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Acs0530 Intestinal Stomas 2004


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Acs0530 Intestinal Stomas 2004

  1. 1. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 30 Intestinal Stomas — 1 30 INTESTINAL STOMAS J. Graham Williams, M.Ch., F.R.C.S. Formation of an intestinal stoma is frequently a component of Both types of stoma effectively defunction the distal bowel; how- surgical intervention for diseases of the small bowel and the colon. ever, loop ileostomy appears to be associated with a lower inci- The most common intestinal stomas are the ileostomies (end and dence of complications related to stoma formation and closure, loop) and the colostomies (end and loop); the less common though it may also carry a higher risk of postoperative intestinal stomas, such as cecostomy and appendicostomy, have limited obstruction.6 The two types of stoma are comparable with respect applications and thus are not considered further in this chapter. to patient quality of life, and the degree of subsequent social For optimal results, it is essential that stoma creation be con- restriction is influenced more by the number and type of compli- sidered an integral part of the surgical procedure, not merely an cations than by the type of stoma formed.8 irritating and time-consuming addendum at the end of a long SELECTION OF STOMA SITE operation. Accordingly, the potential requirement for a stoma should be appropriately addressed in the planning of an intestinal A poorly sited stoma will cause considerable morbidity and procedure. A great effort should be made to counsel the patient adversely affect quality of life. For this reason, great emphasis before operation as to whether a stoma is likely to be needed, what should be placed on selecting the best site for the stoma on the stoma creation would involve, where the stoma would be situated, abdominal wall. In many instances [see Table 1], it may not be pos- and whether the stoma is likely to be permanent or temporary. sible to decide beforehand whether a colostomy or an ileostomy is to be performed. An example would be the case of a patient with a tumor in the lower rectum in which the surgeon’s inten- Operative Planning tion is to perform a restorative resection covered by a loop ileosto- my. In such a case, the surgeon sometimes finds that restorative PREOPERATIVE COUNSELING resection is not technically possible and elects to perform an Ideally, as soon as surgical intervention that may involve a abdominoperineal resection or a low Hartmann resection with an stoma is contemplated, the enterostomal nursing service should end colostomy instead. become involved—though this may not be possible in an emer- A stoma should be brought out through a separate opening in the gency setting. Patients often have misconceptions about the effects abdominal wall, not through the main incision: there is a high inci- stoma will have on their quality of life and consequently may expe- dence of wound infection and incisional hernia formation if the rience considerable anxiety. Adequate preoperative counseling main incision is used as a stoma site. In general, ileostomies are sited helps correct these misconceptions and reduce the attendant anx- in the right iliac fossa, sigmoid colostomies (loop or end) in the left iety. Enough time should be set aside to allow the counselor to iliac fossa, and transverse loop colostomies in either the right or the explore the patient’s knowledge of the disease and understanding left upper quadrant.These positions are preferred because they are of why a stoma may be required. This process involves reviewing conveniently close to the particular bowel segments to be used for the planned operation, describing what the stoma will look like, creating the various stomas. At need, however—as when finding a and explaining how the stoma will function. Visual aids (e.g., suitable site proves difficult because of previous scars or deformi- videos, CD-ROMs, and booklets) can be very useful in this regard ty—both the ileum and the colon can be mobilized to provide suf- and should be freely available to patients and their families. As ficient length to reach most sites on the abdominal wall. simple a measure as showing the patient a stoma appliance and In selecting and marking a stoma site, the following key con- attaching it to the abdominal wall before the procedure can be siderations should be taken into account: helpful in preparing the patient for a stoma. Many patients facing the prospect of stoma surgery also derive great benefit from meet- 1. A flat area of skin is required for adequate adhesion of the ing patients of similar age and background who have a stoma. appliance. 2. The patient should be able to see the stoma. CHOICE OF PROCEDURE 3. Skin creases, folds, previous scars, and bony prominences A number of common indications for stoma formation have should be avoided. been identified [see Table 1]. These indications are usually associ- 4. The stoma site should not be located at the beltline. ated with particular types of stoma, but the association is not 5. The site should be identified with the patient lying, sitting, always a simple or automatic one. In many situations, more than and standing. one option exists, and it can be difficult to select the best avail- 6. Preexisting disabilities should be taken into account. able option for a particular patient. According to received wisdom, the stoma should be brought out of the abdomen through the rectus abdominis, so that the Loop Ileostomy versus Loop Colostomy emerging stoma will be supported and the incidence of paras- Defunctioning of a distal anastomosis after rectal excision and tomal hernia reduced. Several studies, however, have shown that anastomosis may be achieved with either a loop ileostomy or a this approach is not always ideal and that the optimum site for a loop transverse colostomy. A number of nonrandomized stud- stoma should be selected without regard to its position in relation ies1-3 and randomized control trials4-7 have been performed in an to the rectus abdominis.9-11 Once selected, the site is marked with effort to determine which of these two approaches is superior. an indelible pen or tattooed with India ink and a fine needle.
