Stoma (colostomy and ileostomy) closure in children; advice for parents and carers

What is a stoma closure?

Your child currently has either a colostomy (stoma made from their large bowel) or ileostomy (stoma made from their small bowel) which has provided a route for faeces (poo) to leave their body. Stoma closure is an operation to join the bowel back together again therefore enabling faeces to be passed in the normal way through the anus.

This leaflet provides information about care that is needed in preparation for the operation, what happens during the operation itself, care needed in the days following surgery and ongoing care at home.

Preparation before admission to hospital

Review by the surgical team

Review by the surgical team will take place, usually in our outpatient department. This is an opportunity for your child to be assessed to ensure they are ready for their stoma closure, for the operation to be explained to you, for you to ask questions and for any tests needed (for example, x-rays) to be arranged.

Loopogram

Before their stoma is closed, many children will need to come to hospital to have an x-ray of their bowel called a ‘loopogram’. This involves a small tube (catheter) being inserted into the stoma (or sometimes via the anus) and some contrast medium (‘dye’) being injected. The contrast medium helps to show the outline of the bowel on the x-ray. A loopogram is not painful and (unless you are pregnant) you will be able to be present with your child during the procedure. The x-ray will be seen by the surgeon before admission takes place.

Preoperative assessment clinic

You will be asked to complete a ‘health screening questionnaire’ when your child is added to the waiting list; this will be completed over the telephone children will usually be reviewed in the preoperative assessment clinic for blood tests within six weeks of surgery although, if your child requires admission before their day of surgery for bowel preparation, blood tests will be taken during these preoperative days.

Purchasing suitable painkillers

It is important that you purchase some children’s pain killers such as paracetamol (e.g. Calpol) and ibuprofen before admission to hospital so that you have these available at home after discharge. If it is likely that your child will need ‘stronger’ pain killers, these will be supplied via the hospital.

If your child becomes unwell

If your child has a cold, cough or illness such as chicken pox the operation will need to be postponed to avoid complications. Please telephone us (the telephone number is provided at the end of this leaflet) to discuss, prior to coming to hospital.

Starvation times

Your child will not be able to eat and drink before the operation. Specific advice about this will be given on the booking letter once a date for surgery is confirmed.

Admission to Hospital

Your child will be admitted to one of our children’s wards. Whether admission can be on the same day as the operation or is needed 24 to 48 hours before the operation, will depend on the type of stoma your child has, the position of it within the bowel and whether the bowel needs to be emptied of faeces before surgery. The surgical team will inform you of this during the out-patient appointment.

Bowel preparation or ‘bowel prep’

Some children will require their bowel to be clear of faeces (poo) before surgery to help reduce risks such as infection. This is called ‘bowel preparation’ or ‘bowel prep.’ Whether or not your child needs bowel prep and the type of bowel prep needed will depend on their type of stoma and its position within the bowel. Generally, those children with a Colostomy (stoma in the large bowel) are more likely to require bowel prep due to the thicker consistency of faeces in this part of the bowel.

Every child that requires bowel prep will have an individualised care plan made for them and you will be given a copy of this on admission to hospital. Bowel prep is likely to involve the following:

• Children receiving bowel prep are allowed to eat and drink normally until they are admitted but after admission are only allowed clear fluids to drink (water, squash drinks).
• To clear the bowel of faeces, children (especially younger children) will receive bowel washouts via the stoma, via the rectum or both. Bowel washouts are carried out on the ward by a nurse and you can be present during this. Bowel washouts are not painful; the nurse will ensure that your child is kept warm and as comfortable as possible. Babies lie on their backs during washouts but older children lie on their left side so you will be able to position yourself so your child can see you and have a story read for example. Bowel washouts involve passing a small tube a short way into the stoma. A syringe is attached to the other end of the tube and a small amount of warmed salty water is then poured into a syringe. The water flows by gravity down the tube and into the child’s bowel. Once the water is in the bowel the syringe and tube are lowered to enable the water, now containing faeces, to run back out and be collected in a container. This process is repeated several times. Wash outs may also be needed via the rectum using the same technique but with a slightly wider tube, to remove any mucous or faeces present.
• The amount of wash outs required will be stated in your child’s individualised care plan, although the amount does also depend on the result of each wash out (how much faeces is cleared). As the aim of the bowel preparation treatment is for the bowel to be completely clear of stool before the operation, it is important that when the last wash out is performed the fluid that runs back out of the stoma / rectum is clear.
• In older children oral laxative medication is given to help with the process of clearing the bowel of faeces.

When does my child need to stop eating and drinking?

This will depend on whether bowel prep is required or not.

For children who are being admitted on the day of surgery, starvation times will be detailed on your booking letter.

Children admitted before the day of their operation, for bowel prep, can continue to eat and drink normally until admission. Once admitted children receiving bowel prep are permitted to have clear fluids until two hours before surgery. The clear fluids can be a combination of sugar containing clear squash / baby juice and dioralyte. Older children can have clear jellies and ice lollies during this time. While your child is receiving bowel preparation and only clear fluids, the amount they are drinking and how much urine they pass, will need to be recorded by your nurse. This enables doctors and nursing staff to keep a close eye on whether they are having enough to drink.

