Improved Outcomes in Colon and Rectal Surgery part 37 doc

stOMa site Marking In 2007, the American Society of Colon and Rectal Surgeons ASCRS, in collaboration with the Wound, Ostomy, and Continence Nurses WOCN Society developed a position stat

improved outcomes in colon and rectal surgery

other anastomotic configurations after resection in Crohn’s

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132 Landsend E, Johnson E, Johannessen H, Carlsen E

Long-term outcome after intestinal resection for Crohn’s disease

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133 Steele SR Operative management of Crohn’s disease of

the colon including anorectal disease Surg Clin North Am

2007; 87(3): 611–3

134 Penner RM, Madsen KL, Fedorak RN Postoperative Crohn’s

disease Inflamm Bowel Dis 2005; 11(8): 765–77

135 Yamamoto T Factors affecting recurrence after surgery for Crohn’s Disease World J Gastroenterol 2006; 11(26): 3971–9

136 Thaler K, Dinnewitzer A, Oberwalder M et al Assessment

of long-term quality of life after laparoscopic and open surgery for Crohn’s disease Colorectal Dis 2005; 7: 375–81

137 Casellas F, Vivancos JL, Badia X, Vilaseca J, Malagelada JR Impact of surgery for Crohn’s disease on health-related quality of life Am J Gastroenterol 2000; 95(1): 177–82

ostomy after ensuring that the distal anastomosis has healed

This is usually confirmed by a contrast study, often a

gastrograf-fin enema or CT scan with rectal contrast An ostomy reversal

ameliorates and addresses all of the symptoms including the

her-nia, obstruction, and pain After reversal, the skin of the ostomy

can be primarily closed, however extreme vigilance of the wound

is necessary secondary to an increased rate of local wound

infec-tion Depending on the size of the fascial defect and

correspond-ing hernia, additional mesh may be needed for hernia repair

Due to increased risk of infection of most prosthetics, biologic

materials should be considered as a first option For patients who

are not candidates for ostomy reversal, various options are

avail-able and include both open and laparoscopic approaches These

options include primary fascial repair, repair with biologic or

prosthetic mesh, and stoma relocation The approach and the

method of repair is dependant on the surgeon’s preference and

experience Certainly, observation for minimally symptomatic

parastomal hernias is the preferred option until stomal

take-down is possible

intrOduCtiOn

Intestinal stomas, either temporary or permanent, are the

surgi-cal exteriorization of either small or large bowel to the anterior

abdominal wall An ostomy may be placed temporarily, often

when its primary purpose is to divert the fecal stream away from

an area of concern such as a high-risk anastomosis in a field of

prior radiation treatment, following a coloanal repair, or concern

for leak after a stapled end-to-end anastomosis Once the distal

anastomosis has adequately healed, gastrointestinal continuity

can be reestablished when the ostomy is reversed A permanent

stoma is created following an oncologic resection for rectal cancer

that includes removal of the anorectum and associated

sphinc-ter complex In this instance, a descending colostomy would be

required to avoid perineal soiling with a coloanal anastomosis

in the absence of the sphincters While there are various types

of ostomies described for a broad spectrum of disease processes

such as the neo-bladder construction with an ileal conduit, this

chapter will focus solely on outcomes for ostomies created with

the small or large bowel for colon and rectal diseases

required in the emergent setting In 1952, Sutherland et al., (1)

published the first report on the important psychological needs

of patients living with stomas Since then, multiple studies have reported the negative impact ostomies have on overall quality of life.(2–6) It is not surprising that the presence of a stoma is asso-ciated with decreased quality of life measurements in the imme-diate and early postoperative setting.(7) Unfortunately, it often appears that while overall quality of life, return to prior activity levels, pain and fatigue all improve with time following surgery, self-impression views such as body image and sexual function do not seem to change with time.(8) Thus, despite evidence to the contrary that a “return to normalcy” is achievable, many patients

can never get past the idea of having to live with a stoma More

recently, Krouse and colleagues (9) evaluated the quality of life of

239 male patients from multiple Veterans Affairs (VA) hospitals living with stomas Their report, which was a case-control sur-vey study, used various previously-validated quality of life indices

to compare patients with ostomies versus 272 patients who had undergone similar operations, but not requiring stoma forma-tion Their study highlighted multiple important psychosocial facts about patients living with ostomies There was increased self-reported postoperative depression and suicidal ideations among respondents living with ostomies Such feelings may have been compounded by issues of coping and social acceptance, as their fears related mostly to both others’ perceptions of patients with stomas and their own personal fears of having stoma-related accidents As these fears became more frequent, they clinically translated into decreased social interactions and eventual isola-tion The authors’ recommendation of encouraging social net-working among ostomates to clarify issues and limit the trial and error approach that many patients with ostomies undergo, is a valid conclusion which should be supported by all physicians This is not to say that all patients do poorly or are mentally burdened by living with a permanent stoma In a large meta-analysis of 1,443 rectal cancer patients from 11 studies, there was