  2. 2. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 30 Intestinal Stomas — 2 Table 1 Indications for Different Types of Intestinal Stomas Disease Presentation Indication Stoma Type Intention Perforation Defunctioning of bowel Loop or end colostomy Temporary, often permanent Obstruction Relief of obstruction Loop or end colostomy Temporary Colorectal cancer Rectal cancer Low tumor (abdominoperineal End colostomy Permanent resection) Defunctioning of low anastomosis Loop ileostomy or colostomy Temporary Perforation Resolution of sepsis; defunctioning Colostomy Temporary, sometimes permanent of bowel Diverticular disease Obstruction Relief of obstruction Loop or end colostomy Temporary, sometimes permanent Elective resection for fistula Protection of anastomosis Loop ileostomy or colostomy Temporary Acute colitis Defunctioning of bowel End ileostomy (after subtotal Temporary or permanent colectomy) Ulcerative colitis Chronic colitis Eradication of disease End ileostomy (after Permanent panproctocolectomy) Ileoanal pouch procedure Loop ileostomy Temporary Crohn colitis Defunctioning of bowel Loop or split ileostomy Temporary, sometimes permanent Defunctioning of bowel after End ileostomy or colostomy Temporary, often permanent excision Small bowel disease Defunctioning of bowel Loop, end, or split ileostomy Temporary, sometimes permanent Crohn disease Perianal disease Defunctioning of bowel Loop or split ileostomy Temporary, often permanent Excision of disease Ileostomy (after panproctocolectomy) Permanent Colostomy (after rectal excision) Elective resection for septic Defunctioning of bowel Loop or divided loop ileostomy Temporary complications Colon injury Defunctioning of bowel Colostomy or loop ileostomy Temporary, sometimes permanent Trauma Rectal injury Defunctioning of bowel Colostomy Temporary, sometimes permanent Fecal incontinence Defunctioning of anus End colostomy Permanent Functional disorders Sphincter repair Defunctioning of bowel Loop ileostomy or colostomy Temporary Operative Technique of the abdominal wall. For this reason, the same basic principles that apply to intestinal anastomosis also apply to stoma forma- GENERAL PRINCIPLES tion—namely, maintaining an adequate blood supply to both Most abdominal stomas are formed at the end of an open sides of the anastomosis, ensuring that the anastomosis is per- operation performed to resect bowel, drain an infectious focus, formed without tension, and avoiding any preexisting infection. or relieve obstruction. In this setting, a midline incision is gen- In accordance with these principles, the bowel segment used erally the most appropriate choice for gaining access to the should have as much of its blood supply as possible preserved abdominal cavity because it leaves the areas to either side of the during mobilization, and mobilization should be sufficient to midline available for stoma placement. Other incisions may be allow the bowel to be brought through the abdominal wall with- used as well, but more careful operative planning will be out tension and without occlusion of the blood supply at the fas- required. cial level by a too-small hole in the abdominal wall. If these cri- A defunctioning stoma can be created without opening the teria are not met, then either the bowel should be mobilized fur- abdomen by making a trephine hole and using retractors and ther or a new bowel segment should be selected. It is important forceps to identify the relevant bowel loop from which the to make the best possible technical choices at the time of initial stoma will be formed. I generally avoid this approach, for two stoma formation. If the correct principles are not followed at the reasons. First, the trephine hole invariably ends up larger than beginning of the procedure, it is generally futile to hope that the is ideal, and the greater size leads to an increased risk of para- situation will improve thereafter; the usual result is a poor stoma stomal hernia. Second, it is often difficult to be sure that the that requires surgical revision. correct bowel loop has been identified and the correct end opened as a stoma. These disadvantages can be overcome by Creation of Stoma Aperture taking a laparoscopic approach. One port is placed though the It is wise to leave formation of the hole for the stoma until the previously marked site. A tissue forceps is passed down this port end of the procedure because unforeseen events during the oper- and used to grasp and orient the relevant bowel segment. If nec- ation may necessitate a change in the type or the site of the stoma. essary, the bowel can be mobilized by means of laparoscopic A circular incision 2.5 cm in diameter is made at the marked site, dissection. The colon is then divided with a linear stapler, and and the skin is excised. The subcutaneous fat is parted with scis- the proximal end is brought out through a small trephine hole sors and small retractors until the fascia of the abdominal wall is made at the port site. reached. The fat need not be excised: it supports the emerging The fundamental concept in stoma formation is that a stoma stoma, and its absence would leave a potential dead space. A cru- is simply an anastomosis between a piece of bowel and the skin ciate incision is made in the rectus sheath, initially no more than
  3. 3. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 30 Intestinal Stomas — 3 2 cm in each direction.The muscle fibers of the underlying rectus a abdominis are split in the direction of their fibers with an arterial clamp or the tips of heavy scissors.The small retractors are insert- ed deeper to keep the muscle fibers apart, and a small cruciate incision is made in the posterior rectus sheath with an electro- cautery. A swab held against the peritoneum at the stoma site will protect the intra-abdominal organs and the assistant’s fingers from being injured by the electrocautery point. On occasion, the epigastric vessels, which lie between the rec- tus abdominis and the posterior sheath, are injured. Should this occur, the simplest way of dealing with the problem is to open the posterior sheath from inside the abdominal cavity and suture-lig- ate the bleeding point. COLOSTOMY b End The typical site for an end colostomy is the left iliac fossa, and either the sigmoid or the descending colon is used for the stoma. If the rectum has been excised, the inferior mesenteric vessels will have been divided, and the blood supply to the distal colon will come from the middle colic vessels via the marginal artery. It is Figure 1 End colostomy. (a) The end of the colon sits 1 to 2 cm not usually necessary to take down the splenic flexure to mobilize above skin level. Four absorbable sutures are placed, one in each the colon adequately; however, if there