Stoma complications: the Cook County Hospital experience

Stoma Complications

Stoma-related complications are among the most common sources of perioperative morbidity in colorectal surgery. Complications can occur intraoperatively, in the immediate postoperative period, or even months to years after stoma creation. Although some will require urgent surgical intervention, most are treated nonoperatively with a combination of education, appliance adjustment, and behavioral intervention. Optimal management of stoma complications nearly always requires a multidisciplinary team approach, including surgeons, enterostomal therapists, and other allied health professionals, depending on the specific situation. Patients with a functional stoma should be expected to be able to do anything that patients without a stoma can do with minimal exceptions. The treatment of stoma complications therefore centers on improving stoma function and maximizing quality of life. Although timely and comprehensive intervention will result in the resolution of most stoma complications, there is no substitute for preoperative planning and meticulous stoma creation.

Management Strategies for Malignant Left-Sided Colonic Obstruction: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Propensity Score Matching Studies

BACKGROUND

The optimal treatment strategy for left-sided malignant colonic obstruction remains controversial. Emergency colonic resection has been the standard of care; however, self-expanding metallic stenting as a bridge to surgery may offer short-term advantages, although oncological concerns exist. Decompressing stoma may provide a valid alternative, with limited evidence.

OBJECTIVE

To perform a systematic review and Bayesian arm random-effects model network meta-analysis comparing the approaches for management of malignant left-sided colonic obstruction.

DATA SOURCES

A systematic review of PubMed, Embase, Cochrane Library, and Google Scholar databases was conducted from inception to August 22, 2023.

STUDY SELECTION

Randomized controlled trials and propensity score-matched studies.

INTERVENTIONS

Emergency colonic resection, self-expanding metallic stent, and decompressing stoma.

MAIN OUTCOME MEASURES

Oncologic efficacy, morbidity, successful minimally invasive surgery, primary anastomosis, and permanent stoma rates.

RESULTS

Nineteen of 5225 articles identified met our inclusion criteria. Stenting (risk ratio 0.57; 95% credible interval, 0.33-0.79) and decompressing stomas (risk ratio 0.46, 95% credible interval: 0.18-0.92) resulted in a significant reduction in the permanent stoma rate. Stenting facilitated minimally invasive surgery more frequently (risk ratio 4.10; 95% credible interval, 1.45-13.13) and had lower overall morbidity (risk ratio 0.58; 95% credible interval, 0.35-0.86). A pairwise analysis of primary anastomosis rates showed increased stenting (risk ratio 1.40; 95% credible interval, 1.31-1.49) compared with emergency resection. There was a significant decrease in the 90-day mortality with stenting (risk ratio 0.63; 95% credible interval, 0.41-0.95) compared with resection. There were no differences in disease-free and overall survival rates, respectively.

LIMITATIONS

There is a lack of randomized controlled trials and propensity score matching data comparing short-term and long-term outcomes for diverting stomas compared to self-expanding metallic stents. Two trials compared self-expanding metallic stents and diverting stomas in left-sided malignant colonic obstruction.

CONCLUSIONS

This study provides high-level evidence that a bridge-to-surgery strategy is safe for the management of left-sided malignant colonic obstruction and may facilitate minimally invasive surgery, increase primary anastomosis rates, and reduce permanent stoma rates and postoperative morbidity compared with emergency colonic resection.

Colon stenting as a bridge to surgery in obstructive colorectal cancer management

Colonic stent placement is a commonly used bridging strategy for surgery in patients with obstructive colorectal cancer. The procedure involves the placement of a self-expandable metallic stent (SEMS) across the obstructive lesion to restore intestinal patency and alleviate the symptoms of obstruction. By allowing patients to receive surgery in a planned and staged manner with time for preoperative optimization and bowel preparation, stent placement may reduce the need for emergency surgery, which is associated with higher complication rates and poorer outcomes. This review focuses on the role of colon stenting as a bridge to surgery in the management of obstructive colorectal cancer. SEMS as a bridge to surgery for left-sided colon cancer has been demonstrated to be particularly useful; however, further research is needed for its application in cases of right-sided colon cancer. Colon stent placement also has limitations and potential complications including stent migration, re-obstruction, and perforation. However, the timing of curative surgery after SEMS placement remains inconclusive. Considering the literature to date, performing surgery at an interval of approximately 2 weeks is considered appropriate. Therefore, colonic stent placement may be an effective strategy as a bridge to surgery in patients with obstructive colorectal cancer.

Management of the Difficult Stoma

Fecal ostomy creation is a commonly performed procedure with many indications. Better outcomes occur when preoperative patient education and stoma site marking are provided. Despite a seemingly simple operation, ostomy creation is often difficult and complications are common. Certain risk factors, particularly obesity, are strongly associated with stoma-related complications. The ability to optimize the ostomy and stoma in the operating room and to troubleshoot frequently encountered post-operative stoma-related issues are critical skills for surgeons and ostomy nurses alike.

Diverting Stoma-Related Evisceration: A Comprehensive Review of 28 Case Reports Published in the Medical Literature in English

Evisceration is an exceptional complication of diverting a stoma (a common procedure, often considered a minor surgery) with peculiar, specific, features (distinct-to-usual incisional evisceration), due to the presence of a stoma. Available data are limited to a few case reports; some aspects are not fully documented. The results of 28 case reports (full-text articles published in the English literature) were analyzed using 14 variables: age and gender; pathology; surgical setting; index surgery and type of stoma; intended stoma creation; time from surgery to evisceration; type of evisceration; visceral content; cause of evisceration; specific predisposing/risk factors; surgical approach; resection of nonviable content; surgical stoma treatment; and short-term outcome. Urgent surgery resulted in 46.42% resection of nonviable eviscerated content and 7.14% mortality. All issues (some not discussed in previous reviews) were analyzed, to highlight their clinical relevance for surgical practice. The mechanisms (types of evisceration) are different in parastomal and transstomal/intrastomal evisceration; they should be considered as distinct entities. The real (underlying) etiology was identified in 26/28 case reports (92.85%): surgical failure, such as inadequate technique/tactics/strategy (12/26 case reports, 46.15%); trauma (7/26 case reports, 26.92%); and spontaneous necrosis (6/26 case reports, 21.42%). Parastomal hernia and/or prolapse (10/28 case reports, 35.71%) were specific predisposing factors; in such cases, early surgical treatment is recommended. Temporary stoma was a potential risk factor, both for early as well as for late evisceration (e.g., long-standing temporary stoma); in such cases, early take-down or conversion to definitive stoma is beneficial. A local surgical approach (avoiding median laparotomy) was used in 13/28 (46.42%) of case reports. Seven different surgical options were used for surgical stoma treatment, demonstrating versatility; the initial stoma site was preserved in 22/28 (78.57%) of case reports.

Proximal protective diverting ostomy following colon anastomosis for penetrating trauma may not be protective: A matched cohort study

INTRODUCTION

Despite the shift toward liberal primary anastomosis in penetrating colon injuries, some surgeons recommend a protective diverting ostomy (DO) proximal to the anastomosis. This study evaluates the effect of DO on outcomes in patients undergoing colon resection and anastomosis following penetrating trauma.

METHODS

The TQIP database (2013-2018) was queried for penetrating colon injuries undergoing colectomy and anastomosis. Patients receiving DO were propensity matched to patients without diverting ostomy (woDO) (1:3). Outcomes were compared between groups.

