To Split or Not to Split: Colostomy Complications for Anorectal Malformations or Hirschsprung Disease: A Single Center Experience and a Systematic Review of the Literature

IntroductionThe aim of this article is to identify the ideal type and location of colostomy in children with colorectal disease. Patients and MethodsA retrospective case study of children with an anorectal malformation who received a colostomy, born between January 1990 and July 2012. Furthermore, a systematic literature search on colostomies in neonates with an anorectal malformation or Hirschsprung disease. Colostomies were classified as loop or split colostomies in the transverse or sigmoid colon. Outcome measures were mortality and complications such as prolapse, technical difficulties with the reconstruction, urinary tract infections, and others. ResultsThe mortality rate in the 180 children with anorectal malformation was 6%, and none of them were directly related to stoma formation or closure. The overall complication rate was 23% and the specific rates for the two types of procedures and the two locations of the colostomy did not differ (p=0.389 and p=0.667, respectively). All prolapses (n=22) occurred in loop colostomies in the transverse colon. One colostomy required revision because of insufficient length for the reconstruction. Urinary tract infections were not documented. A total of eight studies were included in the systematic review (1982-2011; 2,954 patients). Mortality ranged between 0.1 and 11%. Loop colostomies had more complications than split colostomies (63 vs. 45%; p=0.007), mainly prolapse (18 vs. 6%; p<0.001). Overall complication rate differed between transverse en sigmoid colostomies (62 vs. 51%, p=0.006), and prolapse occurred more often in the transverse colon (23 vs. 7%; p<0.001). Revision because of insufficient length during the reconstruction was needed in 0 to 6%. Two studies reported on urinary tract infections which are as follows: One showed no difference between loop or split colostomies, whereas the other showed frequent episodes of urinary tract infections in 64% of the loop colostomies. ConclusionsThe complication to be avoided in transverse colostomies is prolapse and the surgical technique should be modified accordingly. The procedure of split sigmoid colostomy is meticulous, and the risk of insufficient length for the reconstruction remains.