is any concern regarding quadrant of the stoma. Each suture takes a full-thickness bite of tension on the stoma, full splenic flexure mobilization should be the end of the colon, a seromuscular bite of the emerging colon at performed. For a simple defunctioning end colostomy, only a few skin level, and a subcutaneous bite of the edge of the skin open- small vessels in the mesentery will have to be divided. ing. (b) The stoma is completed by filling in the gaps between the The colon is divided at the relevant site with either crushing four quadrant sutures with interrupted sutures that take full- clamps or a linear intestinal stapler. The adequacy of the vascular thickness bites of the end of the colon and subepidermal bites of supply is checked by inspection. A nontraumatic bowel clamp or the skin edge. The stoma should have a small (0.5 to 1 cm) lip, which facilitates accurate positioning of the colostomy bag. a Babcock tissue forceps is passed through the hole in the abdom- inal wall and used to grasp the closed-off end of the colon. Care is taken when drawing the colon through the abdominal wall to keep than an end colostomy does. This is a particular concern in from twisting the colon and damaging the small vessels in the sup- emergency situations, where the colon may be greatly dilated. porting mesentery.The end of the colon should sit 2 cm above the 2. The larger hole predisposes to formation of a parastomal her- skin surface. To prevent wound contamination, the colostomy is nia, which can be a problem if the stoma is not reversed. constructed only after the skin incision has been fully closed and 3. Loop colostomies are more prone to prolapse than end dressed. The closed-off end of the colon is excised with a sharp colostomies are, possibly as a conseqence of parastomal hernia knife, and the colostomy is constructed with a small spout by formation. everting the bowel wall. The spout helps the patient position the 4. The effluent from the transverse colon can be highly liquid, stoma appliance but should not protrude more than 0.5 to 1 cm and the absence of a spout with loop colostomy may lead to above the surface of the skin. The anastomosis is performed with difficulties with appliance leakage. interrupted absorbable sutures that take bites of the full thickness 5. When a loop colostomy is used to defunction a distal anasto- of the end of the colon and the subcuticular layer of the skin. Small mosis, there is a theoretical risk of damage to the marginal bites are also taken of the seromuscular layer of the emerging artery, which may be the only vessel supplying the distal side colon at the level of the skin [see Figure 1]. of the anastomosis. This technique is sometimes modified by closing the lateral space between the abdominal wall and the colon with absorbable The usual site for a loop colostomy is either the right upper sutures in an effort to prevent internal herniation of the small quadrant (using the proximal transverse colon) or the left iliac bowel. An alternative approach is to tunnel the colostomy to the fossa (using the left colon). The colon segment that will be used hole in the abdominal wall via an extraperitoneal route. This to form the stoma is identified, and peritoneal attachments are approach may prevent herniation and colostomy prolapse,9 but divided to provide sufficient length to reach the desired site on the stoma may be slow to function and difficult to mobilize if a the abdominal wall without tension. If the transverse colon is to reversal or revision operation is performed. be used, the omentum is removed. Care is taken not to damage the marginal artery, which, if occluded, may compromise vascu- Loop lar supply to the distal bowel. A loop colostomy is usually performed as a quick and tempo- A trephine hole is made at the marked site as described [see rary method of relieving acute colonic obstruction or to cover an Operative Technique, General Principles, above].The hole is usu- anastomosis in the distal colon or rectum. Whenever possible, I ally larger than it would be in an end colostomy; the bowel loop avoid using loop colostomies, for the following reasons. to be brought out is often bulky, especially when the colon is obstructed. A small window is made in the mesentery immedi- 1. Because of the need to accommodate two pieces of bowel, a ately adjacent to the colon wall, and a Jacques catheter is passed loop colostomy requires a larger hole in the abdominal wall through this aperture.The Jacques catheter is used as a handle by
  4. 4. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 30 Intestinal Stomas — 4 a b Figure 2 Loop colostomy. (a) A soft catheter or a length of nylon tape is passed through a small window made in the mesentery of the colon, and the pre- pared loop of colon is eased through the hole in the abdominal wall with the aid of the catheter. The catheter or tube is c d replaced by a supporting colostomy rod. (b) A transverse incision is made across the apex of the colon loop. (c) The cut edges of the colon are everted and sutured to the skin edge of the stoma hole with interrupted absorbable sutures that take full-thickness bites of the colon and subepidermal bites of the skin. (d) The rod is left in place for 5 days to support the loop stoma during the early phase of healing. which the colon loop is drawn through the trephine hole in the ILEOSTOMY abdominal wall, with care taken to maintain the orientation of the colon and avoid twisting [see Figure 2a]. The catheter is then End replaced by a plastic or glass stoma rod, which supports the loop End ileostomy is most frequently performed after colectomy at the level of the skin. for inflammatory bowel disease. The most distal segment of the The main incision is closed, and the stoma is matured. A trans- ileum is used (i.e., that immediately proximal to the ileocecal verse incision is made in the apex of the bowel loop [see Figure valve), the reason being that it is important to preserve intestinal 2b], and the two edges are peeled back and sutured to the skin length, both for nutritional reasons and to allow for the possibili- edge of the trephine hole to produce a double opening [see Figure ty that an ileoanal pouch may have to be fashioned in the future. 