Colostomy for large bowel anomalies in children: a case controlled study

Abstract

Background: In children, colostomy may be required as a crucial part of treatment of some congenital anomalies of the large bowel. The procedure is associated with significant complications. This study reviews the morbidity and mortality of colostomy formation and closure for large bowel anomalies over a 10-year period in southeast Nigeria.

Methods: Evaluation of 182 colostomies and 146 colostomy closures performed in children at the University of Nigeria Teaching Hospital Enugu from January 1995 to December 2004.

Results: Hirschsprung's disease (106) and anorectal malformation (76) were the large bowel anomalies requiring colostomy. Of these, 133 (73.1%) were boys, while 49 (26.9%) were girls and their age ranged from 3 days to 15 years (mean 2.8 years). For anorectal malformation, the mean age at colostomy formation was 15.5 days (range 3-75 days), while in Hirschsprung's disease the mean age was 4.6 years (range 8 days-15 years). Ninety-two children (50.5%) had defunctioning colostomy and 90 (49.5%) had loop colostomy, with 177 (97.3%) of these sited in the transverse colon, while the remaining 5 (2.7%) were sited in the sigmoid colon. There were 123 complications that developed in 79 (43.4%) children. Skin excoriation (40 cases) and prolapse (37 cases) were the commonest complications. Other complications included wound infection (20 cases), superficial wound dehiscence (9 cases), stoma stenosis (5 cases), stoma retraction (5 cases), stoma bleeding (3 cases) and 2 cases each of stoma necrosis and burst abdomen. The complications were not dependent on the primary indication but prolapse occurred more frequently in children with Hirschsprung's disease who had colostomy after 5 years of age (P<0.001). Loop colostomy had higher complication rate than defunctioning colostomy (P<0.001). Colostomy revision was required in 15 patients. Death directly related to colostomy formation occurred in 3 (1.6%) patients from severe infection. Complications following colostomy closure (20 cases) occurred in 17 children and include wound infection (11 cases), stitch granuloma (5 cases), and 2 cases each of small bowel obstruction and incisional hernia. These were not related to the duration of the colostomy.

Conclusions: A significant number of colostomies for large bowel anomalies are constructed late in our setting. This is largely due to delayed presentation in Hirschsprung's disease and may be associated with increased morbidity. Loop colostomy is associated with higher rate of complication and as much as possible should be performed less often.