Colostomy is still an important step in the treatment process of congenital abnormalities of the gastrointestinal tract in the newborn and infants as well as in acquired disorders^1,2. The rate of colostomy complications occuring during the treatment of anorectal malformations (ARM), Hirschsprung's disease (HD) and trauma cases may be high despite the surgical advances^3-5.

In this study, the complications and mortality were investigated in patients who had colostomies due to congenital or acquired disorders.

The approval was obtained from Firat University Ethics Committee. Ninety six patients who underwent colostomy procedure due to ARM, HD, trauma and miscellaneous diagnoses (ICD codes Q42.3, Q43.1, T79.8, K56.2, P77, K63.1) between 1996 and 2012 were analyzed retrospectively. The patients were analyzed for their ages, gender, colostomy indications, colostomy types, complications and mortality. The data were analyzed using SPSS program and Chi square test.

A total of 96 patients had colostomies, 57 of them were male and 39 female. The ages of the patients ranged from 1 day to 13 years (mean age 1.1 years); 52 of them were younger than 1 month of age, 24 were representing the group of the age period from 1 month to 1 year and 20 patients were older than 1 year of age (Table 1). The colostomy indications were ARM in 57, HD in 26, trauma in 9, and midgut volvulus by 4 patients (Table 2). The location and the type of colostomy were determined by considering the primer pathology. The colostomy was separated or modified separated in 53, loop in 27, and Hartmann colostomy in 16 patients. The colostomy localisations varied as follows: 61 of them were located in the sigmoid colon 29 in the transverse colon and 6 patients had the colostomy in the cecum. There were 36 postoperative complications in 34 (35%) cases. Peristomal dermatitis was seen in 19 (53 %), stomal bleeding in 4 (11%), prolapse in 4 (11%), stomal ischemia in 4 (11%), evisceration in 3 (8%) and stomal stenosis or obstruction in 2 (5.5%) patients. Complications occured in 14 of the patients with ARM (27%), 13 patients with HD (57%) and 7 (32%) patients with miscellaneous diagnoses. Location related analysis of the colostomy complications revealed that the highest complication rate was seen in the transverse colon (Table 3). However, the difference among the sites was not statistically significant for the complication rates (p>0.05). A revision was needed in 7 patients. Among those patients, the colostomy site was sigmoid colon in 4 and transverse colon in 3 patients, and the type of colostomy was separated colostomy in 4 and loop colostomy in 3 patients. Four of the patients who underwent revision had ARM, were younger than 1 month of age, had transverse colostomies and were of male gender.

Table 1: Age and sex distribution of complications

Table 2: Primary disease distribution of complications in colostomy

Table 3: Location and type of colostomy distribution of complications

Death occurred in 10 of the colostomised patients, but the primary cause of death was not related with colostomy in any of them. All deaths were in the neonatal period, and the most frequent cause was major congenital abnormality. Most of these patients had ARM, were younger than 1 month of age, had sigmoid colostomies and were males.

Colostomy procedure is very commonly needed in the neonatal period. Congenital abnormalities were the most frequent reasons for the need of a colostomy in this age group. Although ARM and HD have been treated without colostomy in the recent years, and we also perform this approach in our clinic, the number of patients needing colostomy is quite high^6,7. The literature indicates that colostomies are most frequently performed in the neonatal period and in the cases with ARM^4,8.

The rate of colostomy complications were reported between 30-74% in the literatüre^3,5,8-10. This rate was 36% in our study. The complications most frequently occurred in patients with ARM and HD. This may be related to similar diagnoses in patients who had colostomies. Cigdem et al have shown that the site of colostomy is not correlated with the development of complications⁴. In our study, the site of colostomy was not considered as statistically significant to be correlated with the complications, in accordance with the literature (p>0.05).

The most frequently encountered complication reported in the literature is peristomal dermatitis which was seen in 30.5% of all complications⁵. In our study, peristomal dermatitis comprised 53% of all complications. We suppose that peristomal dermatitis develops due to inadequate colostomy care and irritation of the insufficiently absorbed bile salts. Peristomal dermatitis does not have an effect on mortality, but it has a negative effect on the quality of life.

The primary disease is important for determining the site and the type of the colostomy. In our study, sigmoid separated colostomy was observed as the most frequent site and type of colostomy. However, loop colostomy was reported as the most frequent colostomy type in the past wheras the sigmoid and transverse colons revealed as the most frequent colostomy sites^1,8.

Mucosal bleeding was reported in 0-10.3% of the patients in the literatüre^5,8. It was the second most frequent complication detected in our study with a rate of 11%. All patients who had mucosal bleeding were under the 1 year of age. This may be related to non-use of the colostomy bags in this age group.

Prolapse is a complication that occurs after colostomy, and sometimes needs a revision. It's rate was 11% in our study. This complication can usually be treated conservatively, but sometimes surgery could be required. Prolapse rate was reported as high as 23.3% in the literatüre⁵, however this rate was relatively low in or study. Three of these 4 cases needed a revision. In cases with the prolapse of distal stoma opening, a purse string suture was used at the level of the fascia^8-11.

The literature indicates stomal stenosis rates between 0.7 and 6.3%^8-10. In our study, the rate of stomal stenosis was found as 5.5%, in accordance with the literature. We have the opinion that stomal stenosis or obstruction could be related to the surgical technique. All stenosis cases were operated in the education period of the surgeons.

The revision rate reported in the literature is as high as 16.7%⁸. Our revision rate was 7%. Revisions were due to prolapse in 3, obstruction in 2, and ischemia in 2 patients. Four patients who had revisions had ARM, were younger than 1 year of age, had transverse colostomies and were males. These variables represent the most frequently seen pathology, age and gender in our patient group, and we consider that these findings occur due to the frequency of these variables. Our revision rate was found to be in accordance with the literature.

The mortality rate has been reported between 2,7- 9.5 % in the literatüre^4,5,8,9,12. In this study, death occurred in 10% of the patients. Colostomy was not the primary reason of death in any of these patients. All patients were in the neonatal period and 8 of them were patients who underwent colostomy procedure due to ARM. Mortalities were related to additional congenital abnormalities, notably to cardiovascular ones.

Congenital abnormalities are the most common disorders necessitating colostomies in children, and additional abnormalities are the most important factors determining mortality. The primary pathology is the most important factor in the development of the colostomy complications. Dermatitis, one of the most frequently seen complications, was found in girls with ARM who were older than one month of age and had transverse separated colostomy. Although colostomies' have high complication rate, the number of patient who need revision is low.