Journal of Pediatric Surgery 51 (2016) 107110

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

The morbidity of a divided stoma compared to a loop colostomy in

patients with anorectal malformation
Shawn T. Liechty, Douglas C. Barnhart, Jordan T. Huber, Sarah Zobell, Michael D. Rollins
Primary Children's Hospital, University of Utah, Salt Lake City, UT

a r t i c l e

i n f o

Article history:
Received 29 September 2015
Accepted 7 October 2015
Key words:
Loop colostomy
Mucous stula
Divided colostomy
Anorectal malformation
Imperforate anus
Colostomy complications
Infection

a b s t r a c t
Purpose: Loop colostomies may contaminate the genitourinary (GU) tract in patients with anorectal
malformations (ARM) owing to incomplete diversion of stool. Stoma complications are also thought to be higher
with a loop versus divided colostomy. We sought to compare the morbidity, including urinary tract infections
(UTI), in these two types of colostomies in children with ARM.
Methods: A review was performed at a children's hospital (19892014). Children with ARM who had a colostomy
performed were identied. Demographic data and outcome variables were collected. Analyses included Student's
t-test, Fischer's exact and logistic regression as appropriate.
Results: 171 patients were identied (loop = 78; divided = 93). Thirty percent of patients with a divided colostomy
and 24% with a loop experienced a stoma complication (p = 0.5). A subgroup analysis of children with a
rectourinary stula (54 divided, 26 loop) was performed to assess for effect of colostomy type on UTI.
After controlling for other UTI risk factors (major GU anomalies, vesicostomy, and prophylactic antibiotics),
loop ostomies were not associated with risk of UTI (OR 0.83, 95% CI 0.272.63). No patient with a loop colostomy
developed megarectum.
Conclusions: Children with ARM who undergo a loop colostomy are not at a detectable increased risk of
experiencing a UTI compared to a divided stoma. The rate of stoma complication is high regardless of the type
of stoma created.
2016 Elsevier Inc. All rights reserved.

Children born with an anorectal malformation (ARM) and no stulous opening on the perineum will generally have a colostomy created
initially and the denitive repair performed at a later time. Creation of
a loop colostomy versus a divided colostomy and mucous stula has
been debated owing to the theoretical risk of contaminating the urinary
tract with a loop stoma [1]. Also, loop colostomy may be more prone to
complications such as prolapse [2,3]. Our practice varies in the type of colostomy created in these newborns. We sought to review our experience
and examine complications associated with each type of colostomy in
this population. Specically, we sought to test the commonly held view
that loop colostomies are associated with an increased risk of urinary
tract infection in children with a rectourinary stula.
1. Methods
Following IRB approval, a retrospective review was performed at our
tertiary care children's hospital (January 1989 to August 2014) of children
born with an ARM who underwent colostomy creation. Patients were
Evidence: Level II.
Corresponding author at: Primary Children's Hospital, University of Utah, Division of
Pediatric Surgery, 100 N. Mario Capecchi, Suite 3600, Salt Lake City, UT 84113-1103.
Tel.: +1 801 662 2950; fax: +1 801 662 2980.
E-mail address: michael.rollins@imail2.org (M.D. Rollins).
http://dx.doi.org/10.1016/j.jpedsurg.2015.10.025
0022-3468/ 2016 Elsevier Inc. All rights reserved.

identied using our Pediatric Colorectal Center database. Patient demographics, associated anomalies, incidence of wound infection, urinary
tract infection (UTI) and stoma complications were collected by
reviewing our electronic medical record. Children with a stulous connection to the genitourinary (GU) tract underwent subgroup analysis.
Children with ARM were excluded from this study if they did not undergo
colostomy creation or if the medical record was incomplete.
All patients were managed by a group of seven surgeons at our
children's hospital. The decision to create a divided or loop colostomy
was at the discretion of the treating surgeon. In the majority of cases,
the divided colostomy was performed in a standard fashion by placing
the proximal sigmoid colon in the lateral aspect of the left lower quadrant
incision and the mucous stula in the medial aspect of the incision. A
small skin bridge was created in between the two stomas. Loop colostomies were created predominantly at the level of the proximal sigmoid
colon. Denitive reconstructions were performed at a later date followed
by colostomy closure.
Wound infection was dened as cellulitis treated with antibiotics or a
supercial surgical site infection requiring opening of the incision or
stoma revision. Patients were considered to have a UTI if they experienced
a febrile illness with positive urine culture and initiation of antibiotics or a
change in the antibiotic regimen if already on prophylactic antibiotics.
Patients with renal dysplasia, vesicoureteral reux or neurogenic bladder
were considered to be at an increased risk of UTI at baseline and were

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S.T. Liechty et al. / Journal of Pediatric Surgery 51 (2016) 107110

Table 1
Type of anorectal malformation and colostomy.

