Ostomies and Stomal Therapy
Sharon L. Dykes, MD, FACS, FASCRS
Minnesota Colon & Rectal Surgical Specialists
Clinical Assistant Professor of Surgery
University of Minnesota
Minneapolis, Minnesota
Introduction
It is estimated that approximately 120,000 new stomas will be created in the United States each year. Others predict that the number of ostomates will continue to increase by 3% annually[1], as stoma creation is routinely performed by a diversity of surgical subspecialists. Despite the frequency with which these procedures are executed, complications remain common. In this article, preoperative considerations and techniques for stoma formation will be described. In addition, prevention and treatment options for managing enterostomal complications will be reviewed.
Preoperative Interventions
In an effort to create an acceptable and functional stoma for both the patient and surgeon, preoperative counseling and planning are crucial. The presence of a stoma is associated with significant psychological morbidity, including fears of bad hygiene, limitation in social or athletic activities, and elimination of intimate relationships. Preoperative counseling entails mental preparation through patient education and psychological support. It is important for the surgeon to relay the need for the stoma, including its benefits, i.e., lifesaving or for symptomatic relief, and to emphasize that its presence does not preclude a normal lifestyle.
A preoperative visit with an enterostomal therapist or member of the United Ostomy Association is recommended, with the goal of reinforcing information given by the surgeon [2]. During the visit, patients should be provided with real-life experiences and encouraged to engage in frank discussions regarding odor, leakage, diet, clothing and sexuality. Information regarding available appliances should be provided and proper stoma care reviewed. Regarding stoma function, the patient should be made aware that an ileostomy is easier to manage than a colostomy. Although ileostomy effluent has a less offensive odor, it is more caustic to the skin than that of a colostomy and will require more frequent appliance changes. In addition, colostomy irrigation is often helpful in eliminating output for 24-48 hours [3]. One recent randomized controlled trial has shown that stoma education is “more effective if undertaken in the preoperative setting”. Chaudhri et al. randomized 42 patients to receive intensive pre-operative (study group) or postoperative (control group) teaching. The study group participated in two pre-operative visits, both conducted in the community, where patients were taught to use and change a pouching system. Postoperative stoma education was standardized for both groups. Shorter intervals to stoma proficiency, earlier discharge from the hospital and reduction in stoma related (postoperative) interventions in the community were reported for the study group[4].
Optimal site selection is a key component for preoperative planning and minimizes postoperative complications. For elective procedures, stoma site marking should be performed prior to surgery. The patient should be evaluated in the supine position as well as while sitting, standing and bending forward. There should be confirmation that the site is visible to the patient. For optimal visibility, the stoma should be placed at the superior apex of the infraumbilical fat fold in the lower quadrant, in the center of the ”ostomy triangle”, bounded by the anterior superior iliac spine, the pubic tubercle and the umbilicus. To prevent interference with the quality of the skin seal and adherence of the appliance, skin creases, bony prominences, scars, and drain sites should be avoided. Ideally, a 6cm area of flat surface should surround the stoma site and the aperture should pass through the rectus muscle to reduce the chance of a parastomal hernia. The belt line should be avoided to prevent direct trauma to the stoma, which can be concealed if placed below the belt line.
In the obese patient and in circumstances where placement below the belt line may not be feasible, the stoma is better situated in the upper abdomen to allow for proper visualization and care. Abdominal wall thickness is also greater below the umbilicus, making stoma creation technically challenging in this area and under these conditions. For patients wearing a brace or prosthesis for back support or for those who are wheelchair bound, stoma marking should occur while wearing the prosthetic or seated in the wheelchair.
Marking of the stoma site can be achieved using a variety of methods. A permanent tattoo can be injected intradermally with methylene blue or the skin can be lacerated using a needle or scalpel. When a marking pen is used to create an “X”, the site should be covered with an occlusive dressing and remain in place until surgery. The mark will remain visible for days, but will fade with washing. The site should be scratched into the skin after the patient is anesthetized, prior to skin cleansing.