RESULTS

After matching, 89 DO patients were analyzed. The DO group had more surgical site infections (32 ​% vs. 21 ​%; p ​< ​0.05) and longer hospital stay (20 [13-27] vs. 15 [9-25]; p ​< ​0.05) compared to the woDO group. Mortality and unplanned operations were similar between groups.

CONCLUSIONS

Diverting ostomy after colon resection and anastomosis is associated with increased infectious complications without decreasing unplanned operations or mortality. Its routine role in penetrating colon trauma needs reassessment.

Repair of stoma prolapse with the "peristomal cerclage" method using vessel tape

Stoma prolapse is one of the most common late complications following stoma construction. Although prolapses can be managed conservatively, they often require surgical revision. This study aimed to describe a revision method called peristomal cerclage applied with local anesthesia to treat stoma prolapse. A 66-year-old male patient with advanced rectal cancer underwent sigmoid loop colostomy one year ago due to a distal occlusive tumor. A revision of the colostomy prolapse that developed postoperatively was planned. After the reduction of the 12 cm prolapse into the abdomen under local anesthesia, a repair was performed in the form of peristomal wrapping of a vessel tape; except for short-term abdominal distension, no complications developed in the patient. He is currently in the postoperative 26th month and terminal period, and his colostomy is working normally. The present report aimed to describe the peristomal cerclage method, a minimally invasive revision procedure applied to patients with stoma prolapse, and to deliver its long-term results. It is important to report the results obtained with the more widespread use of this method.

Surgical management of ostomy complications: a MISSTO-WSES mapping review

BACKGROUND

The creation of an ileostomy or colostomy is a common surgical event, both in elective and in emergency context. The main aim of stoma creation is to prevent postoperative complications, such as the anastomotic leak. However, stoma-related complications can also occur and their morbidity is not negligible, with a rate from 20 to 70%. Most stomal complications are managed conservatively, but, when this approach is not resolutive, surgical treatment becomes necessary. The aim of this mapping review is to get a comprehensive overview on the incidence, the risk factors, and the management of the main early and late ostomy complications: stoma necrosis, mucocutaneous separation, stoma retraction, stoma prolapse, parastomal hernia, stoma stenosis, and stoma bleeding.

MATERIAL AND METHODS

A complete literature research in principal databases (PUBMED, EMBASE, SCOPUS and COCHRANE) was performed by Multidisciplinary Italian Study group for STOmas (MISSTO) for each topic, with no language restriction and limited to the years 2011-2021. An international expert panel, from MISSTO and World Society of Emergency Surgery (WSES), subsequently reviewed the different issues, endorsed the project, and approved the final manuscript.

CONCLUSION

Stoma-related complications are common and require a step-up management, from conservative stoma care to surgical stoma revision. A study of literature evidence in clinical practice for stoma creation and an improved management of stoma-related complications could significantly increase the quality of life of patients with ostomy. Solid evidence from the literature about the correct management is lacking, and an international consensus is needed to draw up new guidelines on this subject.

Healing Peristomal Wounds Around Retracted Stomas with Negative-Pressure Wound Therapy: A Case Series

ABSTRACT

One method for treating a retracted stoma is a vacuum dressing that cleans the wound and protects against intestinal leakage. This case series describes the use of an integrated, single-use negative-pressure wound therapy (NPWT) dressing to treat retracted stomas as an alternative to other noninvasive remedies. The report includes seven patients who were hospitalized in the authors' surgical department from 2019 to 2020. All patients developed severe peristomal infection that failed to respond to local treatment with proper ostomy appliances or specialist dressings. After cleaning each wound and removing necrotic lesions, the authors applied a single-use hydrofiber NPWT dressing to each patient. The dressing was changed every 2 to 5 days, depending on the effects of the therapy. The stoma orifice was covered with a bag with two-piece ostomy systems. The peristomal wound healed in all cases, and leakage was eliminated. The mean time of treatment was 14 days (range, 10-21 days), and the vacuum dressings were changed an average of four times (range, 3-7 times). None of the patients required a stoma translocation or other additional surgery. Three patients received systemic IV antibiotic therapy to treat general infection. Single-use NPWT dressings protect peristomal wounds from bowel leakage and do not hinder the application of stoma bags. This system, similar to standard NPWT devices, effectively protects infected stomas from retraction.

Surgical treatment of stomal prolapse: A systematic review and meta-analysis of the literature

AIM

This study aimed to assess success, recurrence, and overall complication rates among different surgical procedures for stomal prolapse.

METHODS

This study was a PRISMA-compliant systematic review. PubMed, Scopus, and Google Scholar were searched until March 2022. Studies that assessed surgical treatments of stomal prolapse in adults were included. The primary outcome was recurrence of stomal prolapse and the secondary outcome was 30-day complications. A random-effect meta-analysis was used to estimate the weighted mean rates of recurrence.

RESULTS

Six studies published (111 patients; 103 males) were included. 52 (46.8%) patients had end colostomies, 35 (31.5%) had loop colostomies. Seven procedures were assessed and included local stoma reconstruction (40%), stapled local repair (27%), modified Altemeier technique (10%), mesh strip repair (9%), stoma relocation (6%) redo laparotomy repair (5%), and colectomy and end ileostomy (3%). The weighted mean recurrence rate after local stoma reconstruction was 37.2% (95% CI: -1.8 to 76.3), higher than that after the stapled local repair technique (14.9%; 95% CI: 1.7-28.2). The crude recurrence rate of the modified Altemeier technique was 20%, and of stoma relocation was 66.6%. No recurrence was detected after the mesh strip technique (n = 10). The median follow-up ranged between 7 months and 2.5 years.

CONCLUSION

Several surgical techniques are available to treat stomal prolapse. Local stoma reconstruction may be associated with high rates of recurrence while the stapled local repair and modified Altemeier procedure has relatively low recurrence. Further larger studies are needed to compare the efficacy of these techniques.

Indications for, and outcomes of, end ileostomy revision procedures

AIM

Ileostomy complications have been reported in >70% of cases. Older studies have shown ileostomy revision to be required in 23%-38% of patients over a 5-10 year period. There is a paucity of recent data addressing ileostomy revision surgery. We aimed to review end ileostomy revisions in a tertiary centre and analyse indications, procedures performed, outcomes and risks for such surgery.

METHODS

This was a retrospective review in a single institution colorectal referral practice. All patients aged >17 years who underwent a revision of an ileostomy at our institution from 2008 to 2019 were included. Indication for ileostomy revision, operative technique (parastomal vs. intra-abdominal) and outcomes including length of stay, readmission rates, wound complications, medical complications and rate of stoma re-revision were assessed.

RESULTS

Fifty-three patients who underwent 72 end ileostomy revision procedures were included; 20 (27.8%) were re-revision procedures. The majority (76.4%) had their original ileostomy created for inflammatory bowel disease. Indications for ileostomy revision were stoma retraction (36.1%), prolapse (22.2%), stenosis (18.1%) and parastomal hernia (29.2%). Of stoma revisions, 55.6% were performed by a parastomal approach vs. 44.4% by an intra-abdominal approach. Procedures were a combination of laparotomy, laparoscopy or both. The average length of stay was statistically significantly lower in the parastomal approach revision group (2.3 days) compared to the intra-abdominal approach revision group (10.3 days) (P < 0.001). Readmission and wound complication rates were 6.9% and 15.3%, respectively, in the intra-abdominal approach group alone. Medical complication rates were 20.8%.

CONCLUSIONS

End ileostomy complications are common and surgical treatment may result in significant morbidity, readmission and reoperation. Patients should be counselled about these possibilities.

