Experience with Colostomy and Colostomy Reversal in Children in Bauchi

Abstract

Background:

Colostomy is one of the common surgical procedures performed in pediatric surgical practice. The aim of this study was to retrospectively review our experience with colostomy and closure (reversal) in children.

Patients and Methods:

A retrospective review of the data of all children aged 15 years and below who had colostomy and colostomy closure in the past 5 years.

Results:

Of the 67 children who had colostomy 42 (62.7%) boys and 25 (37.3%) girls, with an age range between 13 months and 8 years. Fifty-six (83.6%) of the children were <2 years. Anorectal malformation 53 (79.1%) was the common indication. Divided colostomy was performed in 62 (92.5%) patients and loop colostomy was performed in 5 (7.5%) patients. All the patients had intraperitoneal colostomy closure. A complication rate of 26.4% was seen. Duration of hospital stay ranged between 4 and 10 days. No mortality was recorded.

Conclusion:

Colostomy reversal is a safe procedure but morbidity may ensure and can easily manage.

INTRODUCTION

Surgeons have been performing colostomy as a lifesaving emergency procedure in the treatment of children with congenital or acquired large bowel obstructions as far back as the 17^th century.[1] Colostomy is a temporary means of diverting the fecal stream, decompressing obstructed bowel before a definitive procedure can be done in the face of emergency large bowel conditions such as anorectal malformation, Hirschsprung’s disease (HD), and colonic atresia. Colostomy is lifesaving but the associated morbidity and mortality and social stigma make it unpopular among patients and society.[2]

The purpose of this study is to review the indications, complications, and outcomes of colostomy closure among children below 15 years old at Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria.

PATIENTS AND METHODS

We retrospectively analyzed the records of 67 children who had colostomy closure at ATBUTH, Bauchi from January 2018 to December 2022 (5 years). Information regarding indications for colostomy, types of colostomies, and complications associated with colostomy and its closure were retrospectively reviewed from patients’ operating registers and case notes. Data were presented as median and percentages.

RESULTS

The study had 42 (62.7%) boys and 25 (37.3%) girls with a ratio of 1.7:1. Average age at which colostomy was performed was 5 days, ranging from 2 days–8 years. The average duration of time with colostomy before reversal was 1 year, ranging from 4 months–8 years. All had temporary colostomies. Congenital anomalies of the large bowel are the common indication for colostomy in 65 (97.0%) patients, out of which 59 (89.2%) with anorectal malformations (ARM) and 6 (9.2%) with HD. Two (3.0%) other patients had impalement perineal injury following a fall from mango tree. The site for the colostomy was the sigmoid colon in 56 (83.6%) patients followed by the left transverse colon in 8 (12.0%). The remaining 3 (4.5%) patients had right transverse colostomy. Divided otherwise known as Devine colostomy was done in 62 (92.5%) cases, of which 56 (90.3%) were sigmoid colon and 6 (9.7%) left transverse colon. Loop colostomy was done in 5 (7.5%) patients, of which 3 (6.0%) left transverse and 2 (4.0%) sigmoid. Due to excessive prolapse and long duration of colostomy about 2 (3.0%) patients with loop transverse colostomy had Thiersch’s stitch application under sedation in the procedure room, because of lack of funds patients could not afford the colostomy to be closed on time. Other colostomy-related complications are shown in Table 1. After a day colostomy washout, all patients had intraperitoneal colostomy closure under direct vision through a limited peristomal incision to open the peritoneum. Morbidity associated with colostomy closure was seen in 11 (16.4%) of cases [Table 1]. Due to lack of diathermy about 5 (7.5%) patients, we to had extend the incision and had intraoperative transfusion of 140–200 mL of blood. Duration of hospital stay after colostomy closure ranged between 4 and 10 days with a median period of 7 days. Patients who had superficial surgical site infections were discharged on alternate-day dressings; no secondary procedures were performed in them.

Table 1.

Complications of colostomy closure and formation

	n (%)
Due to colostomy closure
Surgical site infection	5 (45.5)
Septicemia	1 (9.0)
Pyrexia	1 (9.0)
Prolonged ileus	4 (36.4)
Total	11 (100)
Due to colostomy formation
Prolapse	3 (21.4)
Skin excoriation	5 (35.7)
Stenosis	2 (14.3)
Stoma necrosis	3 (21.4)
Hemorrhage	1 (7.1)
Total	14 (100)

DISCUSSION

This report had more boys with colostomy than girls, this is because ARM and HD which are the common indications for colostomy are more common in boys. Nour et al.[3] similarly observed more boys with colostomy than girls because of the high incidence of anorectal malformation and HD in their report, which were generally common in boys than girls.

