Pathophysiology and prevention of loop stomal prolapse in the transverse colon

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.

Feasibility and outcomes of robotic sphincter-preserving surgery for rectal cancer after neoadjuvant treatment in patients with preexisting colostomy

BACKGROUND

Diverting colostomy followed by neoadjuvant treatment is a treatment of choice for obstructive rectal cancer. Such patients may be treated via a robotic approach with several advantages over conventional laparoscopic surgery. Conversely, the existing stoma may interfere with the optimal trocar position and thus affect the quality of robotic surgery. Moreover, the console surgeon does not face the patient, which may endanger the stoma.

METHODS

Patients with rectal cancer who underwent sphincter-preserving surgery were retrospectively investigated using a robotic platform after neoadjuvant treatment at our hospital. Based on pretreatment stoma creation, patients were divided into the NS (those without a stoma) and S groups (patients with a stoma). Baseline characteristics, types of neoadjuvant treatment, short-term surgical outcomes, postoperative anorectal manometric data, and survival were compared between the groups.

RESULTS

The NS and S groups comprised 65 and 9 patients, respectively. Conversion to laparotomy was required in three patients in the NS group. The S group required a longer console time than the NS group (median: 367 vs. 253 min, respectively, p = 0.038); however, no difference was observed in the total operative time (p = 0.15) and blood loss (p = 0.70). Postoperative complication rates, anorectal function, and oncological outcomes were similar between the groups.

CONCLUSIONS

Although console time was longer in patients with a stoma, robotic surgery could be performed safely like in those without a stoma after neoadjuvant treatment.

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.

Risk factors for stoma prolapse after laparoscopic loop colostomy

BACKGROUND

Stoma prolapse (SP) is a common stoma-related complication, particularly in loop colostomies. This study aimed to investigate potential risk factors for SP development after laparoscopic loop colostomy.

METHODS

In total, data from 140 patients who underwent laparoscopic loop colostomy were analyzed between September 2016 and March 2022. Risk factors for SP were investigated retrospectively.

RESULTS

The median follow-up duration after colostomy was 12.5 months, and SP occurred in 33 (23.6%) patients. Multivariate analysis showed that being overweight (body mass index ≥ 25; odds ratio [OR], 8.69; 95% confidential interval [CI], 1.61-46.72; p = 0.012) and having a thin rectus abdominis penetration of the stoma (< 8.9 mm; OR, 8.22; 95% CI, 2.50-27.05; p < 0.001) were independent risk factors for SP. Other patient characteristics and surgical factors associated with stoma construction were unrelated to SP development.

CONCLUSIONS

Being overweight and the route penetrating the thinner rectus abdominis during stoma construction was associated with a significantly higher incidence of SP after laparoscopic loop colostomy. Selecting a construction site that penetrates the thicker rectus abdominis muscle may be crucial for preventing SP.

Stomal Prolapse Due to Sidedness of Transverse Loop Colostomy: A Retrospective Cohort Study

Objectives

Stomal prolapse (SP) is one of the most common complications of loop colostomy and can impair a patient's quality of life. Herein, we evaluated the risk factors for SP to prevent its occurrence after a transverse loop colostomy.

Methods

This retrospective study included 84 patients who underwent loop transverse colostomy between January 2016 and December 2020. We evaluated the incidence of SP and examined the relationship between perioperative factors and SP using univariate and multivariate logistic regressions.

Results

SP occurred in 11 (13.0%) patients. Median time to SP was 99 postoperative days. In the univariate analysis, a right side abdominal wall stoma site, perioperative chemotherapy, and anti-VEGF antibody therapy were associated with a significantly higher incidence of SP. Multivariate analysis identified that construction of a temporary loop colostomy in the right transverse colon during rectal cancer surgery (odds ratio, 5.07; 95% confidence interval, 1.12-22.86) is an independent risk factor.

Conclusions

In this study, multivariate analysis showed that the right side of the transverse colon was a risk factor for SP. Therefore, when constructing a transverse colon loop stoma, the stoma should be constructed in the left transverse colon to prevent SP.

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.

Transverse Colostomy Differs in Outcomes Compared to Sigmoid Colostomy: A Cohort Analysis

PURPOSE

Our aim was to identify any differences in outcomes following transverse versus sigmoid colostomy creation for management of cancer.

