Colostomy in anorectal malformations: a procedure with serious but preventable complications

Purpose

Colostomy for patients with anorectal malformations decompresses an obstructed colon, avoids fecal contamination of the urinary tract, and protects a future perineal operation. The procedure is associated with several significant complications.

Materials and Methods

The medical records of 1700 cases of anorectal malformations were retrospectively reviewed. A total of 230 patients underwent reconstruction without a colostomy. Of the remaining 1470 patients, 1420 had their colostomy performed at another institution (group A) and 50 did at our institution (group B) using a specific technique with separated stomas in the descending colon.

Results

There were 616 complications identified in 464 patients of group A and in 4 patients in group B, an incidence of 33% vs 8% (P < .01). Complications in group A were classified into several groups. The first group was mislocation (282 cases), including 116 with stomas too close to each other, 97 with stomas located too distally in the rectosigmoid (which interfered with the pull-through), 30 with inverted stomas, 21 with stomas too far apart from each other, and 18 with right upper sigmoidostomies. The second largest group was prolapse (119 cases), which occurred mainly in mobile portions of the colon. The third group was composed of general surgical complications after colostomy closure (82 cases), such as intestinal obstruction (47 cases), wound infection (13 cases), incisional hernia (11 cases), anastomotic dehiscence (7 cases), sepsis (3 cases), and bleeding (1 case). Two of the septic patients died. Another group included 62 patients who received a Hartmann's procedure, which we considered to be contraindicated in anorectal malformations. A total of 42 patients suffered from stenosis of the stoma; 29, from retraction.

Conclusions

Most colostomy complications are preventable using separated stomas in the descending colon. Mislocated stomas lead to problems with appliance application, interference with the pull-through, megasigmoid, distal fecal impaction, and urinary tract infections. Loop colostomies lead to urinary tract infections, distal fecal impaction, and prolapse. Prolapse is a potentially dangerous complication that mostly occurs when the stoma is placed in a mobile portion of the colon. Recognizing this makes the complication preventable by trying to create colostomies in fixed portions of the colon or by fixing the bowel to the abdominal wall when necessary. The trend to avoid colostomies is justified; however, colostomy is the best way to prevent complications in anorectal surgery and, when indicated, should be done with a meticulous technique following strict rules to avoid complications.     

Ileostomy and colostomy

The formation of intestinal stomas, mainly ileostomy and colostomy, has become an integral approach to the surgical management of several pathologies of the gastrointestinal tract – in both the emergency and elective patient. The basic underlying principle is that faecal flow is diverted away from the site of the pathology, by bringing an end or a loop of bowel, through the anterior abdominal wall. Either in a temporary capacity or permanent role stomas can reduce morbidity and mortality associated with several conditions of the gastrointestinal tract such as perforated colon, inflammatory bowel disease, bowel obstruction and elective cancer operations, for example a low anastomosis in an anterior resection of rectum. It has to be appreciated though that stomas are not without their own set of complications, both in the early and late phases. Initial concerns can be due to ischaemia of the bowel forming the stoma, stomal retraction and obstruction through to later complications such as parastomal hernia formation, stomal prolapse and peristomal skin changes.     