Children receiving bowel preparation also require intravenous fluids (‘drip’) to be commenced the night before their operation to ensure they are well hydrated before their surgery.

If your child is not taking enough fluids by mouth, or refuses to drink any oral laxative medication, it may be necessary to pass a tube, called a naso- gastric tube, so we can give them the fluids that they need. It may also be necessary to put the ‘drip’ up earlier.

Pre operative blood tests

Children being admitted on the same day as their operation will have their blood tests taken during their pre-operative assessment clinic visit. Children admitted before the day of their operation will have their blood tests taken on the ward. It is common for children receiving bowel washouts to need more than one blood test.

The operation

Stoma closure is carried out under a general anaesthetic. You and your child will have the opportunity to talk to the anaesthetist before surgery. In most cases one parent can be present during the giving of the anaesthetic.

The operation itself involves the surgeon making a cut next to the stoma and freeing the stoma from the abdominal (‘tummy’) wall. It is usual for the ends of the stoma to need to be trimmed slightly and the bowel is then mobilised (‘freed up’) to enable it to be joined (stitched) back together thus enabling the normal passage of faeces through the whole bowel and out through the rectum. The bowel is then placed back inside the abdomen and then the layers of muscle and skin are sutured back together. Stitches used are usually dissolvable. Often steri strips (paper stitches) are placed over the top.

What are the risks / complications of the operation?

As with all operations there are risks but these are rare. They include:

• Bleeding, bruising, infection
• Incisional hernia - this is a protrusion of tissue through the wound and would require a further operation to resolve it.
• Stenosis (narrowing) of the anastamosis site (the site where the bowel is rejoined)
• Leakage from the anastamosis site in the bowel
• Adhesions: This is scar tissue formation which can occur after any abdominal operation. It is a small but lifelong risk which may result in an obstruction (‘blockage’) of the intestine. Symptoms of an adhesion obstruction include cramping abdominal pain and green (bile) vomit.

After the operation

Both parents are usually able to be present in recovery room once their child has woken up. After a period of monitoring transfer back to the ward will take place, unless an underlying condition requires monitoring in our neonatal / high dependency or intensive care unit.

When can my child eat and drink again?

It is normal for the bowel to not work properly initially after stoma closure so most children will be nil by mouth following surgery to allow their bowel to rest and heal. Some children have a naso-gastric tube, with a bag attached to the end, to help prevent them from feeling sick or vomiting whilst their bowel rests.

Doctors and nursing staff will be observing for signs that indicate your child’s bowel is working again, for example the colour and amount of stomach contents draining from the naso-gastric tube, any passage of wind or stool from the rectum. Once such signs are observed, drinking and eating will be started again and gradually increased. Intravenous fluids (a drip) will continue until adequate volumes of drink are being taken orally.

How will my child’s pain be managed?

Before surgery the anaesthetist will discuss pain management plans with you. Medication to control pain may be given through your child’s drip via a pump and rectally as a suppository, until they are able to take medication orally.

What other medicines will my child need?

Intravenous antibiotics will be given immediately before the operation starts. A few more doses of antibiotics will then be given on the ward after the operation.

It is normal for faeces to be passed very frequently once the bowels are working again and initially this could be in excess of 20 times a day. In addition the stool consistency is often very loose. Gradually, over the weeks following stoma closure, the frequency of passage of stool slows and the consistency becomes thicker.

It is extremely important that the skin around your child’s anus and bottom is protected from becoming sore during this time. More information on this is available in the ‘care at home’ section of this leaflet.

Care at home

It is essential that you are vigilant with skin care to prevent the skin becoming sore or even breaking down. This should include:

• Use of topical creams to the skin around the bottom. Creams which are commonly used include Cavilon (a barrier film which is particularly useful in young children and is available on prescription but is only used once per day), Metanium (a barrier cream available on prescription or without and which should be used after every bowel motion) Ilex Paste (a barrier paste available to purchase and available on prescription) and Medical grade Manuka Honey based creams (available on prescription). Your nurse specialist will discuss this with you in detail before your discharge.
• Using a hair dryer on a cold setting to dry the skin
• Keeping your child’s bottom exposed to the air can also help.

If your child’s skin starts to become sore it is important to speak to the nurse specialist without delay for further advice (see number at end of the leaflet).

In the majority of cases the stitches are dissolvable so they do not need to be removed. We will tell you if this is not the case and arrange an appointment for stitches to be removed.

Some discomfort is to be expected so pain killers such as Paracetamol and Ibuprofen should be given regularly for the first days after discharge and then less often as your child recovers (see bottles for instructions regarding doses to use).

Showers are permitted because any dressings used are waterproof. However baths are not permitted for five days.

The dressings can be gently pulled off after seven days (it is easiest and less painful to do this in the bath).

Your child should rest at home following discharge and older children can then build up physical activities after approximately two weeks.

Wound infections are rare but if the wound looks red/sore see your GP.

If fever develops or pain that is not helped by pain killers provided, you should contact your nurse specialist/ GP.

Follow up

You will receive an appointment to attend the outpatients department approximately six to 12 weeks after the operation for review. If you are unable to attend please inform the clinic and rearrange the appointment.

For further information and queries please contact:

The ward you were on . . . . . . . . . . . . . . . . . . . . .

Your nurse specialist team: 01223 586973