In the five-year period, a total of 1,041 pediatric patients were initially included in the study. Out of these patients with stoma, 102 cases had major stoma complications classified as Clavien-Dindo III-V, accounting for a 9.8% prevalence rate of major complications. In this cohort, there were 14 reported deaths directly caused by the stoma complications, accounting for 1.3% of total number of pediatric patients with stoma seen in UP-PGH for 5 years. This represents 13.7% of those who developed major stoma complications.
Most of the patients had their stoma created during the newborn period (neonates age 0–28 days) accounting for 48% of all patients with stoma. This correlates with the top two most common diagnosis that required the stoma creation: anorectal malformation (49.4%) and Hirschsprung’s disease (30.4%). Both conditions are congenital and are diagnosed primarily at the neonatal period. The male-to-female ratio in the cohort with major complications is 1.9: 1. Unfortunately, prematurity, weight, height, and body mass index data were inconsistent and lacking in the medical records, thus was no longer included in the analysis.
Similar frequencies and ratios on age, sex, and primary diagnosis were seen in the cohort with major stoma complications. Neonates who developed stoma complication accounted for 47% of the cohort. The male: female ratio was also the same. And the most common diagnoses were also the same.
Among all the patients with stoma, 42.6% (391/1041) had a double-barrel transverse colostomy which is also the most frequent type of stoma in patients with major complications (34/102). However, looking at the incidence of major complications per type of stoma, those patients with ileostomy had the highest percentage of complications at 12.3% (29/236) which showed significant statistical correlation. However, statistical analysis showed no significant association between the type of stoma (loop vs double-barrel).
Surgeon expertise (surgery trainee vs consultant) and specialty (pediatric surgeon vs general surgeon) at the time of stoma creation also showed no significant association to the development of major stoma complications. Similarly, whether the stoma was created at an elective setting or as an emergency procedure also did not show significant statistical association. Table 1 below shows the demographic and clinicopathologic profiles, patient-related factors, and surgery-related parameters and the presence of major stoma complications. Table 2 then shows the statistical analysis among the different risk factors and development of complication.
Table 1
Demographic Profiles, Patient-related and Surgery-related Factors
| Full cohort | With Major Stoma-related Complication |
| n = 1041 | n = 102 |
| Frequency | Percentage | Frequency | Percentage |
General data | | | | |
Age [n = 920] | | | | |
Neonate (0-30days) | 446 | 48.48% | 44 | 47.31% |
Infant (1mo-1 year) | 197 | 21.41% | 18 | 19.35% |
Toddler (1-2yrs) | 119 | 12.93% | 11 | 11.83% |
Pre-schooler (3–5 yrs) | 55 | 5.98% | 8 | 8.60% |
School-aged (6–12 yrs) | 50 | 5.43% | 6 | 6.45% |
Adolescent (13-18yrs) | 53 | 5.76% | 6 | 6.45% |
Sex [n = 1030] | | | | |
Male | 684 | 66.41% | 67 | 65.69% |
Female | 346 | 33.59% | 35 | 34.31% |
Indication for stoma creation [n = 1023] | | | | |
Anorectal malformation | 506 | 49.46% | 46 | 45.54% |
Hirschsprung Disease | 311 | 30.40% | 32 | 31.68% |
Necrotizing enterocolitis | 16 | 1.56% | 2 | 1.98% |
Intestinal atresia | 17 | 1.66% | 1 | 0.99% |
Intussusception | 47 | 4.59% | 7 | 6.93% |
Others | 126 | 12.32% | 13 | 12.87% |
Type and location of stoma [n = 917] | | | | |
Transverse loop | 123 | 13.41% | 10 | 11.36% |
Sigmoid loop | 31 | 3.38% | 1 | 1.14% |
Transverse DB | 391 | 42.64% | 34 | 38.64% |