Risk of Fecal Diversion in Complicated Perianal Crohn’s Disease

The purpose of the study was to determine the overall risk of a permanent stoma in patients with complicated perianal Crohn’s disease, and to identify risk factors predicting stoma carriage. A total of 102 consecutive patients presented with the first manifestation of complicated perianal Crohn’s disease in our outpatient department between 1992 and 1995. Ninety-seven patients (95%) could be followed up at a median of 16 years after first diagnosis of Crohn’s disease. Patients were sent a standardized questionnaire and patient charts were reviewed with respect to the recurrence of perianal abscesses or fistulas and surgical treatment, including fecal diversion. Factors predictive of permanent stoma carriage were determined by univariate and multivariate analysis. Thirty of 97 patients (31%) with complicated perianal Crohn’s disease eventually required a permanent stoma. The median time from first diagnosis of Crohn’s disease to permanent fecal diversion was 8.5 years (range 0–23 years). Temporary fecal diversion became necessary in 51 of 97 patients (53%), but could be successfully removed in 24 of 51 patients (47%). Increased rates of permanent fecal diversion were observed in 54% of patients with complex perianal fistulas and in 54% of patients with rectovaginal fistulas, as well as in patients that had undergone subtotal colon resection (60%), left-sided colon resection (83%), or rectal resection (92%). An increased risk for permanent stoma carriage was identified by multivariate analysis for complex perianal fistulas (odds ratio [OR] 5; 95% confidence interval [CI] 2–18), temporary fecal diversion (OR 8; 95% CI 2–35), fecal incontinence (OR 21, 95% CI 3–165), or rectal resection (OR 30; 95% CI 3–179). Local drainage, setons, and temporary stoma for deep and complicated fistulas in Crohn’s disease, followed by a rectal advancement flap, may result in closing of the stoma in 47% of the time. The risk of permanent fecal diversion was substantial in patients with complicated perianal Crohn’s disease, with patients requiring a colorectal resection or suffering from fecal incontinence carrying a particularly high risk for permanent fecal diversion. In contrast, patients with perianal Crohn’s disease who required surgery for small bowel disease or a segmental colon resection carried no risk of a permanent stoma.     

Outcomes of continent catheterizable stomas for urinary and fecal incontinence: comparison among different tissue options

OBJECTIVE: To retrospectively review the outcome of appendix, transverse tubularized intestine segments, caecal flap, gastric tube and others tissue options used as a continent stoma for urinary and fecal incontinence. PATIENTS AND METHODS: Between January 1993 and January 2003 we created 179 continent stomas to treat urinary and fecal incontinence in 135 patients (81 females and 54 males; mean age at surgery 13 years, 118, 87%, aged <17 years). We used either appendix (112), a short segment of bowel following the Yang-Monti technique (49), gastric augment single pedicle tube (eight), caecal flap (seven), Casale continent vesicostomy (two) and Meckel's diverticulum (one). Thirty-six patients had both urinary and fecal continent stomas created. RESULTS: The mean follow-up for the appendix group was 46 months for the urinary stoma and 23 months for the Malone antegrade continent enema (MACE) stoma. Stoma-related complications occurred in 24 of 112 (21%) patients; there was complete channel fibrosis in five (4%). The mean follow-up for the Yang-Monti group was 38 months for the urinary and 59.2 months for the MACE stoma. There were stoma-related problems in 11 of 49 (22%) patients, with complete channel fibrosis in three (6%). Overall, in the long-term follow-up, there were stoma-related complications in 42 of 179 (23.5%) procedures. CONCLUSIONS: Continent catheterizable stomas are a feasible and reliable method for treating urinary and fecal incontinence. Long-term success can be accomplished with appendix, transverse tubularized intestinal segments and caecal flaps, with similar complication rates in all groups. Surgeon preference and individual patient status should determine the surgical technique to be used.     

Hirschsprung's disease in young adults

Hirschsprung's disease is rarely seen in the young adult, and presents unique problems in management because of the massive dilatation and hypertrophy that occur proximal to the aganglionic rectum or the rectosigmoid colon. The diagnosis, which may be suspected by barium enema, is confirmed by suction or full-thickness biopsy of the rectum that may be complemented by anal manometry. Based on our experience with eight patients, a two-stage surgical reconstruction is recommended, with a preliminary sigmoid colostomy through the normally innervated colon and an associated defunctionalized stoma constituting the initial operation. The distal colonic stoma permits cleansing of the caudal colon while the normally innervated proximal colon reverts to near normal caliber, usually within 2 to 6 months. This approach is in accord with the recommendation of Fairgrieve. Reconstruction using a Duhamel or Soave procedure has given good results. The Duhamel procedure seems preferable when a considerable discrepancy remains between the ganglionic and aganglionic segments of rectum.     

