A divided descending colostomy is ideal for the management of anorectal malformations (Fig. 19.5). The completely diverting colostomy provides bowel decompression as well as protection for the final repair of the malformation. In addition, this type of colos-tomy facilitates the distal colostogram, which represents the most accurate diagnostic study for determining the anatomy of these defects .
A descending colostomy has advantages over a right or transverse colostomy [10, 11]. There is a relatively short segment of defunctionalized distal colon. Atrophy of the bowel distal to a more proximal colostomy
and development of a microcolon with megarectosig-moid may result when a higher colostomy is utilized. Mechanical cleansing of the distal colon prior to the definitive repair is much less difficult when the colostomy is located in the descending colon. In the case of a large rectourethral fistula the patient may pass urine into the colon, whereas a more distal colostomy allows urine to escape through the distal stoma without significant absorption. If urine remains in the colon and is absorbed, metabolic acidosis may develop.
Loop colostomies permit the passage of stool from the proximal stoma into the distal bowel, which produces urinary tract infection, distal rectal pouch dilatation, and fecal impaction. Prolonged distention of the rectal pouch may produce irreversible bowel damage, leading to a significant bowel hypomotility disorder and severe constipation later in life. Loop colostomies are also prone to prolapse .
A colostomy created too distal in the area of rec-tosigmoid may interfere with the mobilization of the rectum during the pull-through and is a common error.
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