Evaluation of Complications of Colostomy in Children

Introduction

“Stoma” is a Greek word which means opening or mouth.¹ Stoma is a surgically created opening of the intestine on abdominal wall. Intestinal stomas are created to divert the stool away from distal bowel.2 It may be temporary or permanent, depending on the conditions.²

The commonly created intestinal stomata are colostomy and ileostomy.^3,4 Colostomy is mainly done for diversion of the colon or decompression of the colon as a part of management of congenital and acquired gastrointestinal conditions as an emergency or elective surgical procedure.⁵

In adults, conditions like intestinal perforation, volvulus, diverticulitis, trauma, and malignancies may require stoma formation as a part of their management. Intestinal stoma creation in children has different indications than in older persons. Unlike adults, intestinal stoma creation in children is a temporary surgery; majority are done in neonatal period mainly for congenital anomaly, as an emergency lifesaving procedure.^4,5

In children, Intestinal stoma creation is done for different intestinal conditions, such as necrotizing enterocolitis (NEC), intestinal atresia, volvulus, anorectal malformation (ARM) and Hirschsprung’s disease.^6-8 Among them, Hirschsprung’s disease and anorectal malformation are the common indications for colostomy formation in infancy and childhood.^9,10 The colostomy in children is mainly temporary to divert the fecal stream till the definitive procedure is performed.^2,9,10

Colostomies are further classified depending on the way of creation into Hartman’s end colostomy, loop colostomy and double barrel colostomy. Hartman’s end colostomy and loop colostomy are created frequently.¹¹

Complications which occur within 30 days of colostomy procedure are early complications and which occurs after 30 days of colostomy procedure are late complications. Early complications are technical and may require immediate treatment and care, while late complications may be due to early complications or colostomy itself.^7,12,13

Complications are mainly dependent on multiple factors such as surgeon experience, emergency versus elective colostomy creation, colostomy location, patient issues such as age, comorbidities and ability of parents or caretakers to care for stoma.^14,15 Even with careful techniques and care, there is significant morbidity and mortality associated with creation of colostomy.^14,15

The aim of this study was to evaluate the complications of colostomy in children at a tertiary care centre.

Material and methods

This descriptive observational study was conducted in our institution over a period of four years from February 2017 to January 2021. All the children below five years of age who underwent colostomy in our institute were included in the study.

Children who were lost to follow up after colostomy or children with other intestinal stoma like ileostomy were excluded from the study. In every case, detailed clinical history was obtained and physical examination was done. It was followed by relevant investigations. In this study, all children underwent temporary colostomy as the first stage for management of congenital anomaly, as an emergency lifesaving procedure, which was followed by definitive procedure. All colostomies were performed by the consultants.

The demographic and clinical data on age at colostomy procedure, sex, clinical details, indication for colostomy, site, type of colostomy, complications of colostomy procedure, morbidity and mortality due to the colostomy procedure were collected.

Categorical variables were summarized as percentages and quantitative variables were summarized as mean with standard deviation (SD), or median with interquartile range (IQR) according to the distribution of the variable. The data was entered and analyzed in Epi Info version 7 software.

Results

During our study period, 38 children underwent colostomy procedure who had fulfilled our inclusion criteria. Among 38 children, 23 (60.5%) children were of High Anorectal Malformations and 15 (39.5%) children were of Hirschsprung’s disease. Children who had anorectal malformations were younger and underwent colostomy in neonatal period (mean 3 days ± 2.41) compared to those who had Hirschsprung’s disease.

Children with Hirschsprung’s disease underwent colostomy procedure between one month to five years (mean 6.8 months ± 3.55). The duration of colostomy was also short for anorectal malformation between two to nine months (mean 5.6 months ± 2.15) than Hirschsprung’s disease which was four months to 3 years (mean 11 months ± 3.42).

There were 26 (60.4%) males and 12 (31.6%) female children with male-to-female ratio of 2.2:1. Among 26 males, 20 (86.9%) males were of High Anorectal Malformations and 6 (40%) males were of Hirschsprung’s disease.

In our study, all children with High Anorectal Malformations underwent loop high sigmoid colostomy in neonatal period as first stage followed by definitive Ano-rectoplasty between 3 months to 6 months of age followed by colostomy closure 2 to 4 months after definitive ano-rectoplasty. However, all children with Hirschsprung’s disease underwent Hartman procedure with levelling end colostomy as first step, followed by Definitive pull through after 4 months of the procedure.

Complications related to colostomy procedure were seen in 28 (73.7%) children (Table 1). Early complication like wound infection, superficial wound dehiscence, stoma necrosis and bleeding stoma were seen in 13 (34.2%) children, whereas late complications like Peristomal skin excoriation, Colostomy retraction, Colostomy stenosis, Colostomy prolapse, Para-colostomy hernia were seen in 15 (39.5%) children.

