feeding  for  neonates  with  atresia of the duodenum or high jejunum were introduced next.

19,20In 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  evolved  into  a  specialty  in  its 
own  right.21,22  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 CHAPTER 98 
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 Stomas of the Small and Large Intestine 
has led to the creation of appliances in a wide variety of types and sizes, manufactured of well-tolerated biomaterials 
and complemented by numerous stoma care products.27 Not sur- prisingly, at times, parents, caregivers, or 
ostomates contribute innovative ideas to the established management techniques.28 In the contemporary clinical 
setting, primarily because of Michael W. L. Gauderer 
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 the need for Historical Note 
preliminary decompressing enterostomies (ileostomies and co- lostomies).29–33 Conversely, due to an 
ever-increasing number 
------------------------------------------------------------------------------------------------------------------------------------------------ 
of children with a variety of complex surgical and 
nonsurgical The word stoma originates from the Greek stomoun (to provide 
pathologies, there has been a greater demand for 
upper gastro- with an opening or mouth). Intestinal stomas, considered basic 
intestinal access for long-term enteral feeding 
(gastrostomies surgical procedures, have a long and colorful history.1–4 As a 
and jejunostomies),34–38 as well as lower 
intestinal access for method of treating intestinal obstruction, colostomies date back 
antegrade enemas (appendicostomies, tube 
cecostomies, and to the latter part of the eighteenth century and some of the first 
tube sigmoidostomies).39–43 Often requiring a 
team approach, survivors of this procedure were children with an imperforate 
the creation, care, and closure of enterostomas 
continue to anus.5–7 Despite sporadic early successes, the use of stomas 
occupy a substantial portion of pediatric surgical 
practice. in the large intestine and later the small intestine in children evolved slowly. Surgeons were understandably 
reluctant and 
Child with a Stoma even strongly opposed to 
performing these drastic procedures, 
--------------------------------------------------------------------
---------------------------------------------------------------------------- which were associated with major complications. However, as 
An enterostoma in a child is a major disruption of 
normality the experience of surgeons increased toward the end of the 
and frequently leads to substantial psychologic 
trauma for the nineteenth century and beginning of the twentieth century, 
child and parents. However, most decompressing 
intestinal colostomies and occasionally jejunostomies were used to man- 
stomas in the pediatric age group are temporary 
and correc- age a few pediatric conditions. With the advent and the devel- 
tion of the underlying problem often leads to 
closure of the opment of pediatric surgical practice in the mid to late 1900s 
diverting opening. Although pediatric surgeons 
continuously and survival of children with conditions that were formerly 
search for alternatives to intestinal exteriorization, 
an appro- likely to be fatal, the need for stomas increased. Enterostomal 
priately indicated, properly constructed temporary 
stoma is construction techniques, originally developed for adults,8–12 
frequently unavoidable and lifesaving. Moreover, 
in several in- were modified and adapted for use in children, particularly 
stances of noncorrectable and crippling pathologic 
conditions newborns with congenital intestinal obstruction.13–18 New 
of the lower intestinal tract, a permanent, 
well-functioning techniques that combined proximal decompression and distal 
stoma contributes to an improved quality of life.44,45 
1235 
 
Despite  many  advances  related  to enterostomas, their placement, care, and closure are still associated with a surpris- 
ingly  high  rate  of  both  early  and  late  complications.46–70  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. 
1236 PART VII ABDOMEN 
TABLE 98-1 Applications and Considerations for Enterostomas 
Administration of Feedings, Medication, or Both Without entering the jejunal wall: nasojejunal tube, gastrostomy- 
jejunostomy tube34 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-Y108–110 
Proximal Decompression and Distal Feedings Gastrostomy and distal feeding tube, same stoma or separately20,34 Double-lumen 
tube in dilated proximal jejunum with feeding end 
across an anastomosis19; or two single-lumen tubes inserted separately into divided, closed loops of small intestines81 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 catheterization5,52,85 Catheter, T-tube, skin level device placed in intestinal 
lumen37,41,81,88 
Decompression, Diversion, or Evacuation End stoma, single opening11 Double-barrel stoma10,17 End stoma with an 
anastomosis below the abdominal wall13,15 Loop over a small rod or skin bridge8,14 Closed loop with catheter81 or open loop 
with occluding 
valve-type device allowing controlled egress Special stomas such as a catheterizable pouch36,47 

Indications for Enterostomas in Children 

--------------------------------------------------------------------------------------------------------------------------------------------
----  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 intermediate-length 
nutritional  support.36  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  of  children  with  some  types  of 
genetic  cholestatic  syndromes.73–76  As  with  other  segments  of  the  intestine,  exteriorization55,77–80  or  tube 
decompression81  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  necrotizing  enteroco-  litis)  (Figs.  98-6  and  98-7).77–79,82 
Ileal  diversion  has  tradi-  tionally  been  used  in  the  surgical  approach  to  colonic  pathology  (e.g.,  ulcerative  colitis, 
familial  polyposis)  as  tem-  porary, protective, or, at times, permanent stomas.3,4,11,83,84 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. 
 
A B C 
D E 
F 
FIGURE  98-1  Diagrams  of  select-feeding  and  decompressing-feeding  jejunostomies.  A,  Tunneled catheter.9 B,Needle catheter. 
C,  T-tube.82D,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  congenital  hindgut  pathologies  (e.g., 
high  forms  of  imperfo-  rate  anus,5,6,67  late  diagnosis  or  complicated  Hirschsprung  disease,68  complex  pelvic 
malformations,92  colonic  atresia93).  Colostomies are also used in patients with severe colonic, anorectal or perineal 
trauma,32,94,95  perineal  burns,96  and  complications  of  malignant  conditions.58,97  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 
1237 CHAPTER 98 STOMAS OF THE SMALL AND LARGE INTESTINE