no difference in general quality of life scores at 2 years following surgery between those patients undergoing an abdominoperineal resection from those undergoing a low anterior resection with in-continuity reconstruction.(10) These contradictory findings may

improved outcomes in colon and rectal surgery

in part depend on the questionnaire given, the disease process

for which the stoma was created, and the preoperative functional

level of the patient For example, factors such as patient age, (11)

decreased preoperative continence, (12) and severe active

peria-nal Crohn’s fistulizing disease (13) have all been shown to have

an improved quality of life following stoma formation Thus,

while it would be inaccurate to state that placement of stoma

will end up with a lowered quality of life and significant

psycho-logical problems, it also is nạve to think that stoma creation will

not have a significant impact on a patient’s subsequent

immedi-ate and long-term recovery It is well-established, that in

addi-tion to networking, a close relaaddi-tionship with a readily available

and experienced enterostomal therapist is an invaluable aspect

of the multidisciplinary approach These expert therapists can

significantly alleviate initial fears and anxieties that often plague

patients living with a stoma Furthermore, in our experience,

preoperative counseling about expectations, education

regard-ing the indication for the ostomy, and even “practicregard-ing” the

wearing of an appliance before surgery all aid in lessening the

psychological impact on the patient and promotes adaptation to

their ostomy

stOMa site Marking

In 2007, the American Society of Colon and Rectal Surgeons

(ASCRS), in collaboration with the Wound, Ostomy, and

Continence Nurses (WOCN) Society developed a position

state-ment on the value of preoperative stoma marking for patients

undergoing ostomy surgery.(14) Their ultimate goal was to

decrease stomal complications and improve quality of life for

patients In addition to precise step-by-step instructions on

the proper siting of stomas, the statement recommended that all

patients scheduled for ostomy surgery undergo preoperative stoma

marking by an experienced, trained clinician This evaluation

includes examining the patient in the lying, sitting, and stand-ing positions, and accountstand-ing for patient factors such as previous incisions, waist and belt lines, abdominal habitus, and hernias, to determine the optimal stoma position that is crucial to decreasing the incidence of stomal complications One of the more impor-tant aspects of this preoperative marking evaluation is the iden-tification of the rectus abdominus muscle, as placement of the stoma through the rectus muscle may prevent peristomal her-niation or prolapse (Figure 33.1).(15) Furthermore, preoperative siting allows for patient participation and education regarding stoma care and the use of ostomy appliances While this posi-tion statement has yet to be clinically validated, previous reports have demonstrated the importance of preoperative stomal siting

In a retrospective analysis, Bass and associates (16) reviewed a single institution’s stoma complication rate in 593 patients over

an 18-year period The study compared 292 patients who under-went preoperative marking by an enterostomal therapist to the remaining 301 remaining patients who did not undergo pre-operative marking The endpoints of their study, early and late complications, were favorable for the patients who underwent preoperative marking with a 23% versus 43% early complication

rate (p < 0.03) and 9% versus 31% late complication rate (p =

NS) This study, and the joint statement by ASCRS and WOCN, highlights the importance of proper preoperative stoma marking for decreasing complication rates

stOMal tyPes End ostomies

End ostomies, either permanent or temporary, are most often placed in the left lower quadrant of the abdominal wall using the left colon or in the right lower quadrant when utilizing the ileum The indication for stoma creation is important, as this

Figure 33.1 Stomal placement The site is selected to bring the stoma through the rectus abdominis muscle.

the large absorptive capacity of the colon or the storage ability

of the compliant rectum is lost), or when the patient has poor

sphincter function Barring the aforementioned

contraindica-tions, most ostomies can be reversed and thus, are temporary

A common temporary end ostomy performed routinely by

sur-geons is the Hartmann’s procedure Initially described by Henri

Hartmann in 1921 for rectal cancer, this versatile procedure is

indicated for a variety of benign and malignant scenarios where

primary resection of colon and reanastomosis is unsafe or not

possible As discussed later, reversal is associated with

complica-tions and the benefits of stoma reversal must be balanced with

the potential risks to the surgery Ideal candidates for reversal are

young, healthy patients with preserved sphincter mechanisms

The optimal time for this colostomy reversal has been

controver-sial Some have found that reversals after 4 months were

associ-ated with a higher complication rate; after this time, the rectal

stump was less readily accessible and therefore, led to increased

complications.(17) Others have found no outcome differences

between early or late reversals and considered the timing an

insig-nificant factor.(18)