A Consensus on Stomal, Parastomal, and Peristomal Complications

OBJECTIVE

To establish a consensus on terminology used to define stomal, parastomal, and peristomal complications in Australia.

METHODS

A list of stomal, parastomal, and peristomal complications was generated through group dialogue, which was informed by clinical and academic knowledge of the researchers. An extensive literature review was undertaken to identify any additional terms and to create a database of definitions/descriptions. A library of images related to the identified conditions was generated. An online Delphi process was conducted among a representative, purposive sample of Australia expert wound, ostomy, and continence nurses and colorectal surgeons. Ten terms were presented to the panel with descriptive photographs of each complication. Up to three Delphi rounds and, if necessary, a priority voting round were conducted.

RESULTS

Seven of the 10 terms reached agreement in the first round. One term ( allergic dermatitis ) was refined ( allergic contact dermatitis ) and reached agreement in the second round. Two terms ( mucocutaneous granuloma and mucosal granuloma ) were considered by the panel to be the same condition in different anatomical locations and were combined as one term ( granuloma ). Two terms ( skin stripping and tension blisters ) were combined as one term ( medical adhesive-related skin injury ) and reached agreement in round 2.

CONCLUSIONS

A consensus in terminology used to describe stomal or parastomal/peristomal complications will enhance communication among patients and health professionals and advance opportunities for education and benchmarking of stomal, parastomal, and peristomal complications nationally.

The effect of preoperative stoma site marking on risk of stoma-related complications in patients with intestinal ostomy - A systematic review and meta-analysis

AIM

This systematic review and meta-analysis aimed to investigate the effect of preoperative stoma site marking on stoma-related complications in patients with intestinal ostomy.

METHODS

MEDLINE, Embase, CENTRAL, CINHAL, and Google Scholar were searched up to August 2021 for randomised controlled trials (RCTs) and nonrandomised studies of interventions (NRSI) that involved patients with intestinal ostomies comparing preoperative stoma site marking to no marking and which reported at least one patient-relevant outcome. Outcomes were prioritised by stakeholder involvement. Random-effects meta-analyses produced odds ratios (ORs) or standardised mean differences (SMD) and 95% confidence intervals (CIs). The ROBINS-I tool and the GRADE approach were used to assess the risk of bias and certainty of evidence, respectively.

RESULTS

This review included two RCTs and 25 NRSI. The risk of bias was high in RCTs and serious to critical in NRSI. Although preoperative site marking reduced stoma-related complications (OR: 0.45, 95% CI: [0.31-0.65]), dependence on professional or unprofessional care (narrative synthesis), and increased health-related quality of life (SMD: 1.13 [0.38-1.88]), the evidence is very uncertain. Preoperative site marking may probably reduce leakage (OR: 0.14 [0.06-0.37]) and may decrease dermatological complications (OR: 0.38 [0.29-0.50]) and surgical revision (OR: 0.09 [0.02-0.49]). The confidence in the cumulative evidence was moderate to very low.

CONCLUSION

Despite low quality evidence, preoperative stoma site marking can prevent stoma-related complications and should be performed in patients undergoing gastrointestinal surgery given that this intervention poses no harm to patients.

Destructive colon injuries requiring resection: Is colostomy ever indicated?

BACKGROUND

The management of destructive colon injuries requiring resection has shifted from mandatory diverting stoma to liberal use of primary anastomosis. Various risk criteria have been suggested for the selection of patients for primary anastomosis or ostomy. At our center, we have been practicing a policy of liberal primary anastomosis irrespective of risk factors. The purpose of this study was to evaluate the colon-related outcomes in patients managed with this policy.

METHODS

This retrospective study included all colon injuries requiring resection. Data collected included patient demographics, injury characteristics, blood transfusions, operative findings, operations performed, complications, and mortality.

RESULTS

A total of 287 colon injuries were identified, 101 of whom required resection, forming the study population. The majority (63.4%) were penetrating injuries. Furthermore, 16.8% were hypotensive on admission, 40.6% had moderate or severe fecal spillage, 35.6% received blood transfusion of >4 U, and 41.6% had Injury Severity Score of >15. At index operation, 88% were managed with primary anastomosis and 12% with colon discontinuity, and one patient had stoma. Damage-control laparotomy (DCL) with temporary abdominal closure was performed in 39.6% of patients. Of these patients with DCL, 67.5% underwent primary anastomosis, 30.0% were left with colon discontinuity, and 2.5% had stoma. Overall, after the definitive management of the colon, including those patients who were initially left in colon discontinuity, only six patients (5.9%) had a stoma. The incidence of anastomotic leaks in patients with primary anastomosis at the index operation was 8.0%, and there was no colon-related mortality. The incidence of colon anastomotic leaks in the 27 patients with DCL and primary anastomosis was 11.1%, and there was no colon-related mortality. Multivariate analysis evaluating possible risk factors identified discontinuity of the colon as independent risk factor for mortality.

CONCLUSION

Liberal primary anastomosis should be considered in almost all patients with destructive colon injuries requiring resection, irrespective of risk factors.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Stoma-Related Complications: A Single-Center Experience and Literature Review

Introduction: The creation of an abdominal stoma is a common procedure performed by surgeons as a part of the treatment for benign and malignant conditions in general surgery. Stoma formation is simple, but sometimes the associated postoperative complications have an impact on the patients’ physical and psychological state. The majority of complications do not require reoperation, but when it is indicated, we have to assess the most appropriate option for the patient.

Material and Methods: We conducted a retrospective study in a single surgical center, the Department of Surgery, Mureș County Hospital, Târgu Mureș, Romania, using data from patients who have been admitted under elective conditions for stoma-related complications between 2005 and 2019.

Results: A total number of 877 ostomies (653 colostomies and 224 ileostomies) were performed, and 157 patients (17.9%) developed some type of stoma complication and required surgical intervention. The mean age was 64.5 ± 2.1 years, with a male-female ratio of 1.3 to 1. The leading comorbidities included cardiovascular disease (52.2% of cases), obesity (22.2%), and diabetes (18.4%). Parastomal hernia was the most frequent complication (47.5% of cases), followed by stoma prolapse (23.4%), parastomal stenosis (20.3%), and parastomal infection (8.2%). There was an association between age and the type of complication: parastomal hernia, stoma prolapse, and stenosis were more frequent in the elderly; parastomal infection was more prevalent in young patients. A longer hospital stay was observed in case of parastomal hernia.

Conclusions: Stoma formation is associated with significant morbidity. Typically, the complications appear in the elderly. Conservative treatment is essential, but some of the late complications, such as parastomal hernia, stoma stenosis, stoma prolapse, and parastomal infection, require a surgical solution. Parastomal hernias are the most common complications, frequently associated with comorbidities and prolonged hospitalization.

Stoma-related complications and emergencies

Stoma creations are common procedures in surgical specialties. They can be created either as a temporary or a permanent measure. Despite advancements in surgical technique and stoma care, complications are common. Patients experiencing stoma-related complications often present to the emergency department. Emergency physicians are not expected to be stoma experts, yet they are often the first point of contact for patients experiencing stoma-related complications. Accordingly, emergency physicians should be familiar with the types of stomas and complications and emergencies associated with them so that they can appropriately address the problems related to stomas. This article will provide a review of emergencies and complications associated with ileostomies, colostomies, and urostomies.

Comparison of the extraperitoneal and transperitoneal routes for permanent colostomy: a meta-analysis with RCTs and systematic review

Aim

To assess the efficacy of extraperitoneal colostomy (EPC) in preventing stoma-related complications.