Construction
The technique for stoma creation is fairly standard. A 2cm circular skin incision is made with preservation of the subcutaneous fat, which provides support for the stoma. A cruciate incision is formed in the anterior rectus sheath, with subsequent spreading of the rectus muscle and incision of the peritoneum. The surgeon should easily be able to pass two fingers through the stoma aperture and must take care to avoid bowel damage or mesenteric tears, which can occur with excessive pulling in obese patients or in instances where narrow apertures or large appendices epiploicae are present[5].
An important intraoperative technical consideration involves the selection of the intestinal segment for stoma creation. In an emergent situation, when the surgeon is not sure whether the stoma will be temporary or permanent, preoperative assessment of the patient’s daily activities, disabilities and occupation can be beneficial. If there is a possibility of a permanent stoma, especially if advanced age or comorbidity, the surgeon should consider an ileostomy versus colostomy, for ease of management. On the contrary, if stoma reversal is likely, intestinal length should be preserved, especially if there is a history of chronic diarrhea or marginal incontinence. Loop stomas are often preferable in these instances in order to avoid a second laparotomy. When the distended colon is encountered intraoperatively, it is often difficult to assess vascularity and obtain adequate protrusion. The risk of parastomal hernia is also a concern if a large abdominal wall orifice is made to accommodate the colon. In this instance, it is beneficial to decompress the colon prior to maturation.
Techniques have also been described for improving the success rate of stoma creation in obese patients. Maturation of the antimesenteric corner of the colon has been described by Herbert et al., and is appropriate when a short mesentery will not allow full reach of the colon. Mavroidis and Koltun have reported using a Penrose drain to encompass the colon as the bowel is delivered to the skin surface, thereby decreasing resistance. In 2009, Meagher et al. reported a new technique for delivery of the colon through the peritoneum and subcutaneous tissues using the Alexis Wound Protector®. While they reported results in only 8 obese patients, with a mean BMI of 32, they found no incidence of stoma retraction or hernia formation after 14 month follow-up[6].
Complications
Despite extensive surgical experience, complications after stoma creation still occur with relative frequency and often cause social isolation and a significant reduction in quality of life[7]. Factors affecting type and frequency of complications include surgical specialty, surgeon experience, emergency versus elective creation, appropriate preoperative marking and education, and patient issues such as age, obesity, diabetes and ability to care for stoma.
In one prospective study, Robertson et al. examined the incidence of complications in 408 patients with a stoma, created either electively or emergently. Complications were reported at ten days, three and six months, and one and two years. The authors noted that skin excoriation occurred more frequently with an ileostomy, compared to colostomy. As time progressed, incidence rates did not change for stenosis (1-2%), retraction (8-22%) or prolapse (1-3%). The rate of parastomal hernia formation, however, increased with time: 0-40% after colostomy and 0-22% after ileostomy. Overall complication rate was 23.5%[8].
In a separate UK study, Harris et al. reviewed outcomes in 345 patients with stomas, created electively in 70%. The overall complication rate was 25%. The most common complications after colostomy were parastomal hernia, 7.5%, and retraction, 6.8%. Loop colostomies had the highest complication rate at 38%, with prolapse in 13%. For ileostomies, the most common complication was parastomal hernia, 6.7%, followed by retraction and small bowel obstruction, both at 4.5%. The lowest rate was found for ileostomies at 16%[9].
Stoma-related complications may be further subdivided into those occurring early and late in the postoperative period. Kann performed an extensive review of “early” complications, or those occurring less than one month postoperatively, including improper siting, vascular compromise, peristomal skin irritation or infection, acute parastomal herniation, and early postoperative bowel obstruction. He added that pure technical errors, such as maturation of the wrong end of the stoma, should not be discounted[10]. In a similar fashion, Husain et al. provided a descriptive review of “late” complications, defined as those occurring after the initial period of physiological adjustment, thought to be six to ten weeks for most patients. Those included were parastomal hernia, prolapse, retraction, stenosis, obstruction, stomal bleeding and peristomal ulceration[11].
Skin irritation
The degree of peristomal skin irritation may range from dermatitis to full thickness necrosis or ulceration. Mild dermatitis usually occurs as the result of reactive irritation, inflammation, and skin breakdown caused by contact with intestinal effluent, more frequently associated with ileostomies because of the acidic content of the small bowel[12]. Desquamation of the peristomal skin may also result from allergic dermatitis, best treated by identification and removal of the offending substance, or trauma secondary to frequent appliance changes or external accessories. The incidence has been reported from 5 to 25% with a 34% cumulative long-term risk. Management is local wound care[13].