The benefits of an end ileostomy with immediate maturation,

initially described by Brooke in 1952, have decreased the incidence

of stenosis, dysfunction, retraction, and serositis associated with

an ileostomy.(19, 20) Since that time, this has become the standard

technique for ileostomy and most colostomy formations Despite

increasing experience with restorative continuity procedures

such as the ileal pouch-anal anastomosis (IPAA), an end

ileos-tomy remains an important part of the surgical armamentarium

For instance, in patients with toxic megacolon undergoing total

abdominal colectomy, when the principles of “damage control”

surgery are paramount, an end ileostomy following abdominal

colectomy remains the procedure of choice Additionally, an end

ileostomy would be preferred over an IPAA or an ileal-rectal

anastomosis (IRA) for patients with poor anal sphincter

mecha-nisms where continence is questionable Alternatively, in young

healthy patients with inflammatory bowel disease or FAP

requir-ing proctocolectomy, IPAA should be considered, or IRA when

the rectum is spared Purported benefits of an IPAA compared

to the end ileostomy revolve around the maintenance of

conti-nuity and thus, a more psychologically favorable outcome for

the patient Pemberton et al (21) evaluated this relationship by

comparing quality of life for 298 patients with IPAAs and 406

Continent ileostomy

Continent ileostomy, first reported by Nils Kock in 1969, is a less frequently performed procedure due to the technical expertise required, the significant complication rate associated with its nipple-valve mechanism, and the preference for creation of ileoa-nal pouches.(20) Occasioileoa-nally, the continent ileostomy remains a useful option for patients undergoing proctocolectomy for FAP or IBD, or in those patients who develop IPAA failure In 2006, Nessar

et al (23) reported the long-term outcomes of patients

undergo-ing continent ileostomy at the Cleveland Clinic Foundation Their study population included 181 patients with continent ileostomies,

69 of whom previously had an end ileostomy, and 35 patients who had an end ileostomy after excision of a continent ileostomy With

a median follow-up of 11 years, 17% of patients had their conti-nent ileostomy excised; there was only a 7 month complication-free interval, and a 14 month revision-complication-free interval Long-term complications were common, with 30% experiencing valve slip-page, 26% developing pouchitis, 25% with fistula formation, and 15% with parastomal herniation Other complications included valve prolapse, difficult intubation, stoma stricture, and pouch bleeding Importantly, even in centers with significant experience, the complication profile remains considerable Similarly, in a study

by Kohler et al (24) comparing outcomes in patients between end ileostomy, continent ileostomy, and ileal pouch-anal anastomosis (IPAA), those patients with IPAA had fewer restrictions in sport and sexual activities when compared to patients with continent ileostomy Patients with end ileostomy fared the best with regards

to the travel capabilities when compared to the other two In our practice, continent ileostomies are seldom performed Due to the aforementioned complication profile, patients are counseled for either an IPAA, IRA, or an end ileostomy Yet, despite our reluc-tance to perform this procedure, select institutions well-versed in this procedure report excellent outcomes and overall high patient satisfaction.(25–27)

Loop End Stomas

A loop end stoma is a variation in which a section of the bowel

several inches proximal to the divided end of the bowel is brought through the abdominal opening (Figure 33.2) The loop can be supported with a rod and the bowel is opened and matured in a fashion similar to a loop stoma This type of stoma is helpful in challenging situations such as thick shortened

