abdominal fascia, resulting in potential ischemia.
In these circumstances, decompression of the distended colon often
solves both problems. The colon becomes more mobile and reaches the ab-
dominal wall tension-free. In addition, once the luminal pressure has been
Figure 6 The “pseudo-loop” colostomy can be employed in rare cases when no
other stoma can reach the abdominal skin.
The Difficult Stoma 423
relieved, there are less compressive effects secondary to constriction at the
fascial level, resulting in less venous congestion. For these reasons it is best
to decompress the colon and mature the stoma prior to closing the abdomi-
nal incision (as opposed to the traditional approach, where the abdominal
incision is closed first and the stoma is matured secondarily). This will
allow evaluation of stomal perfusion following decompression but prior to
closure of the abdominal wound. If the stoma appears viable, maturation
can be completed. If it still appears ischemic or under tension, further ma-
neuvers may be necessary in order to create a successful stoma.
THE DIFFICULT ILEOSTOMY
Difficulty with undue tension and stomal ischemia is much less common
with end ileostomy than with end colostomy. This is based on the more
redundant nature of the small bowel mesentery, the improved perfusion of
small intestine, and the decreased size of the small intestinal lumen. How-
ever, situations do exist where creation of the end ileostomy can be chal-
lenging. The following steps should be helpful in ensuring a tension-free,
well-perfused stoma:
1. Supraumbilical placement, particularly in the obese individual, is
often beneficial.
2. Mobilization of the small bowel mesentery to the base of the duo-
denum, as done for the ilea-pouch anal anastomosis, often results
in substantial mobility.
3. The ileocolic artery can nearly always be ligated at its origin
without subsequent stomal ischemia.
4. An oversized abdominal wall trephine is beneficial in decreasing
tension and improving perfusion in thickened bowel with short
mesentery.
5. Although not ideal, a “noneverted” ileostomy can be created in
an emergency situation.
These maneuvers once again will nearly always lead to the creation
of a well-perfused ileostomy without undue tension. However, in the rare
case that an end ileostomy cannot be safely created, once again a “pseudo-
loop” ileostomy may be necessary. All the maneuvers previously described
in the creation of a pseudoloop colostomy are performed. The end of the
terminal ileum is stapled closed and the antimesenteric border of the bowel
just proximal to the terminal portion of the terminal ileum is brought
through the anterior abdominal wall. Once this has been completed, an en-
terotomy is made in the antimesenteric ileal wall and the bowel is matured
primarily without eversion to the abdominal skin (similar to the “pseudo-
loop” colostomy see Fig. 6). This results in a less than ideal stoma, but it
can be revised at a later date or taken down as appropriate.
424 Cataldo
POSTOPERATIVE EVALUATION
OF THE MARGINAL STOMA
In the early postoperative period, essentially all stoma-related complica-
tions are secondary to ischemia. Difficulty at this point revolves around
proper evaluation and treatment. Ischemia can be divided into several cate-
gories: First, superfascial vs. subfascial ischemia and, second, mucosal vs.
full-thickness ischemia. Mucosal ischemia is most commonly self-limiting
and results in mucosal sluffing and regeneration, with no long-term conse-
quences. Muscular ischemia, which is superfascial and usually confined to
bowel, results in stomal stenosis or separation. This leads to a stenotic re-
tracted stoma that is difficult to manage but does not require urgent surgical
treatment. Finally, subfascial full-thickness ischemia, if untreated, will lead
to intestinal necrosis, intraperitoneal soilage, and potential intra-abdominal
catastrophe.
For these reasons it is important to distinguish between mucosal and
full-thickness ischemia and between subfascial and superfascial ischemia.
This is done in the following ways. A pediatric test tube is lubricated and
inserted into the stomal lumen. This can be illuminated with a penlight or
an ophthalmascope. Due to its optics, the ophthalmascope allows for better
viewing. If pink mucosa is identified above the fascial layer, no further
treatment is necessary. If ischemic mucosa is identified subfascially, further
treatment may be necessary. In order to assess muscular perfusion, an 18-
gauge needle is used to prick the site of mucosal ischemia. If bright red
blood is seen emanating from the puncture site, the muscle is well perfused
and observation is appropriate. If no bright blood emanates, this may be
indicative of muscular ischemia.
