1238 PART VII ABDOMEN

A B C

D E F
FIGURE 98-3 Examples of decompressing, diverting, or evacuating stomas. A, End stoma (inset shows typical maturation).11 B, Double-barrel stoma.10
C, End-to-side anastomosis with distal vent for irrigation.13 D, Side-to-end anastomosis with proximal vent.15 E, Loop stoma.8 F, End stoma with closed
subfascial distal of the end of the intestine (inset shows rodless end-loop stoma).

TABLE 98-2 attachment of the bowel to the abdominal wall. 36,37,100,101 Di-
Enterostoma Exit rect percutaneous endoscopic jejunostomy (PEJ) is applicable to
Proximal Stoma older patients but difficult in small children due to limita-
Through celiotomy incision tions imposed by the endoscopic equipment.102 A number of
Through separate opening image-guided jejunostomies have been described but have
With proximal and distal limbs close to each other been within the purview of radiologists in a few pediatric
With proximal and distal openings apart centers.37,103,104 Laparoscopic or laparoscopically assisted tech-
Multiple stomas niques are now used with increasing frequency in all age
Variations of the above groups.105–107 Bringing the loop directly to the abdominal wall
and placing a skin-level access device is simple and effective.
Distal Stoma Peristomal leakage is always a concern. An alternative intended
Exteriorization as mucus fistula adjacent to or separate from to decrease this problem is the more complex Roux-en-Y
proximal intestine
approach.108,109 However, this method has a greater potential
Partial closure and placement next to the proximal stoma92
for serious complications such as volvulus and internal
Closure and replacement into abdominal cavity
hernias with intestinal obstruction.110,111
Closure after placement of a catheter for subsequent access
for irrigation or contrast studies
The choice of access device depends on the type of stoma and
the age of the child.27,112 Because straight catheters can be diffi-
cult to immobilize or replace in conventional tunneled jejunos-
various urinary tract dysfunctions to provide a catheterizable tomies, a good alternative is a T-tube for infants (because it does
conduit to the urinary bladder.98,99 not obstruct the narrow lumen) (see Fig. 98-1, C), and an original
type button (Fig. 98-1, D) or other nonballoon skin-level device
for older pediatric patients. Balloon-type devices are suitable for
Choice of Enterostoma the Roux-en-Y loop (see Fig. 98-2). As with a gastrostomy, these
- ------------ ------------- ------------ ------------- ------------ ------------- ------------ ------------- ------------ ------------- ------------ ------ devices are both replaceable as an office procedure.
FEEDING JEJUNOSTOMY
Various approaches for establishing direct long-term access to ILEOSTOMY
the jejunum are now available. “Open” placement through a In intra-abdominal interventions requiring intestinal resection,
small, left upper quadrant incision permits excellent identifica- such as neonatal necrotizing enterocolitis, many surgeons prefer
tion of the stoma site in the proximal jejunum, as well as secure to exteriorize a single-end stoma through a counterincision
 CHAPTER 98 STOMAS OF THE SMALL AND LARGE INTESTINE 1239

A B C
FIGURE 98-4 Examples of options for the management of infants after intestinal resection. A, Exteriorization of proximal intestine through a counter-
incision and closure of distal intestine beneath the abdominal wall. B, Same procedures as in A with exteriorization of proximal end of distal intestine
through the wound edge. C, Arrangement after resection of two intestinal segments.

A B
FIGURE 98-5 Sigmoid colostomies. A, Separated stomas. The proximal intestine is at the upper end of the incision, and the mucus fistula is at the
lower one. B, Loop colostomy. The intestine is exteriorized over a rod or skin bridge or with the help of sutures. The circumscribing comma-shaped incision
is used for takedown and pull-through procedures.