Fungal irritation of the peristomal skin, secondary to overgrowth and colonization of Candida albicans, is also commonly seen. Antifungal ointments and creams do not allow for appropriate seal of the stoma appliance unless dried before application. Antifungal powders, however, have been helpful. Abscess, fistula formation and ulcerations are usually sequelae of inflammatory bowel disease and will not be discussed.
Adherence to intraoperative principles of stoma construction will help avoid this particular postoperative complication. Persson et al. prospectively evaluated 180 patients for skin problems secondary to leakage. Diameter and height were measured for all stomas. They encountered leakage/skin problems in nearly all patients with an ileostomy height less than 2cm and in almost half of patients with a colostomy height less than 5mm[14].
Stenosis
The stenotic stoma usually occurs secondary to ischemia, infection or retraction. Ischemia may be apparent immediately after stoma creation or may not be evident for months. The overall incidence is 2-14%[11]. Colostomy strictures behave differently from ileostomy strictures and can usually be followed expectantly, managed with dietary modification and colostomy irrigation. More aggressive measures involve stomal dilatation. Because the effect of dilatation is temporary, the procedure is often repeated, resulting in fibrosis, additional scarring and recurrent stenosis. When temporizing and/or non-operative methods are unsuccessful, surgical revision is the definitive treatment. Beraldo recently described the use of W-plasty reconstruction for the stenotic stoma. Although the procedure was reported for only five patients, patient satisfaction was high without evidence for recurrent stenosis after one year median follow-up[15].
Retraction
Although considered an early complication after stoma formation, late occurrences may be seen in up to 6% of colostomies and 3-17% of ileostomies created. The most common reasons are weight gain after stoma formation and short length of exteriorized segment[11]. Symptomatology includes leakage and skin irritation secondary to poorly fitting stoma pouches. In obese patients or in circumstances of intra-abdominal infections, where the mesentery is thickened or shortened, intraoperative considerations should include formation of an end loop stoma. Preventive efforts have also included positioning supporting rods of glass or plastic at the time of stoma creation. This technique has been associated with postoperative difficulty in placement of stoma appliances. More recently, Harish et al. described the use of a subcutaneous 16-18 French suction drain as a similar conduit to prevent retraction, but without the subsequent pouching problems[16]. At least one randomized controlled trial has been recently performed to support discontinuation of these practices. Speirs et al. randomized 60 patients requiring loop ileostomy to a bridge or bridge-less protocol. The patients were assessed for 3 months until stoma closure. No differences in retraction rates were found between the two groups[17].
Non-operative management of the retracted stoma, especially if temporary, should involve the use of a convex stoma appliance with belt. If surgical revision is required, local procedures can be performed, especially for repair of the retracted ileostomy. Laparotomy may be necessary for colostomy revisions which require splenic flexure mobilization. There has been one recent report of a revision using a stapled technique. Less than half of the patients, however, achieved a satisfactory result after one or more stapling procedures in that study [18].
Prolapse
Stomal prolapse is most commonly observed with transverse loop colostomies, ~30%[11], but the overall rate is much lower at 7 to 11%. With regard to prevention, there have been conflicting reports whether fixation of the mesentery or bowel wall to fascial edges is helpful. Opponents warn that this practice complicates repeat laparotomy or revision. Initial management should include nonoperative attempts at reduction. Sugar has been successfully used as a dessicant in these circumstances[19]. When skin excoriation, bleeding and/or incarceration persist, surgical correction is necessary.
One recently reported technique of prolapse repair requires no sedation. Dodd et al. have described the placement of a figure of eight stitch in the mucosa and submucosa of the efferent limb of a loop stoma, holding it in the reduced position. The authors note the transitory effect of the procedure, which can result in significant stomal bleeding and swelling when repeated[20]. Nevertheless, the described technique is an option for patients unable to undergo general anesthesia or sedation. Other descriptive procedures, requiring minimal to no anesthesia, include a “modified” Altmeier procedure, an adaptation of the Delorme procedure[21] and several stapling techniques, whereby a linear cutting or Contour® stapler is used to excise the prolapsed segment[22-25].
