45 Stoma Complications

45

Stoma Complications

Neil Hyman and Richard Nelson

643

Despite substantial advances in surgical technique and

enterostomal therapy, complications after stoma creation remain extremely common. The rate of stoma-specific com- plications in the literature varies quite widely, ranging from 10% to 70% depending on the methodology of the study, the length of follow-up, and the definition of a “complication.”

For example, virtually all ostomates will have at least transient episodes of minor peristomal irritation and skin irritation is the most frequently reported stoma complica- tion. Studies only reporting problems that require revisional surgery will obviously report a much lower rate of compli- cation. As such, the relative incidence and frequency of the specific complications will tend to be quite variable from series to series.

Stoma-related complications may be classified as those that are metabolic or best managed by medical intervention and those that have a purely structural etiology and are best man- aged by surgical intervention. Among the medical complica- tions, the most common early complications are peristomal skin irritation, leakage, high output, and ischemia. The most frequently reported late complications include dehydration and nephrolithiasis, cholelithiasis in ileostomy patients, bleeding in patients with liver disease, and of course also in those with recurrence of the disease for which a stoma was created, such as Crohn’s disease. In this chapter, we will make some general comments about the incidence and nature of stoma complications. We will then review the specific prob- lems of a high-output stoma, parastomal dermatitis, bowel obstruction, and later complications such as stoma stenosis, peristomal hernia, and stomal prolapse.

Incidence

The prevalence of intestinal stoma complication has been assessed in a number of publications. From Cook County Hospital, the incidence of stoma complications was recorded in 1616 patients.

A total of 34.2% of these individuals experienced a complication related to their stoma, 27.7% of

those individuals having an early complication, and only 6.5% a late complication. This publication also assessed the location of various stomas and their risks of complication.

The location with the highest risk was loop ileostomy with a rate of almost 75%. The only other stoma location to have a complication rate exceeding 50% was descending end colostomy with 65%. The location of an intestinal stoma with the lowest risk was an end colostomy of the transverse colon, in which 69 individuals had an overall complication rate of only 5.8%.

In a publication from Hong Kong, the specific type of com- plication associated with each stoma location was described.

Parastomal hernia was most often seen with an end sigmoid colostomy in that series, although it was prevalent with all stoma types except ileostomy. Stomal stenosis was seen more often with a loop sigmoid stoma, prolapse with a transverse colostomy, and skin excoriation with an ileostomy. This series included 322 stomas in 316 individuals. Risk factors leading to these complications have been assessed in several publications, including a case series from Holland, in which emergency stoma construction was significantly associated with both stomal necrosis and high stoma output.

Obesity was associated with an increase in stoma necrosis. Among the leading diseases needing stoma formation, Crohn’s disease and colonic ischemia were both associated with increased risk for ostomy- related complications. Crohn’s disease was more prevalently associated with retraction and ischemia causing stoma necrosis.

The series included 345 stomas in 266 patients.

In reports from Louisiana State University in New Orleans

and Swansea in the United Kingdom,

logistic regression was

done to assess which risk factors were independently associ-

ated with complications. In the former study, inflammatory

bowel disease and obesity both were associated with higher

risk. A preoperative visit by an enterostomal nurse was asso-

ciated with a significantly lowered risk of complications. In

the latter publication, emergency surgery was usually associ-

ated as an independent risk factor for finding a stoma in a skin

crease and early skin excoriation. Diabetes was associated

with later skin problems.

Skin Problems

Skin Irritation/Leakage

Skin irritation (Figure 45-1) is very common among patients with a stoma. The problem is far more often seen in patients with an ileostomy because of the liquid, high alkaline, active enzymatic caustic effluent

; this highlights the need for proper technique when an ileostomy is created. Nugent et al.

describe the results of a study using quality of life questionnaires in 391 ostomates. Fifty-one percent reported problems with a “rash” and 36% had experienced leakage, both of which were much more frequently seen with ileostomies than colostomies. Thirty percent of patients with a colostomy and 55% with an ileostomy had experienced a reaction to the adhesive. However, only 8% of ostomates reported a substantial degree of difficulty associated with skin irritation.

Although a minor degree of skin irritation on occasion is probably inevitable, most significant cases of skin irritation are potentially preventable. Preoperative marking by an enterostomal therapist can help assure proper siting and a secure fit. Appropriate location and careful appliance fitting minimizes the noxious, irritating effect that can be associated with leakage on unprotected peristomal skin. Patients also need to be monitored for allergic reactions to the components of the appliance. An adequate spigot with a close-fitting face- plate prevents exposure of the peristomal skin to the ileostomy effluent. However, even the best-fitting appliances around the best-made stoma will leak if frequent emptying of the appliance is not practiced and pooling of effluent around the base of the stoma occurs.