(see Figs. 98-4, A, 98-6, and 98-7). A more expedient
alternative is to bring the proximal intestine through the
end of the incision (see Fig. 98-4, B). However, with this
approach, wound complications are more common. In addi-
tion, if the stoma must remain for a prolonged period of
time and the child gains weight, the fold created by the laparo-
tomy incision may interfere with fitting of the stoma appliance
(see Fig. 98-7).
With a healthy distal intestine and anticipated downstream
patency, the distal limb may be closed and placed intra-
abdominally adjacent to the proximal stoma. Otherwise, exte-
riorization as a mucus fistula is prudent (see Fig. 98-4, B).
The use of an exteriorized loop stoma rather than an end
stoma is an alternative in which the intact mesentery pro-
vides maximal perfusion.79 A double-barreled stoma is a
time-honored option.77,78 To save as much intestine as possi-
ble, the placement of multiple stomas may be necessary (see
Fig. 98-4, C). Although some ileostomy types were developed
specifically for newborns with meconium ileus, they are no
longer used. However, T-tube ileostomies have been useful
for the instillation of liquefying solutions.82
In children with ulcerative colitis or familial polyposis, the
enterostomal principles are similar to those established for
adult patients. Choices for a temporary protective diverting
1240 PART VII ABDOMEN
FIGURE 98-6 One-year-old boy with severe necrotizing enterocolitis with
loss of distal ileum and colon down to the peritoneal reflection before rea-
nastomosis. Liquid stools precluded earlier reestablishment of intestinal
continuity. Notice the appliance mark and the appropriate distance from
the incision, the umbilicus, the inguinoabdominal fold, and the right anterior
superior iliac spine.
FIGURE 98-7 Same child as in Figure 98-6 in a sitting position. Notice the
deep crease produced by the transverse supraumbilical incision. A stoma
brought out through such an incision would have precluded proper use of
the pouch, and a revision would have become necessary.
ileostomy include a simple loop, an end (distally closed) loop,
and an end stoma, with the closed distal end under the fascia
(see Fig. 98-3, F).
APPENDICOSTOMY, TUBE CECOSTOMY,
OR TUBE SIGMOIDOSTOMY
The choice of antegrade colonic enema (ACE) depends on the
type of colonic pathology being managed. With normal peris-
talsis, either the right41 or left40,113 colon may be chosen for
access. However, if dysmotility is a concern, access to the right
colon is indicated. If the appendix is present, it is exteriorized
with or without interposition of a “valve” by either an “open,”88
or laparoscopic approach.43,90 If the appendix is no longer avail-
able, the wall of the cecum may be fashioned into a conduit that
is then brought to the skin level.114 Exteriorizing the appendix
at the umbilicus has cosmetic advantages. Either the appendix
or the conduit so constructed is then catheterized to instill
the enema fluid. A simpler technique, especially if there is no
appendix, is the placement of skin-level device in the cecum
by an open115 or percutaneous approach.87 For patients with
normal colonic motility, access to the left colon by means of a
sigmoid irrigation tube can be advantageous.40
COLOSTOMY
Most colostomies fall into three categories: right transverse, left
transverse, and sigmoid. The significant physiologic and ana-
tomic differences among these three must be taken into con-
sideration when choosing the site for the stoma. For infants
with high imperforate anus, the high (proximal) sigmoid is
the preferred site for exteriorization (see Fig. 98-5).62,116 The
main advantages are firmer stools with less tendency for skin
excoriation, less tendency for prolapse, less surface for urine
absorption, and less contamination of the urinary tract in male
children with rectovesical fistula. Sigmoid stomas assist evacua-
tion of meconium from the often dilated distal portion of the
bowel during the initial procedure. The precise site is easily iden-
tified using the pelvic peritoneal reflection as a guide. A further
advantage is that there are no scars in the epigastrium. However,
if the low or mid sigmoid is inadvertently exteriorized, there may
be interference with the blood supply, as well as insufficient
bowel length for the future pull-through.67,116 If the stoma is
placed in the transverse colon, there is always adequate bowel
length for pull-through, and the intestine is easy to mobilize
and has a smaller diameter and no meconium. The disadvantages
of transverse colon colostomy, however, are sizeable: The stools
are looser, skin maceration and dehydration are more common,
there is a greater prolapse rate, and there is an increased possi-
bility of urinary tract problems. In addition, adequate evacuation
of meconium is nearly impossible. Although high sigmoid loop
colostomy is still used (Fig. 98-8), contemporary preference is
for separation of the stomas, particularly in boys (Fig. 98-9).67
In children with Hirschsprung disease requiring a pre-
liminary colostomy, the best site is the dilated segment that con-
tains normal ganglion cells found proximal to the transition
zone. A loop colostomy is usually chosen, although the ten-
dency for prolapse is increased.68 Because most transition zones
are in the sigmoid colon, this lower left quadrant stoma is taken
down at the time of the definitive corrective operation (see
Fig. 98-5, B). If separation of the stomas is chosen, the distal
intestine should not be oversewn in patients with Hirschsprung
disease, particularly if the aganglionic segment is long, because
mucus cannot be appropriately evacuated or washed out.
Although similar data are not available in children, properly
constructed loop colostomies are fully diverting in adults. 117
Select Technical Aspects
---------- ------------ ------------- ------------ ------------- ------------ ------------- ------------ ------------- ------------ ------------- ---------
Feeding jejunostomies are generally placed in the left upper
abdomen, slightly above the umbilicus, not so cephalic as
to interfere with a possible gastrostomy and/or fundoplication.