improved outcomes in colon and rectal surgery

mesentery, tenuous blood supply, or friable bowel Its advantage

is that no blood vessels are divided and with a rod, the tension

is on the back wall of the bowel rather than the

mucocutane-ous anastomosis This type of stoma is slightly more difficult to

pouch as it is slightly oval and may not have the protrusion of a

well-formed end stoma

Diverting or loop ostomies

The ultimate purpose when creating a diverting stoma is to

pre-vent the fecal stream from reaching a distal segment of distal

small bowel or large intestine for the purpose of either

treat-ing or preventtreat-ing a leak To that end, either a loop colostomy

or ileostomy will suffice However, an ileostomy is often

pre-ferred due to its perceived ease of closure Proponents of a loop

colostomy cite the lower risk of high stomal output leading to

fluid and electrolyte abnormalities occasionally seen with a loop

ileostomy The common indications for concomitant proximal

fecal diversion include protection of distal at-risk

anastomo-sis, especially low-lying colo-anal anastomosis and ileal pouch

anal-anastomosis (IPAA), complicated diverticulitis, treatment

of anastomotic leaks and pelvic sepsis, large bowel obstruction,

trauma, extensive perianal Crohn’s disease, and less commonly,

fecal incontinence

The indication for a concomitant proximal fecal diversion for

low lying anastomosis, most commonly performed for rectal cancer,

has been intensely studied Wong and Eu (28) reported the results

from a prospective, comparative study of 1,078 patients

undergo-ing elective low or ultra-low (defined as colonic anastomosis to the

anal canal) anterior resections from 1994 to 2004 In the diverted

group, 28% developed a clinically significant leak while of the

non-diverted group, 13% had a clinically significant leak (p = 0.86) 95%

of these leaks required a salvage operation, and analysis revealed

no statistical difference between anastomotic leak complications

between patients undergoing and not undergoing fecal diversion

These authors concluded that a defunctioning ileostomy did not

influence the complication rate of a rectal anastomosis, rather it

minimized the clinical sequela of leaks in high risk patients They

recommended that proximal diversion should be used on a selected

basis In another prospective study from Sweden, the Rectal Cancer

Trial On Defunctioning Stoma (RECTODES) randomized 234 patients undergoing low rectal (<15 cm from the anal verge) anas-tomosis to fecal diversion versus no diversion.(29) Their primary endpoint was to assess whether there was a difference in the rate

of symptomatic anastomotic leakage in patients between the two arms of the study While there was a disproportionate number

of patients (72%) not undergoing randomization due to various factors including intraoperative concerns requiring diversion, the total number of patients with and without diversion were simi-lar (116 pts vs 118 pts) Patient characteristics were simisimi-lar with increased operative times for those undergoing stoma placement as the only statistically significant difference between the two patient cohorts In their analysis, patients without a defunctioning stoma had significantly more symptomatic leakages (28%) when com-pared to those without proximal diversion (10%) The group not undergoing diversion consequently constituted 75% of all urgent reoperations Of the 28 out of 33 patients without initial fecal diversion who developed a leak, urgent reoperation was accom-panied with either a loop ileostomy or permanent end colostomy Consequently, these investigators recommended routine defunc-tioning loop stoma in low anterior resections for rectal cancer Based on these and other studies, it is now generally acknowledged that a proximal defunctioning stoma does not abolish the risk of leakage, but certainly mitigates the consequences In our practice, defunctioning stomas are almost always placed for any anastomo-sis within 5 cm of the anal verge, although exceptions such as the one stage IPAA occurs occasionally Furthermore, patient factors such as previous irradiation, intraoperative hemodynamic insta-bility, poor nutrition, and chronic steroid use lead us to liberally

“protect” the distal anastomosis

When deciding to perform a proximal fecal diversion or a defunctioning stoma, the two traditional options include a trans-verse loop colostomy or a loop ileostomy These two options were compared in a prospective randomized study by Williams et al for elective protection of distal anastomoses.(30) In their analysis, nearly all complications were twice as common with transverse colostomies than ileostomies and included infection at the time

of creation and at takedown, odor, leakage, and skin problems Additionally, multiple visits to the stoma therapist were needed

Figure 33.2 Z-Plasty repair for stenosis A, incisions in skin and bowel B, completed repair.

The incidence of stoma complications varies in surgical literature

from 10–70%, and can range from minor skin irritation to

parasto-mal herniation requiring operation.(33–35) The wide variance in

complication rates is due to the definition of complication and the

length of follow-up in the studies Furthermore, there are a

multi-tude of factors that influence complication rates, including the type

and location of the ostomy, patient factors such as gender, BMI,

diagnosis, and urgency in which the procedure is performed In a

study from Cook County Hospital, the incidence of stoma

com-plications was 34% in a review of 1,616 patients, with 28%

hav-ing an early complication (<30 days from time of surgery) and 7%

late complication (>30 days).(36) In a national audit, Cottam and

associates identified 1,329 (34%) patients out of a cohort of 3,970

stomal patients that developed early complications (<3 weeks from

times of surgery) defined as stoma retraction, necrosis, ischemia,

muco-cutaneous separation, and dehiscence.(37) Statistically

sig-nificant factors increasing postoperative complications were stoma

height (<20 mm for ileostomy and <7 mm for colostomy), female

gender, loop ileostomy, advanced BMI, younger age, malignant

diagnosis, and emergent procedures Similarly, in a prospective

study of 97 patients, Arumugam et al found elevated BMI, diabetes,

and emergency surgery as significant risk factors for the

develop-ment of stoma complications.(38) In yet another study evaluating

risk factors for stoma complications, Saghir and colleagues

identi-fied advanced age, advanced American Society of Anesthesiologists

(ASA) grade, and noncolorectal specialty-trained surgeons

per-forming the ostomy as risk factors for stoma complications.(39)