Majority of complications, 17 (44.7%) were seen in end colostomy made in children with Hirschsprung’s disease.

Colostomy site wound infections were managed well with regular dressing and antibiotics. Superficial wound dehiscence (Figure 1) was treated initially with regular dressing followed by secondary suturing. Colostomy stoma necrosis which occurred in end colostomy in Hirschsprung’s disease was managed by revision colostomy. Bleeding from the stoma was seen in three children, which was controlled with pressure dressing

Peristomal skin excoriation (Figure 2 & 3) which was the commonest complication was managed successfully with topical ointment application like zinc oxide and resulted in good recovery in all the children.

Among two children with colostomy retraction after end colostomy in Hirschsprung’s disease, one required revision colostomy and other was managed conservatively. Colostomy stenosis and one patient with colostomy prolapse (Figure 4) underwent revision surgery, while two children with colostomy prolapse were managed conservatively till definitive surgery.

Paracolostomy hernia was seen in two children with end colostomy in Hirschsprung’s disease which were repaired along with the colostomy closure during definitive procedure.

Systemic complications such as sepsis, pneumonitis were seen in early post-operative period in 8 (21.1%) children, among which two (5.3%) children succumbed due to severe sepsis and respiratory failure which is not due to colostomy related complications.

Discussion

Colostomy is a common emergency procedure performed in paediatric age, mainly for congenital anomalies.16 This emergency life-saving procedure is a major surgical procedure associated with morbidity and mortality. Majority of related complications are preventable with good surgical technique and qualitative follow-up care. More than 90% of pediatric colostomies were performed for large bowel obstruction due to Hirschsprung’s disease or anorectal anomalies.^17,18

Male preponderance with male to female ratio of 2.2:1 recorded in our study is consistent with gender distribution findings in other reports.^16,18-20

In our study, all children with High Anorectal Malformations underwent loop high sigmoid colostomy in neonatal period, as this method is easy for fashioning and colostomy closure. Loop colostomy has been considered as ideal for most temporary indications in pediatric age due to its simplicity and ease of closure.²¹

In this study, colostomy was done in 60.5% children with High Anorectal Malformations and 39.5% children with Hirschsprung’s disease. This is at variance with few earlier reports where Hirschsprung’s disease was a more common indication for colostomy.^16,18 Also, children with anorectal malformation presented at a younger age than those who had Hirschsprung’s disease because of absent anal opening and absolute intestinal obstruction.^16,18,22 The variance in our setting may be due to relative incidence of Hirschsprung’s disease and anorectal malformation in our demographic area.

In our study, complications related to colostomy procedure were seen in 73.7% children and majority of complications (44.7%) were seen in end colostomy made in Hirschsprung’s disease children. However, colostomy related complications range from 28-74% in different studies. The morbidity from colostomy related complications has been reported to be as high as 42- 75%.^22,23,24

The common complication in our study was parastomal skin excoriation, which occurred in 18.4% children. This is due to poor colostomy care by parents or care takers as majority of them were uneducated and from rural areas. This leads to constant maceration of the skin, allergic reaction to stools, infection of the macerated skin. Stoma bags for children are not easily available and their use in children is difficult in rural areas with poor hygiene. Parents or care takers of children with colostomy were taught to use napkins and clean the site frequently with water to prevent excoriations. Skin protective ointments, barrier dressing was helpful to prevent parastomal skin excoriation and deep excoriations may need earlier closure.^16,22,23,24 Local wound infection occurred in six children (15.8%) which is most likely due to improper nursing care. Colostomy retraction, Colostomy stenosis, Colostomy prolapse, Para-colostomy hernia were other late complications seen in our study which were similar with colostomy related complications in different studies.^{16,17,18,22,23,24} Most of these late complications occur due to poor surgical technique, surgeons’ inexperience in colostomy procedure. Majority of these complications can be managed by either revision of colostomy or early definitive surgery and repair. In our study, mortality seen in 5.3% children was due to severe sepsis and respiratory failure, which is not related with colostomy related complications. However, morbidity and mortality related to colostomy creation in children for congenital indications is high in various studies.^18,22,23,24 Preoperative counselling of parents and caretakers, education about good stoma care and early stoma closure achieves satisfactory results. Parents and caretakers of children with colostomy needs to be educated on colostomy care, hygiene, diet and skin care techniques.^22,25,26

Conclusion

Although, colostomy complications are common in children, majority of the colostomy complications can be prevented or minimized by good surgical technique, education of parents on colostomy care and hygiene.

Conflict of Interest

Nil.

Financial support

Nil.