Age at the formation of colostomy was generally late in our report compared to other reports who observed age at the formation of colostomy between 1 day and 1 year.[3,4] The average age at the formation of colostomy in our report was 5 days, ranging from 2 days to 8 years. We observed early age at formation of colostomy in children with ARM than in children with HD and perineal traumas. This is because patients with ARM presented in the neonatal period with acute intestinal obstruction. Poverty, ignorance, or distance are usually the common reasons for delayed presentation and therefore, increased age at formation of colostomy in developing countries.[5,6,7]

ARM and HDs are the common indications for emergency colostomy in the pediatric age group[8] ARM accounted for 88.1% and HD 9.0% of the colostomies performed in this study. A similar finding has been reported by other studies in the subregion.[9,10] Other reasons for colostomy included severe perineal trauma, and abdominal trauma associated with severe peritoneal contaminations.

Colostomy is generally associated with significant morbidity and mortality.[4] Prolapse was the significant complication in our report, it was associated with repeated bleeding in about 2.0% of the patients. The stoma was reduced by the bedside and a purse string was applied under sedation. Prolapse is usually common among patients with a transverse loop or divided colostomy but was also found among patients with longstanding divided sigmoid colostomies that were not closed because of lack of funds. Overall, there less complication colostomy-related complications observed in patients with sigmoid colostomy than with transverse colostomy.

Furthermore, our report like many others[11,12] had not observed significantly associated malnutrition in patients with sigmoid colostomies like in patients with the transverse colostomy, because a significant length of the colon is available for nutrient absorption and growth. Transverse colostomy was often performed in patients with long-segment aganglionosis, severe recto sigmoid trauma, persistent cloaca, and colonic atresia. A significant number of the transverse colostomy was done under local anesthesia in neonates unsafe for general anesthesia due to poor clinical condition in a late presentation like a report by Lukong et al.[13] In our experience, the transverse colon is easily accessible under local anesthesia. The peritoneum is opened using a right transverse incision taken through the right lateral part of the rectus muscle and the right transverse colon is exteriorized and the right flexure is divided and used as colostomy.

Skin excoriation is commonly associated with colostomy, but more in patients with transverse colostomy due to the liquid nature of the feces. In our report, poor general hygiene and malnutrition contributed to the increase in the incidence of skin excoriations among our patients. Other reasons for skin excoriation are poor dietary habit choices, nonavailability of colostomy bags, and poor patient education.

There was no documented mortality from colostomy reversal in this report. Duration and extend of the mechanical bowel preparation, technique of anastomotic closure, and age at colostomy closure have reduced mortality associated with colostomy closure in our report. Mortality from colostomy reversal often follows anesthetic complications, anastomotic leaks, and intraabdominal abscess as observed by Nmadu[14] in Zaria who reported a mortality rate of 2.8% due to anastomotic leaks, intestinal obstruction, and intr-abdominal abscess in children of a relatively smaller age group. Significant mortality has also been observed among patients with ARM due to syndromic associations.[15] We have not observed such findings in our report. Late age at colostomy closure, mechanical bowel preparation, and technique of anastomosis have reduced mortality-associated complications of colostomy reversal in our report. At a relatively older age, the rate of postanesthetic airway complications which happens commonly in children is less as observed in this report.

Colostomy washout with warm normal saline 1–2 days was part of the preoperative preparation required before we reversed the colostomy. The stoma is thoroughly irrigated with about 500–1000 mL of normal saline infused through Foley’s catheter using a bladder syringe. This is done three times a day with each session lasting between 20-30 minutes and on the morning of the surgery. Studies have shown varying outcomes of mechanical bowel preparation on developing surgical site infections in children following colostomy reversal. Colostomy washout reduces the risk of fecal spillage during closure.[16]

We do not believe that patients will have to be subjected to a very wide laparotomy to bring the ends of the two stomas together. Rather a limited peristomal incision enough to open the peritoneum and perform an end-to-end anastomosis under direct vision is all that is required. Rarely, we do extend the incision to do a limited adhesiolysis. This approach is the preferred technique of colostomy closure in our patients with either a divided or loop stoma.

There was a comparable morbidity of 45.8%, which is relatively lower compared to reports by Mollitt et al.[17] who had a morbidity of 61.6%, and Al Salem et al.[5] with 74.6%. Sample size could account for this difference in morbidity rates since patients’ clinical conditions are similar. Septicemia, paralytic ileus, and pyrexia were managed in the 1^st week of the formation of the colostomy, with antibiotics and replacement of electrolyte deficits.

CONCLUSION

Prompt colostomy done based on sound surgical principle is an important staged surgical treatment of large bowel obstructions in children. Its reversal or takedown after definitive treatment is a safe surgical procedure. However, it is important to let parents know of the possible morbidities and the need for their treatment when necessary.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.