Background

Transperitoneal colostomy (TPC) is a widely used surgical approach. However, TPCs have been reported to have increased risks of stoma-related complications, such as parastomal hernias, stomal retraction, and stomal prolapse. The purpose of EPC is to reduce these complications. However, there is still a lack of evidence-based studies.

Materials and methods

MEDLINE, EMBASE, Web of Science, Scopus, MOOSE, PubMed, Google Scholar, Baidu Scholar, and the Cochrane Library were searched to conduct a systematic review and meta-analysis with RCTs. The meta-analysis was performed with RevMan 5.4 software.

Results

This study included 5 eligible RCTs. Compared with the TPC group, the EPC group had lower incidence rates of parastomal hernias (RR, 0.14; 95% CI, 0.04–0.52, P = 0.003, I² = 0%) and stomatal prolapse (RR, 0.27; 95% CI, 0.08–0.95, P = 0.04, I² = 0%), but a higher rate of defecation sensation (RR, 3.51; 95% CI, 2.47–5.0, P < 0.00001, I² = 37%). No statistically significant differences were observed in stoma retraction, colostomy construction time, stoma ischemia, or stoma necrosis.

Conclusion

Extraperitoneal colostomies are associated with lower rates of postoperative complications than transperitoneal colostomies. A randomized controlled trial meta-analysis found that permanent colostomies after abdominoperineal resection resulted in better outcomes.

Minimizing Enterostomy Complication in Neonates, Lessons Learnt from Three European Tertiary Centres

INTRODUCTION

Stoma formation in neonates is often a life-saving procedure across a variety of conditions but is still associated with significant morbidity. Tube stoma technique was originally described for short bowel patients, but in selected cases of neonates this approach could prevent the incidence of stoma-related complications. The aim of the study was to evaluate the safety and utility of tube stomas as an alternative to conventional enterostomy in the neonatal population.

MATERIAL AND METHODS

A retrospective multicentre analysis of neonates undergoing emergency laparotomy and tube stoma formation between 2005 and 2017 was performed. Tube stoma complications were analysed. The investigation focused on stricture, skin lesion, enteric fistula and prolapse.

RESULTS

Thirty-seven neonates underwent tube stoma fashioning during the study period. Tube-stoma complications were limited to three patients (8.1%), with two children (5.4%) requiring additional stoma surgery during the first 30 days because of an enterocutaneous fistula, and one child (2.7%) for bowel stenosis.

CONCLUSIONS

In select neonates, such as those with proximal enteric stomas, the tube stoma avoids some of the commonly encountered complications (prolapse, skin excoriation). Further prospective studies are needed to validate these findings in order for us to recommend this technique as superior.

A Comparative Study between Scanning Devices for 3D Printing of Personalized Ostomy Patches

This papers presents a comparative study of three different 3D scanning modalities to acquire 3D meshes of stoma barrier rings from ostomized patients. Computerized Tomography and Structured light scanning methods were the digitization technologies studied in this research. Among the Structured Light systems, the Go!Scan 20 and the Structure Sensor were chosen as the handheld 3D scanners. Nineteen ostomized patients took part in this study, starting from the 3D scans acquisition until the printed ostomy patches validation. 3D mesh processing, mesh generation and 3D mesh comparison was carried out using commercial softwares. The results of the presented study show that the Structure Sensor, which is the low cost structured light 3D sensor, has a great potential for such applications. This study also discusses the benefits and reliability of low-cost structured light systems.

Colostomy orifice complications: a case report of a prolapsed colostomy with necrosis of the eviscerated greater omentum

Evisceration and necrosis of the greater omentum at the site of a prolapsed colostomy is a rare situation. Considered an early stoma complication, it often occurs during the first month after surgery. We report the observation and our attitude to such a situation in a 56-year-old patient who underwent initial surgery for a locally advanced rectal adenocarcinoma after receiving neoadjuvant radio-chemotherapy. A loop colostomy for decompression was performed due to large bowel obstruction. On the 10th day after surgery, he was readmitted for an oedematous prolapsed colostomy and a necrotic end of the greater omentum, which eviscerated through the colostomic hole, secondary to severe ascites. Emergency re-intervention involving resection of the prolapsed stoma with the necrotic segment of the omentum was performed. The three factors associated with the development of this rare peri-colostomy complication were: emergency surgery, locally advanced rectal tumor, and increased intra-abdominal pressure.

Primary Adenocarcinoma at Colostomy Site: Report of a Clinical Case

Colorectal cancer (CRC) is the fourth most frequently diagnosed cancer in the United States and it is found in 17% of patients thought to have complicated diverticular disease. However, primary adenocarcinoma rarely occur in the colostomy site and the risk of developing malignancy is similar to that of any other colonic segment. Polyps found in CRC screenings can be divided into the following types: hyperplastic polyps, polyps with no malignant potential, adenomatous polyps, polyps with malignant potential, and malignancies. Local complications of the colostomy can appear in the immediate, early, or late postoperative period, with an incidence ranging from 15 to 30%; neoplasia is even less common.

Patient-Related Factors Associated With Stoma and Peristomal Complications Following Fecal Ostomy Surgery: A Scoping Review

PURPOSE

Ostomy creation is often an integral part of the surgical management of various diseases including colorectal malignancies and inflammatory bowel disease. Stoma and peristomal complications may occur in up to 70% of patients following ostomy surgery. The aim of this scoping literature review was to synthesize evidence on the risk factors for developing complications following creation of a fecal ostomy.

DESIGN

Scoping literature review.

SEARCH STRATEGY

Two independent researchers completed a search of the online bibliographic databases PubMed, MEDLINE, Cochrane, Google Scholar, and EMBASE for all articles published between January 1980 and December 2018. The search comprised multiple elements including systematic literature reviews with meta-analysis of pooled findings, randomized controlled trials, cohort studies, observational studies, other types of review articles, and multiple case reports. We screened 307 unique titles and abstracts; 68 articles met our eligibility criteria for inclusion. The methodological rigor of study quality included in our scoping review was variable.

FINDINGS/CONCLUSIONS

We identified 6 risk factors associated with an increased likelihood of stoma or peristomal complications (1) age more than 65 years; (2) female sex; (3) body mass index more than 25; (4) diabetes mellitus as a comorbid condition; (5) abdominal malignancy as the underlying reason for ostomy surgery; and (6) lack of preoperative stoma site marking and WOC/ostomy nurse specialist care prior to stoma surgery. We also found evidence that persons with a colostomy are at a higher risk for prolapse and parastomal hernia.

IMPLICATIONS

Health care professionals should consider these risk factors when caring for patients undergoing fecal ostomy surgery and manage modifiable factors whenever possible. For example, preoperative stoma site marking by an ostomy nurse or surgeon familiar with this task, along with careful perioperative ostomy care and education of the patient by an ostomy nurse specialist, are essential to reduce the risk of modifiable risk factors related to creation of a fecal ostomy.

Predicting Early and Late Readmissions Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Background

Postoperative readmissions not only burden the healthcare system but may also affect clinical outcomes of cancer patients. Despite this, little is known about readmissions after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), or their impact on survival outcomes.

Patients and Methods

A single-institution retrospective cohort study of CRS-HIPEC procedures from April 2001 and September 2019 was performed. Early readmission (ERA) was defined as hospitalization within 30 days of discharge post-CRS/HIPEC, while late readmission (LRA) was defined as hospitalization between day 31 and 90 after discharge. Patient demographic, oncological, and perioperative factors were analyzed to identify predictors of readmission, and comparison of survival outcomes was performed.