Results of a nationwide prospective audit of stoma complications within 3 weeks of surgery

OBJECTIVE: Actuarial analysis of stoma complications (problematic stomas) is lacking. The objectives of this audit were: to identify the incidence of stoma complications within the UK; to highlight any dissimilarity of incidence from centre to centre; to ascertain if the height of the stoma (distance of stoma lumen from the skin) at the time of fashioning is a predisposing factor to problems; and finally to initiate much needed research. METHOD: Commencing 1st January 2005, stoma care services nationwide (256) were invited to audit prospectively their next 50 enteric stomas or for a period of 1 year which ever came first. The definition of a problematic stoma being one, which needed one or more accessories to keep the patient clean and dry for a minimum period of 24 h. The incident is to have happened within 3 weeks of surgery. Factors taken into account were: type of stoma, height of stoma within 48 h of surgery; emergency or elective procedure, problem identified, BMI, gender and underlying diagnosis of the patient. The identities of the participating centres are confidential. RESULTS: Of the 256 hospital-based stoma care services within the UK, 93 (36%) participated. A total of 3970 stomas were recorded, of which 1329 (34%) were identified as problematic. Sixty-two centres reported 45-50 stomas with a range of complications 6-96%. The loop ileostomy was found to be the stoma which causes most problems. A stoma of <10 mm is a predisposing factor to complications and problems are more likely to occur following an emergency procedure. More men than women have stomas formed, but have significantly fewer problems and there is no significant difference between underlying diagnoses. CONCLUSION: The stoma height, stoma type and gender of the patient are significant risk factors identified in this audit. The BMI of patient did not affect the outcome. Patients undergoing an emergency procedure are more likely to have a problematic stoma. The significant variation of complications from centre to centre indicates surgical technique as being the key factor in stoma formation and subsequent quality of life for the patient.     

Concealed umbilical stoma: long-term evaluation of stomal stenosis

PURPOSE: The technique of forming a concealed umbilical stoma has been described previously and includes a posterior umbilical flap for improved cosmesis and stenosis prevention. We assessed long-term stomal stenosis. MATERIALS AND METHODS: We reviewed retrospectively the charts of 46 patients (mean age at surgery 14 years) of whom 35 had undergone concealed umbilical stoma creation and 11 the Malone antegrade continence enema procedure for continent urinary diversion. Urinary stomas were created from appendix in 20 cases, ileum in 8, sigmoid colon in 5, bladder in 1 and stomach in 1. Malone antegrade continence enema stomas were constructed from appendix in 10 cases and sigmoid colon in 1. A total of 21 patients underwent urinary diversion and augmentation cystoplasty. RESULTS: At followup of 12 to 84 months (median 3.4 years) 93.5% of patients had an intact stoma with no need for surgical revision. Of the remaining patients 3 (6.5%) required revision of the stoma at skin level for stomal stenosis at 1, 4 and 38 months after initial surgery and 2 had a brief period of indwelling catheterization for correction of stenosis. CONCLUSIONS: The concealed umbilical stoma technique provides an excellent cosmetic result with a low rate of stomal stenosis in patients requiring intermittent bladder or bowel catheterization.     

Cost-effectiveness of defunctioning stomas in low anterior resections for rectal cancer: a call for benchmarking

