The Following paper was presented by John M. MacKeigan M.D., of the Ferguson Clinic, at the October 3, 2000, meeting of the Grand Rapids Ostomy Association.

Stoma Complications


John M. MacKeigan, M.D.

Complications related to stomas may occur early or late, intermittently or progressively, and may be acute or chronic in nature. Therapy depends on the degree and acuteness of symptoms. Some consideration for the general health of the patient and the prior surgeries, scars, and complications is appropriate.

While acute complications such as ischemia, bleeding, retraction, infection, and fistula formation may occur postoperatively, we will mainly consider our approach to common problems such as prolapse and hernia, and complications related to closure.

Prolapse

Prolapse of a stoma occurs in one to sixteen percent of patients. There is very little difference between ileostomies and colostomies in incidence, symptoms, and presentation. Stomal prolapse occurs with and without an associated hernia. The subcutaneous or hidden form of prolapse occurs above the fascial opening but is often classified as a hernia. For practical purposes, both have a normal or slightly enlarged fascial opening and may or may not reduce spontaneously. It may require repair depending on the severity and progression of symptoms and the health of the patient.

The size and incidence of prolapse is related to obesity, ascites, pregnancy, and chronic obstructive lung disease. While all prolapse is not preventable, some measures may be undertaken to reduce the incidence. These include:

Most mild elements of prolapse and nonprogressive prolapse can be managed with reassurance and some adjustment of the appliance. Acute onset of symptoms with ischemia and pain may resolve with bedrest and observation. Operative therapy is indicated for gangrenous change, acutely painful and non-reducible prolapse, and progressive chronic prolapsing with ulceration, bleeding, and serious drainage.

Operative therapy in high risk patients and perhaps as an initial procedure in many patients, may be sufficient with local excision and advancement of the redundancy along with reformation of the stoma. This is particularly true if the prolapse is fixed and not sliding.

In many incidences, this is insufficient because of the sliding component or associated hernia.

Loop stoma should be placed in continuity again, if possible. Otherwise, conversion to an end stoma with recreation is appropriate with or without a mucous fistula. Relocation with appropriate repair of the associated hernia is the best option for most prolapses, if conditions warrant.

Peristomal Hernias

Some of the same issues of selection of surgery and non-operative management for prolapse are appropriate for hernias. Combined defects are common.

Etiological factors and issues of prevention are similar. However, herniation may be often a consequence of urgent surgery, compromises on site selection, and be related to long-standing stomas.

Most patients with bulging around the stoma have minimal symptoms or problems. Examination with the patient standing and straining, and after removal of the appliance, assists evaluation. Most hernias are a form of sliding hernia. It may be difficult to differentiate a peristomal hernia and whether its contents are intestine or omentum. A CT scan may be of value in detecting hernias in the extremely obese.

The indications for surgical correction are similar to stomal prolapse. Acute symptoms of ischemia or infection require an acute surgical correction. Most hernias require careful assessment of the degree of disability and the severity of symptoms. Mildly symptomatic or asymptomatic hernias require no surgery. Paraileostomy hernias may require surgery more often because of special problems of managing the effluent.

Nonoperative therapy requires reassurance, efforts at weight reduction where appropriate, and the use of an elastic binder for support.

Operative repair include:

  1. local repair - parastomal or intra-abdominal
  2. relocation
  3. local repair with prosthetic material

An approach for each individual patient seems best. If a stoma is poorly situated, relocation is preferable. Mesh repair may be appropriate if the patient has no prior problems and likes the location. Multiple scars of the abdomen may lead to a local or mesh repair.

No one large series with long follow-up is available. Resiting and mesh repairs have similar ranges of recurrence (5%-35%). Simple repair may recur in 70 percent. Infection with mesh occurs in less than 15 percent and is serious in less than five percent. Few report associated complications such as bleeding, fistulae, or bowel injury.

Loop Stomas

Loop stomas are used more commonly over the last 20 years, and particularly loop ileostomy. This has occurred with the advent of low coloanal or colorectal anastomoses, and ileoanal pouches. Appreciation for the complications related to loop stomas has resulted. There are many and include ileostomy dysfunction, ureteral calculi, skin irritation, small bowel obstruction, retraction, and prolapse. Loop ileostomy has been used more frequently than loop colostomy at a rate of five to one at the University of Minnesota.

Stoma Closure

One aspect of stomas relates to complications which prevent closure of a stoma. Loop stomas seem to lose their diversion capabilities increasingly after three months. Various series report complications with closure from 38 to 62 percent. However, complications of elective closure of loop ileostomies for ileoanal pouch or low rectal anastomosis, seems to be at a much lower rate.

Complications of closure with anastomotic leakage vary from zero to 23 percent. Postoperative Obstruction and wound infection shows even more variation.

There is variability in the literature whether more cømplications occur related to ileostomy closure or colostomy closure. A recent series of 350 patients shows 11 percent major complications and 13 percent minor complications from loop ileostomy closure and a nine percent major and 20 percent minor complication rate for colostomy closure.

The timing of closure after all healing has occurred, nutritional deficiencies are corrected and steroids discontinued is preferable. Complications seem to be less for closure after eight weeks from the time of creation of the stoma.

Closure requires preoperative evaluation or correction of anal stenosis, anastomotic complications, and assurance of distal patency.

Techniques for closure are variable from sewn to stapled anastomoses. Complete circumferential mobilization is desired and intraperitoneal placement of the anastomosis. In some instances, the laparoscope may have a role in assisting the procedure.

The additive complications of creation of a stoma and its closure need to be appreciated, considered in analysis of results of procedures and studied further to help lower mobility.

References

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2. Rubin MS, Bailey HR. Parastomal hernias. In: MacKeigan JM, Cataldo PA, eds. Intestinal Stomas-Principles, Techniques and Management. St. Louis: Quality Medical Publ, 1993:188-197.

3. Nogueras JJ, Wexner SD. Stoma prolapse. In MacKeigan JM, Cataldo PA, t Eds. Intestinal stomas — Principles, Techniques and Management. St. Louis: Quality Medical Publ, 1993:188-197.

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8. Park, JJ, et al Stoma Complications, The Cook County Hospital Experience, Dis Colon Rectum 1999;42: 1575-1580

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12. - Fonkalsrud, EW, et al, Comparison of Loop Versus End Ileostomy for Fecal Diversion after Restorative Proctocolectomy for Ulcerative Colitis, J. Am. Coll. Surg. 2000;190:414-422