Results

Overall, 342 patients who underwent CRS-HIPEC were included in the study. The incidence of ERA and LRA was 18.5% and 7.4%, respectively. High-grade postoperative complication was the only independent predictor of ERA (HR 3.64, 95% CI 1.47–9.02), while comorbid hypertension (HR 2.71, 95% CI 1.17–6.28) and stoma creation (HR 2.83, 95% CI 1.23–6.50) were independent predictors for LRA. Patients with readmission had significantly worse disease-free survival than patients who had no readmission (NRA) (LRA 1.1 years, ERA 1.2 years, NRA 1.8 years, p = 0.002), and patients with LRA had worse median overall survival (2.1 years) than ERA patients (3.3 years) or patients without readmission (4.4 years) (p < 0.001).

Conclusions

Readmission following CRS-HIPEC is associated with adverse survival outcomes. In particular, LRA may portend worse prognosis than ERA.

The Use of a Stoma Rod/Bridge to Prevent Retraction: A Systematic Review

PURPOSE

We evaluated evidence related to the use of a rod (bridge) to prevent stoma retraction during loop ostomy construction.

METHODS

We completed a systematic review of the literature. We searched MEDLINE, EMBASE, and COCHRANE databases up to December 4, 2019. We posed the following question based on a PICO format. Do adult patients undergoing ostomy surgery experience less stomal retraction when compared to patients managed without placement of a stoma rod?

FINDINGS

Our initial search returned 182 articles; after reading studies in full, 5 articles were identified that collectively enrolled 1058 participants. Four studies were randomized controlled trials and one was a prospective cohort study. Meta-analysis could not be performed because of the small number of studies and the heterogeneity of outcomes measurements. The incidence of stoma retraction ranged between 0%-8% in patients managed with a rod and 0.78%-8.2% in patients with no rod. The number of reported adverse events was low. Placement of a stoma rod was associated with more adverse outcomes than in patients managed without a rod. Adverse events included local edema, stoma necrosis, skin necrosis, peristomal moisture-associated skin damage (irritant dermatitis), peristomal abscess, bleeding, and mucocutaneous separation.

CONCLUSIONS

Stoma rod does not seem to reduce the risk of stoma retraction and might result in other adverse events.

IMPLICATIONS

We recommend avoidance of stoma rod/bridge placement during ostomy surgery.

Practical insights into stomas in inflammatory bowel disease: what every healthcare provider needs to know

PURPOSE OF REVIEW

Despite advances in medical and surgical therapy in inflammatory bowel disease (IBD) management, intestinal stomas can be needed in a significant proportion of patients. The impact of stomas in patients' lives is significant, and the topic is still challenging for different specialties involved in IBD care.

RECENT FINDINGS

Indications for intestinal ostomies in IBD can occur in elective (malnutrition, anemia, or previous steroids) or emergency (perforation, abdominal abscess, obstruction) settings. Different types of stomas can be used (loop, end, or double loop ostomies) depending on different clinical scenarios. Ileostomies are more frequently needed in IBD patients than colostomies, which may be associated with higher rates of recurrence in Crohn's disease. Only 16.6% of patients with diverting stomas for perianal Crohn's disease have successful transit restoration, and stomas become permanent. Prevention of complications is based on adequate preoperative demarcation and meticulous surgical technique. IBD stoma-related morbidity can occur in up to 70% of patients, are more common in Crohn's disease, and can be classified into early or late complications.

SUMMARY

A multidisciplinary approach including gastroenterologists, surgeons, and stoma nurses is essential for IBD patients who will face the challenge of having a stoma during their disease course.

The effectiveness of preoperative stoma site marking on patient outcomes: A systematic review and meta-analysis

AIMS

This study systematically reviews the literature regarding preoperative stoma site marking and discusses the effectiveness of the procedure on complication rates, self-care deficits and health-related quality of life (HRQOL).

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

Our review was conducted following the PRISMA guidelines. PubMed, EMBASE, Cochrane and CINAHL databases were searched to obtain articles published in English. Articles were also retrieved from Korean databases as well. Our last search was conducted on 2 June 2019.

REVIEW METHODS

Two reviewers independently selected relevant studies, evaluated their methodological quality and extracted data. Experimental and observational studies were included. Our main focus was on complication rates, self-care deficits and HRQOL. We conducted meta-analysis using the statistical software spss 25.0 and Stata 13.0.

RESULTS

Of the 1,039 articles reviewed, 20 were included for review, and 19 were used for quantitative synthesis. Preoperative stoma site marking reduced complication rates (odds ratio [OR]: 0.47; 95% confidence interval [CI]: 0.36-0.62; I² : 70.6%), lowered self-care deficits (OR: 0.34; 95% CI: 0.18-0.64; I² : 0%), and increased HRQOL (standardized mean difference, 1.05; 95% CI: 0.70-1.40; I² : 0%). Quality appraisal results for both the individual studies and the studies overall were excellent. The possibility of publication bias was low.

CONCLUSIONS

Our findings indicate that preoperative stoma site marking improves patient outcomes: stoma-related complication rates and self-care deficits decrease and HRQOL rises. For this reason, preoperative stoma site marking should be a mandatory procedure in clinical settings. The practice should also be supported by policymakers and healthcare expert associations.

IMPACT

Preoperative stoma site marking reduces overall complication rates by 53% and skin problems by 59%. Preoperative stoma site marking also improves self-care and health-related quality of life. We recommend that preoperative stoma site marking should be a mandatory procedure in clinical settings.

Penetrating colonic trauma and damage control surgery: Anastomosis or stoma?

BACKGROUND

The management of colon injuries in damage control surgery (DCS) remains controversial.

METHODS

A retrospective study investigating outcomes of penetrating colonic trauma in patients who survived beyond the initial repeat laparotomy (IRL) after DCS was performed. Patients over 18 years with penetrating colon injury and who underwent DCS from 2012 to 2020 were included from our electronic trauma registry. Demographic data, admission physiology and Injury Severity Score (ISS) were reviewed. Patients were classified into three groups: primary repair of non-destructive injuries at DCL, delayed anastomosis of destructive injuries at IRL and diversion of destructive injuries at IRL. Outcomes observed included leak rates, length of intensive care unit stay, length of hospital stay, morbidities, mortality and colon-related mortality.

RESULTS

Out of 584 patients with penetrating colonic trauma, 89 (15%) underwent DCS. After exclusions, 74 patients were analysed. Mean age was 32.8 years (SD 12.5); 67 (91%) were male. Mechanism of injury was gunshot in 63 (85%) and stab 11 (15%) patients. Seventeen patients underwent primary repair at DCS, of which one leaked. Twenty patients underwent delayed anastomosis at IRL. Of these, five (25%) developed leaks. Mortality was significantly higher for those with an anastomotic leak compared to those without (p < 0.001). Thirty-seven patients were diverted at IRL. Overall mortality (p = 0.622) and colon-related mortality (p = 0.592) were not significantly different across groups.

CONCLUSION

Delayed anastomosis at IRL following DCL was associated with a leak rate of 25% in this study. When anastomotic leak did occur, it was associated with significant mortality. Delayed anastomosis should only be undertaken in highly selected patients.

Quality of Life (QoL) Among Ostomized Patients – a cross-sectional study using Stoma-care QoL questionnaire about the influence of some clinical and demographic data on patients’ QoL

Introduction In Portugal around 20,000 individuals are ostomized, with all the associated changes in patients’ everyday life that can compromise their Quality of Life (QoL).

Objectives Assess and compare QoL of a group of ostomized patients according to sex, age group, type of surgery, primary disease, stoma duration and stoma type.