As evident in these studies, various patient and surgeon factors can

increase the risk of developing complications Thus, it is

impera-tive for the surgeon caring for these patients to be well aware of

not only the things they can do to prevent these complications, but

also how do deal with any complications should they arise In the

following section, the presentation and management of common

complications will be addressed

Skin Complications

Skin conditions are common among patients living with stomas and

are more prevalent in patients with ileostomies than colostomies

(5) Common causes include fungal or bacterial infections,

irrita-tion from the ostomy effluent, folliculitis, contact dermatitis from

the appliance, a manifestation of IBD such as pyoderma

gangreno-sum, or simple skin excoriation from frequent appliance changing

ation should be given for ostomy reversal, revision or repositioning the ostomy, or if possible, converting a high output ileostomy to a lower output colostomy

Retraction

Stoma retraction occurs in up to 15% of patients and is most often the result of a technical error from improper construction and/or tension.(40–42) Postoperatively, complete retraction of the stoma into the abdomen mandates immediate re-exploration and re-creation of the ostomy Fortunately, this potentially cata-strophic complication is extremely rare Partial stoma retraction occurs more frequently and is more problematic for an ileostomy than a colostomy In ileostomies, retraction leads to difficulties with appliance placement and subsequent skin irritation In the thicker viscous colostomy effluent, skin irritation is less of an issue and can often be conservatively managed In severe cases, opera-tive stoma revision may be required The principles of revision include tension free ostomy and adequate eversion emphasizing the Brooke method

Ischemia and Stenosis

Ostomy necrosis, due to either arterial insufficiency or venous engorgement, presents in the early postoperative period and is first recognized by mucosal ischemia Arterial insufficiency is a complication of overaggressive mesenteric mobilization with resultant lack of small vessel collateralization to the mucosa

It can also be seen in patients with foreshortened or thickened mesenteries, in obese patients with thick abdominal walls, or after an inadequate fascial opening Likewise, stoma necrosis from venous engorgement as the etiology ultimately leads to the same end result Clinically, differentiating the etiology of necro-sis is not important as management is the same regardless of the cause When both considering and managing stoma necrosis, it is imperative to identify the proximal extent of ischemia This can be done by a simple bedside “test-tube test” in which a clear test tube

is inserted into the stoma and then trans-illuminated or direct visualization is obtained via a pediatric anoscope or proctoscope Necrosis seen below the fascia mandates re-exploration and revi-sion while necrosis isolated above the fascia can be conservatively managed Surgically, principles of revision include excision back

to healthy, viable bowel, and recreation of the stoma This may entail a more thorough intraabdominal mobilization to reduce

improved outcomes in colon and rectal surgery

tension through the abdominal wall, revision of the fascial

open-ing, or ensuring no kinking of the blood supply In very difficult

cases, consideration for a loop-end ostomy is advised since less

mesenteric mobilization is required

Conservative management of stoma necrosis is possible when

the necrosis is isolated above the level of the fascia Simple

mea-sures, such as maintaining an adequate blood pressure for stoma

perfusion and awaiting edema resolution after bowel

manipula-tion can avoid the morbidity of a re-exploramanipula-tion Even with frank

necrosis, conservative measures with local wound care should be

attempted However, conservative management of stoma

isch-emia is a risk factor for ostomy stenosis which occurs in 2–9%

of patients.(34, 40, 41) Stoma stenosis is described as narrowing

of the lumen of the ostomy at the skin or fascia level and is due

to luminal contraction from scar tissue formation In addition

to ischemia, stenosis can occur due to insufficient skin excision

at the stoma site, peristomal abscess, or mucocutaneous

separa-tion Stenosis, easily diagnosed by visual inspection and digital

exam of the stoma, is rarely clinically significant and can be

man-aged with a low residue diet and stool softeners In refractory and

symptomatic cases, dilation, excision of scar tissue, or stoma

revi-sion can be performed A local type of revirevi-sion involves a Z-plasty

repair (Figure 33.3).(43, 44)

