Approximately 160,000 people in Germany live with an enterostomy [1], of which about 70% have a colostomy and 20% have an ileostomy [2]. The average age of those affected is in the 7th decade of life.
Differentiated according to the intestinal segment used:
- Ileostomy
- Jejunostomy
- Colostomy
- Cecostomy
- Transverse colostomy
- Sigmoidostomy
On webop.de you will find the following educational contributions on this topic:
Colostomy (Sigmoidostomy) Placement, Loop, Laparoscopic
Rectal Resection according to Hartmann
Ileostomy Reversal (without Resection) with Skin Closure in Gunsight Technique
The creation of a stoma has a significant impact on quality of life. The success of treatment and the quality of life of the stoma patient depend on careful care and professional pre- and postoperative stoma therapy/care [10, 33, 51].
An intestinal stoma may be indicated for various reasons, such as in neoplastic diseases, to protect risk anastomoses, or after radical oncological bowel resections (e.g., abdominoperineal rectal extirpation), sepsis after bowel perforations (e.g., sigmoid diverticulitis), bowel resections in chronic inflammatory bowel diseases (ulcerative colitis, Crohn's disease), in congenital anomalies, and in emergency situations such as after abdominal trauma, ileus, ischemia, or perforation [4, 14].
The tension-free creation of prominent and well-perfused stomas requires appropriate expertise of the surgeon, especially in obese abdominal walls and short, thickened mesentery. A functionally flawless stoma significantly contributes to improved patient quality of life and the avoidance of complications [49]. Preoperative stoma marking is an important measure to avoid stoma complications, ideally performed jointly by surgeons and stoma therapists [3, 14].
Prominence
Enterostomies should, whenever possible, be created prominently, i.e., the lumen should protrude above the skin level of the abdominal wall. The manageability of the stoma and the rate of complicated stomas depend on the prominence of the stoma [8, 35]. It is recommended that ileostomies and colostomies should protrude at least 2 cm above the skin level. Strong abdominal walls and a compact, shortened mesentery, as in obesity, Crohn's disease, and tumor diseases, are among the circumstances that make prominent creation difficult or even impossible.
Bridles
Bridles are used in loop stomas to prevent retraction of the loop. However, the data on the use of bridles is sparse. In a single randomized controlled trial, no difference was found between groups with and without bridles for early retraction in loop ileostomies [47]. Regarding the different materials of bridles, some observational studies have shown that flexible bridles, such as rubber reins, provide better postoperative care compared to rigid bridles [21, 25, 43].
Prophylaxis of Parastomal Hernias
Parastomal hernias can occur in up to 50% of all stomas within the first few years after stoma creation [24]. Hernia repair is problematic, as despite the use of meshes, recurrences occur in nearly 1 in 5 patients. Therefore, in recent years, prophylactic surgical procedures have increasingly been investigated to reduce the number of hernias. These include various mesh techniques, including extraperitoneal tunneling [13, 22]. Compared to conventional stoma creation without mesh repair, the retromuscular placement of lightweight polypropylene meshes showed a reduction in hernia rates without differences in morbidity, mortality, quality of life, or costs [7].
Laparoscopic Stoma Creation
In the last 20 years, the laparoscopic technique has increasingly been established as the access route for stoma creation. Prospective randomized data are not available, but numerous observational studies have shown advantages for the short-term postoperative course after laparoscopic creation with comparable morbidity [50]. In loop ileostomies, care must be taken during laparoscopic creation not to twist the loop and not to kink the mesentery in terminal ileostomies [30].
Complications
Complications are distinguished as early (occurring < 3 months after stoma creation) and late complications (> 3 months after creation) [24]. Early complications can occur for operative-technical reasons (e.g., unfavorable outlet site, stoma opening placed too far, insufficient mobilization, necrosis, mucosal bleeding, parastomal abscesses, stoma avulsion, leakage) [24, 37]. 20 to 70% of patients experience late structural complications, e.g., due to care-dependent factors such as leaving the stoma in place too long, lack of training, but also retraction and parastomal hernias [4, 49]. Stoma complications drastically reduce patients' subjective quality of life [38]. According to studies, ileostomies have the highest complication risk (about 75%), followed by end-descending colostomies (about 65%).