Material and methods Ostomized patients observed in Stomatherapy department in between January 1st and May 30th 2017 was enrolled. QoL was assessed using the questionnaire Stoma Care QoL Questionnaire). Four domains were evaluated: Self-esteem and Self-image – SeSi Score; relation with Family and Friends – FF Score; relation with Sleep and Fatigue – SF score and ostomy Device Functioning insecurities – DeF score.

Results Urostomy patients had significantly higher Total Scores, SeSi and FF scores than colostomy and ileostomy patients. Regarding SeSi Score, patients aged 70 years old or more and malignant diseases presented significantly higher scores than their younger counterparts and benign causes, respectively. FF Score document that patients with malignant diseases have significantly higher scores than patients with benign diseases.

Conclusions Ileostomy and colostomy patients have a significantly lower QoL than urostomy patients mostly because of its impact on social relations and self-esteem and self-image.

Colorectal resection in emergency general surgery: An EAST multicenter trial

OBJECTIVE

Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients.

METHODS

This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. χ, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality.

RESULTS

A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53-71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1-6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p < 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p < 0.001), on vasopressors (61 vs. 13, p < 0.001), have pneumoperitoneum (131 vs. 41, p < 0.001) or fecal contamination (114 vs. 33, p < 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p < 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality.

CONCLUSION

This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Thirty years of the health care service for ostomy patients in Juiz de Fora and surroundings

OBJECTIVE

to establish the epidemiological profile of ostomized patients treated at the Health Care Service for Ostomy Patients in Juiz de Fora and region (SASPO/JF) and to quantify the pathologies that led to the stoma as well as the ostomy-related complications.

METHOD

a retrospective study was carried out with the analysis of 496 medical records of patients registered at HCSOP/JF over 30 years and who remained in at the service in June 2018. The following variables were considered: age, sex, pathology that led to the stoma, type, time, location and complications of stomas.

RESULTS

53.43% were male patients and 46.57% female. The average age was 56.24 years among men and 58.40 years among women. Eight patients had two types of ostomies simultaneously and a total of 504 ostomies were as follows: 340 colostomies (67.46%), 117 ileostomies (23.21%) and 47 urostomies (9.33%). Additionally, 47.65% of the colostomies and 76.92% of the ileostomies were temporary, while all urostomies were permanent. In 70.24% of cases, the reason for making the stoma was malignancy. There were 277 stomas with one or more complications (54.96%).

CONCLUSIONS

most of the ostomized patients were over 50 years old and the main diagnosis that led to the stoma was malignancy. Ileostomies had a higher percentage of complications than colostomies and urostomies and, for all types of stomas, the most frequent complication was dermatitis.

Enhanced recovery after surgery nursing program, a protective factor for stoma-related complications in patients with low rectal cancer

BACKGROUND

This study aimed to investigate the association between enhanced recovery after surgery (ERAS) nursing program and stoma-related complications (SRCs) and prognosis in patients with low rectal cancer (LRC) undergoing abdominoperineal resection with sigmoidostomy.

METHODS

LRC patients who underwent elective abdominoperineal resection with sigmoidostomy between May 2016 and May 2019 were retrospectively enrolled. The occurrence of early major or minor SRCs (within postoperative 30 days) was set as the primary end-point. Clinicopathological variables and laboratory tests were compared between patients with or without SRCs. The univariate and multivariate logistic regression analyses were performed to investigate risk factors for SRCs. Hospitalization satisfaction-related and prognosis-related variables were compared between LRC patients with or without ERAS nursing program.

RESULTS

A total of 288 patients were enrolled and the incidence of SRCs was 26.7% (77/288). ERAS nursing program was the only independent risk factor for SRCs in LRC patients (OR 2.04, 95%CI 1.31-3.12, P = 0.016) by the multivariate logistic regression analysis. Moreover, ERAS nursing program was associated with higher hospitalization satisfaction rate, faster bowel function recovery, better psychological status, and higher quality of life.

CONCLUSIONS

ERAS nursing program was a protective factor for SRCs and associated with improved prognosis in LRC patients undergoing elective abdominoperineal resection with sigmoidostomy.

Minimally Invasive Correction of Prolapsed, Gangrenous Distal Limb of Loop Ileostomy to End-Loop Stoma

Introduction

Prolapse can be a complication of loop stomas. A prolapsed stoma which cannot be reduced or complicated with strangulation needs surgical correction. This case report describes a minimal access correction of a prolapsed gangrenous distal limb of ileostomy. Presentation of Case. A 67-year-old male patient was diagnosed with a lower rectal carcinoma, staged T3N1M0. Following neoadjuvant chemoradiation, he underwent a laparoscopic anterior resection with a defunctioning loop ileostomy. One month later, he presented with prolapse of the distal limb of the ileostomy. The limb was gangrenous and the gangrenous part was removed by using a linear GI stapler, and the loop ileostomy was converted to end-loop ileostomy. Discussion. It is a simple and technically feasible method for treating a prolapsed loop of the stoma. It is less invasive and has minimal postoperative complications. This technique reduces the duration of the hospital stay of the patient.

Conclusion

Stapled assisted correction of prolapsed stoma avoids unnecessary laparotomy and aids in expedite recovery after surgery. It is beneficial for a surgeon to be familiar with the minimal access correction for stoma prolapse.

Validation and Clinical Experience With a Turkish Language Version of the Pittman Ostomy Complication and Severity Index

PURPOSE

The purpose of this study was to evaluate the content validity and interrater reliability of a Turkish language version of the Pittman Ostomy Complication and Severity Index (OCSI).

DESIGN

Psychometric evaluation of instrument.

SUBJECTS AND SETTING

The sample comprised 90 individuals living with an ostomy for 2 to 6 months. Their mean age was 59.48 years (SD 13.292); 52.2% were female. Almost two-thirds (73.3%, n = 66) had experienced at least 1 ostomy complication. The study was conducted in the Wound and Stoma Therapy Unit of the Dokuz Eylül University Hospital General Surgery Clinic and Polyclinic in Izmir, Turkey.

METHODS

A Turkish language version of the OCSI was created using a translation, back-translation technique. The instrument's content validity was analyzed by 26 experts. Interrater reliability test was evaluated using Cohen's κ and intraclass correlation coefficients. Data were collected between January 15, 2017 and July 30, 2017 through face-to-face interviews conducted in our Wound and Stoma Therapy Unit.

RESULTS

The overall content validity index was 0.95. Cohen's κ coefficient varied from 0.70 and 1.0 for all items. The Pearson correlation coefficient and intraclass correlation coefficient were 0.982 (P = .000) and 0.986 (P = .000), respectively, indicating good internal consistency. The most prevalent complications were leakage (41.1%), peristomal moisture-associated skin damage (42.2%), and stomal retraction (27.7%).

CONCLUSIONS

Findings indicate that the Turkish language version of the Pittman OCSI is a reliable and valid instrument for assessment of presence and severity of early postoperative complications in individuals with an ostomy. We found the instrument parsimonious, easy-to-use, and clinically practical. It can be used to determine appropriate interventions to prevent or treat complications and evaluate the effects of nursing interventions designed to improve outcomes for patients with ostomies.

Outcomes of stapler repair with anastomosis for stoma prolapse

PURPOSE

The published data on the outcomes of an operative repair for stoma prolapse are limited. This study aimed to clarify the long-term outcomes of stapler repair with anastomosis for stoma prolapse.

METHODS

Twenty-four patients (15 men, median age 64 years, range 33-88 years) undergoing 25 stapler repairs with anastomosis were prospectively registered, and their medical records were retrospectively reviewed.