FIGURE 98-8 Five-month-old child with high imperforate anus. The
proximal sigmoid loop colostomy is equidistant from the umbilicus, the
anterior superior iliac spine, and the inguinal fold. The original incision
is only slightly longer than the stoma. Notice the raised “spur” between
the two lumina, essential for proper diversion of stool.
FIGURE 98-9 Neonate with high imperforate anus. A divided proximal
sigmoid colostomy was placed. The separation of the bowel ends mini-
mizes the incidence of stoma-related problems.67 The proximal bowel is
slightly everted, and the mucus fistula is flush with the skin. (Courtesy
Dr. Mark Levitt.)
In the “open” technique, the proximal jejunum is approached
through a small, upper left quadrant incision. The ligament of
Treitz is identified, and the catheter or skin-level device is
inserted in the antimesenteric portion of the intestine, 10 to
20 cm distal to the duodeno-jejunal junction. A purse-string
suture of fine multifilament synthetic absorbable material is
placed around the enterotomy and tied. The catheter or skin-
level device is then brought out through a counterinci- sion.
A second purse-string suture, made of monofilament
synthetic absorbable suture is applied, with the sutures alter-
nating between the intestine and the exit site of the catheter
in the abdominal wall. When tied, this second suture approx-
imates the intestinal serosa to the parietal peritoneum in a
watertight manner.100
CHAPTER 98 STOMAS OF THE SMALL AND LARGE INTESTINE 1241
If a PEJ is chosen, the retaining intraluminal bumper must
be size appropriate. Laparoscopic control can be used to
increase the safety of PEJ, particularly in patients with abnor-
mal epigastric anatomy. With laparoscopically assisted jeju-
nostomies, particularly the Roux-en-Y type, proper loop
orientation is essential. To minimize leakage (the most com-
mon problem with jejunostomies), appropriately sized skin-
level devices must be selected. Devices that are too short or
excessive tension on immobilizing crossbars must be avoided
to minimize bowel wall or skin ischemia.
Decompressing ileostomies are usually placed in the right
lower quadrant (see Figs. 98-4 and 98-6). The umbilicus is a
possible site for a stoma118 and is an excellent choice for the dis-
tended proximal intestine in newborns who have gastroschisis
with atresia (Fig. 98-10).
Figure 98-11, A illustrates both appropriate and undesir-
able stoma exit sites in neonates, infants, and small children
(e.g., those with necrotizing enterocolitis). Figure 98-12, B
demonstrates ideal exit sites in older children or adolescents
(e.g., those with ulcerative colitis or familial polyposis). Lap-
arotomy incisions in the lower quadrants should be avoided in
patients who may eventually have long-standing or permanent
stomas because such incisions can create an uneven surface
that interferes with pouch adherence.
When an enterostoma is anticipated, it is important that the
site of the stoma and possible alternatives are marked on the
abdominal wall before any incision is made. This planning is
desirable in both elective and emergency settings. For elective,
long-standing stomas, the best location is determined and
marked the day before the operation (Fig. 98-12, A and B).
The exit site should be located over the convex midportion
of the rectus muscle, away from the incision, umbilicus, bony
prominences, and skin folds. Special attention must be paid in
overweight children because of the deep creases of the abdom-
inal wall. In older children, if a vertical midline laparotomy is
planned, it is advisable to create the opening for the ileostomy
before making the incision. This is done in order to achieve a
FIGURE 98-10 Four-month-old child with gastroschisis and small bowel
atresia during reestablishment of bowel continuity. The dilated and edema-
tous ileus was brought out as an end stoma through the umbilical site. The
proximal closed end of the colon was attached to the side of the ileum
underneath the abdominal wall. This maneuver allows prompt identification
of the distal bowel, minimizing dissection and incision size.