Particular attention must be given to older patients who may have limitations in eyesight or dexterity. Patients with a high-output stoma are at particular risk for skin irritation and ulceration if they do not have an appropriately fitted

appliance. Obesity has been frequently reported to be associ- ated with an increased risk of skin irritation, which is likely attributable to technical problems with stoma construction.

Strong consideration should be given to placing the stoma in the upper abdomen where there is typically much less creas- ing of the abdominal wall, subcutaneous fat, and the patient can see it much more readily.

The patient should be instructed to avoid creams or oint- ments that may interfere with the adherence of their appli- ance. In the postoperative period, a stoma will tend to become less edematous and the abdomen becomes less distended. As such, it is quite common to need to “downsize” the appliance at the first postoperative visit to minimize exposed skin.

Changing a stoma too frequently may lead to excessive “wear and tear” on the parastomal skin; however, too long an inter- val between changing the appliance may be associated with erosion of the protective barrier.

Even with the help of an excellent enterostomal therapist, specific skin infections may occur. Fungal overgrowth is evi- dent when there is a bright red rash around the stoma with associated satellite lesions. This is typically easily treated by dusting the peristomal skin with an appropriate antifungal powder. If the dermatitis conforms precisely to the outline of the stoma appliance, then an allergic reaction to the wafer or other component of the appliance is likely the culprit (Figure

reactivation of inflammatory bowel disease, or the develop- ment of pyoderma gangrenosa. Antibiotics, steroids, release of appliance pressure, and local applications of epidermal growth factor have all been tried to resolve the pyoderma.

There is no correlation with Crohn’s disease activity in remote portion of the bowel and the occurrence of pyoderma around the stoma.

FIGURE 45-1. Stomal skin irritation. FIGURE45-2. Allergic skin reaction.

High-output Stomas

A high-output state is typically described in association with an ileostomy, rather than a colostomy. Marked diarrhea and dehydration occur in 5%–20% of ileostomy patients, with the greatest risk occurring in the early postoperative period. An ileostomy usually functions by the third or fourth postopera- tive day.

The output typically peaks on the fourth post- operative day, with outputs of 3.2 L or more reported.

Because the ostomy effluent is rich in sodium, hyponatremia can be a problem. The particular window of vulnerability for dehydration seems to be between the third and eighth post- operative day. However, in time, the small bowel typically adapts and there is a steady decrease in ostomy output.

However, patients with an ileostomy, particularly those who have had concomitant small bowel resection, remain at risk to become dehydrated. Most often, this is easily managed by oral rehydration with one of the commonly available sports drinks. However, patients who have lost considerable absorp- tive surface because of previous bowel resection and/or those with recurrent/residual active Crohn’s disease are at particular risk. In addition to the loss of absorptive surface area, ileal resection also removes the fat or complex carbohydrate stim- ulation of the so-called “ileal brake” which slows gastric emp- tying and small bowel transit.

Fluid and electrolyte maintenance in these patients may require a period of par- enteral hydration and nutrition. Elements of the diet can aug- ment output and should be avoided in marginal cases. These might include foods high in sugar, salt, or fat.

Ileostomy diarrhea may be treated in its milder forms with fiber supplements or cholestyramine which can thicken secre- tions, but not change water content. Often opiates may be required to slow intestinal transit. In refractory cases, somato- statin analog has been used with some success. Somatostatin reduces salt and water excretion and slows gastrointestinal tract motility. However, its clinical usage has met with vari- able results.

Special mention is made of patients with a proximal ostomy required to treat complications of an anasto- motic leak. Good results have been reported with exterioriz- ing the leak and reinfusing the ostomy effluent into the downstream limb until gastrointestinal continuity can be restored. This has led to weaning parenteral nutrition in a substantial number of patients.

Nephrolithiasis

A related problem in patients with an ileostomy is the devel- opment of urinary stones. The obligatory loss of fecal water, sodium, and bicarbonate reduces urinary pH and volume.

Whereas approximately 4% of the general population devel- ops urinary stones, the incidence in patients with an ileostomy is approximately twice that. Whereas uric acid stones com- prise less than 10% of the calculi in the general population, they comprise 60% of stones in ileostomy patients. There is also an increase in the incidence of calcium oxalate stones,

and as a result, foods high in oxalate, such as spinach, should be avoided by ileostomates.