2c, d]. The bridge remains in place for 5 days, by which time the In certain instances, it is necessary to create an end ileostomy stoma is usually beginning to function properly.The rod can then from a more proximal segment of the ileum. be removed because by this point, the stoma is fixed in place and The terminal ileum is mobilized, a large avascular window is unable to retract into the abdominal cavity. opened between the ileocolic vessels and the ileal branches of the Double-Barrel superior mesenteric vessels, and the ileocolic vessels are divided where they branch from the superior mesenteric vessels. The ter- At one time, there was a vogue for creating a double-barrel minal ileum is usually supplied by two arcades of vessels, which colostomy to defunction the colon. Although the height of join the ileocolic vessels adjacent to the cecum. These arcades the vogue has passed, this type of stoma still has a place in the must be divided as close to the ileocolic vessels as possible to pre- management of colorectal trauma. After resection of a dam- serve the blood supply to the terminal ileum [see Figure 3]. The aged segment of the colon, the proximal and distal ends of ileocecal fold (Treves’s fold) is dissected away from the terminal the colon are tacked together along the antimesenteric surfaces ileum, which can then be divided flush with the ileocecal valve, with interrupted absorbable sutures. The resulting double end either with a linear stapler or with a knife between bowel clamps. is then brought out through a trephine incision at the relevant The trephine incision is created at the previously marked site, site. The double-barrel configuration makes the colostomy and a Babcock tissue forceps is passed into the abdominal cavity easier to close: closure can be performed after mobilization and used to grasp the divided end of the ileum. The terminal by resection and a sutured anastomosis or via a double-stapled ileum and the supporting mesentery are gently eased through the technique. aperture, with the mesenteric surface oriented superiorly, until 5
  5. 5. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 30 Intestinal Stomas — 5 Line of Division a Vascular Arcades b Right Colic Superior Artery Mesenteric Artery Ileocolic Artery Cut Edge of Ileal Branch Mesentery Ligated Vessels Stapled End of Ileum Figure 3 End ileostomy. Shown is preparation of the terminal ileum. (a) Care is taken when dividing the blood supply of the right colon to preserve the arcades supplying the terminal ileum. The line of division of the vessels and the mesentery is shown (dashed line). (b) The mesentery of the terminal ileum is divided so as to preserve the vascular arcade adjacent to the ileum. A segment of well-perfused ileum at least 10 cm long is created, which can be brought through the abdominal wall opening to provide sufficient ileum for creation of a spout. cm of ileum protrudes above the abdominal skin.The cut edge of the ileal mesentery is secured to the peritoneum of the back of the anterior abdominal wall, along the line of the lateral border of the rectus abdominis, with an absorbable suture. This measure helps stabilize the stoma and is thought to prevent stoma prolapse, volvulus, and internal herniation around the stoma. The stapled end of the ileum is excised to produce a fresh bleeding 4 cm. 5 cm. end.The emerging ileum is then everted to yield a spout about 2.5 cm long. This is accomplished by placing a suture on either side of the mesentery and a third suture on the antimesenteric side, which lies inferiorly.The superior sutures take bites of the serosa of the emerg- Feet Head ing ileum, 5 cm from the cut end of the bowel, and the inferior suture includes a serosal bite 4 cm from the cut edge [see Figure 4].When the sutures are tied, an everted spout is created that points downward into the ileostomy appliance.12 The mucocutaneous anastomosis is then completed with a series of interrupted absorbable sutures. Loop A loop ileostomy is employed to rest the distal bowel or to pro- tect an anastomosis.The ileal loop used should be as distal as pos- sible while still maintaining adequate mobility; if there is any ten- sion, a more proximal loop may be required. The technique of loop ileostomy formation is similar to that of loop colostomy for- mation. A Jacques catheter is used to draw the loop through the Figure 4 End ileostomy. The ileum having been brought through abdominal wall trephine hole, ideally with the proximal limb in the abdominal wall, the ileostomy is created by everting the end the lower position [see Figure 5a]. Care is taken to distinguish the of the ileum. Three sutures are placed: one on the antimesenteric side and one to each side of the mesentery. Each suture takes a proximal and distal limbs of the loop and to keep from rotating full-thickness bite of the cut edge of the ileum, a seromuscular the loop during its passage through the abdominal wall. A mark- bite of the emerging ileum at skin level, and a subepidermal bite ing suture is useful for identifying the proximal side of the loop. of the skin edge. The spout is created when these sutures are tied. A supporting rod may be used, but it is not necessary, and it can A nontoothed forceps or a Babcock tissue forceps is sometimes hinder the fitting of the stoma appliance. helpful for everting the ileum. Gaps between the three sutures are The ileostomy is created by making a circumferential incision filled in with further absorbable sutures, which include only the around 80% of the distal limb at the level of the skin, with the end of the ileum and the skin edge.
  6. 6. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 30 Intestinal Stomas — 6 a b Figure 5 Loop ileostomy. (a) A soft catheter or a length of nylon tape is passed through a small window made in the mesentery of the ileum, and the ileal loop to be used for the stoma is eased through the hole in the abdominal wall and left protruding a few centimeters above skin level. A suture is placed to mark the distal limb. (b) A semilunar incision is made in the mesenteric border of the distal limb at skin level, extending around most of the circumference of the ileum. (c) A Babcock tissue forceps is inserted into the loop and used to grasp c d the wall of the proximal limb. The cut edge of the ileum is peeled back to evert the bowel wall and create a spout from the proximal limb of the loop. (d) The stoma is completed by placing interrupt- ed absorbable sutures between the cut edge of the ileum and the subepidermal layer of the skin. A few of these sutures also take a seromuscular bite of the emerging ileum at skin level. mesenteric side preserved [see Figure 5b]. The cut edge of the geon is encountering difficulty in preparing a sufficient length of proximal limb is then everted to create a spout for the ileostomy well-vascularized ileum for a conventional end ileostomy. In a [see Figure 5c]. A Babcock tissue forceps is sometimes used to loop-end ileostomy, the ileum is prepared as in a conventional apply gentle traction to the mucosal side of the proximal limb. end ileostomy, but the vascular arcades are left undisturbed. A The cut edge of the ileum is anastomosed to the skin with a series small window is made in the mesentery 5 to 10 cm proximal to of interrupted subcuticular