children - Europe PMC

Ann R Coll Surg Engl 1996; 78: 526-530

Colostomy complications in infants and

children S Nour

FRCSEd(Paed)

M D Stringer

Senior Registrar in Paediatric Surgery

FRCS(Paed) Consultant Paediatric Surgeon

J Beck

FRCS Consultant Paediatric Surgeon

Department of Paediatric Surgery, Leeds General Infirmary

Key words: Stoma, complications; Hirschsprung's disease; Anorectal malformation

This study analyses the morbidity and mortality of colostomy formation and closure over a 17-year period during which 138 consecutive infants and children had a colostomy formed as the initial management of Hirschsprung's disease or anorectal malformation. Complications after colostomy formation were encountered in 38 (27.5%) patients and included colostomy prolapse, stenosis, retraction, dysfunction, skin excoriation and parastomal hernia. The complication rate with transverse colostomies was higher than with other types. Colostomy closure was associated with complications in nine patients (6.5%), the most serious of which was adhesive small bowel obstruction (5). The mortality was less than 1%, but significant morbidity still exists. Refinements in surgical technique may help reduce the incidence of complications, but stoma prolapse, particularly with transverse colostomies, remains a major challenge.

Colostomy formation and subsequent closure are imsurgical steps in the management of Hirschsprung's disease, high and intermediate anorectal malformations (1) and neonatal necrotising enterocolitis. Both procedures are associated with morbidity and mortality (2-4). It is partly for this reason that some paediatric surgical centres advocate definitive surgery for Hirschsprung's disease and anorectal malformations without preliminary stoma formation (5-8). The aim of this study was to review the complications of both colostomy formation and subsequent closure in a portant

consecutive series of infants and children with Hirschsprung's disease or an anorectal malformation.

Patients and methods The case notes of 138 consecutive neonates, infants and children undergoing surgery at the Leeds General Infirmary between 1977 and 1993 were reviewed. There were 85 patients with Hirschsprung's disease and 53 patients with an anorectal malformation. Table I shows the clinical details. The stoma site and type differed according to the personal preferences of the consultant paediatric surgeon. Operations were performed by both trainees and consultants. During the study period, most infants with Hirschsprung's disease underwent initial laparotomy, multiple colonic biopsies and siting of a ganglionic stoma determined by frozen section histology. Loop colostomies were constructed over a skin bridge (9,10). Since 1987, all infants with an intermediate or high anorectal malformation have had a divided and separated descending colostomy as described by Pena (11). Table II shows the type and site of the stomas. Colostomy closure was performed at a mean age of 10.7

Table I. Clinical details of patients Clinical details Male: Female

Hirschsprung's

Anorectal

disease (n = 85)

malformations

71:14

(n = 53) 39:14

47 34 4

50 3 0

Age at stoma

formation Correspondence to: S Nour, Consultant Paediatric Surgeon, Leicester Royal Infirmary, Leicester LE1 5WW

1-28 days 1-11 months over 1 year

Colostomy complications in infants and children

527

Results

Table II. Colostomy site and type Hirschsprung's disease (n = 83)*

Anorectal malformations (n = 53)

Results are summarised in Table III and Table IV.

67 14

12 0

Sigmoid colostomy Loop Divided

Complications of colostomy formation In all, 38 children (27.5%) developed complications direct result of colostomy formation.

2 0

10 1

Descending colon colostomy Divided and separated

0

30

Site and type of stoma Transverse colostomy Loop Divided

*Operative details of stoma absent in two patients with Hirschsprung's disease and transverse colostoniies months (range 1.5-28 months) for Hirschsprung's disease and 12.4 months (range 1.5-38 months) for anorectal malformation, and the mean duration of subsequent follow-up was 5.7 years (range 6 months to 16 years). All patients undergoing colostomy closure were treated with perioperative prophylactic antibiotics. Statistical analysis was by the x2 test for proportional differences.

as a

Prolapse Colostomy prolapse occurred in 26 (18.8%) children, 19 (73%) of whom had a loop transverse colostomy (Table III). Prolapse was significantly more common in transverse colostomies than in divided descending colostomies x2 = 6.6 df= 1, P