Bowel Obstruction

Life table analyses suggest that bowel obstruction is a rather common complication of ostomy creation. As many as 23%

of patients with an ileostomy have been reported to develop bowel obstruction. Adhesions are probably the most common cause, but small bowel volvulus or internal hernia may also be the cause. Although it is frequently mentioned that suture of the mesentery to the lateral abdominal wall may prevent volvulus or obstruction, retrospective analyses have not shown any benefit to this maneuver. Treatment is not dissim- ilar to other patients presenting with a mechanical small bowel obstruction.

However, special note must be made of food bolus obstruc- tion. Many patients with an ileostomy will develop signs and symptoms of bowel obstruction because of the accumulation of poorly masticated or digested food (e.g., popcorn, peanuts, fresh fruits, meat, and vegetables). A careful history may reveal dietary indiscretions. Furthermore, the possibility of a food bolus obstruction should be considered in any patient with an ileostomy who has radiologic evidence of a distal obstruction. A well-lubricated finger can be gently inserted into the stoma to feel for impacted material. A red rubber catheter is inserted gently into the ostomy and saline irriga- tion initiated. If suspicious concretions begin to pass into the stoma, the irrigations may be carefully repeated until the obstruction is relieved. A water-soluble contrast enema through the obstructed stoma may also be both diagnostic and therapeutic by dislodging the bolus.

Ischemia

Edema and venous congestion are very common after stoma creation because of mechanical trauma and compression of the small mesenteric venules as they traverse the abdominal wall. This is typically self-limiting and requires no treatment.

However, stomal ischemia (Figure 45-3) is more serious and

often related to tension on the mesentery or excessive mesen-

teric division, particularly in obese patients. A stoma of ques-

tionable viability may be examined by insertion of a glass test

tube or flexible endoscope into the stoma. If the stoma is

viable at fascial level, then the patient may be carefully

observed. However, if there is question about the viability of

the stoma at fascial level, immediate laparotomy and stoma

revision is required. Early ischemia is seen in 1%–10% of

colostomies and 1%–5% of ileostomies.

Stomas do not get

better once the patient is awake, but generally only get worse

in the early postoperative period. Every effort must be made

at construction of the original stoma to make one of perfect-

appearing viability, assuring good blood flow in and out to the

skin. It never takes as long to do this as it does to manage an

ischemic or necrotic stoma.

Late Hemorrhage

Late stomal bleeding may be caused by direct trauma, but heavy bleeding is, especially from an ileostomy, caused by portal hypertension and the development of stoma varices.

Many therapies have been described for this, but none sub- jected to rigorous clinical trials. Correction of coagulopathy and direct pressure are important first steps. Whether direct treatment by injection sclerotherapy or systemic treatment by some form of porto-systemic shunt provides better short- and long-term outcome is undecided. The placement of a trans- hepatic intrahepatic portal shunt (TIPS) is a nonoperative alternative that should be considered. Ostomy revision does not provide a lasting solution.

Surgical Complications

Surgical complications of intestinal stoma formation can broadly be divided into those that occur early, those that occur long (late) after their construction, and those that occur at stoma closure. Early complications of stoma con- struction include necrosis, retraction (Figure 45-4), skin irri- tation, small bowel obstruction, surgical wound infection, and sepsis. Late complications are dominated by prolapse (Figure 45-5), peristomal hernia, skin irritation, and fecal fistula. Closure-related complications include surgical wound infection, fecal fistula, anastomotic dehiscence, small bowel obstruction, and incisional (peristomal) hernia (Figure 45-6).

The prevention and management of each of these compli- cations are best assessed in randomized, controlled clinical trials. A total of 18 randomized trials have been performed in some way related to stoma construction

(Table 45-1).

The most common study design has been randomization of patients to receive either temporary loop colostomy or loop ileostomy, then following these patients for various compli- cations.

The operations for which these stomas were

done were either low anterior resection for carcinoma or a mixture of colonic procedures related to both cancer and diverticular disease. Table 45-2 shows a metaanalysis of each of the complications that have been assessed in some or all of these publications. These analyses show that the only signif- icant difference between the two stoma locations was an increased risk of stoma prolapse associated with loop colostomy. In the other cases, there was no significant differ- ence in the risk of complications listed in Table 45-1.

Statistical heterogeneity did not exist for any of these calcu- lations, validating the metaanalysis. The risk of overall com- plication is perhaps less in all these studies because these were temporary stomas. A much more thorough metaanalysis has recently been published.

FIGURE 45-3. Stomal ischemia.

FIGURE 45-4. Stomal retraction.

