Neonatal Ostomy and Gastrostomy Care
Linda C. D’Angelo
Dorothy Goodman
Kara Johnson
Laura Welch
June Amling
Introduction
An ostomy is the construction of a permanent or temporary opening in the intestine (enterostomy) or urinary tract (urostomy) through the abdominal wall to provide fecal or urinary diversion, decompression, or evacuation (1). Gastrostomies (G-tubes) are stomas that allow direct access into the stomach and are used for feeding, medication administration, and decompression. This chapter discusses care of simple and complex enterostomies (ileostomies, colostomies), urostomies, vesicostomies, and gastrostomies (see also Chapter 44).
A. Definitions
1. Enterostomy: a surgical procedure in which a piece of the intestines is diverted through a stoma in the abdominal wall. The segment of the intestines diverted gives name to the subsequent ostomy: colostomy (colon) and ileostomy (ileum).
2. Gastrostomy: creation of an artificial external opening into the stomach for nutritional support or gastrointestinal compression. Typically, this would include an incision in the patient’s epigastrium as part of a formal operation. It can be performed through surgical approach, percutaneous approach by interventional radiology, or percutaneous endoscopic gastrostomy (PEG).
3. Ileal conduit: a type of urinary diversion, where a small urine reservoir is created from a segment of bowel (ileum) and is brought out through an opening in the abdominal wall to drain the urine.
4. Stoma: surgically placed opening.
5. Urostomy: a urinary diversion constructed to bypass a dysfunctional portion of the urinary tract.
6. Vesicostomy: an opening directly from the bladder through the abdominal wall, urine flows freely through the stoma from the bladder.
ENTEROSTOMIES AND UROSTOMIES
A. Indications
Ostomies may be indicated in the neonate for a variety of congenital or acquired conditions (Table 45.1). The stoma
is usually temporary, and reanastomosis of the bowel or urinary tract with closure of the stoma is performed during infancy or early childhood (2, 3).
is usually temporary, and reanastomosis of the bowel or urinary tract with closure of the stoma is performed during infancy or early childhood (2, 3).
TABLE 45.1 Conditions Necessitating Ostomy in the Neonate | ||||||||||||||||||||||
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B. Types of Ostomies
1. Enterostomies
a. There are several types of intestinal (enterostomy) stomas.
 FIGURE 45.1 A: End stoma. The end of the bowel is everted at the skin surface. B: Loop stoma. Entire loop of bowel is brought to the skin surface and opened to create a proximal, or functioning, end and a distal, or nonfunctioning, end. The distal side is called a mucus fistula because of the normal mucus secretions it produces. C: Double-barrel stoma. Similar to a loop stoma, except the bowel is divided into two stomas, a proximal and a distal stoma. The distal stoma functions as a mucus fistula. (Reprinted from Gauderer MWL. Stomas of the small and large intestine. In: O’Neil JA, Rowe MI, Grosfeld JL, et al., eds. Pediatric Surgery. 5th ed. St. Louis, MO: Mosby; 1998:1349. Copyright © 1998 Elsevier. With permission.) |
b. The patient’s condition, the segment of bowel affected, and the size of the patient’s abdomen often determine the type of stoma and its external location. Figure 45.1 depicts the most common types of neonatal stomas and the affected section of bowel (1).
2. Urinary diversion
a. Vesicostomies are the more common urinary diversion in the neonate.
b. Ileal conduits and urostomies are more complex and are generally preformed in late infancy or early childhood.
C. Ostomy Assessment
The neonate with a stoma needs careful observation and assessment for a variety of potential complications (4). Monitoring the infant for function of the ostomy is vital in the initial postoperative period. Possible surgical complications are paralytic ileus, intestinal obstruction, anastomotic leak, and stomal necrosis. The factors to be considered during evaluation of the stoma are listed below.
1. Stomal characteristics
a. Type of stoma: the segment of bowel from which the stoma is made.
b. Anatomical location
 FIGURE 45.2 Immediately postoperative loop ileostomy. Segment of bowel on left is the exteriorized perforation from necrotizing enterocolitis. |
d. Size: the stoma shape (round, oval, mushroom, or irregular) and diameter (length and width) in inches or millimeters are noted. In the early postoperative
period, the stoma will be edematous. After the first 48 to 72 hours, the edema should resolve and result in a reduction in size of the stoma; however, it should remain everted from the skin surface. Stomas generally continue to decrease in size over 6 to 8 weeks postoperatively. It is not uncommon for the stoma to become edematous when exposed to air while changing the pouch; this edema generally resolves quickly when the pouch is replaced.
period, the stoma will be edematous. After the first 48 to 72 hours, the edema should resolve and result in a reduction in size of the stoma; however, it should remain everted from the skin surface. Stomas generally continue to decrease in size over 6 to 8 weeks postoperatively. It is not uncommon for the stoma to become edematous when exposed to air while changing the pouch; this edema generally resolves quickly when the pouch is replaced.