The frequency of skin changes varies from 18 to 55% due to placement-related and patient-specific care problems. These changes can range from mild erythema to ulcerations and severe infections. They can usually be controlled by consistent conservative therapy, adjustment of care, and patient education.
| Complication | Frequency [%] | Procedure after Failure of Conservative Measures | Note |
| Retraction | 1-9 | Parastomal mobilization, if necessary, relaparoscopy/-tomy with remobilization | 30-40% of all parastomal complications |
| Prolapse | 2-22 | Resection, if necessary, new placement on the opposite side | loop > end, loop colostomy > loop ileostomy (16-19% vs. 2%) |
| Hernia | 14-40 | Mesh implantation, if necessary, new placement on the opposite side | unusual as an early complication (0-3%) |
| Mucocutaneous Dehiscence and Abscess | 4-25 | Relief, drainage | usually manageable by adjusting stoma care |
Necrosis
|
2-20 0-3 | superficial: usually no surgical intervention required deep: relaparoscopy/-tomy with remobilization and resection | early endoscopy via stoma |
Source: Gröne, J. Stoma. coloproctology 40, 145–160 (2018)
Measures to Prevent and Optimize Stoma Complications
- Preoperative stoma marking by stoma therapists and surgeons
- Professional pre- and postoperative stoma therapy/care
- Structured, specialized surgical and stoma-specific follow-up, close collaboration with general practitioners and stoma therapists
- If necessary, reevaluation of stoma reversal or reconnection surgery
- Stringent and timely treatment of complications, especially structural complications
Management of Parastomal Hernias
The suture repair of parastomal hernias has a recurrence rate of up to 70%. Especially for large parastomal hernias, mesh repair or repositioning should be considered. Despite the lack of randomized controlled studies, significantly lower recurrence rates of 7 to 17% have been found for the different mesh techniques "onlay," "sublay," retromuscular, "keyhole," and "Sugarbaker repair." The implantation of meshes in parastomal hernias has a low complication rate, and mesh infection ranges between 2 and 3%. It seems that laparoscopic repair is a safe option compared to the open procedure [20].
High-output Ileostomy
Early dehydration occurs in about 16–30% of all patients after ileostomy creation and is one of the most common causes of hospital readmission after ileostomy creation. Excessive secretion through the stoma calms down in many cases, yet up to 50% of patients require long-term medication [5].
Medication Therapy for High-output Ileostomy
| Group | Substance | Dose | Note |
| Opiates | Loperamide Codeine Tinctura opii | 2-4 mg 3-4x daily 15-60 mg 3-4x daily 2-20 drops 3-4x daily | no addiction risk addiction risk addiction risk |
| Bile Acid Binders | Cholestyramine | 4 g 1-4x daily | for chologenic diarrhea |
| Secretion Inhibitors | Omeprazole Octreotide | 40 mg 1-2x daily 50-250 µg 3x daily s.c. | ∅ short bowel |
Source: Gröne, J. Stoma. coloproctology 40, 145–160 (2018); Dosages without guarantee!
In general, stoma output ranges between 0.2 and 0.7 liters per day. The definition of a high-output ileostomy is not uniform, which is why the secretion amount varies between 1000 and 2000 milliliters within 24 hours depending on the author. Clinical impairment and the development of renal failure due to the loss of water, sodium, and magnesium, as well as later malnutrition, are very likely at amounts over 2000 ml. A useful approach to reducing hospital readmission rates due to dehydration is the use of standardized treatment pathways:
- Patient education,
- ensuring self-care,
- documentation and control of intake and output after hospital discharge,
- nutritional counseling,
- outpatient support and care by stoma therapists, and
- early outpatient follow-up appointments.