FIGURE 45-5. Stomal prolapse.

Stoma Closure

Looking at the other end of a stoma’s history, there are two randomized trials that compared stapled anastomosis to hand-sewn anastomosis during stoma closure, the first in patients who had an ileostomy closure after ileo pouch anal reconstruction

and the second in a more mixed group of surgical patients.

The only complication cataloged in both trials was the risk of small bowel obstruction subsequent to closure. The risk of obstruction was significantly less in the metaanalysis in patients having stapled closures as opposed to hand-sewn (Table 45-2). There was also no statistical het- erogeneity in this analysis. Time to flatus was reported to be less among the stapled closure patients in the first trial, although length of hospital stay was equivalent in both stud- ies. In the second trial, the risk of fecal fistula and surgical wound infection was slightly lower among those patients having a stapled closure.

It is common practice to wait a minimum of 1.5–3 months before closing an intestinal stoma after its construction. This practice was assessed in a randomized trial related to trauma laparotomy patients having temporary colostomies. Patients were randomized to either early or late stoma closure. The average length of time for closure in the early group was 11.8 days and in the late group 104.8 days.

There was no over- all difference in complications between these two groups, nor individually for fecal fistula, small bowel obstruction, or sur- gical wound infection. The last six trials listed in Table 45-1 compared either patients getting a stoma with patients not getting a stoma or various types of stoma construction and resection in complicated large bowel obstruction. Unfor- tunately, stoma-related complications were not reported in any of these trials.

Parastomal Hernia

Regarding surgical management of each of the complications listed in Table 45-1, there are regrettably no informative ran- domized trials. There are many case reports and case series, but these are seldom presented with the comparison group that allowed quantitative assessment of the efficacy of the procedures being described. Therefore, opinion concerning

the treatment of prolapse, hernia, retraction, or necrosis is anecdotal and not evidence based.

The difficulty in choosing the right therapeutic approach is best described in a thorough review by Carne et al.

of paras- tomal hernia, a condition that is a useful surrogate for all the other stoma-related complications. In that review, incidence of hernia is described to occur in anywhere from 0% to 48.1%

of individuals. Much of this variation is clearly attributable to definition, because some herniation (similar to some degree of hemorrhoids) can be seen in many patients, whereas more conservative observers would only describe a hernia that pre- vents the patient either from maintaining the appliance over their stoma or one that causes obstructive symptoms. The risk of recurrence is also well discussed in this review. It is found to be so prohibitively high that it seems best to be conserva- tive in undertaking operative repair, limiting surgery only to those most symptomatic patients.

Prevention of parastomal hernia includes discussion of the following parameters: the site of the stoma related to the rec- tus muscle, the size of the abdominal aperture, the use of pro- phylactic mesh implantation at various levels in the abdominal wall, transperitoneal versus extraperitoneal tunnel- ing of the stoma, and fixation of the stoma to the abdominal fascia. Of interest in this review is that there are six cited stud- ies that have examined whether or not a stoma should be placed lateral to the rectus border to prevent hernia. Most authors found that it made no difference.

The prophylactic use of mesh wrapped around the stoma has in fact been subjected to one randomized trial in patients getting permanent intestinal stomas.

Among 54 patients, none with the mesh developed hernia, whereas 8 of 27 with- out mesh did. There was no small bowel obstruction in any of these patients. Other case series of prophylactic mesh use have described both stomal stenosis and erosion and infec- tions related to mesh placement, which have tended to make this not a very popular technique.

The options available for repair of parastomal hernia include direct local tissue repair, resiting of the intestinal stoma with closure of the primary aperture, and the applica- tion of mesh around the stoma at various levels within the abdominal wall. Once again there are no randomized trials comparing any of these techniques. Three techniques, colon fascia repair, mesh, and relocation in a small series were assessed in a nonrandomized trial. Surgical wound infection was more common when mesh repair was used and recurrent hernia much more common when there was just direct fascial repair around the stoma.

All of the operations that have been described to repair parastomal hernia can be applied to patients with prolapse, retraction, and skin irritation associated with flush ileostomy.

In addition, for patients with prolapse, local amputation and reanastomosis can be used, often with low morbidity. The best operation to perform in individuals having significant compli- cations is closure of the stoma and restoration of intestinal continuity. This should be done whenever possible.

FIGURE 45-6. Peristomal hernia.