HYPOTHESIS: Anastomotic leakage is the most important cost driver in patients who undergo low anterior resection (LAR) for rectal cancer. Creating defunctioning stomas to protect colorectal anastomoses may also have a major effect on the overall costs. Unselected creation of defunctioning stomas in most of these patients may be associated with higher overall costs compared with a program that has a low rate of defunctioning stomas and an acceptable anastomotic leakage rate. DESIGN: Cost-effectiveness analysis. SETTING: Secondary referral center. PATIENTS: Performing a cost analysis from the viewpoint of a hospital provider, we reviewed data of 70 consecutive patients who underwent LARs with (n = 19) or without (n = 51) a defunctioning colostomy. A scenario analysis was performed using data derived from the medical literature to assess a plausible range of leakage and stoma rates. MAIN OUTCOME MEASURE: Costs per treatment option and incremental cost-effectiveness ratio according to various treatment scenarios. RESULTS: Performing an LAR without a stoma and no anastomotic leakage is associated with significantly lowest costs (8.400 euro; P<.001) compared with patients with a stoma (13.985 euro) and patients with anastomotic leakage (42.250 euro). The most important cost drivers were anastomotic leakages and defunctioning stomas. A leakage rate of 16.5% in patients without a stoma would be necessary to balance the overall costs of patients with stomas. The incremental cost-effectiveness ratio would be 158.705 euro and 60.915 euro per leak, respectively, avoided in patients with defunctioning stomas assuming a leakage rate lower than 3% and 6%, respectively, in patients who did not undergo a colostomy. A 1-way sensitivity analysis revealed that duration and costs of intensive care unit care were the only factors that may considerably alter our results. CONCLUSIONS: A suggested benchmark for an LAR should be a rate of 10% or less for defunctioning stomas and anastomatic leaks; that would limit the overall costs to 12,000 euro per patient treated. Against the background of a lack of universally valid criteria for the creation of defunctioning stomas, our aim should be to reduce the rate of defunctioning stomas because of their major effect on the overall costs especially in programs with a lower leakage rate. Higher leakage rates despite higher stoma rates depend more on the skill of the surgeon than on the characteristics of the patient and higher leakage should lead to a change in surgical technique strategy.     

Emergency laparoscopic management of perforated sigmoid diverticulitis: a promising alternative to more radical procedures

BACKGROUND: Classic emergency surgical management of complicated perforated sigmoid diverticulitis is based on the principle of a two-stage operation, with colon resection and temporary stoma (Hartmann's procedure). But the later second-stage operation can be technically difficult and can be associated with a significant morbidity rate. We argue that laparoscopy may be beneficial in such patients with peritonitis in terms of operative results and could facilitate later surgical management. STUDY DESIGN: We studied all consecutive patients with perforated sigmoid diverticulitis requiring emergency surgery between January 2000 and December 2004. RESULTS: Twenty-four patients underwent emergency laparoscopic management for perforated sigmoid diverticulitis. Nineteen patients (80%) were found to have a purulent or fecal diffuse peritonitis. No conversion and colostomy were necessary. The overall morbidity rate was 8%; 2 patients with pelvic abscesses required radiologic drainage. The median hospital stay was 12 days (range 7 to 35 days). Prophylactic sigmoid resection was performed by laparoscopy in all patients, with a conversion rate of 16%. CONCLUSIONS: Laparoscopic treatment of generalized peritonitis secondary to diverticulitis is feasible and safe and may be a promising alternative to more radical surgery in selected patients, avoiding fecal diversion and allowing a delayed elective laparoscopic sigmoid resection.     

Stomas

The construction of intestinal stomas is a major part of a surgical procedure. A stoma should be formed by a surgeon who is not only technically skilled but also understands the potential metabolic and mechanical problems associated with an ileostomy or colostomy. Because of many of the complications are preventable, careful preoperative planning by the surgeon in conjunction with an enterostomal therapist is important to minimize the incidence of technical complications and to help prepare the patient psychologically for life with a stoma. When a complication does arise, it should be recognized promptly and dealt with appropriately.     

Cloacal exstrophy—pull-through or permanent stoma? : A review of 53 patients

Purpose

Patients with cloacal exstrophy have complex anomalies of the genitourinary and gastrointestinal tract with a spectrum of colonic length. Often, colon is lost during the initial management by use of ileostomies and for urologic and genital reconstruction. It is a common belief that these patients require permanent stomas, which we hypothesized is inaccurate, and therefore reviewed our experience with exstrophy, focusing specifically on a patient’s potential to undergo a colonic pull-through.

