Management of Divided Sigmoid Colostomy in Children
A divided sigmoid colostomy is the preferred approach for most pediatric cases requiring colostomy, offering lower complication rates and better nutritional outcomes compared to other colostomy types. 1
Indications for Divided Sigmoid Colostomy in Children
- Primary indications:
- Anorectal malformations
- Hirschsprung's disease
- Sigmoid volvulus
- Colonic atresia
- Traumatic rectal perforation
- Severe functional constipation (in select cases)
Surgical Technique Considerations
Approach Selection
- Open technique: Traditional approach, especially for unstable or very small infants
- Laparoscopic-assisted technique: Offers improved cosmesis and reduced wound complications 2
- Average operating time: 74.5 minutes
- Allows for feeds and stoma production within 24 hours
Anatomical Placement
- Location: Distal descending colon or sigmoid flexure
- Type: Divided colostomy with complete separation of proximal and distal limbs
- Prevents fecal contamination of distal segment
- Allows for proper distal limb evaluation
Special Considerations by Patient Population
Low birth weight infants (<2.5 kg):
- Consider transverse loop colostomy under local anesthesia instead of divided sigmoid colostomy
- Mortality significantly higher with divided sigmoid colostomy under general anesthesia in this population (44% vs 2.9% in normal weight infants) 3
Short bowel syndrome patients:
- Distal sigmoid colostomy can provide benefits of restored bowel continuity while protecting perineal skin
- Helps improve fluid/electrolyte absorption and energy absorption from carbohydrate fermentation 4
Postoperative Management
Immediate Care
- Monitor for early complications (11.6% incidence) 1
- Initiate enteral feeding within 24 hours when possible
- Provide meticulous stoma care to prevent skin complications
Long-term Management
- Regular nutritional assessment
- Sigmoid colostomies have lower malnutrition rates than transverse colostomies (16.9% vs 34.9%) 1
- Early closure when clinically appropriate to minimize complications
- Monitor for stomal complications (69.8% incidence) 1
Complications and Prevention
Major Complications
- Mortality: 1.8% with colostomy closure 1
- Anastomotic leak: 7.1% with colostomy closure 1
- Wound infection: 12.6% with colostomy closure 1
Common Stomal Complications
- Prolapse: Most common complication
- Proper stoma creation with adequate fixation
- Peristomal skin excoriation:
- Meticulous skin care
- Proper appliance fitting
- Malnutrition:
- Regular nutritional assessment
- Early closure when appropriate
Colostomy Closure Considerations
- Plan for closure as soon as clinically appropriate
- Ensure resolution of the primary condition before closure
- Anticipate and monitor for potential closure complications:
- Anastomotic leak (7.1%)
- Wound infection (12.6%)
Special Clinical Scenarios
Sigmoid Volvulus
- For uncomplicated cases with successful endoscopic decompression, sigmoid colectomy should be performed to prevent recurrence 5, 6
- In complicated cases (ischemia, perforation), urgent sigmoid resection with end colostomy (Hartmann procedure) is indicated 5
- End colostomy creation is preferred for hemodynamically unstable patients or those with significant comorbidities 5
Severe Functional Constipation
- Hartmann procedure with end colostomy formation may be considered in severe intractable cases
- High patient satisfaction reported (100% in a small series) with low associated morbidity 7
- Complications include mild rectal discharge and stomal prolapse
Conclusion
A divided sigmoid colostomy represents the optimal approach for most pediatric patients requiring colostomy, with better nutritional outcomes and manageable complication rates. Special consideration should be given to low birth weight infants, who may benefit from alternative approaches. Proper stoma care, regular nutritional assessment, and timely closure are essential to minimize morbidity and mortality.