Parastomal Hernias

By definition, a stoma is a hernia in the anterior abdominal wall,

thus leading Goligher to state that the true rate of parastomal

hernias is 100% As such, parastomal hernias are a well-known

complication of stomal surgery, and can be a major source of

morbidity (Figure 33.4).(45) The incidence of hernias ranges

from 5–10% of stomal patients with colostomies more prone

to herniate than ileostomies.(34, 46) Fortunately, most are well tolerated and manageable nonoperatively However, approxi-mately 30% of hernias require operative repair for symptoms that include bleeding, obstruction, abdominal masses, poor fitting appliances, and leakage.(47, 48) Surgical therapy has cen-tered on stomal relocation, primary fascial repair, and prosthetic mesh—alone, or in combination Each of these has been widely touted; however, significant morbidity and complication rates up

to 88% have left surgeons searching for a better answer to this difficult problem.(49–52) Equally frustrating is the high rate of

recurrence following initial repair Rubin et al found an initial

recurrence rate of 60%, with approximately 70% having subse-quent failures following additional surgery for both primary fas-cial repair alone and stomal relocation.(51) Although prosthetic mesh has shown improved results over stomal relocation and primary fascial repair, these reports are hindered by low patient numbers and lack of long-term follow-up to draw meaningful conclusions regarding complications and recurrences.(49–51, 53–56) A variety of surgical mesh repair techniques exist, includ-ing a circumferential onlay mesh, two separate intraperitoneal pieces placed lateral to the stoma, one large piece placed via a midline approach, and an incomplete mesh ring.(49, 53, 57, 58) Additionally, both open and laparoscopic approaches have been used.(59, 60) Yet, fear of mesh infection and erosion has led to concerns regarding mesh use, and the perceived need to avoid any contact between the bowel and mesh.(57)

At our institution, one operative approach to symptomatic parastomal hernias commonly used is primary fascial repair with nonabsorbable suture and placement of mesh via a “stove-pipe” hat repair (Figure 33.5) In this technique, one piece of mesh is placed overlying the fascial repair, the stoma is then pulled through

Figure 33.3 Loop end colostomy A, loop of

bowel brought through abdominal wall opening

B, stoma rod is placed through the mesenteric opening to support the loop on the skin and the bowel is opened C, Completed loop colostomy.

(C)

the center of the mesh, thus creating a 360-degree repair An

addi-tional piece of mesh is then tacked to both the bowel

circumfer-entially and to the onlay mesh Once constructed, this creates the

“stove-pipe hat” appearance In selected cases, an additional piece

of mesh is placed beneath the fascia to provide additional

sup-port Drains are routinely placed at the time of surgery

In a recent review of our experience, we analyzed 58 patients

that underwent parastomal hernia repair with polypropylene

mesh.(64) With a mean follow-up of 50.6 + 40.1 months, the

overall complication rate related to the polypropylene mesh was

36.2%, and occurred at a mean of 27.2 months Complications

encountered included recurrence (25.8%), surgical bowel

obstruction (8.6%), prolapse (3.4%), wound infection (3.4%),

fistula (3.4%), and mesh erosion (1.7%) No patients required

extirpation of the mesh Data analysis demonstrated that stomas

placed for underlying colorectal cancer were associated with a

decreased rate of complications while increased complications

were significantly associated with younger age (59.6 vs 67 years,

p < 0.05) With the increased availability and use of the biologic

the abdominal wall, distended abdomen, and increased abdominal pressure Prolapses are most commonly seen in loop stomas with the distal loop more prone to prolapse The diagnosis is easily con-firmed by inspection and the treatment depends on the severity of the prolapse In severe prolapse, stoma obstruction and ischemia may result from excessive tension on the underlying mesentery Ischemic changes manifested as ulceration or dusky appearance of the bowel mandates expeditious surgical intervention and resto-ration of blood flow In the more chronic setting, prolapse can be managed conservatively with manual reduction and symptomatic relief of discomfort or pain The application of the ostomy appli-ance is important for patients who suffer from prolapse The skin barrier opening should be cut to accommodate the stoma at its larg-est size and two piece pouching systems with plastic rings should be avoided to prevent strangulation Surgery may ultimately be neces-sary to resect the prolapse and revise the stoma if symptoms persist Again, especially in the setting of loop colostomies, using a portion

of bowel near the flexures where it tends to be more tethered, may aid in decreasing the incidence of prolapse

Special Consideration

Morbidly Obese Patients

Morbid obesity, defined as a body mass index >35 kg/m2, is a pub-lic health epidemic in the United States with the prevalence in the adult population ranging from 2.8–5.1%.(62, 63) The impact of obesity on the complication profile of patients undergoing col-orectal surgeries have been well documented and include a higher incidence of wound infection, dehiscence, wound herniation, anastomotic, pulmonary, cardiovascular, thromboembolic com-plications, increased operative time and length of hospital stay, and overall increased morbidity and mortality.(61) Additionally, morbid obesity has been found to increase the complication rates associated with stomas A prospective risk factor analysis of 97 patients for stoma complications found that elevated BMI was independently associated with an increased rate of ostomy retrac-tion, early skin excoriaretrac-tion, and overflow.(36) Furthermore, in a retrospective review of 156 patients undergoing stoma formation,