If muscular ischemia exists below the level of the fascia, then in all
circumstances stoma revision is required. If muscular ischemia is confined
to the subcutaneous tissues, then either surgery or observation may be ap-
propriate. If the ischemic stoma was designed to be temporary, then perhaps
observation with subsequent stomal take-down rather than revision is ap-
propriate. This, however, will often result in a stoma that is difficult to
pouch, but it will be a short-term problem resolved with eventual stoma
take-down. However, if the stoma was a created as a permanent stoma,
then revision in the early postoperative period may be most appropriate, as
muscular ischemia, even at the superfascial level, will result in significant
stomal stenosis, requiring revision at some time in the future.
CONCLUSIONS
Intestinal stomas represent intestinal anastomoses, and all principles impor-
tant in the creation of any anastomosis should apply to their creation. The
The Difficult Stoma 425
success of their creation will often be a major determinant of the individu-
al’s quality of life following major abdominal surgery. Their creation should
not be relegated to junior members of the surgical staff with limited clinical
knowledge and less practical experience.
Preoperative marking, particularly in the multiply operated or disabled
patient, is most important in preventing postoperative complications and
improving quality of life. In creating temporary stomas, it is best to con-
sider the implications of stoma take-down and do what is possible at the
primary operation in order to decrease the morbidity and mortality of sec-
ondary surgery.
The previously mentioned “technical tips,” applied judiciously, should
result in the creation of a well-perfused, tension-free stoma in even the
most difficult circumstances.
REFERENCES
1. Williams NS, Nasmyth DG, Jones D, et al. Defunctioning stomas: a postopera-
tive controlled trial comparing loop ileostomy with loop transverse colostomy.
Br J Surg 1986; 73:566–570.
2. Mileski WJ, Regs RV, Joehl RJ, et al. Rates of morbidity and mortality after
closure of loop and end colostomy. Surg Gynecol Obstet 1990; 171:17–21.
3. Unti JA, Abcarian H, Pearl RK, et al. Rodless end-loop stomas— a seven-year
experience. Dis Colon Rectum 1991; 34:999–1004.
22
Pediatric Intestinal Stomas
Michael V. Tirabassi, David B. Tashjian,
Gregory Banever and Stanley Konefal
Department of Surgery, Baystate Medical Center,
Springfield, Massachusetts, U.S.A.
INTRODUCTION
Creation of intestinal ostomies in children is required for the treatment or
palliation in a variety of disease processes. Pediatric patients with intestinal
ostomies continue to be a management challenge. These patients differ
from adults both in indications and technique. Successful care of the pediat-
ric patient with an intestinal ostomy can be a complex and lengthy process
requiring family education and support. The underlying disease processes,
acquired or congenital, place stress on the patient, family, and caretakers.
Both ostomy creation and closure are considered major interventions and
are not without complication: complication rates exceeding 50% have been
observed. Good management and prevention of complications requires
close follow-up and high-quality care at home. Fortunately most pediatric
ostomies are temporary and can be closed after resolution of a disease pro-
cess or after additional reconstructive surgery.
The use of ostomies in infants and children has been changing. Histor-
ically, ostomies were used more frequently in the pediatric population. Indi-
cations once common are now changing, as in infants with cystic fibrosis
complicated by meconium ileus. The major indications for ostomies in the
pediatric age group are discussed in this chapter. Current trends in the liter-
ature, which are also presented, offer alternatives to the traditional creation
of an ostomy, particularly in the management of necrotizing enterocolitis
and Hirschsprung’s disease.
NECROTIZING ENTEROCOLITIS
Background
Necrotizing enterocolitis (NEC) is predominantly a disease of premature
infants, with those of lower gestational age and birth weight being at the
427