If therapy refractoriness is present, the possibility of early reversal of the loop ileostomy should be considered, which is safely possible upon evidence of primary anastomotic healing after rectal resection [9].
Stoma Reversal
To treat or remedy stoma complications, it is important to consider the possibility of reversal (loop ileostomy) or reanastomosis (end-descending/sigmoidostomy). The reversal of a protective ileostomy is generally simple but can also be difficult due to adhesions. More challenging is a reanastomosis after a Hartmann's operation, with relatively high mortality and morbidity. Normally, reanastomosis is performed openly, but it is technically feasible to perform the reconnection laparoscopically after a previous Hartmann's operation [23].
Studies show that the reversal of a temporary ileostomy can be performed early and safely at the latest 12 weeks after creation. However, the latency between creation and reversal is often longer, and in 9 to 57% of patients, reversal does not occur at all [11, 16, 18, 46]. Older patient age, lower body mass index, increased comorbidity, the presence of an end stoma, and neoadjuvant radiation therapy are all identified as independent factors for the absence of reversal [11, 12, 26]. Progressive tumor disease, complications during the primary procedure, and especially anastomotic insufficiency are further causes for leaving a stoma [16, 28].
There are currently no recommendations in the literature for the optimal timing of ileostomy reversal, and handling varies greatly depending on the clinic [32]. Inflammatory adhesions between the bowel and abdominal wall, as well as between the bowel loops, make early stoma closure 10 to 14 days after creation difficult. According to experience, inflammatory adhesions take at least 6 to 10 weeks to regress, which justifies the recommendation to plan the reversal about 3 months after stoma creation.
Some studies have shown that in selected patients who recovered quickly after the primary operation, the stoma could be reversed as early as 1 to 2 weeks later without increasing morbidity or mortality, which positively affected quality of life and possible stoma complications [9, 15]. In principle, the period between stoma creation and reversal should be kept as short as possible. Reversal requires evidence of complete healing of the downstream anastomosis through endoscopy and imaging, and the patient must have sufficiently recovered.
A prospective randomized study investigated the prognostically favorable timing of stoma reversal in patients with adjuvant chemotherapy for rectal cancer after low anterior resection [42]. A colostomy should be reversed no earlier than 6 months after discontinuity resection. If severe peritonitis occurs, one should wait between 9 and 12 months to ensure that patients have sufficiently recovered and the extent of potential adhesions is minimized.
Some working groups reported an increase in complication rates with a longer delay between stoma creation and continuity restoration, which is partly due to atrophy of the rectal stump and associated technical difficulties [36, 41, 48]. However, the clinical and nutritional status of the patient improves with delayed reanastomosis, leading to fewer complications, as shown in several studies [6, 36].
Loop Stoma: In terms of morbidity, hand-sewn and stapler sutures are equivalent. Stapler anastomosis appears to be associated with a shorter operation time and a lower postoperative obstruction rate, but also with higher costs [27, 29]. Compared to side-to-side anastomosis, hand-sewn end-to-end anastomosis was associated with higher morbidity and longer hospital stays [39]. The data on skin closure after ileostomy reversal show that the purse-string skin suture is significantly better in terms of septic wound complications than linear skin closure, with no differences in hernia rate, operation time, hospital stay, and patient quality of life [17, 40].
Hartmann Situation: A review with data from 450 operations for the laparoscopic approach in continuity restoration showed lower morbidity and shorter hospital stays compared to relaparotomy, indicating that the laparoscopic approach can be used as a safe alternative with appropriate expertise [45]. Reanastomosis can be performed with low morbidity and particularly low anastomotic insufficiency once patients have sufficiently recovered [19, 31]. Generally, continuity restoration can be performed after sigmoid discontinuity resection once the left flexure is mobilized and, if necessary, ligation of the inferior mesenteric artery and vein is performed. In some cases, resection of the transverse colon involving the middle colic artery and vein with ascending rectostomy is required to ensure a tension-free anastomosis. The need for a temporary loop ileostomy must be assessed based on the patient's general and nutritional status.