RESULTS

The median length of prolapse was 10 cm (range 5-22). Stoma prolapse repair was performed by means of 16 loop colostomies, four end colostomies, three loop ileostomies, and one end ileostomy. A stapler was used 4.6 times on average (range 4-8). The average operative time and bleeding were 40.8 (range 15-75) min and 40 (range 0-214) mL, respectively. No mortality and morbidity were observed after surgery. A recurrence of stoma prolapse was reported in only one of 25 repairs (4%) at the proximal limb of loop ileostomy during a median follow-up period of 1 year (range 1-120 months). However, a new stoma prolapsed in one untreated limb of loop stoma.

CONCLUSIONS

Stapler repair with anastomosis is a safe and minimally invasive treatment option for stoma prolapse with a low recurrence. However, the effectiveness of reparing stoma prolapse on the proximal limb of loop ileostomy might be limited.

Morbidity of Diverting Ileostomy for Rectal Cancer: Analysis of the American College of Surgeons National Surgical Quality Improvement Program

There is controversy regarding the potential benefits of diverting ileostomy after low anterior resection (LAR). This study aims to examine the morbidity associated with diverting ileostomy in rectal cancer. A retrospective review of LAR cases was performed using the American College of Surgeons National Surgical Quality Improvement Program (2005 to 2011). Patients who underwent LAR with and without diversion were selected. Demographics, intraoperative events, and postoperative complications were reviewed. Among the 6337 cases sampled, 991 (16%) received a diverting ileostomy. Patients who were diverted were younger (60 vs 63 years), predominantly male (64 vs 53%), and more likely to have received pre-operative radiation (39 vs 12%). There was no significant difference in steroid use, weight loss, or intraoperative transfusion. Postoperatively, there was no significant difference in length of stay, rate of septic complications, wound infections, and mortality. The rate of reoperation was lower in the diverted group (4.5 vs 6.9%). Diversion was associated with a higher risk-adjusted rate of acute renal failure (OR 2.4; 95% CI (1.2, 4.6); P < 0.05). The use of diverting ileostomy reduces the rate of reoperation but is associated with an increased risk of acute renal insufficiency. These findings emphasize the need for refinement of patient selection and close follow-up to limit morbidity.

A Rare Case of Prolapsed Sigmoid End Colostomy Complicated by Small Bowel Incarceration Treated with Manual Reduction and Emergency Surgery

Patient: Male, 74-year-old

Final Diagnosis: Prolapsed colostomy with small bowel incarceration

Symptoms: Small bowel obstruction

Medication:—

Clinical Procedure: Emergency laparotomy

Specialty: Surgery

Factors associated with failure of Enhanced Recovery After Surgery (ERAS) in colorectal and gastric surgery

Background: The Enhanced Recovery After Surgery (ERAS) pathway is widely applied in the perioperative period of stomach and colorectal surgery, and can decrease the length of hospital stay of the patients without compromising the safety of the patients. However, some patients are removed from this pathway for various reasons. Here we found some factors that taking the patients out from the procedures. Methods: A retrospective analysis of collected data of 550 patients over a 3-year period was conducted, with 292 in the ERAS group and 258 in the conventional care group. Then various basic elements were analyzed to explore the reasons for the failure to complete the ERAS program. Results: Total length of hospital stay after surgery was significantly shorter in the ERAS group, and a similar incidence of complication rates were observed in the two groups. In this study, the significant factors that associated with complications were advanced age (OR 2.18; p = .031), history of abdominal surgery (OR 2.03; p = .04), incomplete gastrointestinal obstruction (OR 3.42; p < .001), laparoscopic surgery (OR 0.39; p = .004) and intraoperative neostomy (OR 2.37; p = .006). Conclusions: We found that advanced age (>80 years old), history of abdominal surgery, gastrointestinal obstruction and stoma formation were the risk factors. We anticipated to design a risk assessment system upon the high-risk patients from the present ERAS pathway, and make a modified ERAS pathway for those patients.

Ostomy Complications in Crohn's Disease

Ostomy creation is a routine surgical procedure that has earned its place high in the surgeon's armamentarium in dealing with challenging situations. However, it is not without its complications. In this article, we review the common complications including parastomal hernia, prolapse, mucocutaneous junction separation with ischemia and stenosis, peristomal skin conditions, and infections. Additionally, we review conditions that arise in association with underlying Crohn's disease, such as peristomal inflammation, fistula formation, and pyoderma gangrenosum.

Lateral pararectal versus transrectal stoma placement for prevention of parastomal herniation

BACKGROUND

A parastomal hernia is defined as an incisional hernia related to a stoma, and belongs to the most common stoma-related complications. Many factors, which are considered to influence the incidence of parastomal herniation, have been investigated. However, it remains unclear whether the enterostomy should be placed through, or lateral to the rectus abdominis muscle, in order to prevent parastomal herniation and other important stoma complications.

OBJECTIVES

To assess if there is a difference regarding the incidence of parastomal herniation and other stoma complications, such as ileus and stenosis, in lateral pararectal versus transrectal stoma placement in people undergoing elective or emergency abdominal wall enterostomy.

SEARCH METHODS

For this update, we searched for all types of published and unpublished randomized and non-randomized studies in four medical databases: CENTRAL, PubMed, LILACS, Science Ciation Index, and two trials registers: ICTRP Search Portal and ClinicalTrials.gov to 9 November 2018. We applied no language restrictions.

SELECTION CRITERIA

Randomized and non-randomized studies comparing lateral pararectal versus transrectal stoma placement with regard to parastomal herniation and other stoma-related complications.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We conducted data analyses according to the recommendations of Cochrane and the Cochrane Colorectal Cancer Group (CCCG). We rated quality of evidence according to the GRADE approach.

MAIN RESULTS

Randomized controlled trials (RCT)Only one RCT met the inclusion criteria. The participants underwent enterostomy placement in the frame of an operation for: rectal cancer (37/60), ulcerative colitis (14/60), familial adenomatous polyposis (7/60), and other (2/60).The results between the lateral pararectal and the transrectal approach groups were inconclusive for the incidence of parastomal herniation (risk ratio (RR) 1.34, 95% confidence interval (CI) 0.40 to 4.48; low-quality evidence); development of ileus or stenosis (RR 2.0, 95% CI 0.19 to 20.9; low-quality evidence); or skin irritation (RR 0.67, 95% CI 0.21 to 2.13; moderate-quality evidence). The results were also inconclusive for the subgroup analysis in which we compared the effect of ileostomy versus colostomy on parastomal herniation. The study did not measured other stoma-related morbidities, or stoma-related mortality, but did measure quality of life, which was not one of our outcomes of interest.Non-randomized studies (NRS)Ten retrospective cohort studies, with a total of 864 participants, met the inclusion criteria. The indications for enterostomy placement and the baseline characteristics of the participants (age, co-morbidities, disease-severity) varied between studies. All included studies reported results for the primary outcome (parastomal herniation) and one study also reported data on one of the secondary outcomes (stomal prolapse).The effects of different surgical approaches on parastomal herniation (RR 1.22, 95% CI 0.84 to 1.75; 10 studies, 864 participants; very low-quality evidence) and the occurrence of stomal prolapse (RR 1.23, 95% CI 0.39 to 3.85; 1 study, 145 participants; very low-quality evidence) are uncertain.None of the included studies measured other stoma-related morbidity or stoma-related mortality.

