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Stoma 1
Stoma 1
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
associations23 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,
28
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.
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.
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 hypertension50 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
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 atresia93). 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