Sigmoid DB | 115 | 12.54% | 9 | 10.23% |
Ileostomy | 236 | 25.74% | 29 | 32.95% |
Others | 21 | 2.29% | 5 | 5.68% |
Surgeon performing the stoma [n = 989] | | | | |
GS trainee | 3 | 0.30% | 0 | 0 |
General Surgeon | 112 | 11.32% | 16 | 16.16% |
Pediatric surgery trainee | 770 | 77.86% | 68 | 68.69% |
Pediatric Surgeon | 104 | 10.52% | 15 | 15.15% |
Presence of major complication [n = 1038] | | | | |
None/ I-II | 936 | 90.17% | | |
Class III | 75 | 7.23% | | |
Class IV | 13 | 1.25% | | |
Class V | 14 | 1.35% | | |
Table 2
Factors associated with major stoma-related complications of pediatric patients with intestinal stomas
Patient and Surgery-related Factors | Presence of complications | Absence of complications | p-value |
n = 102 | n = 936 | |
Frequency | Percentage | Frequency | Percentage | |
Indication for stoma creation [n = 1021] | | | | | 0.827 |
Anorectal malformation | 46 | 45.54% | 458 | 49.78% | |
Hirschsprung Disease | 32 | 31.68% | 279 | 30.33% | |
Necrotizing enterocolitis | 2 | 1.98% | 14 | 1.52% | |
Intestinal atresia | 1 | 0.99% | 16 | 1.74% | |
Intussusception | 7 | 6.93% | 40 | 4.35% | |
Others | 13 | 12.87% | 113 | 12.28% | |
Type of stoma [n = 917] | | | | | 0.020 |
Colostomy | 54 | 61.36% | 606 | 73.10% | |
Ileostomy | 34 | 38.64% | 223 | 26.90% | |
Type of colostomy [n = 660] | | | | | 0.591 |
Loop | 11 | 20.37% | 143 | 23.60% | |
Double barrel | 43 | 79.63% | 463 | 76.40% | |
Surgeon performing the stoma [n = 989] | | | | | 0.110 |
GS trainee | 0 | 0.00% | 3 | 0.34% | |
General Surgeon | 16 | 16.16% | 96 | 10.79% | |
Pediatric surgery trainee | 68 | 68.69% | 702 | 78.88% | |
Pediatric Surgeon | 15 | 15.15% | 89 | 10.00% | |
Urgency [n = 1018] | | | | | |
Emergency | 92 | 90.20% | 777 | 84.83% | |
Elective | 10 | 9.80% | 139 | 15.17% | |
The most common major complication encountered in this cohort was stomal prolapse and post-operative adhesions or obstruction, both accounting for 39.2% of all major complications. Table 3 summarizes the types and frequencies of major stoma complications encountered in the cohort.
Table 3
Type and Frequency of Major Stoma Complication
Frequency of specific type of major complications | n: 102 |
Stomal prolapse | 20 |
Postoperative adhesions/obstruction | 20 |
Intussusception | 10 |
High output stoma | 10 |
Dehiscence | 9 |
Stomal necrosis | 8 |
Wrong locations | 5 |
Leak | 4 |
Stomal retraction | 3 |
Fecaloma | 3 |
Iatrogenic perforation | 2 |
Incisional hernia | 2 |
Others | 6 |
The most common surgical intervention for the major complications was a stoma revision which was done in 36.2%. Other surgical procedures reported are a bowel diversion in 15.9%, closure of the intestinal stoma in 7.2%. Table 4 shows the different surgical interventions done to manage the stoma complications.
Table 4
Type and Frequency of Surgical Intervention
Frequency of surgical intervention done to manage complications | n: 69 |
Revision of stoma | 25 |
Diversion | 11 |
Re-siting | 6 |
Adhesiolysis | 4 |
Reduction, closure of colostomy | 4 |
Fecal disimpaction | 3 |
Reduction alone | 3 |
Repair of dehiscence | 3 |
Drainage | 2 |
Repair of hernia | 2 |
Adhesiolysis, closure of colostomy | 1 |
Adhesiolysis, evacuagion of abscess | 1 |
Reduction, stomal biopsy | 1 |
Repair of hernia, closure of colostomy | 1 |
Resection - anastomosis | 1 |
Resection of prolapse + definitive surgery | 1 |
As for the median time from stoma creation to the presentation of major stoma complication due to its creation was 433.5 days or 14 months with a wide range of 1 day to 18 years. However, looking at the histogram showing distribution of the frequencies of the stoma complication across yearly-time intervals from stoma creation, almost half of the complications have occurred within the first year of stoma creation.