AUTHORS' CONCLUSIONS

The present systematic review of randomized and non-randomized studies found inconsistent results between the two compared interventions regarding their potential to prevent parastomal herniation.In conclusion, there is still a lack of high-quality evidence to support the ideal surgical technique of stoma formation. The available moderate-, low-, and very low-quality evidence, does not support or refute the superiority of one of the studied stoma formation techniques over the other.

Evaluation of Cholestyramine 15% Ointment in Relieving Pruritus and Burning After Ileostomy: A Rrandomized, Double-Blind Placebo-Controlled Clinical Trial

Purpose/Aims: Skin irritation is a common ileostomy problem that causes burning and pruritus among patients due to the leakage of intestinal discharge around the stoma. This clinical trial was performed to evaluate the efficacy of topical cholestyramine (15%) on the reduction of the levels of burning and pruritus after an ileostomy. Material and methods: The patients were randomly divided into two groups of treatment and control (n = 15). The intervention group was subjected to one fingertip of cholestyramine, whereas the other group received the placebo ointment (approximately 0.5 g) on the skin immediately after the surgery and twice a day for 2 months. The primary outcome measure was the severity of burning and pruritus measured by a visual analog scale at different times after an ileostomy. Results: Out of 34 patients, four cases were excluded due to the inappropriate completion of the questionnaire (n = 2) and unwillingness to attend the follow-up visits (n = 2). Therefore, 30 patients were included in the study. The levels of burning among patients in the cholestyramine were lower in weeks 3, 4, and 8 compared to the placebo group. Moreover, lower levels of pruritus were observed among patients in the treatment group in weeks 4 and 8 after an ileostomy. No side effects were reported among the patients. Conclusions: Topical cholestyramine was found to be effective in the management of burning and pruritus resulting from an ileostomy among the population under study.

Colostomy on CT and fluoroscopy: What the radiologist needs to know

Colostomies are commonly created in conjunction with colorectal surgery performed for both malignant and benign indications. Familiarity with the different types of colostomies and their normal imaging appearance will improve radiologic detection and characterization of colostomy complications. The radiologist plays a large role in assessment of colostomy patients either via fluoroscopic technique or multidetector computed tomography (CT) in order to help identify ostomy complications or to aid the surgeon prior to colostomy reversal. In this article, we will review: (1) the types of colostomies and indications for their creation; (2) the proper radiographic technique of ostomy evaluation; and (3) the potential complications of colostomies and their imaging manifestations.

Management of penetrating intraperitoneal colon injuries: A meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

The management of penetrating colon injuries in civilians has evolved over the last four decades. The objectives of this meta-analysis are to evaluate the current treatment regimens available for penetrating colon injuries and assess the role of anastomosis in damage control surgery to develop a practice management guideline for surgeons.

METHODS

Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines section of EAST conducted a systematic review using MEDLINE and EMBASE articles from 1980 through 2017. We developed three relevant problem, intervention, comparison, and outcome (PICO) questions regarding penetrating colon injuries. Outcomes of interest included mortality and infectious abdominal complications.

RESULTS

Thirty-seven studies were identified for analysis, of which 16 met criteria for quantitative meta-analysis and included 705 patients considered low-risk in six prospective randomized studies. Seven hundred thirty-eight patients in 10 studies undergoing damage control laparotomy and repair or resection and anastomosis (R&A) were included in a separate meta-analysis. Meta-analysis of high-risk patients undergoing repair or R&A was not feasible due to inadequate data.

CONCLUSIONS

In adult civilian patients sustaining penetrating colon injury without signs of shock, significant hemorrhage, severe contamination, or delay to surgical intervention we recommend that colon repair or R&A be performed rather than routine colostomy. In adult high-risk civilian trauma patients sustaining penetrating colon injury, we conditionally recommend that colon repair or R&A be performed rather than routine colostomy. In adult civilian trauma patients sustaining penetrating colon injury who had damage control laparotomy, we conditionally recommend that routine colostomy not be performed; instead, definitive repair or delayed R&A or anastomosis at initial operation should be performed rather than routine colostomy.

LEVEL OF EVIDENCE

Systematic review/meta-analysis, level III.

[Effectiveness of various approaches for acute malignant colonic obstruction]

AIM

To determine optimal treatment strategy for acute malignant colonic obstruction.

MATERIAL AND METHODS

349 patients with acute malignant colonic obstruction were retrospectively analyzed for the period 2005-2017. All patients were divided into two groups depending on surgical approach. Surgical group comprised 259 patients, endoscopic group - 90 patients. Both groups were comparable by gender, age, level of intestinal obstruction and duration of the disease. However, morbidity and mortality rate were significantly different.

RESULTS

In surgical group incidence of complications was 63.3%, mortality - 19.7%. In group of endoscopic stenting the same values were 8.9% and 6.7%, respectively. Significant differences of morbidity and mortality were observed between groups (p<0.05).

CONCLUSION

Endoscopic stenting should be preferred over surgery to eliminate colonic obstruction in patients with acute malignant ileus.

Preoperative stoma site marking: a simple practice to reduce stoma-related complications

BACKGROUND

To evaluate the incidence and identify the risk factors of stoma-related complications in a consecutive series of patients treated at a single institution.

METHODS

For this retrospective analysis, the medical records of patients followed up at the stoma care centre of our institution over the last 16 years were reviewed. The primary end point was the incidence of stoma-related complications. Risk factors were tested using univariate and multivariate Cox proportional hazards models.

RESULTS

Of a total of 1076 patients, 604 received a colostomy and 472 an ileostomy. In all, 1055 stoma-related complications were recorded in 797 patients. Univariate analysis identified the following risk factors for stoma-related complications: male sex (p = 0.032), emergency surgery (p = 0.010), open surgery (p < 0.001), and ileostomy creation (p = 0.004). Preoperative stoma site marking was noted to play a protective role (hazard ratio 0.739; 95% confidence interval 0.576-0.947; p = 0.017). Multivariate analysis confirmed male sex and ileostomy creation as risk factors (p = 0.030 and p = 0.013, respectively) and preoperative stoma site marking as an independent protective factor (p = 0.001).

CONCLUSIONS

Stoma-related complications are quite common, especially when an ileostomy is present. Preoperative stoma site marking was noted to play a highly protective role not only in reducing the complication rate but also in improving the patients' quality of life.

The incidence of stoma related morbidity - a systematic review of randomised controlled trials

Introduction Several stoma related complications can occur following ileostomy or colostomy formation. The reported incidence of these conditions varies widely in the literature. A systematic review of randomised controlled trials reporting the incidence of stoma related complications in adults was performed to provide the most comprehensive summary of existing data. Methods PubMed, CINAHL® (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Library were searched for trials assessing the incidence of complications in adults undergoing conventional stoma formation. Data were extracted by two independent reviewers and entered into SPSS® for statistical analysis. The Cochrane Collaboration tool for assessing risk of bias was used to critically appraise each study. Cochran's Q statistic and the I2 statistic were used to measure the level of heterogeneity between studies. Results Overall, 18 trials were included, involving 1,009 patients. The incidence of stoma related complications ranged from 2.9% to 81.1%. Peristomal skin complications and parastomal hernia were the most common complications. End colostomy had the highest incidence of morbidity, followed by loop colostomy and loop ileostomy. There were no trials involving patients with end ileostomy. There was a high level of detection bias and heterogeneity between studies. Conclusions This systematic review has summarised the best available evidence concerning the incidence of stoma related morbidity. The high level of heterogeneity between studies has limited the accuracy with which the true incidence of each stoma related complication can be reported. Large, multicentre trials investigating homogenous participant populations are therefore required.