Loop vs Divided Stoma in Children: Considerations for Selection
Loop stomas are generally preferred over divided stomas in children due to their lower complication rates (8.7% vs 31.1%), easier creation and reversal, and requirement of only a single stomal aperture. 1
Types of Stomas and Their Configurations
Loop Stoma
- Created by bringing a continuous piece of intestine through the abdominal wall and opening the anterior wall
- Results in two intestinal openings side by side within the same skin aperture
- The active proximal end (draining stool) is typically made dominant while the defunctionalized distal end is diminutive 2
- Indications:
- Distal obstruction (to alleviate obstruction and permit drainage)
- Temporary diversion (to protect distal anastomosis)
- When easy reversal is anticipated 2
Divided Stoma (End Stoma)
- Created when the intestine is divided with the proximal end brought out as a stoma
- The distal end is typically left within the abdomen
- Sometimes the distal end is brought out as a separate mucus fistula
- Indications:
Comparative Advantages and Disadvantages
Loop Stoma Advantages
- Easier to create and reverse (both pieces of intestine are at skin level)
- Requires only a single stomal aperture
- Lower complication rates in children (8.7% vs 31.1% for divided stomas) 1
- Shorter operating time for reversal (82.2 ± 51.4 vs 183 ± 84.5 minutes) 1
- Shorter hospital stay after closure (5.5 ± 2.7 vs 11.3 ± 3.9 days) 1
Loop Stoma Disadvantages
- Higher risk of prolapse, particularly with transverse loop colostomies 4
- May be more difficult to pouch effectively
Divided Stoma Advantages
- End stoma is easier for patients to pouch 2
- Better fecal diversion (less risk of spillage into distal segment)
- Lower risk of prolapse compared to loop stomas
Divided Stoma Disadvantages
- Higher overall complication rate in children 4, 1
- More invasive reversal surgery (requires locating the stapled-off distal end within the abdomen) 2
- If created with mucus fistula, results in two separate stomas/abdominal wall defects 2, 3
Anatomical Location Considerations
- Sigmoid colostomies are associated with lower complication rates compared to transverse colostomies (52% versus 81%) 5
- Right side of the colon is usually avoided for colostomy creation due to:
- Large diameter
- Liquid effluent
- Tendency to create a large stoma prone to leakage 2
Common Complications and Management
Skin excoriation (most common complication in children) 4
- Prevention: proper sizing and fitting of ostomy appliances
- Treatment: barrier powder + skin sealant
Prolapse (more common in transverse loop colostomies) 4
- May require surgical revision
Chronic blood loss from stoma (second most common problem) 4
- Requires monitoring for anemia
Other complications: retraction, stenosis, parastomal hernia 6
Special Considerations for Pediatric Patients
- Preoperative planning is crucial, including site marking by a stomatherapist 3
- Consider the child's growth potential when placing the stoma
- Family education and support are essential components of care 7
- Access to wound/ostomy nurse consultation improves outcomes 3
Disease-Specific Considerations
For meconium ileus, congenital intestinal atresia, and necrotizing enterocolitis:
- Bishop-Koop procedure (a modified loop ileostomy) shows better outcomes than divided stomas 1
For anorectal malformations and Hirschsprung's disease:
- Sigmoid colostomy should be used whenever possible due to lower complication rates 5
In conclusion, when creating a stoma in children, the surgeon should carefully weigh the benefits and risks of each configuration. The evidence suggests that loop stomas generally offer advantages in terms of lower complication rates and easier reversal, making them preferable in most pediatric cases where temporary diversion is needed.