Chapter 39: Ostomy Care

I. INDICATIONS

A variety of surgical procedures may require an ostomy, a temporary or permanent artificial opening in the intestine (enterostomy) or urinary tract (urostomy). An ostomy is performed for gastrointestinal or urinary diversion. Ostomies in the neonatal intensive care unit are most commonly intestinal for the management of necrotizing enterocolitis (NEC), anorectal malformations, meconium ileus, Hirschsprung disease, volvulus, and intestinal atresias, and these disease entities are discussed elsewhere in this book. A gastrostomy (surgical opening in the stomach) may be necessary for feeding or decompression in a variety of conditions, such as the inability to swallow (neurologic or congenital anomalies), esophageal abnormalities, and prolonged poor oral feeding. Urinary diversions are sometimes performed. This chapter will only discuss ostomy care in gastrointestinal diversions since they are the more common in neonates.

II. OSTOMY CLASSIFICATION

1. Ileostomy. Stoma opening from the ileum used for NEC, intestinal malrotation or volvulus, and small bowel atresia or stenosis.

2. Colostomy. Stoma opening from the colon used for NEC, Hirschsprung disease, malrotation or volvulus, imperforate anus, and colonic atresia.

3. Mucous fistula. Distal nonfunctioning limb of intestine secured flush to skin with a mucocutaneous anastomosis.

4. Hartman pouch. Distal intestine is left in the abdominal cavity rather than removed or secured as mucous fistula, allowing reconnection to stoma at later date.

5. Double-barrel stoma. Loop of bowel is completely divided and 2 ends brought out as stomas to abdominal surface. Skin and fascia are closed between ends to provide separation of stomas.

6. End ostomy. Intestine is completely divided. The functioning proximal end is everted, elevated above skin, and secured circumferentially.

7. Loop ostomy. The intestine is incompletely divided with an opening at the antimesenteric side, while leaving the mesenteric side intact. This is used when temporary diversion or minimal surgical procedure is needed and not performed as often as end ostomy.

8. Gastrostomy. Surgical opening into the stomach, where a gastrostomy tube is inserted into the opening for nutritional support, medications, or gastrointestinal decompression. It can also be placed by interventional radiology in a less invasive way.

9. Urostomy. Opening made to divert urine from the urinary tract to the outside of the body through an intestinal stoma. Rare in the neonate.

10. Vesicostomy. Surgical opening from the bladder to the skin for urinary diversion. More common in neonate (posterior urethral valves, neurogenic bladder).

III. EQUIPMENT

1. Ostomy. Ostomy bag or pouch (1-piece or 2-piece system), skin barrier wafer, skin preparation agents, sterile water, gauze pads, petroleum gauze, and gloves. Products that improve security of pouch include plasticizing or liquid skin sealants (use on intact or damaged skin), skin barrier paste (protect exposed skin), adhesive agents (improve adherence), and skin barrier powder (dusted onto denuded skin to form protective crust).

2. Gastrostomy tube. 12- to 14-F balloon or mushroom gastrostomy tube. Silicone is preferred over latex skin barrier.

IV. PROCEDURES

1. Ileostomy and colostomy...