METHODS

Transverse and sigmoid colostomies are used to manage cancer-related complications including obstruction, perforation, and fistulation. The decision to use either colostomy is largely based on the surgeon's preference and the location of the cancer complication. All patients treated for cancer complications with the use of a sigmoid or transverse colostomy at National University Hospital between January 2011 and December 2016 were included. Patient characteristics and distribution frequencies were reported based on the operation performed. Post procedure morbidity and mortality was compared. Univariate and subgroup analysis were performed.

RESULTS

This was a single-center, retrospective cohort study of 93 patients who underwent a colostomy creation over a 5-year duration. Of the 93 patients included, 56 underwent a transverse colostomy (median age 59, 26 male, 30 female) and 37 a sigmoid colostomy (median age 64, 20 male, 17 female). According to univariate analysis, higher rates of stoma prolapse were seen patients with transverse colostomies. There were no differences in complications between a laparoscopic or open approach. There were no differences in the rate of other postoperative complications.

CONCLUSION

Sigmoid colostomies were associated with a lower prolapse rate compared to transverse colostomies for cancer management. The manner of surgical approach did not affect rate of postoperative complications.

Italian Guidelines for the Nursing Management of Enteral and Urinary Stomas in Adults: An Executive Summary

PURPOSE

This article is an executive summary of Italian guidelines for nursing management of enteral and urinary ostomies in adults.

METHODS

Scoping review and generation of evidence and consensus-based clinical guidelines.

SEARCH STRATEGY

The Multidisciplinary Italian Study group for STOmas (MISSTO) was founded in 2018. This group created guidelines for management of enteral and urinary ostomies in adults based on a scoping review of the literature. The research included previous guidelines, systematic reviews, meta-analyses, randomized clinical trials, cohort studies, and case reports. Five main topics were identified: "stoma preparation," "stoma creation," "stoma complications," "stoma care," and "stoma reversal" (for enteral stomas)." All the studies were evaluated according to the GRADE system and AGREE II tool. Recommendations were elaborated in the form of statements, with an established grade of recommendation for each statement. For low levels of scientific evidence statements, a consensus conference composed of expert members of the major Italian scientific societies in the field of stoma management and care discussed, corrected, validated, or eliminated the statements. A final version of the guidelines with definitive recommendations was elaborated and prepared for publication.

FINDINGS/CONCLUSIONS

This document represents the first Italian guidelines on enteral and urinary stoma management to assist nurses caring for persons with an enteral or urinary ostomy.

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.

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.

Current Management of Intestinal Stomas and Their Complications

Inappropriate stoma site, improper management of stoma, and stoma complications lead to diminished quality of life of ostomates. Healthcare professionals involved in stoma creation and/or care should have the fundamental and updated knowledge of the management of stomas and their complications. This review article consists of the following major sections: principles of perioperative patient management, early complications, and late complications. In the “principles of perioperative patient management” section, the current concepts and trends in preoperative education, stoma site marking, postoperative education, and patient educational resources are discussed. In the “early complications” section, we have focused on the etiology and current management of ischemia/necrosis, fluid and electrolyte imbalances, mucocutaneous separation, and retraction. In the “late complications” section, we have focused on the etiology and current management of parastomal hernia, stoma prolapse, parastomal varices, and pyoderma gangrenosum. Pre- and postoperative patient education facilitates the patient's independence in stoma care and resumption of normal activities. Healthcare providers should have basic skills and updated knowledge on the management of stomas and complications of stomas, to act as the first crisis manager for ostomates.

Indications for and complications of intestinal stomas in the children and adults at a tertiary care hospital in a resource-limited setting: a Tanzanian experience

BACKGROUND

An intestinal stoma, though a life-saving procedure on the care of many gastrointestinal conditions, carries significant number of complications. This study describes the common indications, complications, and management of stomas and identifies the factors that are associated with these complications in a tertiary care hospital in Tanzania.

METHODS

A cross-sectional study of patients with intestinal stomas was conducted at Bugando Medical Centre (BMC) between July 2016 and June 2017. Ethical approval to conduct the study was obtained from relevant authority before the commencement of the study.