Parastomal Hernia
The true incidence of parastomal hernia has been difficult to establish because of underestimation and lack of reporting. Cingi et al. studied 23 patients with enterostomies and closed enterostomy sites by physical examination and computerized tomography for the detection of hernias, hernia content, and relationship to the rectus muscles. Physical examination alone detected parastomal herniation in 52%, whereas the addition of computed tomography gave a corrected incidence of 78 %[26]. Parastomal hernia often arises as a late complication, although some say it is an inevitable consequence of stoma formation[27]. They more commonly occur after formation of sigmoid colostomy than ileostomy and overall rates range from 16 – 50%[28]. In the early postoperative period, occurrence is less frequent, at a rate of 4.6 to 13%, and is usually secondary to a large fascial defect[10].
Experts have categorized risk factors into three main groups: patient variables, disease processes, and technical aspects[28]. Patient variables include smoking status, malnutrition, age and waist circumference[29]. Obesity, diabetes, ulcerative colitis, chronic obstructive airway disease, raised intra-abdominal pressure, postoperative sepsis, perioperative steroid use and malignancy are among the comorbidities associated with the development of parastomal hernias. Technical factors include emergency procedures, when preoperative siting is not possible, siting of the stoma outside of the rectus muscle, and aperture size, which has been shown to be an independent predictor of hernias in a multivariate analysis[28].
Attention to proper surgical technique in creating a well vascularized, non-traumatized, tension free anastomosis between the skin and intestine is recommended for prevention. Aperture size should be limited to two to three of the surgeon’s fingers. Although laparoscopic techniques, commonly used for stoma creation, are safe and probably superior to open techniques, they have not proven effective in hernia prevention[30]. While fascial fixation and creation of an extraperitoneal path may decrease risk, a statistically significant advantage has not been demonstrated using these techniques.
The only method that has reduced the rate of parastomal hernia in a randomized trial is the use of a prophylactic mesh. There have been three randomized trials, five prospective observational studies, and other descriptive techniques promoting a benefit for prophylactic mesh placement, whether onlay or sublay, at the time of initial stoma creation [27, 31-38]. Follow up periods ranged from 2 to 68 months. Infections and other long-term complications were rarely reported. Recurrent hernia after prophylactic mesh placement was less than 15% for all studies included. These results have raised questions regarding the short- and long-term advantages of placing mesh at the primary operation and the best location for mesh placement in the abdominal wall. Such outcomes should be confirmed in larger, double-blinded, randomized controlled clinical trials.
Asymptomatic parastomal hernia does not mandate repair, as the risks of incarceration, obstruction, and strangulation are low. Mild discomfort should be treated with abdominal support and girdles. Definitive repair is indicated for incarceration, obstruction, strangulation, chronic pain or leakage. Despite the fact that local procedures obviate the need for laparotomy and stoma relocation, recurrence rates remain high. Direct repair of the fascial defect with suture alone is associated with a recurrence rate of 50-100% and repair with prosthetic or biosynthetic material up to 88% [39-41].
Over the last five years, several prospective, observational and retrospective studies have tried to define the role of laparotomy and relocation in parastomal hernia repair (PSH). Baig et al. retrospectively analyzed 27 patients who underwent PSH repair with stoma relocation to the opposite side of the abdominal wall. The operation was performed without a midline laparotomy in 11 patients (41%). There was only one recurrence in the group without a laparotomy compared to three in the group with laparotomy. The mean follow-up periods were 36.8 and 56.6 months in the groups without and with a laparotomy, respectively. PSH repair with relocation without laparotomy was associated with a significantly shorter hospital stay, possibly due to the lack of a midline abdominal wound. The authors acknowledged that significant intraabdominal adhesions may prohibit feasibility in some patients[42]. Historically, relocation has been associated with recurrence rates as high as 68%.
Efforts to decrease recurrence rates have produced descriptive reports of PSH repair with synthetic mesh materials, used in overlapping onlay or sublay positions. Earlier concerns regarding erosion of the stomal bowel wall have been addressed by a recently described technique, where the mesh aperture is fashioned by folding back and stitching in place the triangular flaps from its middle to form a rolled rather than sharp edge[43]. Consequently, over the last five years, prosthetic biomaterials, such as polypropylene, PTFE, and Sepramesh have been deemed safe for contact with the bowel and have demonstrated improved PSH recurrence rates [43-49]. With median follow-up periods up to 33 months, recurrence rates have been limited to 19%. These reports have been predominantly retrospective, and, therefore, prospective and comparative studies are required to reinforce these results.