Methods

All patients with exstrophy or exstrophy variant treated by the authors were retrospectively reviewed. Their ability to form solid stool was assessed via bowel management involving a constipating diet, antidiarrheals, bulking agents, and a daily enema through the stoma. Patients who underwent successful bowel management through the stoma were offered a pull-through.

Results

Fifty-three patients were treated over a 26-year period, including typical cloacal exstrophy (27), or a covered variant (16), and complex anorectal malformations with short colon (10). Newborn operations (48 done at other institutions, 5 by us) involved ileostomy in 11 or end colostomy in 42. Eight patients with ileostomies suffered acidosis and failure to thrive and underwent “rescue” operations to incorporate all defunctionalized colon into the fecal stream. Four had colon used for their urologic reconstruction and 6 for their genital reconstruction, leaving them borderline or unable to form solid stool. Twenty-three are undergoing bowel management or being observed for growth of the colonic pouch to determine if they are pull-through candidates. Of the others, 90% (27/30) underwent colonic pull-through. Ten percent (3/30) had a permanent stoma. Of 20 available for follow-up after pull-through, 17 are clean with bowel management (85%), 2 (10%) have voluntary bowel movements with occasional soiling, and 1 is incontinent but noncompliant.

Conclusions

Indication for pull-through depends on successful bowel management through the stoma, which depends on the ability to form solid stool. To maximize this potential, it is crucial to use all available hindgut for the initial colostomy and avoid use of colon for urologic or genital reconstruction. Most patients have poor prognosis for bowel control but can remain clean with bowel management. Our experience indicates that a permanent stoma is not required for the most of these patients and that bowel management can keep them clean, which we believe provides them with a better quality of life. Using these criteria, most exstrophy patients, contrary to popular belief, are candidates for a pull-through.     

The role of stomas in the initial and long-term management of Hirschsprung disease

AimTo review the role of stomas in the initial and long-term management of Hirschsprung disease (HD).MethodsPatients treated for HD at our institution between January 2004 and August 2021 were identified. Data were collected regarding: demographics, indication/bowel location/type of stomas performed and outcomes, pull-through (PT) procedure, and follow-up duration.ResultsNinety-five patients (78 male) were identified including one early unrelated death. Forty-four of 94 (47%) required a stoma before PT procedure. Of these 44, 38 (86%) had ileostomies and the remaining six (14%) colostomies; one ileostomy remains long-term. The commonest indication for initial stomas was washout failure (41%).Ninety-one patients had undergone primary PT or secondary PT with stoma closure at the time of the study.A further new stoma was required after primary PT or three-stage management in 20/91 (22%). The commonest indications were constipation/soiling (25%) and anastomotic leak (20%). Seven out of 20 (35%) were performed within 30 days of a previous procedure and all were closed; three patients required further long-term stomas. Thirteen (65%) required a stoma >30 days, nine remain long-term. Surgical revision of stomas was required in 14/56 (25%) – prolapse and retraction being the commonest indications. Overall, 56/94 (60%) patients required stomas (pre- and/or post-PT) to manage their condition and 13/94 (14%) have a long-term stoma in place. Mean follow-up was 7.8 years (0.5 - 17.6).ConclusionsStomas remain an integral part of HD management both initially (47%) and long-term (14%); they carry a considerable associated morbidity. Ileostomy is preferred for initial management.Level of EvidenceLevel III     

