Ostomies And Stomal Therapy

Michael P. Spencer, MD, FACS, FASCRS
Clinical Assistant Professor of Surgery
Division of Colon and Rectal Surgery
Department of Surgery
University of Minnesota
Minnesota, Minneapolis

History

The history of intestinal stomas has its roots in biblical accounts of spontaneous fistula formation resulting from trauma and strangulated viscera. While the ancient Greeks speculated about the role of surgical intervention for intestinal obstruction, it was not until 1776 that the first intentional stoma was created. Pillore, a French surgeon is credited with performing the first stoma, a cicostomy for the treatment of an obstructing rectal cancer. Throughout the remainder of the 17th century, contributions from Dubois, Calisen, Duret, Fine and others lead to the acceptance of surgical intervention for refractory intestinal obstruction.

During the 1800's, issues such as abdominal vs. lumbar colostomy, end or loop colostomy and eventually intestinal resection with anastomosis were evaluated. Diverting ileostomy was not commonly employed until the late 1800's, while technically a less demanding procedure the difficulties with post operative care were such that the procedure failed to gain popularity. Ileostomy remained a procedure of last resort until Brocke, who in 1952, described his method of evagination. At the same time, work by Turnbull and Crile at the Cleveland Clinic contributed greatly to the understanding of stoma physiology adding to the safety and acceptance of ileostomy. Rupert Turnbull is also credited with recognizing the need to develop specialists in ostomy care, with the assistance of one of his patients, Norma Gill. Together they created the first school for enterostomal therapists in 1961.

Advances in stomal therapy and surgical management have made it possible for the over one million individuals with stomas living in this country the ability to maintain a reasonably normal lifestyle.

Preoperative Assessment

Like any surgical procedure, an open discussion regarding the risks, goals and alternatives of the proposed procedure is mandatory. In contrast to other surgical procedures, many patients facing a stoma have a preconceived bias of ostomics, often based on ignorance and fear. Taking additional time to dispel these thoughts and utilizing the resources of an enterostomal therapist is often helpful. The use of models, photographs, diagrams and videotapes are also useful teaching aids to alleviate patient and family fears.

Accurate preoperative marking of potential stoma sites is critical and has a direct bearing on subsequent function. Not only should personal preferences of the patient be taken into account but anatomic landmarks such as scars, skin folds, costal borders and the margins of the rectus abdominus are vital in minimizing future complications. The right and left lower quadrants are typically considered ideal sites for stomas; alternate sites include the upper quadrants, umbilicus, midline above or below the umbilicus and occasionally lumbar areas. When two or more stomas are being considered, it is even more crucial to work out ideal locations preoperatively. It is occasionally useful to have the patient place the stoma appliance and wear it prior to surgery to ascertain the optimum position. Special consideration should be given to obese patients and disabled patients as their habitus or dependent position may obscure infraumbilical sites. Patients who have had radiation therapy or reconstructive procedures such as myocutaneous(TRAM) flap are best served y avoiding those locations. Whenever possible, complete preoperative evaluation should be offered even for those patients receiving temporary ostomies. Proper placement should reduce complications and optimize function.

Stoma Construction

The exteriorization and maturation of a segment of bowel be it small intestine or colon is an integral part of many operations. Like any procedure adherence to basic surgical principles providing tension free, well vascularized and no traumatized tissue to the abdominal wall should optimize outcomes. Creating the ostomy opening in the abdominal wall with consistent results is facilitated by following a routine that provides optimum traction and exposure. To maintain equal traction on the skin and fascia, my preference is to clamp both the rectus sheath and scarpas fascia with Kocker or similar clamps then retract away from the intended stoma site. Next, a lap pad is then placed beneath the abdominal wall and elevated with the surgeon's hand. This generally provides a more stable and uniform surface for creating the stoma.

A circular skin opening is then made ideally with a scalpel vs. a scissors which tends to produce an oval defect. The skin disc is then excised and subcutaneous fat bluntly retracted to the anterior rectus sheath. The fascia is then incised in a vertical direction approximately two finger widths in length. The rectus muscle is then split exposing the posterior fascia which is then incised similar to anterior fascia. A horizontal or crucate incision can usually be avoided which should help to minimize hernia formation. Typically the stoma opening is dilated to accommodate two digits; obese patients, however, may require slightly greater opening. A Babcock clamp can then be inserted to grasp the bowel which is then delivered through the defect. At least 3-4 cm. of bowel should be exposed above the skin for adequate maturation. To complete maturation, the mucosa is fixed to the dermas circumferentially.

