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Ostomies And Stomal Therapy

Jonathan E Efron MD, FACS, FASCRS
Cleveland Clinic Florida

Introduction

Knowing how to create and manage enteral stomas is a vital aspect of all colorectal surgical practices. This syllabus will review the preoperative evaluation of patients who are to receive stomas, different techniques of stoma formation, and the management of enterostomal complications.

Preoperative interventions

Helping the patients psychologically adapt to the changes that occur to life style and body image is essential to ensuring a high quality of life after formation of a stoma. It is generally accepted that preoperative counseling in patients who are undergoing elective formation of a stoma is essential to allay patients' fears and help with postoperative adaptation. This task is usually performed as an outpatient by support staff such as a trained enterostomal therapist. Jeter stressed the importance of preoperatively counseling colorectal cancer patients who are undergoing formation of a stoma. (Jeter 1992) Patient fears and misconceptions need to be quelled and questions should be answered. Common concerns include recurrence of disease, pain associated with the stoma, social and sexual activity with the stoma, and care of the stoma. Providing other pertinent information such as the location of support groups is also helpful.

Minimizing postoperative complications as well as improving postoperative quality of life requires adequate preoperative site selection of the stoma. Marking the correct location of a stoma must take into account the patient's body habitus and physical limitations as well as any supports or braces utilized by the patient. The patient must be able to visualize the stoma and access the stoma without difficulty. Creases or divets that occur on patient's abdomen, either naturally or secondary to scarring from prior surgery, should be avoided. Stomal siting should be performed in the supine position, with the patient sitting and standing. Bringing the stoma through the rectus abdominus muscle seems to provide the best stability and support for the stoma. In a patient with average body habitus the small infraumbilical bulge in the middle of the rectus muscle provides an ideal location. Ideally there should be six to eight cm of flat skin around the stoma.

Obese patients should have the stoma sited higher in the abdomen to avoid poor visualization and placement of the stoma in an abdominal wall crease that is only evident when the patient is sitting or standing. When creating a stoma in an emergent situation it may not be possible to adequately preoperatively mark the patient. In these situations, it is better to keep the stomas higher in the abdomen to avoid postoperative difficulties such as the patient's inability to see the stoma.

Technical aspects of formation

Many techniques are available for formation of a stoma. The stoma should be sited preoperatively as mentioned above. Sjodahl et al in 1988 examined 130 patients to determine if the location of the stoma was relative to the formation of parastomal hernia formation. (Sjodahl et al) They found that significantly fewer hernias formed when the stoma was brought out through the rectus abdominus muscle. Other studies such as the one by Ortiz et al found no statistical difference in the rate of paracolostomy hernia formation, whether or not the stoma was matured through the rectus abdominus muscle. (Ortiz et al). The defect in the abdominal wall is usually made through the rectus abdominus muscle. The size of the defect is dependent on the size of the bowel and its mesentery. Traditional teaching states that it should allow at least the passage of two fingers. A vertical or cruciate incision is made in the anterior abdominal wall fascia and the stoma is brought through the defect. Care is taken not to twist the mesentery. The stoma is then matured with absorbable suture after the midline incision or other incisions are closed. Brooke sutures are used to mature ileostomies.

An end loop stoma may be utilized in difficult cases where the size of the patient's abdominal wall or significant intra-abdominal inflammation have thickened the bowel and mesentery making it difficult to mature a stoma without compromising the intestinal blood supply.

After completing maturation, a digit should be passed through the stoma past the abdominal wall fascia to ensure that the opening in the fascia is adequate and not too tight, which may lead to post operative bowel obstruction. A life table analysis performed by Leong et al. on complications following ileostomy formation found that fixation of the mesentery and closure of the lateral space made no difference in the postoperative complication rate of intestinal obstruction or herniation. (Leong AP et al.) Londono-Schimmer et al. found that an extraperitoneal course of the stoma did have a significantly lower risk of hernia formation than a trans peritoneal course. (Londono-Schimmer et al.) There is currently no definitive data within the literature to support the act of fixation of the mesentery or closure of the lateral space.

Complications

Prolapse

Stomal prolapse occurs most commonly with transverse loop colostomies and more commonly with ileostomies than colostomies. The rate of stomal prolapse ranges from 7% to 11%.(Cheung MT 1995, Londono-Schimmer 1994) Prolapsed stomas may become incarcerated or strangulated. Reduction of an incarcerated prolapsed stoma may be facilitated by the use of an osmotic agent such as sugar. There may be difficulty with pouching prolapsed stomas and often they require repair. Initial, simple, prolapsed stomas are often repaired with local resection of the prolapsed segment of bowel with reformation of the stoma at the original stoma site. Recurrence of the prolapse may require further resection and relocation of the stoma. In patients who are not candidates for general anesthesia, Abulafi et al described a modified Delorme procedure where the redundant mucosa is resected with plication of the muscle. Incarceration of a prolapsed stoma may initially be treated in the same fashion as an incarcerated rectal prolapse. As long as there is no sign of necrosis, reduction of the stoma may be facilitated by applying either sugar or salt to help decrease edema. Repair may then be performed on an elective basis.

Parastomal herniation

Parastomal herniation occurs in approximately 30% of all stomas formed. They more commonly occur in colostomies then ileostomies. A randomized prospective study performed by Edwards at al. found that complications from transverse loop colostomies (including herniation) were significantly greater then those from loop ileostomies. (Edwards et al.) Patients who are not candidates to undergo surgical repair of their parastomal hernias may be managed with stomal hernia belts. These devises may help decrease pain and make it easier for the patient to apply the stomal pouching device.