In contaminated procedures, the use of biologic materials or grafts, such as acellular porcine dermal matrix, may minimize the incidence of synthetic mesh-related complications, such as erosion into viscera and fistula [50-52]. Aycock reviewed a series of 11 patients who underwent parastomal hernia repair with acellular dermal matrix. Mean follow-up was 8.7 months (range: 1-21 months). Two patients developed wound infections that did not require implant removal and healed with local wound care. Three patients developed recurrent hernias. They concluded that PSH repair with acellular dermal matrix results in recurrence rates comparable to those reported in the literature for synthetic mesh repair[53]. Additionally, stoma relocation and implant removal, in cases of wound infection, can be avoided. Taner et al. found similar results in thirteen consecutive patients, who underwent open parastomal hernia, whereby the posterior and anterior rectus fascia at the stoma site was reconstructed with human acellular dermal matrix. Patients were followed prospectively for 290 +/- 119 days and data were reviewed for rate of postoperative complications, hernia recurrence, and patient satisfaction. There were two cases of asymptomatic hernia recurrence as determined by computerized tomography. These patients did not require any intervention. Overall patient satisfaction with the procedure was high [54]. There has been one recent retrospective comparison study performed reviewing outcomes in 22 patients, who underwent an open PSH repair. In two patients, direct fascial repair was performed without mesh. Thirteen had reinforcement with biologic mesh, and seven underwent translocation. Recurrence was lowest among those patients who underwent mesh repair [55].
The role of laparoscopy is evolving for PSH repairs. Avoidance of second laparotomies and operations in contaminated fields has reduced the risk of mesh infection. Laparoscopic PSH repairs can generally be divided into two groups: “keyhole-techniques” and “Sugarbaker techniques”. Recent reports utilizing a laparoscopic “modified Sugarbaker technique” have largely been retrospective [56-58], but initial results demonstrate similar or better recurrence rates when compared to open techniques. Two recent retrospective studies have reviewed the outcomes of conventional PSH repairs (primary suture repair, stoma relocation, and mesh repair) with laparoscopic repairs (keyhole and Sugarbaker techniques). McLemore reviewed forty-nine patients, who underwent repair of symptomatic parastomal hernias. There were no significant differences in the incidence of surgical site infections (11% laparoscopic vs 5% conventional, P = .60) or complication rates (63% laparoscopic vs 36% conventional, P = .67) [59]. Pastor performed a retrospective review of twenty-five patients who underwent laparoscopic or open parastomal hernia repair. Parastomal hernia recurred in four laparoscopic patients (33.3%) and seven open patients (53.8%) after 13.9+/-4.5 months and 21.4+/-4.3 months, respectively, P=0.43 [60]. Both studies concluded that laparoscopic PSH repair, especially the modified Sugarbaker technique, is a feasible operation with similar short-term outcomes to conventional repairs.
Although there was initial success with “keyhole techniques” for PSH repair [61, 62], recent reports have found “an intolerably high recurrence rate with the currently available meshes.” [63, 64] Muysoms et al. retrospectively reviewed twenty-four patients who underwent laparoscopic repair of a symptomatic parastomal hernia. No major intra- or postoperative complications were encountered. During a mean follow-up of 21.2 months, ten recurrences (41.7%) were diagnosed. In patients treated with a "keyhole technique", the recurrence rate was 72.7% (8/11) with a mean follow-up of 30.7 months. In patients treated with a "modified Sugarbaker technique", the recurrence rate was 15.4% (2/13) with a mean follow-up of 14.0 months. Similar to others, these authors abandoned the "keyhole techniques" because of a high recurrence rate and have transitioned to a "modified Sugarbaker technique" with promising early results. Other recently described laparoscopic techniques for PSH repair include meshplasty with stoma relocation[65], and a two-mesh sandwich procedure [32, 66] both of which have demonstrated low complication and recurrence rates in the early postoperative period.
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