 FIGURE 45.3 Premature infant with double-barrel colostomy. |
e. Stomal height: the degree of protrusion of stoma from the skin. Ideally, the surgeon will evert the stoma prior to suturing it to the skin to produce an elevation, which will promote a better seal with the ostomy wafer. With the stoma elevated above the surface of the skin, the effluent will be more likely to go into the pouch instead of staying in contact with the skin (2). Eversion of the stoma, referred to as maturing the stoma, is not always possible in neonates, in whom blood supply may be tenuous, and in situations in which the bowel is markedly edematous (1, 5).
2. Viability: a healthy stoma should be bright pink to beefy red and moist, indicating adequate perfusion and hydration (see Fig. 45.2). The stoma is formed from the intestine, which is very vascular and therefore may bleed slightly when touched or manipulated, but the bleeding usually resolves quickly. The stoma is not sensitive to touch because it does not have somatic afferent nerve endings (4).
a. A purple or dark brown to black stoma with loss of tissue turgor and dryness of the mucous membrane may indicate ischemia and possible stomal necrosis.
b. Distal aspect of stoma may be necrotic and later slough; the base is most indicative of a healthy stoma, and whether there is any output.
c. A pale pink stoma is indicative of anemia.
3. Stomal complications
a. Bleeding
(1) Hemorrhage during the immediate postoperative period is caused by inadequate hemostasis (4).
(2) Trauma to stoma caused by improper fitting pouch. A wafer cut too close to the stoma can injure the delicate tissue. Stomal lacerations can occur as a result of the edge of the wafer rubbing back and forth against the side of the stoma, especially as the infant’s activity increases (4).
b. Necrosis: caused by ischemia and may be superficial or deep. Necrosis extending below the facial level may lead to perforation and peritonitis, requiring additional surgical intervention (4).
c. Mucocutaneous separation: caused by a breakdown of the suture line securing the stoma to the surrounding skin, leaving an open wound next to the stoma.
d. Prolapse: telescoping of the bowel out through the stoma. In infants, this condition is frequently related to poorly developed fascial support or excessive intra-abdominal pressure caused by crying.
e. Retraction/recession: the stoma is flush or recessed below the skin surface. This condition may result from insufficient mobilization of the mesentery or excessive tension on the suture line at the fascial layer, excessive scar formation, or premature removal of a support device (4).
f. Stenosis: the lumen of the ostomy narrows at either the cutaneous level or the fascial level. Sudden decrease in output may indicate stenosis.
4. Peristomal skin: peristomal skin should be intact, nonerythematous, and free from rashes. However, frequently the stoma(s) is not separate from the surgical incision (Fig. 45.4). There is often not enough space on the infant’s abdomen for the surgeon to create separate
incisions. In addition, stomas are often in close proximity to the umbilicus, ribs, groin, and/or mucus fistula, which may interfere with pouch selection and adherence (6).
incisions. In addition, stomas are often in close proximity to the umbilicus, ribs, groin, and/or mucus fistula, which may interfere with pouch selection and adherence (6).
 FIGURE 45.4 End ileostomy and wound closure with retention sutures posing a challenge for placing a pouch. |
5. Peristomal complications
a. Dermatitis
(1) Allergic: product sensitivity.
(2) Contact: local irritation from the procedure of cleaning and application of ostomy products.
(3) Irritant: most common type of peristomal skin complication seen, generally are from the leakage of fecal effluent on the skin.
b. Infection
(1) Bacterial
(2) Candidal
(3) Fungal
(4) Viral
c. Mechanical trauma: epidermal stripping, abrasive cleansing techniques, and friction due to ill-fitting equipment are the most common causes of mechanical injury to the peristomal skin.
d. Hernia: peristomal hernia appears as a bulge around the stoma that occurs when loops of the bowel protrude through a facial defect around the stoma into the subcutaneous tissue (4).
D. Enterostomy Care
1. Immediate postoperative care
a. Assess stoma for adequate perfusion.
b. Until there is output from the stoma, it is not necessary to apply an ostomy pouch.
Keep stoma protected and moist with petrolatum gauze. When an enterostomy begins to produce, it is preferable to pouch. The pouch will protect the stoma, the peristomal skin, the suture line, and any central lines in that area. Pouching allows for qualifying and quantifying output. Before applying pouch, make sure to gently remove any residue of petrolatum gauze, which will interfere with the pouch adhesion.
c. Cover the mucus fistula with a moisture-retentive dressing to keep it from drying out. When securing a dressing on a neonate, use low-tack adhesives. There is increased risk of skin tears in neonates, especially when they are premature with delayed epidermal barrier development. Avoid placing petrolatum gauze over the pouching surface for the stoma, as it can impede adherence.
2. Subsequent care
a. Regular assessment of the stoma.
b. Protect peristomal skin from the effects of the effluent by pouching (Fig. 45.5). The effluent from a small-bowel stoma contains proteolytic enzymes that can rapidly cause skin erosion. Ideally, the pouch should remain in place for at least 24 hours. In some low-birth-weight neonates, the pouch may only last 12 hours. The average wear time is 1 to 3 days.
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