Table 3
Baseline characteristics of subset with rectourinary stula.

Malformation

Loop

Divided

Total

Rectal atresia/stenosis
Rectoperineal
Rectovestibular/vaginal
Cloaca
Rectobulbar/prostatic
Rectobladder neck
Imperforate anus without stula
Unknown
Total

5
3
27
4
14
8
6
11
78

7
8
10
17
27
8
9
7
93

12
11
37
21
41
16
15
18
171

categorized as having an UTI predisposing GU anomaly. Patients were

considered to have developed a megarectum if signicant rectal dilation
was identied on the preoperative distal colostogram or if tapering of
the rectum was required at the time of the anorectoplasty.
The primary outcome was the prevalence of urinary tract infection
with additional outcomes including any stoma complication and
wound infection. Statistical analysis was performed with SAS 9.2 software (SAS Institute, Cary, NC). Univariate analysis was performed
using Student's t-test for continuous variables. Categorical variables
were compared using Fischer's exact test. Multivariable modeling was
performed using logistic regression.
2. Results
One hundred seventy-eight patients were identied. Seven patients
were excluded owing to incomplete records. The mortality rate was 9%
(12/16 with congenital heart disease). Seventy-eight of the 171 patients
had a loop colostomy (46%). The types of ARM in our cohort are shown
in Table 1. Baseline characteristics including gender, gestational age,
birth weight, presence of a genitourinary anomaly associated with UTI,
presence of a vesicostomy, and stoma duration were similar between
the two groups (Table 2). Patients were more likely to be given a divided
colostomy if a rectourinary stula was present (p = 0.0047). The
majority of patients had the colostomy performed at the level of the
proximal sigmoid colon (94%; loop = 75, divided = 89).
A subgroup analysis of 80 children with a rectourinary stula (54
divided, 26 loop) was performed to assess for effect of colostomy type
on UTI risk. The two groups were not different in terms gestational
age, birth weight, GU anomalies, vesicostomy, prophylactic antibiotics,
or stoma duration (Table 3). The prevalence of at least one episode of
UTI was 44% in the divided colostomy group and 39% in the loop colostomy group. This difference was not signicant (p = 0.64). Univariate
analyses (Fischer's exact test) showed genitourinary anomalies,
vesicostomy and prophylactic antibiotics to be associated with signicant increased risks of at least one episode of UTI. Patients with renal
dysplasia, vesicoureteral reux, or neurogenic bladder were at 3.1 fold
increased risk of developing a UTI (p = 0.001). Vesicostomy was
associated with a 2.1 fold increased risk (p = 0.01) and prophylactic
antibiotics risk was 2.0 fold (p = 0.014). The results of a logistic regression model including these risk factors and stoma type are shown in
Table 4. On logistic regression, when controlling for urinary anomalies
Table 2
Baseline characteristics.
Loop (78)
Gestational age median
(min-max)
Birth weight median
(min-max)
Rectourinary stula
GU anomaly associated with UTI
Vesicostomy
Stoma duration (median weeks)

Divided (93)

Loop (26)
Gestational age (Median)
Birth weight median
(min-max)
GU anomaly associated with UTI
Vesicostomy
Prophylactic antibiotics
Stoma duration (median weeks)

Divided (54)