RESULTS

A total of 167 patients (M: F = 1.2:1) were enrolled in the study. The mean age at diagnosis was 0.6 ± 1.4 years for children and mean age for adults was 36.7 ± 15.8 years. Anorectal malformation (110, 89.4%) was the most common indication for intestinal stoma formation in children, while bowel perforation (14, 31.8%) was the main indications in adults. The sigmoid colon (137, 82.0%) was the most common anatomical site for stoma formation followed by the ileum (18, 10.8%). Stoma prolapse (18, 41.9%) was the most frequent complication of a stoma, whereas, surgical site infection (9, 34.6%) was the most frequent complication after stoma closure. Thirty five (26.7.%) of the children developed stomal complications, while only 8 (22.2%) of the adults developed complications. The level of training of operating surgeon and timing of surgery were the main predictors of stoma-related complications (p < 0.034 and 0.013), whereas the level of training of the operating surgeon and the type of stoma closure were significantly associated with the complications related to stoma closure (p < 0.001).

CONCLUSION

The intestinal stomas performed at BMC are associated with various complications, which in turn, become a burden to the patients. The insights observed in the current study may apply to other tertiary hospitals in Tanzania and Africa at large. We suggest that the keystones for improvement and control in the formation and complications of intestinal stomas are the following; colostomy formation should rarely be done in transverse colon, the procedure should be carried out by senior doctors (specialist) or junior doctors under close and direct supervision of the specialists, using proper meticulous techniques, and the need to determine and/or improve techniques for early detection of complications.

Ostomy-Related Complications

Ileostomy or colostomy formation is an important component of many surgical procedures performed for a wide range of disorders of the gastrointestinal tract. Despite the frequency with which intestinal stomas are created, stoma-related complications remain common and are associated with significant morbidity as well as cost. Some of the most prevalent complications of stoma formation which will be detailed in this article include peristomal skin complications, retraction, stomal necrosis, stomal stenosis, prolapse, bleeding, dehydration from high ostomy output, and parastomal hernia. The authors will review these common complications, detail means to avoid or prevent them, and outline recommendations for management.

The modified Altemeier procedure for a loop colostomy prolapse

Loop colostomy prolapse is associated with an impaired quality of life. Surgical treatment may sometimes be required for cases that cannot be closed by colon colostomy because of high-risk morbidities or advanced disease. We applied the Altimeter operation for patients with transverse loop colostomy. The Altemeier operation is therefore indicated for rectal prolapse. This technique involves a simple operation, which includes a circumferential incision through the full thickness of the outer and inner cylinder of the prolapsed limb, without incising the abdominal wall, and anastomosis with sutures using absorbable thread. We performed the Altemeier operation for three cases of loop stomal prolapse. Those patients demonstrated no postoperative complications (including obstruction, prolapse recurrence, or hernia). Our findings suggest that this procedure is useful as an optional surgical treatment for cases of transverse loop colostomy prolapse as a permanent measure in patients with high-risk morbidities or advanced disease.

Avoidance and management of stomal complications

The construction of an intestinal stoma is fraught with complications and should not be considered a trivial undertaking. Serious complications requiring immediate reoperations can occur, as can minor problems that will subject the patient to daily and nightly distress. Intestinal stomas undoubtedly will dramatically change lifestyles; patients will experience physiologic and psychologic detriment with stoma-related problems, however minor they may seem. Common complications include poor stoma siting, high output, skin irritation, ischemia, retraction, parastomal hernia (PH), and prolapse. Surgeons should be cognizant of these complications before, during, and after stoma creation, and adequate measures should be taken to avoid them. In this review, the authors highlight these often seen problems and discuss management and prevention strategies.

Laparoscopic correction of right transverse colostomy prolapse

Colostomy prolapse is a frequently seen complication of transverse colostomy. In one child with recurrent stoma prolapse, we performed a loop-to-loop fixation and peritoneal tethering laparoscopically. No prolapse had recurred at follow-up. Laparoscopic repair of transverse colostomy prolapse seems to be a less invasive method than other techniques.

Peritoneofascial suture method for facilitating loop ileostomy mobilization

BACKGROUND

Ileostomy closure is a minor procedure and is performed through a small peristomal incision. However, a hard adhesion increases the technical difficulty. A peritoneofascial suture (PFS) will reduce the adhesion layers of the abdominal wall. This study was performed to evaluate whether the PFS method may decrease the extent of adhesions between the bowel and the abdominal wall opening and facilitate ileostomy mobilization.

