What are the recommendations for creating a divided stoma in pediatric patients with two separate incisions for both loops, leaving the skin between the loops intact?

Recommendations for Creating a Divided Stoma in Pediatric Patients with Two Separate Incisions

Creating a divided stoma in pediatric patients with two separate incisions for both loops, leaving the skin between intact, is generally not recommended as it results in two separate stomas/abdominal wall defects, which increases the risk of complications and makes management more challenging for patients and caregivers. 1, 2

Current Guideline Recommendations for Stoma Configuration

Preferred Approaches

• End Stoma: The intestine is divided with the proximal end brought out as a stoma, while the distal end remains in the abdomen 1, 2
• Loop Stoma: A continuous piece of intestine is brought through a single abdominal wall opening with two intestinal openings side by side within the same skin aperture 1, 2

Mucus Fistula Considerations

• A mucus fistula (bringing out the distal end through a separate incision) is generally avoided when possible due to:

  • Creation of two separate stomas/abdominal wall defects
  • Increased difficulty in pouching and management
  • Higher risk of complications 1

• Mucus fistulas should be reserved for specific situations:

  • Significant risk of leak in the stapled-off end
  • Distal obstruction
  • Poor tissue integrity 1

Evidence from Pediatric Surgical Practice

Two-Port Laparoscopic Technique

• A two-port laparoscopic technique for creating a descending colostomy with separated stomas has been described for newborns with anorectal malformations 3
• This technique eliminates the incision between two stomas and its complications, allows for painless stoma bag changes immediately after surgery, avoids twisting of the colostomy, and permits a cosmetically pleasing incision at colostomy closure 3

Comparison of Techniques

• The Bishop-Koop procedure (a type of loop stoma) has shown better outcomes compared to divided stomas in neonates with meconium ileus, congenital intestinal atresia, and necrotizing enterocolitis 4
• Stoma-related complications were significantly lower with Bishop-Koop (8.7%) compared to divided stomas (31.1%) 4
• Operating time for ostomy reversal and length of hospital stay were significantly shorter with Bishop-Koop procedure 4

Practical Considerations for Pediatric Stoma Care

Challenges in Developing Countries

• Caring for a child with a stoma can be particularly challenging in resource-limited settings 5
• Modern devices such as colostomy bags and accessories may be expensive and not readily available 5
• Multiple stomas would further complicate management for caregivers

Stoma Complications and Prevention

• Skin breakdown and leakage are common complications of stomas 2
• Risk factors include:
  • Obesity
  • Placement in skin creases
  • Loop configuration
  • Liquid effluent
  • Flush stoma 2

Technique to Minimize Complications

• For loop ileostomies, anti-mesenteric fixation can minimize the risk of volvulus by widening the attachment of the adjacent ileum to the parietes 6
• This technique has shown no complications in over 30 loop ileostomies followed for a minimum of 4 years 6

Standardized Perioperative Care

• A standardized perioperative care process for stoma closure can significantly reduce surgical site infection rates 7
• SSI rates declined from 42.8% to 13.9% after implementation of standardized perioperative bowel and abdominal wall care processes 7

Conclusion

Based on current guidelines and evidence, the preferred approach for pediatric stoma creation is either an end stoma or a loop stoma through a single incision. Creating a divided stoma with two separate incisions should be limited to specific clinical scenarios where the benefits outweigh the increased risk of complications and management challenges.