P-value

39.0 weeks (2741) 37.5 weeks (3041) 0.44

2920 g (9703345) 2853 g (9603843) 0.32
15 (60%)
2 (7.7%)
8 (31%)
48

33 (67%)
11 (20%)
17 (31%)
48.3

0.61
0.20
1.0
0.24

that predispose to UTI, stoma type, vesicostomy, or the use of prophylactic antibiotics was not associated with increased or decreased risk
of UTI. In this multivariable model GU anomalies continued to be signicantly associated with UTI.
Thirty percent of patients with a divided colostomy and 24% with a
loop colostomy (Table 5) experienced a stoma complication (p = 0.5).
Seventeen percent in the divided stoma group and 14% of those with a
loop colostomy required stoma revision (p = 0.7). Patients with a
vesicostomy were at an increased risk of experiencing a stoma complication which required colostomy revision (RR = 3.19, p = 0.0071). No
patient with a loop colostomy developed megarectum.
3. Discussion
Creation of a colostomy is often the initial surgical management of
newborns with anorectal malformations. A divided stoma created at
the junction of the descending and sigmoid colon has been recommended [4]. The proximal stoma is created using the rst mobile part
of the colon immediately distal to the descending colon where there is
a normal retroperitoneal attachment. The stomas are then placed
within the incision and separated enough to allow the stoma bag to
cover only the proximal stoma thereby isolating the mucous stula.
Potential advantages of this technique compared to a loop colostomy
include a smaller and more manageable stoma, decreased incidence of
stoma prolapse, elimination of risk for fecal impaction in the distal
loop and preservation of sufcient length of colon distal to stoma for
tension free pullthrough [1,5,6]. Furthermore, it is believed that creating
a loop colostomy in these children increases the risk of UTI from fecal
contamination through the rectourinary stula [1].
In this study, we were unable to detect a signicant difference in
stoma complications or the need for stoma revision between the loop
colostomy and divided stoma groups. This is similar to the ndings
of Patwardhan et al. [4] but contrary to others who have reported an
overall incidence of any stoma complication as 31%63% with loop
colostomy versus 15%45% with divided stomas [2,3]. Our incidence of
stoma prolapse (loop 8% vs. divided 10%) was slightly lower than
other reports of 15%18% with loop colostomies and similar to the
3%6% reported for divided stomas [14]. This is likely owing to the
fact that we created the majority of our stomas at the rst mobile part
of the sigmoid colon, immediately distal to the descending colon, regardless of whether or not we separated the bowel. The reason for the
association between vesicostomy and need for colostomy revision is
unclear, but is likely related to the limited space on the abdominal
wall in these young children.
It is not surprising that we were more likely to create a divided
stoma in malformations with a rectourinary stula given the often

P-value

38.0 weeks (2741) 38.0 weeks (2941) 0.7

2719 g (9703345)

2835 g (7853945)

0.12

26 (40%)
15 (60%)
4 (5%)
47.7

54 (64%)
33 (67%)
13 (14%)
43

0.005
0.61
0.07
0.77

Table 4
Results of logistic regression for risk of UTI (includes only children with rectourinary stula).
Risk factor

Odds ratio (95% CI)

P-value

Divided ostomy
Urinary anomaly
Prophylactic antibiotics
Vesicostomy

1.2 (0.383.7)
5.5 (1.717)
2.7 (0.799.4)
2.3 (0.4711)

0.78
0.005
0.11
0.30

S.T. Liechty et al. / Journal of Pediatric Surgery 51 (2016) 107110

Table 5
Stoma complications.

Parastomal hernia
Stoma necrosis
Stoma prolapse
Stoma retraction
Peristomal skin breakdown
Stoma stricture
Wound cellulitis
Other
Stoma revision
Total complications

Loop (n = 78)

Divided (n = 93)

P-value

0 (0%)
0 (0%)
6 (7.7%)
6 (7.7%)
2 (2.3%)
0 (0%)
2 (2.6%)
3 (3.8%)
11 (14.1%)
19 (24%)

2 (2.2%)
2 (2.2%)
9 (9.7%)
2 (2.2%)
4 (4.3%)
1 (1.1%)
3 (3.2%)
5 (5.4%)
16 (17.2%)
28 (30%)

0.50
0.50
0.78
0.14
0.69
1.00
1.00
0.73
0.68
0.48

reported concern for potential contamination of the urinary tract. A previous report found that ARM patients with loop colostomies had an
approximately four fold increase in UTIs (64% vs. 15%) compared to
divided stomas [1]. However, no signicant difference was detected in
the incidence of UTI regardless of stoma type in our subgroup of patients
with a rectourinary stula which supports the ndings of others [2,4].
Our study is unique in that we performed a subgroup analysis of
patients with a rectourinary stula and controlled for other risk factors
for UTI whereas the previous reports included all ARM patients
including those without a rectourinary stula.
It has been noted that the presence of an associated urinary tract
anomaly signicantly impacts the risk of UTI in patients with ARM
[2,4,7]. Similarly, we found that patients with renal dysplasia,
vesicoureteral reux, or neurogenic bladder were at a 3 fold increased
risk of developing a UTI regardless of stoma type.
Finally, we hypothesized that the risk of wound infection would be
increased in patients with a divided stoma placed on either end of the
incision. Our overall incidence of wound infection or peristomal skin
breakdown was very small but there does not appear to be a signicant
difference. Pena et al. experienced no wound infections in 50 divided
stomas [1] and Patwardhan et al. reported only 1 patient (10%) with a
divided stoma who suffered a skin dehiscence [4].
The limitations of this study are those inherent to any retrospective
review with limited numbers of patients. Despite the fact that this is the
largest single center series, and the only study that analyzed a subgroup
of patients with UTI risk factors, there is a possibility that a larger sample
size may detect a difference in UTI between the stoma groups. It is also
possible that we failed to identify minor infectious or stoma complications. This possibility is mitigated for major complications by the fact
that we are the only children's hospital within a ve state referral region
and the largest healthcare provider that uses a centralized electronic
medical record. It would therefore be very unlikely that a complication
that required reoperation would not be captured.
4. Conclusions
Children born with ARM who undergo loop colostomy are not at a
demonstrable increased risk of developing UTI compared to a divided
colostomy. The largest risk factor for developing a UTI is the presence
of GU anomaly. Stoma complication rates are high in children with
ARM in both loop colostomy and divided stoma groups and a signicant
number of patients will require stoma revision. Placing the colostomy at
a location with minimal mobility, thoroughly irrigating the distal limb
and leaving sufcient length of colon distal to the colostomy for the subsequent repair are key principles to follow regardless of the type of
stoma created.
Author contribution
Shawn T. Liechty: study design, data collection, manuscript creation.
Douglas C. Barnhart: study design, data analysis, manuscript revision.