absorbable sutures. The distal limb is the closed end of the ileum, and a nylon tape or a Jacques catheter sutured flush with the skin. On the proximal side, several sutures is used to draw this distal ileal loop through the abdominal wall. take bites of the serosa of the emerging ileum at skin level. The The stapled closed end of the ileum lies just within the abdomi- corners of the incision in the ileum are drawn around the proxi- nal cavity. The ileostomy is then constructed in essentially the mal limb of the ileostomy to accentuate the spout effect and cre- same manner as a conventional loop ileostomy. ate a thin, semilunar distal limb opening [see Figure 5d]. An alternative approach is to create a divided loop ileostomy, Split which some consider superior to a conventional loop stoma.13 A split ileostomy is created by bringing out the two cut bowel The construction technique for this stoma is similar to that of its ends at different sites.The proximal end is usually terminal ileum, conventional counterpart. The distal limb of the ileostomy is but the distal end may be either ileum or colon, depending on the divided with a linear cutting stapler after the loop is brought indication for stoma formation. This procedure forms a mucous through the abdominal wall.The closed distal end is tacked to the fistula, and only a small stoma appliance is usually required. The side of the emerging spout of the proximal end below skin level, distal end can be either included in the closure of the abdominal and the proximal end is fashioned into an everted spout as in a wound or brought out through a separate trephine hole on the conventional end ileostomy. A divided loop ileostomy is slightly opposite side of the abdomen from the ileostomy. The advantage more difficult and expensive to construct than a conventional of a split ileostomy is that it completely defunctions the bowel loop ileostomy, but it has the advantage of achieving complete without the risk of intra-abdominal leakage from a closed distal defunctioning of the distal bowel (because there is no chance that stump.The disadvantage is that it is more difficult to close: closure the ileostomy contents will spill over). usually necessitates reopening of the main incision. Loop-End Continent A loop-end ileostomy can be useful in cases where the ileum A continent ileostomy involves formation of a reservoir and and its supporting mesentery are grossly thickened and the sur- placement of a nonreturn nipple valve, which is emptied regular-
  7. 7. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 30 Intestinal Stomas — 7 ly via a catheter, so that the patient need wear only a small cap approximated with interrupted seromuscular absorbable sutures appliance. The surgical technique is demanding and beyond the [see Figure 6d]. Sometimes, a limited ileal resection is required if scope of this chapter; it is described more fully elsewhere.14 the stoma site is in poor condition, and a conventional end-to-end anastomosis is performed to restore intestinal continuity. It is pos- STOMA CLOSURE sible to close a loop ileostomy with a double-stapled technique; however, there does not appear to be much advantage in doing so. Loop Ileostomy Two randomized trials and a nonrandomized study comparing Closure of a loop ileostomy is usually a simple local procedure suture closure with stapled closure yielded conflicting results with that does not require the main incision to be opened. The opera- respect to complication rates,15-17 but both randomized trials tion is easier to perform if a period of at least 12 weeks is allowed reported that extra costs were incurred when staples were used. to elapse between formation of the stoma and closure so that Once the enterotomy is closed, the loop of ileum is returned to there is time for edema and inflammatory adhesions to settle. the abdominal cavity, and the stoma site is closed with interrupt- Dissection is facilitated by injecting epinephrine (1:100,000 solu- ed nonabsorbable sutures. tion) into the subcutaneous plane around the stoma. A divided loop ileostomy is closed in the same manner An incision is made in the peristomal skin 2 mm from the as described above. Care should be taken to identify the closed mucocutaneous junction [see Figure 6a].The incision is deepened distal end and to fully mobilize both limbs of the ileum from into the subcutaneous fat until the serosa of the emerging bowel the abdomen. The closed distal end is separated from the proxi- appears. Sharp dissection is continued circumferentially in this mal limb, and the staple line is excised to yield a fresh end. plane, dividing the fine adhesions between the bowel and its The proximal end is unfolded and a simple end-to-end anasto- mesentery and the subcutaneous fat [see Figure 6b]. Blunt dissec- mosis is performed with interrupted sutures.There may be a sig- tion should be avoided because it can easily lead to serosal tears. nificant size discrepancy between the two limbs. Again, a double- Some difficulty may be encountered at the fascial level, and care stapled technique may be employed as an alternative closure must be taken with the dissection if adhesions are particularly method. dense. Eventually, the peritoneal cavity is entered, and the remaining adhesions are identified with a finger and divided. Loop Colostomy The emerging ileal loop is withdrawn from the abdominal cav- A loop colostomy is closed in much the same manner as a loop ity, and the mucocutaneous junction and the rim of skin are ileostomy after the emerging colon is mobilized away from the excised. The everted proximal end of the stoma is unfolded [see subcutaneous fat and the abdominal wall by means of sharp dis- Figure 6c]; some sharp dissection is usually required to accom- section. Transverse closure is achieved with interrupted plish this. The freshened edges of the enterotomy are then absorbable sutures. a b Figure 6 Stoma closure: loop ileosto- my. (a) Epinephrine is infiltrated into the subcutaneous tissues around the ileostomy, and an incision is made through the full thickness of the skin 2 mm from the mucocutaneous junction. (b) The emerging ileum is mobilized by dividing adhesions between the bowel c d and the subcutaneous fat and the abdominal wall until the bowel is com- pletely free. (c). The everted segment of ileum is reduced by a combination of sharp and blunt dissection, and the edge of the opening in the ileum is excised to leave fresh supple ileum for anastomosis. (d) The opening in the ileum is closed with a single layer of interrupted absorbable sutures that take bites of the seromuscular layers only. The ileal loop is then returned to the abdominal cavity, and the defect in the abdominal wall is closed with interrupted nonabsorbable sutures.