The basic tenets of stoma construction apply for colostomy, ileostomy, urostomy, loop ostomies and laparoscopic assisted stomas. Cicostomy and the creation of continent stomas require special consideration and are beyond the scope of this review.

Complications

Complications following the creation of a stoma are experienced by 20-40% of patients, nearly half of which will eventually require revision. Early complications such as ischemia, hemorrhage, stenosis, fistula and retraction are often the result of technical error. Late complications include prolapse, obstruction, hernia and skin irritation. These too can be related to poorly constructed stomas or may be a related to poorly constructed stomas or may be a result of poor care and management. Another factor accounting for complications is recurrent disease which, if unresponsive to medical management, frequently leads to re-operation.

Stomal Ischemia
Ischemia ranges from harmless mucosal sloughing to frank necrosis. The cause may be related to aggressive stripping of mesentery, a stenotic fascia defect or excessive tension causing devascularization of the stoma. If the viability is in question, it should be assessed prior to closure of the incision when possible. If evaluation reveals necrosis extending below the fascia, immediate reconstruction is required.

Hemorrhage
Minor hemorrhage from the stoma is common and rarely requires intervention. As the bleeding is usually mucosal, it is self-limited or will respond to light pressure. Active bleeding implies failure to ligate a mesenteric vessel, and this should be identified and ligated prior to leaving the operating room.

Mucocutaneous Separation
Separation along the mucocutaneous border occurs to some extent in many patients. this typically occurs because of undue tension and or separation of sutures. Supportive care will usually resolve this problem, but gross separation can lead to eventual stricture and serositis.

Infection/Fistula
Perostomal abscess or infection is often related to an infected hematoma or fistula. If an abscess is suspected, the wound should be evaluated and debrided as needed. Strict attention to hemastasis suture placement and contamination diminish the occurrence of these problems. Beyond the immediate post operative period, fistula formation or infection may signal recurrent Crohn's disease.

Stoma Retraction
Retraction of a stoma, particularly an ileostomy, can lead to leakage and severe skin problems. Retraction, not surprisingly, is the most common reason for re-operation and can usually be prevented by minimizing tension. Suture fixation of the bowel is not sufficient to prevent retraction if the bowel has not been adequately mobilized. A convex stoma plate or use of a support belt may help to minimize problems; however, most patients will eventually come to revision.

Prolapse
Prolapse is seen most frequently with loop colostomy as this is often a temporizing procedure, the prolapse can be managed with reduction and supportive care until definitive surgery is planned. If the prolapse persists and disrupts pouching or is otherwise symptomatic, revision is indicated. Consideration should be made to convert the loop to an endo-colostomy and mucus fistula if the primary pathology can not be resolved.

Peristomal Hernia
Peristomal hernia is common complication and has been reported in as many as 50% of patients. Factors that predispose to development of hernia include stoma placement lateral to the rectus, a large stoma aperture, obesity, prior abdominal incisions, malnutrition and would infection. Minor cases may respond to conservative management with abdominal binders, but symptomatic cases will require repair. Relocation is the preferred method for correction if the patient is able to tolerate a laparotomy. Many local procedures have been described and are useful in some settings.

Skin Complications

Contact dermatitis is the most common disorder associated with stomas. This can result from allergic reactions to components of the ostomy appliance or, more frequently, exposure of peristomal skin to ostomy effluent. Erosion of the skin can result in prolonged and repeated exposure of stoma content which in turn hinders appliance placement and sets up a vicious cycle of leaks and progressive skin irritation. Breaking this cycle with improved cleansing of peristomal skin, application of descents or steroids, use of skin barriers, antifungals and occasionally antibiotics improve appliance fit and eventually diminish leaking and continued irritation.

Additional anatomic factors may predispose a patient to leaking and dermatitis. These include peristomal hernia, prolapse, retraction and skin folds, all of which can disrupt appliance contact. Correction of these problems must be addressed as previously detailed in order to provide long term relief.

Placement, construction and management of intestinal stomas can be technically demanding and often requires long term support and patience on the part of patient and physician. Even in the hands of the most experienced surgeon, difficult complications arise. These often require a multidisciplinary approach to resolve. As with many situations, future complications are related to the initial procedure and one should strive to prevent such occurrences. As stoma construction usually takes place at the end of a procedure, it often receives less attention as the important phase of the procedure has been completed. Ostomy construction is then relegated to junior staff, occasionally unsupervised. The conduct of stoma construction will have direct and long term consequences on ostomy function, persistent attention is warranted.

Surgeons, particularly those designated experts in the field of intestinal surgery, must be mindful that our patients will judge our surgical skill on a daily basis. It is imperative we do all we can to insure patient satisfaction each and every time a stoma is created.

References

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