Split stoma and mucus fistula

• Bowel is divided and both ends brought out through abdominal wall separately
• Proximal end is the functioning stoma and distal end is the mucus fistula
• Operation note should make it clear where the stoma and mucus fistula are situated on the abdomen
• Stoma and mucus fistula may sometimes be fashioned side-by-side without a skin bridge. The wound is closed with dissolvable sutures

Fig.1: Split stoma and mucus fistula

End stoma without mucus fistula

• Proximal bowel end is brought out through abdominal wall as stoma and distal end is closed and left within the abdominal cavity

Fig. 2: End stoma without mucus fistula

Loop stoma

• Formed by suturing a loop of bowel to the abdominal wall and making an opening into bowel, which remains in continuity

Fig 3: Loop stoma (slightly prolapsed)

Application of stoma bag

• Before stoma starts working, fit an appropriately sized stoma bag and empty 4–6 hrly
• In a split stoma and mucus fistula, fit the stoma bag on the proximal stoma only, where possible, and leave mucus fistula exposed and dressed with a paraffin gauze dressing (e.g. Jelonet) or Vaseline® and non-sterile gauze dressing 
• Change bag every 1–3 days (maximum) or if it leaks
• Remove using a stoma adhesive remover wipe
• Clean skin around stoma with warm tap water and dry with non-sterile gauze

Monitoring

• Examine baby’s abdomen and stoma daily 
• Look for:
  • dehydration
  • abdominal distension
  • wound infection or breakdown
  • peri-stomal skin excoriation
  • granulation tissue formation 
  • stomal bleeding
  • discolouration of stoma or mucus fistula
  • stomal prolapse or retraction
  • stoma bag leakage 
  • rectal discharge
• If stoma becomes dusky or black, call the surgical team
• If skin surrounding the stoma is excoriated, identify cause and treat

Weight

• Babies with small bowel stoma: measure and record weight daily. Inadequate weight gain or weight loss may be secondary to:
  • insufficient calorie intake
  • malabsorption 
  • dehydration (high stoma output)
  • electrolyte abnormalities (high stoma output)

Stoma effluent

• Maintain a regularly updated fluid balance chart and record:
  • fluid intake and stoma losses 
  • colour and consistency of stoma effluent

Serum electrolytes

• Measure at least every 2 days in the first 7 post-operative days

Urinary electrolytes (sodium and potassium)

• Monitoring is extremely important for nutrition and growth
• Measure weekly
• Babies with stomata (especially small bowel stomata) are at risk of losing a significant amount of sodium into the effluent. They will often fail to gain weight if total body sodium is depleted. Serum sodium is an unreliable indicator of total body sodium
• Urinary sodium and Na⁺:K⁺ ratio are better indicators
• Sodium supplements usually required in babies with a small bowel stoma until the stoma closed
• If urinary sodium is <20 mmol/L or ratio of concentration of urinary sodium to potassium is <3:1, increase sodium intake 

Total parenteral nutrition and no enteral feeds

• Check surgical discharge letter and operation notes for instructions on starting enteral feeds
• Introduce enteral feeds slowly and increase gradually (see Nutrition and enteral feeding guideline) 
• Useful indicators of potential feed intolerance are:
  • vomiting and abdominal distension
  • bile in nasogastric aspirates
  • large nasogastric losses
  • low stoma losses – indicating dysmotility/obstruction
  • high stoma losses – indicating malabsorption
  • reducing substances or fat globules in the stool/stoma effluent

Combination of parenteral nutrition and enteral feeds

• Increase enteral feeds gradually (see Nutrition and enteral feeding guideline) 
• It is not possible to predict how much enteral feed baby will be able to tolerate. As a general rule, the more distal the stoma, the better the absorption of feeds
• The amount of stoma effluent and presence/absence of reducing substances or fat in the stoma effluent should guide the advancement of enteral feeds
• Do not automatically increase enteral feed in response to weight gain, but rather in response to stoma output volume

Full enteral feeds

• Tolerance of enteral feeds can fluctuate with time and babies with stomata are at high risk of life-threatening dehydration and electrolyte abnormalities as a result of gastroenteritis. There should be a low threshold for readmission to hospital and appropriate resuscitation

High stoma output

• Daily output >20 mL/kg/day in premature or low-birth-weight babies and 30 mL/kg/day in term babies
  Measure serum and urinary electrolytes
• Replace stoma losses (when >20 mL/kg/day) mL-for-mL using sodium chloride 0.9% with potassium chloride 10 mmol in 500 mL IV
• Consider either reducing or stopping enteral feeds until losses decrease, liaison with surgical team is encouraged
• Test stoma effluent for reducing substances and fat globules
• If reducing substances are positive or fat globules present, consider reduction of enteral feed or changing type of enteral feed after consultation with a surgeon, specialist surgical outreach nurse or dietitian
• Perform blood gas; (stoma effluent may be rich in bicarbonate and metabolic acidosis may be present; consider sodium bicarbonate supplementation)

Mucus fistula

• If present, consider recycling of stoma effluent (see Recycling stoma losses via a mucus fistula guideline). Before recycling, consult surgical team to decide whether a contrast study through the mucus fistula is required 
• If contrast study advised, make arrangements with surgical unit and inform surgical team when the study will take place
• Surgical team will review and advise if recycling may start
• If baby not thriving, consider parenteral nutrition (see Parenteral nutrition guideline)

• If none of the above measures are effective, stop enteral feeds, start parenteral nutrition and consult surgical team to discuss surgical options

Stomal stenosis

• May be present if:
  • stomal output reduces or stoma stops functioning
  • stoma effluent becomes watery
• Call surgical team for advice

Prolapse

• Call surgical team for advice. If stoma is discoloured, emergency action required

• Often aimed to be performed when baby is well and thriving, which may be after discharge from hospital
• Indications for early closure are:
  • failure to achieve full enteral feeds
  • recurrent stomal prolapse with/without stomal discolouration
  • stomal stenosis
  • high stoma output not responding to measures outlined above

• Discharge when baby well, tolerating feeds and thriving
• It is the responsibility of the ward/unit nurse to teach parents stoma care
• When discharge planned, inform: 
  • secretary of surgical consultant who fashioned the stoma to arrange outpatient follow-up
  • local stoma care specialist to order stoma supplies for home and support family
  • neonatal surgical outreach service (if involved in care)

Who to call when you need help?

Surgical team

• Call team of consultant surgeon who performed the surgery 
• In an emergency out-of-hours, contact on-call surgical registrar 
• Stoma care specialist [e.g. Gail Fitzpatrick at BCH (mobile 07557 001653)] for management of stoma-related complications, and parent and staff training
• Neonatal surgical outreach service [e.g. Louise Lawrence (mobile 07769 367483)] for advice, support and training on surgical management

• https://bwc.nhs.uk/neonatal-surgical-outreach-service
• http://www.e-lfh.org.uk/programmes/paediatric-surgery/