  8. 8. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 30 Intestinal Stomas — 8 Postoperative Care Table 2 Incidence of Common A clear stoma appliance is cut to the proper size and placed on Complications of Intestinal Stomas the stoma before the patient leaves the operating room. A degree of edema is to be expected in the first week. In addition, the stoma Ileostomy Colostomy Colostomy may appear somewhat dusky; this is a sign that the aperture in the Patients18 Patients46 Patients9 abdominal wall is the correct size. It often happens that the Complication (N = 150) (N = 126) (N = 203) patient becomes alarmed at the initial appearance of the stoma and requires reassurance that the stoma will look better as time No. (%)* No. (%)† No. (%)‡ passes. Skin problems 44 (34) 17 (14) 24 (17.4) When the stoma starts to function, the clear appliance is changed for the chosen appliance, and the patient is instructed in Obstruction 27 (23) 9 (7) 11 (13.7) how and when to empty the pouch. When confident with this Retraction 19 (17) — 3 (1.5) aspect of stoma management, the patient is instructed in how to cut the plate to the correct size and how to change the stoma bag Hernia 16 (16) 14 (11) 43 (36.7) or flange (if he or she is using a two-piece appliance). An ileosto- Prolapse 12 (11) 4 (3) 11 (11.8) my works throughout the day, often showing an increase in activ- ity after meals. The appliance will therefore require regular emp- Fistula 11 (12) 3 (2) 2 (1.0) tying, a task that some patients find inconvenient. A loop trans- Stenosis 6 (5) 11 (9) 10 (7.3) verse colostomy may be as unpredictable as an ileostomy in this Necrosis 1 (1) — — regard; however, a sigmoid colostomy may have a more pre- dictable activity, similar to the frequency of normal bowel move- * All complications recorded at clinic review. Complication rate expressed as cumulative prob- ability from life-table analysis. ments. Some patients find that quality of life is improved by irri- †Retrospective review of all patients who underwent end colostomy formation. gating the colostomy with water instilled via a special appliance. ‡All complications recorded at clinic review. Complication rate expressed as cumulative proba- bility from life-table analysis. This procedure induces a full colonic clearout and allows the patient to wear a less obtrusive cap appliance for 24 to 48 hours, until irrigation is repeated. Complications Detailed discussion of stoma care is beyond the scope of this chapter. A key role is played by the enterostomal therapist, who Complications after stoma formation are frequent and varied is an important point of contact for the patient, providing ad- [see Table 2] and can adversely affect quality of life.The complica- vice, instruction, and emotional support in the postoperative tion rate has been reported to be about 25% after a colostomy for- period. Skin complications are common, and most can be man- mation and as high as 57% after an end ileostomy18 and 75% after aged by the enterostomal therapist. Many such complications a loop ileostomy.19 Cumulative complication rates at 20 years result from contact between the peristomal skin and digestive have reached 76% in patients undergoing ileostomy for ulcerative enzymes; common causes include poor appliance fit and stoma colitis and 56% in those undergoing ileostomy for Crohn dis- retraction. Skin problems can usually be resolved by means of ease.20 As noted [see Postoperative Care, above], many complica- simple measures such as switching to a different appliance, us- tions can be successfully managed with enterostomal care.18 This ing a convex flange, applying barrier cream, or filling dips in is fortunate because the results of surgical correction are often the peristomal skin with stoma paste. Given that surgical compli- unsatisfactory, with many patients requiring further surgical revi- cations such as fistula formation and parastomal hernia may pre- sion of their stomas.21 sent as skin problems, it is important that the surgeon and the Careful assessment is warranted when a patient presents with enterostomal therapist work closely together in addressing these stomal complications. Such complications may be interrelated or problems. may have a different cause from what initial examination suggests. For example, skin damage may be a result of a poorly fitting appli- ance, but the poor fit may itself be caused by a parastomal hernia Troubleshooting or a flush ileostomy. Furthermore, stomal complications may Wound infection after stoma closure is common. Drainage of arise from renewed activity of the underlying disease (e.g., recru- the incision with a small corrugated drain can help reduce the descence of Crohn disease21-23 or recurrence of cancer). incidence of such infection. Some surgeons leave the stoma site ISCHEMIA open and allow it to heal by second intention. Incisional hernia can develop in the stoma site, and its inci- Mild ischemia of the stoma is common in the early postoper- dence is increased by wound infection in the postoperative peri- ative period but usually resolves within a few days. More pro- od. Because the defect is relatively narrow, the hernia can lead to found ischemia can result in necrosis of all or part of the cir- significant symptoms. Repair is usually necessary. cumference of the bowel end used to form the stoma. Satisfac- Breakdown of the anastomosis lying beneath the incision will tory healing of the stoma depends on an adequate blood supply. lead to a fecal fistula, with discharge from the stoma site. If the fis- Problems with the blood supply are more common with end tula is simple and there is no distal obstruction, it is likely to heal stomas than with loop stomas; likely causes include excessive spontaneously. Expert nursing is required to manage the fistula division of mesenteric blood vessels, tension on the stoma from effluent while healing occurs to prevent damage to the surround- inadequate mobilization, and a too-narrow aperture through the ing skin. abdominal wall that constricts the vessels at the fascial level. It is If there is a complex inflammatory mass at the closure site, a good idea to prepare the relevant bowel segment for use in a spontaneous healing is less likely. Laparotomy may be required, stoma some time before the end of the operation so that any with resection of the stoma site and reanastomosis or further problems with the blood supply will be evident before the stoma stoma formation, depending on the patient’s condition. is fashioned. An obviously ischemic stoma should be revised at