Duchesne et al found obesity, defined as a BMI > 30 kg/m2, was significantly associated with stoma complications, most com-monly, stoma necrosis, prolapse, and skin irritation.(65) Similarly, Leenan and Kuypers found that obese patients had a significantly higher percentage of overall stoma complication (47 vs 36%)

Figure 33.5 “Stove-pipe” hat repair: Parastomal hernia repair with mesh

demonstrating the onlay piece of mesh in as well as circumferential component

overlying the fascial repair An additional piece (not shown) may be placed in the

sub-fascial location as well (Courtesy of Patrick Y Lee, M.D.)

Figure 33.4 Computed tomography image of a patient with a parastomal hernia

The arrowhead represents a herniated portion of small bowel adjacent to the

ileostomy (arrow) Also note the large midline incisional hernia

improved outcomes in colon and rectal surgery

including a higher incidence of stoma necrosis.(40) Cottam’s

group, in a nationwide audit of stoma complications, found that

increasing BMI, even that not meeting criteria for “morbid

obe-sity”, was associated with more stoma problems.(37)

Various reasons for a higher complication rate in the obese

include a relatively shortened and fatty mesentery, thicker

abdomi-nal wall through which the stoma must traverse, poor small

ves-sel circulation associated with comorbidities of obesity, and the

physical difficulties of stoma appliance application in the

redun-dant pannus Ultimately, these factors predispose obese patients

to undergo increased mesenteric mobilization so that the bowel

reaches the skin, with the end result being arterial insufficiency to

the super-fascial stoma Additionally, an inadequate fascial opening

or physical compression of the abdominal wall on the stoma as it

traverses the abdominal wall may lead to constriction of venous

return with resultant stoma engorgement, stenosis, or necrosis

In morbidly obese patients undergoing stoma formation in an

elective setting, preoperative weight loss should be encouraged

Realistically however, sufficient weight loss to favorably impact the

complication profile is unlikely There may be a unique subset of

patients who can defer abdominal surgery requiring stoma

forma-tion until after undergoing bariatric surgery In these cases, stoma

formation should be delayed until massive weight loss has stabilized

as significant changes on the abdominal wall may require ostomy

revision if the order of surgery is reversed In addition to timing

of surgery, the preoperative preparation of the morbidly obese

patient is critical This high risk patient population should undergo

age appropriate and comorbidity appropriate risk stratification and

work-up as they are at increased risk for perioperative complications

In regards to ostomy complications, preoperative stoma marking is important in all patients undergoing stoma formation, but is argu-ably even more important in this patient population already at increased risk for local skin complications Large skin creases prone

to superficial fungal infections in the obese should be avoided, as well as low lying ostomies which may be difficult for the patient to adequately visualize and properly maintain (Figure 33.6)

Technically, a sufficient fascial opening should be made to easily accommodate the bowel through the abdominal wall Conservative mesenteric mobilization is encouraged, with mini-mal length required for the bowel to reach the skin without ten-sion for proper maturation the ultimate goal In patients with foreshortened mesenteries or those with significant abdominal wall thickness, a loop ostomy, or end-loop stoma in which a loop of bowel is brought through the fascia and the distal por-tion closed allowing a few addipor-tional centimeters of bowel length for construction, should be considered as these are less prone

to complications associated with vascular insufficiency Finally, removal of some local adipose tissue through which the stoma will traverse is reasonable, although over-aggressive “de-fatting” may lead to skin necrosis

Additional options include a modified abdominoplasty (abdom-inal wall countering), localized flaps with skin or fat removal, or liposuction Although frequently successful, these techniques have potential for significant morbidity Patients who may ben-efit from these techniques include those with stomal retraction (especially those who have bowel limitations [e.g., continent ileo-stomies, dense intraabdoninal adhesions or short gut], prolapse, large peristomal hernias, abdominal wall laxity (usually resulting from major weight loss), and peristomal skin problems such as pyodermia In many of these patients stomal relocation may not

be the best option

A modified abdominoplasty or abdominal wall contouring

is similar to the technique employed by plastic surgeons.(66, 67) A low curvilinear transverse incision is made at the inferior abdominal fold or 2–3 cm above the pubis and anterior superior iliac spines and carried down to the fascia (Figure 33.7) A flap

of skin and subcutaneous tissue is created by electrocautery dis-section in a cranial direction, just above the fascia Perforating vessels are identified and ligated or cauterized As the dissection continues the stoma will be encountered With the flap on trac-tion, the intestine is separated from the skin and subcutaneous tissue Care is taken to avoid injury to the bowel or its blood sup-ply The dissection should err on leaving additional subcutane-ous fat attached to the intestine This can be carefully resected later A similar maneuver may be performed at the umbilicus if