METHODS

Forty-two patients (24 males and 18 females) with a mean age of 57 years (range = 31-80 years) and who were undergoing ileostomy closure were enrolled. The PFS group and the conventional group had 18 and 24 patients, respectively. The intraoperative findings such as degree of adhesion, mobilization time, and associated bowel injury were analyzed.

RESULTS

The thickness of the abdominal wall and the rectus abdominis was similar in both groups. The overall operation time was shorter in the PFS group than in the conventional group (50.9 vs. 80.4 min, respectively, p = 0.001). The ileostomy mobilization time was also shorter in the PFS group than in the conventional group (18.9 vs. 44.7 min, respectively, p < 0.001). The procedure was technically easier in the PFS group more frequently than in the conventional group (77.8 % vs. 31.6 %, respectively, p = 0.013). Bowel injury during mobilization was more common in the conventional group than in the PFS group (50.0 % vs. 16.7 %, respectively, p = 0.053).

CONCLUSIONS

The peritoneofascial suture method is a simple procedure, and it may facilitate ileostomy mobilization by decreasing adhesion layers. To confirm the technical advantage of this method a randomized study will be needed.

Simple excision and closure of a distal limb of loop colostomy prolapse by stapler device

Stomal prolapse is one of the common complications in transverse colostomy and can be managed conservatively in most cases; however, laparotomy and reconstruction of the stoma may sometimes be required, especially in case of irreducible colostomy prolapse. We have reported a simple local repair with reconstruction of the loop colostomy. We herein report a new more simple technique to avoid laparotomy and allow excision of the irreducible colostomy prolapse and complete closure of the distal limb of loop colostomy when no decompression is required in the distal limb of the stoma. In this procedure, the number of stapler and the time with blood loss for the operation can be saved.

Stomal prolapse in children with chronic intestinal pseudoobstruction: a frequent complication?

AIM

The aim of the study was to evaluate the morbidity rate of stoma in children diagnosed with chronic intestinal pseudoobstruction (CIPO) and try to determine risk factors.

MATERIAL AND METHODS

Twenty-two children (65%) of 34 referred to our center between 1988 and 2008 had a stoma. They were compared with 22 other children referred for another pathology necessitating a stoma.

RESULTS

The incidence of stomal prolapse in CIPO children was 45% vs 9% in non-CIPO children (P = .01). Prolapse occurred between the first postoperative day and the 10th postoperative month, with a median of 2 months. Surgical management was required in 60%, with an intestinal necrosis rate of 20% leading to intestinal resection. No mortality was noted. No risk factors favoring prolapse in CIPO children were identified.

CONCLUSION

Children with CIPO have a high rate of stomal prolapse with an increased risk of intestinal necrosis. Careful management of the stoma is necessary to avoid the risk of intestinal resection, which may aggravate the underlying intestinal disorder.

[Stoma prolapse and stoma retraction]

Prolapse and retraction of an intestinal stoma are postoperative complications which severely decrease the quality of life of patients and in some cases lead to an operative revision. Both entities should be treated with sophisticated care by specialized stoma therapists in the early phase in order to prevent secondary problems such as dermal ulceration. However, in case of additional problems, such as ileus, bleeding, incarceration or impossibility of adequate stoma care, an operative revision is indicated. It remains an individual decision whether a local or a transabdominal revision of the stoma is necessary.At present the level of information and the number of well designed studies dealing with prolapse or retraction of a stoma are unsatisfactory and there are merely studies which report on prolapse and retraction as an incidental finding rather than primarily focusing on these problems. In addition there is a lack of clear cut definitions for both entities which would allow a comparison of data obtained in different studies.There is clearly a demand for a structured scientific clarification as the occurrence of stomal retraction or prolapse may present psychological and medical problems for the patients and therefore needs to be treated, conservatively and/or operatively, by both stoma specialists and surgeons.

Late stomal complications

Ostomy creation is a common surgical procedure performed by a variety of surgical specialties. Complications associated with stomas are frequent and run the gamut from technical, mechanical, physiologic, and psychologic. The impact of these complications ranges from simple inconvenience to life threatening. The majority of these complications may not occur for years following creation of the stoma. In this article, the author reviews many of the late complications associated with stomas and options regarding their management.