  9. 9. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 30 Intestinal Stomas — 9 the time of operation. Such revision may include mobilization of stoma corrects the problem in the short term, but the prolapse a more proximal bowel segment. often recurs quickly. Repairing a coexisting parastomal hernia can Patchy necrosis that is confined to the mucosa can be managed lower the risk of recurrence, but it involves a more extensive oper- expectantly and usually heals by second intention. Complete ation [see Parastomal Hernia, below]. Neither ensuring that the necrosis of an ileostomy is an indication for urgent revision. emerging stoma is brought through the rectus abdominis nor fix- Necrosis of a colostomy may not necessitate revision if the seg- ing the mesentery to the abdominal wall appears to prevent stoma ment is short. However, a fistula may form at the fascial level, or prolapse.20 stenosis may develop as the necrotic segment heals. RETRACTION STENOSIS Stoma retraction is more of a concern with an ileostomy than Stenosis of the stoma is a consequence of postoperative with a colostomy because of the possibility of leakage from the ischemia. Mild stenosis can be managed with simple dilatation appliance. Retraction generally results from poor adhesion be- and may not cause many symptoms, particularly if the effluent is tween the serosal surfaces of the everted stoma but may also liquid. Substantial stenosis of a colostomy can lead to subacute reflect the presence of a parastomal hernia. If the retracted obstruction that must be managed with surgical revision. ileostomy is fixed in position, laparotomy will probably be Sometimes, revision can be accomplished as a local procedure. A required to correct the problem, though it is worthwhile to disk of skin that includes the stenosed stoma site is excised. The attempt local mobilization of the stoma after incising the muco- distal colon is mobilized and sutured to the new skin opening. In cutaneous junction. If the retracted ileostomy is mobile, the prob- most instances, however, it is not possible to mobilize sufficient lem can be corrected by inserting a series of interrupted ab- length with this approach, and laparotomy is required for ade- sorbable sutures through the full thickness of the everted stoma quate mobilization. to fix the walls together. A similar effect can be obtained by pulling the retracted stoma upward with tissue forceps, then fix- PROLAPSE ing the walls together with several firings of a noncutting linear Prolapse may occur with any type of stoma but is most com- stapler inserted into the ileostomy, with care taken to avoid the mon with loop colostomy. Patients with loop colostomies usually mesentery [see Figure 7].24 have a degree of parastomal hernia, which allows adequate space PARASTOMAL HERNIA for prolapse of the emerging bowel. Appearances are often alarm- ing, and symptoms are usually related to difficulties with fitting an Formation of an abdominal stoma necessarily involves creating appliance or to leakage. The best treatment option is to close the a defect in the abdominal wall to accommodate the emerging stoma (if appropriate). Another option is to divide the loop bowel. Such defects may become enlarged as a result of tangen- stoma, thus creating an end colostomy, and then to return the tial force applied to the edge of the opening, and this enlargement closed distal end to the abdomen. Amputation of the prolapsed may lead to hernia formation. The tangential force is related to the radial force and the radius of the opening; in turn, the radial force is related to the intra-abdominal pressure and the radius of the abdominal cavity.25 Consequently, tangential forces are greater in larger openings in obese patients, who are thus at greater risk for parastomal hernia. Patients undergoing emer- gency procedures in which dilated bowel is used to form a stoma are also likely to be at increased risk for hernia formation. Care must be taken to make an opening that is just large enough for the emerging bowel. An incision that admits only two fingers is appropriate for most elective indications. Several authors have addressed the problem of enlargement of the stoma opening by reinforcing the opening with a prosthetic ring or a sheet of Marlex mesh.25,26 One randomized trial com- pared the incidence of parastomal hernia in patients undergoing conventional end colostomy with the incidence in patients under- going colostomy with insertion of a partially absorbable lightweight mesh between the posterior rectus sheath and the rectus abdomin- is.27 At 12 months, eight of the 18 patients with a conventional colostomy showed evidence of parastomal hernia formation, com- pared with none of the 16 with a mesh-reinforced colostomy.27 There remains some controversy over the issue of where the stoma site should be located in relation to the rectus abdominis. Some authors claim that hernia formation is less frequent when the stoma emerges through the rectus abdominis28-30; however, other authors dispute this claim,9-11 and a clinical and radiologic Figure 7 Illustrated is an alternative method of stabilizing a study of paraileostomy hernia found no differences in incidence retracted ileostomy. The ileostomy is everted to its full extent between stomas brought out through the rectus abdominis and with a Babcock tissue forceps. The site of the mesentery is identi- stomas brought out more laterally.31 fied. A noncutting linear stapler is inserted with the anvil in the The incidence of parastomal hernia formation varies widely stoma, with care taken to avoid the mesentery. The stapler is among published studies [see Table 3]. This wide variation reflects fired several times to fix the two walls of the ileum together. both differences in length of follow-up and differences in the
  10. 10. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 30 Intestinal Stomas — 10 Table 3 Incidence of Parastomal Hernia Formation Duration of Total No. of Patients with Author(s) Date Stoma Type Hernia (No. [%]) Follow-up (yr) Patients Watts et al47 1966 Ileostomy 3.4 (mean) 119 3 (2.5) Burns48 1970 Colostomy* 1–21 307 16 (5.2) Saha et al49 1973 Colostomy* 1–6 200 2 (1.0) Kronborg et al50 1974 Colostomy† 1–10 362 42 (11.6) Harshaw et al51 1974 Colostomy‡ 1–7 99 9 (9.1) Marks and Richie52 1975 Colostomy‡ 1–6 227 23 (32.6§) Burgess et al53 1984 Colostomy† 1–10 124 6 (4.8) von Smitten et al54 1986 Colostomy 8 54 26 (48) Carlstedt et al55 1987 Ileostomy|| 1–26 203 3 (1.5) Weaver et al22 1988 Ileostomy NA 111 9 (8.1) Sjödahl et al30 1988 All stomas¶ 1–36 130 9 (6.9) Porter et al46 1989 Colostomy‡ <8 130 14 (10.8) Williams et al31 1990 Ileostomy** 1–16 46 13 (28.2) Hoffman et al56 1992 Colostomy‡ < 10 111 5 (4.5) Leong et al10 1994 Ileostomy† < 20 150 16 (16.0§) Martin et al57 1994 All stomas¶ NA 242 15 (6.2) Londono-Schimmer et al9 1994 Colostomy‡ 10 203 43 (36.7§) Carlsen and Bergan58 1995 Ileostomy 2.6 (mean) 224 4 (1.8) Mäkelä et al59 1997 Colostomy 8 80 9 (11.3) Cheung et al60 2001 Colostomy 7 322 126 (39.1) * Details of method of follow-up not provided. †Prospective follow-up of patients undergoing stoma construction. ‡Retrospective study of patients undergoing stoma construction. §Figure represents cumulative rate, based on life-table analysis. ||Incidence based on