Cloacal exstrophy: individualized management through a staged surgical approach

Cloacal exstrophy, centered on the maldevelopment of the primitive streak mesoderm and cloacal membrane, results in bladder and intestinal exstrophy, omphalocele, gender confusion, and hindgut deformity. The surgical management and outcome of 10 of 14 survivors (1965 to 1988) are described. Genotypic males (6) were assigned male (2) or female (4) phenotype. Genotypic females (4) were unchanged. All had omphalocele closure in the newborn period. Two had loop stomas. Eight had end stomas (ileostomy [6], ileocolostomy [2]). Toddler and adolescent reconstruction differed in each. Early in the study, abdominoperineal pull-through failed in four patients, necessitating permanent stoma. Four patients had a stoma from the outset. Augmentation using colon remnant improved water loss and nutrition in two infants. Exstrophy turn-in for urinary reservoir was considered in all, but was impossible in three who required urinary diversion. Six patients had exstrophy turn-in and now void by clean intermittent catheterization (4), continent vesicostomy (1), and incontinent (1). Hindgut augmentation improved urinary capacity in two. Two genotypic-phenotypic males had penile lengthening. Four genotypic male-phenotypic females had early orchiectomy with subsequent clitoroplasty or vaginoplasty. Four genotypic-phenotypic females had clitoroplasty or vaginoplasty. Cloacal exstrophy is compatible with a useful life and sound psychologic development, but requires staged reconstruction with long-term support and follow-up.     

Enterostomy in Crohn disease

Indications, technique and prognosis of 129 enterostomies in Crohn's disease are reported. Advanced perianal or entero-genital fistulas represented the predominant indication (60% of primary, 46% of repeated stomas). 85% of stomas were created in combination with intestinal resections. Preferred type of stoma was a loopileostomy (76% of primary stomas), whereas colostomies were avoided whenever possible because of increased complications. Patients initially presenting with rectal involvement or perianal fistulas were prone to need a stoma during the course of their disease while intraabdominal fistulas, abscesses, age, sex, and longstanding disease where of no prognostic significance. Up to now 50% of all temporary stomas and a third of those created for distal fistulas could be closed. The chance of closure increased significantly with duration of symptoms less than 7 years, not more than one previous operation or absence of rectal involvement.     

Management of peristomal pyoderma gangrenosum

BACKGROUND: Pyoderma gangrenosum (PG) occurs in about 1% to 5% of patients with inflammatory bowel disease (IBD). Peristomal pyoderma gangrenosum (PPG) is particularly difficult to manage. STUDY DESIGN: A retrospective chart review was performed on all patients with IBD in whom PPG developed from 1997 to 2007 at the Milton S Hershey Medical Center. RESULTS: Sixteen patients (11 women) were identified. Seven had Crohn's disease (CD), seven had ulcerative colitis (UC), and two had indeterminate colitis. Six patients underwent total proctocolectomy, six patients had total abdominal colectomy (TAC), and four patients had diverting loop stomas. PPG occurred an average of 18.4+/-7.5 months after stoma creation. Twelve patients had active IBD when PPG developed. Two patients had stoma revisions and both had recurrence of the PPG with the new stoma. Medical therapy was successful in eight patients. Five patients had their stomas closed, with active PPG, and all five resolved their lesions. In four of five, surgical management was altered because of PPG (one early stoma closure, two ileal pouches without stomas, one ileal pouch with high body mass index). Of the seven and six patients treated with cyclosporine or infliximab, respectively, there were only two successes with each. CONCLUSIONS: PPG is more common in the presence of active IBD. Surgical closure of the stoma was successful in resolving PPG in all patients. Cure rate of PPG was poor with cyclosporine and only marginally better with infliximab. Medical treatment of PPG is imperfect, and the best therapy is stoma closure when possible.     

No-trocar laparoscopic stoma creation

Creation of an intestinal stoma may be necessary in a wide variety of colorectal diseases of both benign and malignant character. Open and laparoscopic techniques can be used for the fecal diversion. We report a case of a patient with a diverticulitis of the sigmoid colon with abscess formation and fistulation to the abdominal wall and vagina. Owing to severe comorbidity, a permanent fecal diversion was prepared. We performed a laparoscopic no-trocar technique. Only 1 incision, at the planned stoma site, was used. The abdominal wall was elevated with gaspers, no pneumoperitoneum or trocars were used. The laparoscope and reuseable laparoscopic graspers were introduced through the stoma site to correctly identify and grasp a loop of the terminal ileum. Finally, the loop ileostomy was placed on a bar. This laparoscopic technique is a valid alternative to standard laparoscopic stoma creation. Different techniques for stoma creation are discussed.     