Figure 36.6 Loop ileostomy in an obese patient It

is important to consider stoma placement in the lying (A), seated (B), and standing (C) positions Note the placement of the ostomy with relation

to the pannus and mid-line incision Improper cutting of the stoma appliance cause peristomal skin excoriations This patient was preoperatively marked by an enterostomal therapist with good postoperative functional outcome.

Figure 33.7 Redundant abdominal wall folds of skin associated with ileostomy

retraction (A) Frontal view (B) Sagittal section demonstrating skin and subcutaneous

fat incisions.

(B) (A)

the surgeon and patient prefer to preserve it in its normal

loca-tion Again care is taken to preserve the tissue’s blood supply If

the umbilicus is not to be maintained, it can be amputated at the

fascial level The flap dissection is continued cranially just above

the fascia until enough laxity or length is obtained in the upper

flap for the upper edge of the previous stomal opening to reach

the inferior portion of the incision without excessive tension or

to the costal margins Any associated peristomal hernia can be

repaired at this time with suture repair of the fascia and/or mesh

(synthetic or biologic) reinforcement

As the flap is retracted inferiorly, new sites for the ostomy and,

if desired, the umbilicus are selected and openings created in the

flap Excess subcutaneous fat can be carefully removed to thin

the flap Fortunately, there is usually less subcutaneous fat above

the umbilicus compared to below it The excess, distal portion

of the flap is excised (Figure 33.8) The intestine and umbilicus

are brought through the respective flap openings and matured

with interrupted absorbable sutures (Figure 33.9) Excess bowel

or umbilical tissue can be carefully excised Closed suction drains

are placed below the flap to avoid seromas and the inferior

inci-sion is closed in layers As intraabdominal dissections are avoided

with this technique, patients usually recover quickly Morbidity

is usually associated with infection, flap ischemia, or seromas

These are managed with wound care

A more localized procedure involves the use of flaps to modify the abdominal wall around the stomas Most involve peristomal dissections and removal of skin and subcutaneous fat This can be performed via a medial or inferolateral approach (Figure 33.10)

An incision is made down to the fascia and advanced toward the stoma The ostomy is dissected free of the skin and subcutaneous tissue as described above After the stoma is freed, lateral or cra-nial dissection will provide enough laxity to advance the previous stoma site to the incision (advancement flap) As above, a new ostomy opening, in fresh skin, is created Excess fat may be excised around the stoma and redundant midline skin is resected

If the skin flap is not redundant enough to advance the origi-nal ostomy opening to the midline, the subcutaneous fat can

be excised and the stoma returned to its original skin opening through the thinned flap Either method is performed in such a manner to leave a smooth, flat, thinned flap that provides a flat surface to site the appliance The stoma is matured and the inci-sion is closed Subcutaneous closed suction drains are placed above and below the stoma

The circumstomal approach starts with an incision around the stoma at the mucocutaneous junction With careful dissection, the bowel is separated from the subcutaneous tissue down to the fascia The subcutaneous tissue is then separated from the fascia with electrocautery in a circumferential manner to a point 7–8 cm out from the stoma A wedge of subcutaneous tissue is circumfer-entially created from the upper skin edge to meet the outer edge

of the extrafascial dissection Small closed suction drains may be placed and the ostomy is matured to the skin edges If there was

a preoperative stenosis, the skin opening may be enlarged or the bowel may be matured with a Z-plasty technique.(43, 68) If the preoperative stomal opening was too large or it becomes too large from the dissection, the diameter of the opening can be reduced with interrupted sutures (Figure 33.11) This type of closure has been referred to a “Mercedes technique”.(69)

Rapid and significant weight gain in ostomy patients may pro-duce stomal retraction If attempts at weight loss have not been successful and stomal revision is not desirable or feasible (e.g., con-tinent ileostomy or short gut patients), liposuction is an excellent option This method is preferred if there is no associated stomal

(B).Sagittal section.

Figure 33.9 Ileostomy relocated through upper flap and skin incisions closed

Closed suction drains placed below flaps (A) Frontal view, (B) Sagittal section.

excision, (C) After removal of excess subcutaneous tissue, incision is closed, flaps attached to fascia, and stoma matured with adequate eversion.