reoperation rate. ¶Patients presenting to a specialist stoma clinic. **Patients specifically reviewed for hernia formation. methods used to identify parastomal hernias. Given that many 1. Local repair. This approach to hernia repair is the simplest of hernias are small and asymptomatic, the true incidence of hernia the three but also the least successful.32-34 The stoma is mobi- formation may well be higher than the reported figures. It is gen- lized, and the sac is identified and removed. The defect in the erally accepted, however, that paracolostomy hernias are more fascia of the abdominal wall is narrowed around the emerging common than paraileostomy hernias. It is unclear why this is so, bowel with a series of interrupted nonabsorbable sutures. but the reason is likely to involve the size of the opening in the The repair is completed by recreating the mucocutaneous abdominal wall. anastomosis. Parastomal hernias are often asymptomatic, and in obese pa- 2. Repair with prosthetic mesh. Mesh repairs have become tients, they may not be apparent on clinical examination. Patients increasingly popular as different meshes have become avail- usually present with an unsightly bulge at the stoma site, but they able and as surgeons have become aware of the advantages of may also have other symptoms, such as leakage around the stoma these materials in hernia surgery. The mesh can be inserted appliance, skin problems, or difficulty in irrigating a colostomy. intra-abdominally,35,36 in the preperitoneal plane [see Figure Rarer presenting symptoms include intestinal obstruction and 8],32,37 or in the subcutaneous plane.38,39 Regardless of where strangulation of the bowel loop within the hernia. Clinical exam- the mesh is inserted, the basic principle is the same—namely, ination usually suffices for making the diagnosis, particularly to achieve and maintain a narrowing of the stoma site by sur- when performed with the patient standing. Small hernias in rounding the emerging bowel with a sheet of mesh in which a obese patients can be a challenge to diagnose; in this setting, hole is cut to accommodate the stoma. computed tomographic scanning limited to the stoma area can 3. Stoma relocation. The stoma can be moved to a fresh site on be helpful.31 the abdominal wall without reopening the main incision. The Surgical repair of a parastomal hernia often yields disappoint- stoma is fully mobilized, and a new hole is made in the abdom- ing results and should be considered only if the patient’s symp- inal wall. A plane is developed between the peritoneum and toms are troublesome. Many patients manage reasonably well by the abdominal contents by means of blunt finger dissection wearing a suitably adapted appliance and a support belt. When between the existing stoma site and the new one. The mobi- surgical repair is indicated, it follows one of three possible lized stoma is then passed through the new hole.40 If difficul- approaches: ties are encountered, a laparotomy will be required. An alter-
  11. 11. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 30 Intestinal Stomas — 11 a b Hernia Defect Closed Hernia Defect in Fascia Mesh Inserted over Peritoneum Abdominal Wall Intact Muscle Peritoneum Figure 8 Depicted is preperitoneal mesh repair of parastomal hernia. (a) The midline incision is reopened without disturbing the stoma. The space between the peritoneum and the muscles of the abdominal wall is opened widely, with care taken not to damage the bowel as it emerges from the abdominal cavity. The con- tents of the hernia are returned to the abdominal cavity, and the defect in the peritoneum is repaired with absorbable sutures. (b) A piece of nonabsorbable mesh is cut to shape to cover the defect in the abdominal wall and to just accommodate the emerging bowel. The mesh swatch is placed round the bowel on the intact peritoneum, and the two tails of the swatch are sutured together so as to encircle the bowel. The defect in the muscle layer is closed with a few interrupted nonabsorbable sutures. native approach is to reroute the stoma through a new fascial OBSTRUCTION defect while maintaining the existing skin aperture.The origi- Conditions that may cause intestinal obstruction after stoma nal fascial defect is repaired with mesh.41 formation include stenosis of the stoma, parastomal hernia, post- The best method of repair has not been established.42 Most operative adhesions, and recurrent disease (e.g., Crohn disease in published studies have included relatively few patients who the proximal ileum or recurrent cancer). Management depends were followed for a relatively short time. With longer follow-up, on the cause of the obstruction. Retrograde contrast studies are recurrence rates as high as 76% have been reported. Local useful for identifying the site and determining the likely cause of repair is associated with the highest recurrence rate,43 and sto- obstruction. ma relocation carries an increased morbidity (from incisional FISTULA hernia at the original stoma site).44 Nor is mesh repair free of problems: intra-abdominal placement of mesh is associated with A fistula may form adjacent to a stoma as a consequence of a significant risk of adhesions to the mesh and of small bowel inadvertent full-thickness placement of a suture through both obstruction.45 The risk of mesh infection is highest when the walls of the stoma during formation, pressure necrosis at skin mesh is placed in a superficial position through a parastomal level from a tightly fitting stoma appliance, or recurrent disease, incision. especially Crohn disease in the ileum proximal to the stoma. At present, the best approach is to tailor repair to the individ- Surgical treatment usually involves laparotomy and reformation ual patient’s condition and situation. For more specific recom- of the stoma at a new site. mendations, randomized trials of the different methods of para- OTHER COMPLICATIONS stomal hernia repair will be required.There is a growing amount of evidence in favor of inserting prosthetic mesh at the time Other, less common complications arising after stoma forma- of stoma formation in an effort to reduce the incidence of this tion include bleeding, perforation, skin ulceration, and the devel- complication. opment of cancer [see Table 4]. Table 4 Additional Complications Arising after Stoma Formation Complication Cause Differential Diagnosis Treatment Trauma Portal hypertension Review of stoma appliance Bleeding Inflammatory polyps Recurrent disease and technique Perforation Traumatic (irrigation) Stercoral (constipation) Laparotomy and revision of Recurrent disease stoma Review of stoma appliance Skin ulceration Contact dermatitis Pyoderma gangrenosum and technique Recurrence at stoma site Cancer formation Inflammatory polyps Resection De novo cancer formation
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Stephenson BM, Phillips RKS: Parastomal her- Figures 1 through 8 Tom Moore.