A comparison of end versus loop stomas for ileal conduit urinary diversion

We compared the loop and end stoma techniques for ileal conduit urinary diversion in 54 and 27 adults, respectively, with serious bladder disease during a 3-year interval. Followup by trained enterostomal therapists averaged nearly 2 years for all patients. Stenosis occurred in 12 end stomas (44 per cent) but not in any loop stomas. We believe that this result reflects the inherently better blood supply of the loop stoma, which we recommend over the end ileostomy for patients undergoing ileal diversion.     

Intestinal stoma complications in immunocompromised children

BACKGROUND/PURPOSE: When performing an urgent gastrointestinal operation on an immunocompromised child, the pediatric surgeon may have to decide between performing an intestinal anastomosis (and risk leakage or sepsis) or creating an intestinal stoma. This study evaluates the postoperative course of those patients treated with intestinal stomas and the long-term survival rate of such patients. METHODS: A 13-year retrospective review of immunocompromised children with intestinal stomas was performed. Patients were assessed as to their diagnosis, indication for surgery, stoma type, postoperative complications (within 30 days of surgery), ostomy-related complications, and survival. RESULTS: 19 stomas (8 ileostomies and 11 colostomies) were created in 18 patients. Six children had immunodeficiency disorders; 12 were immunosuppressed from chemotherapy treatment for cancer. Indications for surgery included infectious complications (n = 8); neoplasm-induced bowel obstruction, perforation, or invasion (n = 10); and Hirschsprung's disease (n = 1). Postoperative complications occurred in 13 cases (68%); two warranted reoperation. Four of six patients with neutropenia had serious postoperative infectious complications. Stoma complications occurred in 6 cases (32%); 1 required revision. All 3 patients in whom bleeding developed from their stoma site were thrombocytopenic. Nine of 18 patients (50%) died, yet no patient died of complications attributable to their stomas. Of the surviving 9 children, 6 underwent stoma takedown at a mean of 19 months after creation; 1 has a permanent colostomy, and 2 currently are undergoing chemotherapy. CONCLUSION: Although immunocompromised children who require intestinal stomas frequently die of their underlying illnesses and their stomas often produce considerable morbidity, stoma creation does not jeopardize their chance of survival.     

COMPLICATIONS OF AN ABDOMINAL STOMA: AN ANALYSIS OF 322 STOMAS

This paper reports a series of 316 patients with 322 stomas, of which 156 were end-sigmoid colostomies (48.5%) and 123 urological ileal conduits (38.2%). An overall complication rate of 66.8% was detected, with parastomal herniation rate, stenotic rate, and prolapse rate of 31.1, 10.2 and 6.8%, respectively. Complications were detected much later in a urological stoma than in a colostomy. Patients bearing an abdominal stoma should be followed up stringently. The creation of an abdominal stoma should not be regarded as a minor surgical procedure. Certain stomas, such as loop transverse colostomy, should be avoided whenever possible.     

Simplified urinary diversion in patients with preexisting or imminent colostomy.

The indications for urinary and fecal diversion often mirror each other and at times overlap. Between 1980 and 1990 we encountered 14 patients with preexisting or newly diagnosed rectosigmoid disease who required diverting colostomy and urinary diversion. We describe a simple method for managing urinary diversion in these patients, which avoids a bowel anastomosis. The preexisting or newly created colostomy is used as the urinary stoma for a colon conduit, while a proximal colostomy is created for fecal diversion. This technique has proved to be beneficial and should be considered for high risk patients who require urinary and fecal diversion, and for whom an abbreviated operation would be desired.