TABLE45-1. Randomized, controlled trials related to intestinal stomas

Author, Prolapse

reference, operation RCT? Group 1 (N) Group 2 (N) (group 1/group 2) Stomal hernia Fecal fistula Retraction

Edwards et al.,¹⁶ Yes Loop Loop 2/0 2/0 1/0

LAR colostomy, 36 ileostomy, 34

Law et al.,¹⁷ Yes LC, 39 LI, 39 3/0 0/1 0/0

LAR

Gooszen et al.,¹⁸ Yes LC, 39 LI, 37 16/1 0/2 2/1 1/4

mix

Khoury et al.,¹⁹ Yes LC, 29 LI, 32 1/1

mix

Williams et al.,²⁰ Yes LC, 24 LI, 23 2/0

mix

Hull et al.,²¹ Yes Stapled Sewn

IPAA closure, 31 closure, 30

Hasegawa et al.,²² Yes St., 70 Sewn, 70 0/2

mix

Velhamos et al.,²³ Yes Early, Late, 20, 104.8 d 1/1

trauma lap. 18 ×= 11.8 d

closure

Berne et al.,²⁴ Yes Skin open after Skin closed, 38

mix stoma closure, 38

Janes et al.,²⁵ Yes Mesh to prevent No mesh, 27 0/8

permanent stomas hernia, 27

Tang et al.²⁶ Yes Adhesion barrier No barrier, 54 5/3

#1, LAR around stoma, 51

Tang et al.²⁶ Yes Barrier, 34 No barrier, 36 1/1

#2, LAR

Grobler et al.,²⁷ Yes Loop No stoma, 22

IPAA ileostomy, 23

Graffner et al.,²⁸ Yes Loop col., 25 No stoma, 25 1/3

LAR

Xinopooulos et al.,²⁹ Yes Stent, 15 Stoma, 15 large bowel

obstruction

Fiori et al.,³⁰ Yes Stent, 11 Stoma, 11

LBO

Kronborg,³¹ Yes 3 stage 2 stage

LBO

Zeitoun et al.,³² Yes Primary Secondary

divertic. resect., 55 resect., 50

RCT, randomized, controlled trial; LAR, low anterior resection of the rectum with anastomosis; IPAA, total colectomy with ileal pouch anal reconstruction.

Small bowel Surgical Incisional Skin

Sepsis obstruction wound infection Time to flatus Death hernia irritation Length of stay Comment

1/0 2/1 2/2 5/0

2/1 1/3 2/1 3/2 7/4

1/2 9/11

3/2 2/3

2/2 8/3 7/3

1/2 1.7/2.2 Equal

2/10 6/7 8/10

1/0 3/2

3/1 +1 for subq drained group 0/0

5/4 3/3 Variable

closure Times

2/2 2/2 Uniform

Closure time

28/60

1/3 days 0/0

Both had Stomas

12/9

TABLE45-2.Metaanalysis of similar studies; odds ratios, 95% confidence intervals, and Pvalue for heterogeneity Small bowel Surgical wound Comparison groupsProlapseStomal herniaFecal fistulaRetractionSepsisobstructioninfectionTime to flatusSkin irritation Loop ileostomy and 10.720.681.790.390.971.041.891.231.35 loop colostomy 2.79–41.220.09–5.160.36–8.90.07–2.270.17–5.480.34–3.170.72–4.940.32–4.810.59–3.09 0.780.280.90.400.400.640.660.720.27 Stapled and sewn ileostomy closure0.23 0.06–0.87 0.51 Stoma wrap in an adhesion barrier1.641.26 0.94–6.090.40–3.9 0.730.84

Conclusions

In conclusion, none of the risk factors listed for stoma com- plications at the beginning of this chapter (obesity, emergent construction, diabetes, Crohn’s disease, ischemic colitis) are actually within the control of the operating surgeon except for the role that an enterostomal nurse has in preoperative assess- ment of stoma patients. Second, in choosing the type of intes- tinal stoma to perform, the retrospective studies and randomized study often conflict. Ileostomy would seem to be more at risk for complication than the case series,

yet loop colostomy clearly is associated at least with increased risk of prolapse in the randomized trials.

Randomized clinical trials are difficult to perform. They are expensive, they take a great deal of time and effort, and recruitment of participants is often painfully difficult. But this study design is the most valid means of determining the effi- cacy of any therapeutic intervention. Table 45-1 demonstrates the feasibility of doing randomized trials in a number of clin- ical settings related to intestinal stomas. Yet relating to the treatment of complications of intestinal stomas (not their ini- tial construction) there are none. There are enough individu- als that have intestinal stomas and enough surgeons who need to know how to prevent these very prevalent complications to answer all of the unanswered questions related to stoma com- plications.

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