Fig. 42.1. 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. (Adapted 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: Mosby; 1998:1349, with permission.)

Table 42.1 Conditions Necessitating

Ostomy in the Neonate

Disease/Congenital Anomaly Most Common Location of Stoma

Intestinal atresia Duodenum, ileum, or jejunum

Meconium ileus Ileum

Necrotizing enterocolitis Ileum or jejunum

Hirschsprung disease Sigmoid colon

Imperforate anus/anorectal

malformations

Colon

Volvulus Ileum or jejunum

Bladder exstrophy Bladder

294 Section VII ■ Tube Replacement

(2) Contact dermatitis: Most common type of peristomal skin complication seen, generally from

the leakage of fecal effluent on the skin.

b. Infection

(1) Bacterial

(2) Candidal

c. Mechanical trauma: Epidermal stripping, abrasive

cleansing techniques, or friction due to ill-fitting

equipment are the most common causes of mechanical injury to the perist-omal skin.

d. Hernia: A 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. Ostomy 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. 42.5). 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-birthweight neonates, the pouch may

only last 12 hours. The average wear time is 1 to

3 days.

c. The pouch must be changed if there is any evidence

of leaking effluent under the skin barrier wafer.

Frequent pouch changes, however, can result in

denuded skin, especially in the premature infant

(2,4,7). In situations with frequent leaking and

pouch changes, expert help (certified wound ostomy

Fig. 42.3. Premature infant with double-barrel colostomy. continence nurse) may be required to preserve the

Fig. 42.2. Immediately postoperative loop ileostomy. Segment

of bowel on left is the exteriorized perforation from necrotizing

enterocolitis.

Fig. 42.4. End ileostomy and wound closure with retention

sutures posing a challenge for placing a pouch.