Three surgical techniques are currently available for repairing a parastomal hernia: Localized fascial repair, localized fascial repair with mesh, and relocation of the stoma. Rubin et al described their experience with repairing parastomal hernias. Fifty five patients underwent parastomal hernia repair. (Rubin et al.) Thirty six patients had localized fascial repair, 25 patients had their stoma relocated, and 7 patients underwent fascial repair with prosthetic mesh implantation. Complications were higher in stomal relocation then fascial repair. The recurrence rates of first time repairs were 76% for localized fascial repair and 33% in those patients who underwent relocation. Recurrent parastomal hernias repairs failed in all patients who underwent localized repair without mesh, in 71% of those who underwent relocation of their stoma, and in 33% of those that had mesh repair. The authors conclude from their study that at the initial presentation of a parastomal hernia, it should be repaired by relocation. Recurrent hernias, however, should be repaired with implantation of mesh.

Tekkis et al. reported on 5 cases of parastomal hernias repaired by the implantation of mesh and a literature review that compiled a total of 72 parastomal hernia repairs with the implantation of mesh. The total failure rate was 8.3% and related to recurrence and infection. (Tekkis et al.) Byers reported on 19 patients who underwent parastomal hernia repair through local repair without mesh or repair relocation. The recurrence rate was significantly high in the non-mesh group. (Byers et al). Morris-Stiff et al related 5 year follow up on 7 patients who underwent repair of parastomal hernias and found a 29% recurrence rate. (Morris-Stiff et al.) Helal et al reported a 89.5% success rate on repairing parastomal hernias that occurred in association with continent urinary diversion with implantation of mesh for all large hernias. (Helal et al.) Stephenson and Phillips described eight patients treated with localized resiting and repair with mesh. In a 15 month follow up period they had no recurrences. (Stephenson BM and Phillips RK.) Cheung et al described a 40% recurrence rate in patients who had the stoma relocated. In that series the majority were relocated without laparotomy. (Cheung et al)

Parastomal hernias are a difficult problem. Because of the high recurrence rates, regardless of the type of repair, small asymptomatic hernias may best be managed by observation and support with a hernia belt. Surgical therapy for primary large symptomatic parastomal hernias is either by local repair with mesh implantation or stomal relocation. Recurrent hernias are best treated by local repair with mesh implantation.

Stenosis

Stomal stenosis usually occurs secondary to ischemia, infection, or retraction of the stoma. It occurs in approximately 10% of stomas matured. (Cheung MT) Management requires either dilatation or revision of the stoma. Dilatation should initially be performed in the operating room and requires frequent daily dilatation by the patient to prevent recurrent stenosis. The act of dilating leads to scarring and therefore this is only a temporary solution for those who are not surgical candidates. Local revision of the stoma provides optimum repair and may prevent various problems that occur with frequent dilatations such as bleeding from local trauma. Local repair requires excision of the stenotic site including scarred skin, mobilization of the stoma to prevent recurrent retraction with maturation as a tension free stoma.

Retraction

Retraction of a stoma may lead to difficulty with adequate pouching. Retraction is more common in obese patients and may be related to compromised blood flow to the stoma. If necrosis occurs above the fascia and the patient is not septic, over time the stoma may heal, but with retraction. A way of avoiding retraction in difficult patients is to form an end loop stoma. This technique is helpful where there is intra-abdominal infection causing the bowel and its mesentery to be thickened and non pliable. It may also be helpful in obese patients. The bowel and mesentery is divided and the proximal limb of the bowel is brought out as a loop. The non-functioning end of the stoma ends in a short stump with the staple line that may be above or below the fascia. The distal portion of bowel is left within the abdomen as a long Hartmann's pouch.

If retraction does occur, the use of a convex stoma appliance often allows for adequate pouching without leakage and skin contamination. The use of a convex appliance with a stoma belt also may help decrease leakage. If the patient has significant leakage, especially of an ileostomy, local revision may be required.

Skin Irritation

Skin irritation is a common problem in patients with stomas. It is more common in patients with ileostomies than colostomies and occurs in 34% of patients. (Leong et al.) Skin irritation for stomas may be secondary to contact dermatitis, mechanical trauma, infections, or peristomal hyperplasia. Identifying the cause of the irritation is essential to adequate therapy.

Contact dermatitis may occur secondary to an allergic reaction or to irritation. A complete assessment of the devices, powders, and pastes being used by the patient must be performed and if an allergic reaction is expected, the offending agent must be eliminated. Skin barriers such as powders or hydrocolloid dressings may help with significant irritant contact dermatitis. If patients have severe inflammation with desquamation the use of non adhesive pouching systems may be required until the skin has healed.

Infections may occur around the stoma that result in irritation and pain. The most common is a candidal infection. Immunosupressed or diabetic patients are more susceptible to the fungal infection. Controlling leakage and moisture build up with the use of an antifungal powder is the treatment of choice.

Peristomal hyperplasia refers to hyperplastic tissue that occurs at the base of the mucocutaneous junction of the stoma and is believed to be secondary to exposure of the skin to effluent over a prolonged period of time. Changing the pouching appliance of the patient to prevent continued exposure is the treatment of choice.

References

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