109

Jordan T. Huber: data collection, manuscript revision.

Sarah Zobell: data collection, manuscript revision.
Michael D. Rollins: study design, data analysis, manuscript revision.
Appendix A. Discussions
Presented by Shawn Liechty, Salt Lake City, UT
SHAHAB ABDESSALAM (Omaha, NE): Why were so many stomas
created if there weren't stulas?
SHAWN LIECHTY: For the children with anorectal malformations who
did not have stulous connection, they still underwent the
pull-through procedure later in their lives and the rectum
had to be diverted at birth so those children still underwent
stoma creation.
SHAHAB ABDESSALAM: But generally if they don't have a stula to the
urinary system they have it to the perineum or somewhere
where you can dilate up the track and to a primary repair
electively, so why were so many diverted with an ostomy?
SHAWN LIECHTY: In the cases without a stula?
SHAHAB ABDESSALAM: Yeah.
SHAWN LIECHTY: Because of the current common practice to divide
the stoma in these patients and the past conversation
between using the loop or divided. This data also started
in 1989 and continued to 2014, so there may have been a
difference in the divided and ostomies created earlier in
this series but I did not see any of that evidence.
SHAHAB ABDESSALAM: Maybe you're not quite catching the question.
Why do they even have an ostomy?
MICHAEL ROLLINS: So a number of these children were imperforate
anus without stula and then a number were given divided
stomas for rectovestibular stula which we did not include
in the subgroup analysis. Finally, there was a third group
where we could not determine where the stula was located
based on our review. Thank you for that point. That is why
there were so few.
JEAN-MARTIN LABERGE (Montreal, QC): Thank you for your very nice
presentation, and I'm glad I'm not the only one who still does
loop colostomies. I thought I was becoming alone in my camp.
I was taught many years ago that a well-constructed loop
colostomy, if the spur of the loop is above the level of the
fascia, you do not have any spill-over or it is minimal. Number
two, even in boys with rectourinary stula, we tend now to
do the denitive repair much earlier. We don't wait six
months, eight months like we used to in the early days, so I
don't think you have time to get much UTI. And the third
point I'd like to make is those fans of divided stula, it
seems like this dogma now has been taken to the extent
of all stomas. I travel to Africa regularly and I have seen kids
in ______ who had the divided stoma for Hirschsprung's
disease and then ______ half of their wounds get infected
and then they dehisce and then they eviscerate, so it's really
taken something that is a nice prophylactic against UTIs to a
major, major complication when these wounds break down.
Yes, the controversy will continue but thank you for providing some evidence that the loop is not so bad after all.
SHAWN LIECHTY: Thank you for your comments.
HOWARD GINSBURG (New York, NY): Thank you for that presentation. Did you discriminate how the colostomies were
performed, the divided colostomies? Were they brought out
through the wound or were they brought out through a
separate incision or a separate stoma? We found that there
is a difference in the infection rate whether they are brought
out through a wound or through a separate stoma.
SHAWN LIECHTY: Thank you for the question. Early on in our study,
most of the stomas were brought out through the wound.

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S.T. Liechty et al. / Journal of Pediatric Surgery 51 (2016) 107110

Later on with the introduction of the laparoscopic colostomy,

many of them were brought out through a separate stoma.
Regardless of the type of creation, the wound complications
rates were lower than we expected in the divided group.
We are not sure why but we did expect those complications
rates to be higher if a skin bridge was created, but there did
not seem to be a difference between the divided and loop
groups in that regard.
TIMOTHY JANCELEWICZ (Memphis, TN): Do you happen to have an
idea of what percentage of your revisions were conversions
to a divided stoma, if any, because I've had to do that once
or twice.
SHAWN LIECHTY: There were a few cases of the conversion to the divided stoma but those were minimal. Most remained created
as the type of stoma initially created. Of note too I think that
creating the stoma in an area of minimal mobility, the connection between the descending and sigmoid colon where the

retroperitoneal fascia attaches really helped us minimize the

rates of prolapse and reduce the rates of stoma complications.

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