Stoma Construction Research Articles

The nutritional impact of diverting stoma-related complications in elderly rectal cancer patients

Diverting stomas following rectal cancer surgery can affect patients' quality of life, and their complications may negatively affect patients' long-term outcomes and quality of life. The purpose of this study is to investigate the relationship between diverting stoma-related complications and nutritional status. In a retrospective study of 114 patients aged 65 years and older who underwent diverting loop ileostomy following rectal cancer surgery between June 2004 and March 2011, we analyzed retrospectively diverting stoma-related complications and nutrition status for the following time periods: before stoma construction, before stoma closure, and after stoma closure. Complications related to the diverting stoma developed in 24 (21.1%) patients and complications related to stoma closure in 11 (9.6%) patients. Nutritional screening performed prior to stoma closure showed that patients who experienced stoma formation-related complications had lower albumin levels (P = 0.016) and lower total lymphocytes (P = <0.0001). Body weight loss was more severe in patients with stoma-related complication (P = 0.036). Diverting stoma-related complications may affect patient's nutritional status. Stoma closure operation and proper nutritional support may be important for avoiding complications and improving patients' long-term outcomes and quality of life.

Clinical outcome of transperitoneal ureterocutaneostomy using the transverse mesocolon.

The aim of the present study was to demonstrate that the treatment outcome of transperitoneal ureterocutaneostomy using the transverse mesocolon is not inferior to that of conventional retroperitoneal ureterocutaneostomy. The enrolled subjects were 26 patients who underwent ureterocutaneostomy among a total of 160 cases of urinary diversion performed at our institution between March, 2004 and November, 2011. A total of 11 cases and 18 ureters were treated by transperitoneal ureterocutaneostomy via the transverse mesocolon, with 7 bilateral ureterocutaneostomy cases. All the cases of retroperitoneal ureterocutaneostomy were unilateral, totaling 15 patients and 15 ureters. Postoperative adverse events (ileus, acute pyelonephritis), catheter-free status and renal function [blood urea nitrogen (BUN) and serum creatinine (Cr) values] were retrospectively evaluated between the groups treated by the different surgical procedures. Ileus was only observed in 1 case and improvement was achieved through conservative therapy alone (P=0.827). Acute pyelonephritis developed in 3 (27.3%) transperitoneal and 8 (53.3%) retroperitoneal cases, with all the cases recovering following treatment with antibiotics alone (P=0.199). A catheter-free status was achieved in 3 cases (27.3%) and 4 ureters (22.2%) in the transperitoneal group and in 2 cases and 2 ureters (13.3%) in the retroperitoneal group (P=0.393). There was no significant change in renal function (BUN and serum Cr values) in the transperitoneal ureterocutaneostomy cases at the postoperative, early postoperative (1 month following surgery) or the final follow-up examination (P=0.739 and 0.078). In conclusion, transperitoneal ureterocutaneostomy allows for the construction of a cutaneous stoma using a shorter ureter, with a treatment outcome that is comparable to that of retroperitoneal ureterocutaneostomy.

An overview of surgical stoma construction and its effects on the child and their family

Having a stoma can be a difficult adjustment for the child or young person and his or her family. Children's stoma nurses provide support and education to the family at this time to help them come to terms with the changes this requires. This article discusses the different types of stoma, why a stoma might be needed, how the children's stoma nurse can help prepare the child or young person and his or her family for having a stoma, the practical aspects of stoma care and possible complications that might be experienced and how to manage them.

Diagnosis and management of parastomal pyoderma gangrenosum.

Parastomal pyoderma gangrenosum (PPG) is an unusual neutrophilic dermatosis characterized by painful, necrotic ulcerations occurring in the area surrounding an abdominal stoma. It typically affects young to middle-aged adults, with a slight female predominance. The underlying etiology for PPG remains enigmatic but aberrant immune response to injury may play a pivotal role. The reported risk factors for the development of PPG include the presence of extra-intestinal manifestations, autoimmune disorders and obesity, along with local factors, such as the presence of parastomal hernia or pressure ulcer. PPG can develop at any time after the stoma construction. The histopathological features of PPG are not pathognomonic and its diagnosis is mainly based on clinical features. The management of PPG often requires a multidisciplinary approach, with a combination of local wound care and systemic medications.

ストーマ造設術後早期合併症に対するモルダブル皮膚保護剤付ストーマ装具の有用性

【目的】ストーマ造設術後早期合併症に対してモルダブル皮膚保護剤付ストーマ装具（バリケア®ナチュラMフランジ）が有用であるか明らかにする．【対象と方法】対象はストーマ造設症例64例である．前期32症例はポスパック・K®（P群）を使用，後期32症例はバリケア®ナチュラMフランジ（M群）を使用した．２群間の患者背景，ストーマ関連早期合併症を含む術後アウトカムを比較検討した．【結果】患者背景に有意差は認めなかった．初回交換時のストーマ浮腫はM群が有意に少なかった（71.9％ vs 93.8％：p＝0.020）．また，初回交換時の装具面板下への便漏れも有意にM群が少なかった（25.0％ vs 50.0％：p＝0.0375）．入院期間中の皮膚障害発症率ならびに，退院時の皮膚障害スコアは有意にM群が少なかった（43.7％ vs 68.7％：p＝0.019，0 vs 2：p＝0.033）．【結語】モルダブル皮膚保護剤付ストーマ装具はストーマ造設術後早期合併症，特にストーマ周囲皮膚障害に対して有用であると考えられた．

Living with Stoma: Long-term Effects on Patients’ Quality of Life

Introduction: Constructing end stoma is a recognized surgical option for management of anatomical anomalies and bowel dysfunctions. Yet, the long-term outcome for that creation is not known. For finding answer for the question on “the long term outcome for living with permanent stoma after five years of creation” we conducted this survey. Objective: Patients have right to know about the possible adverse that may result after surgical operations before giving consent to proceed. However, the long-term outcome after the first five years after construction of end stoma has not been examined. This study is aimed at identifying these possible adverse. Methods and patients: Members of the United Ostomy Association of America have been requested to complete online survey. Results: Seventy-eight respondents took part in this survey. The diagnosis was ulcerative colitis in 33, Crohn’s disease in 11, colonic perforations in 10, bowel tumors in 5, post-radiation severe bowel damage in 3, severe constipation in 4, and no diagnosis was given by further 4 participants. Two participants gave history of congenital malformations (Ehlers Danlos Syndrome and Imperforate anus respectively) Conditions, such as: intestinal obstruction, infected J pouch, diverticulitis, Familial Adenomatous Polyposis (FAP), Ovarian carcinoma and indeterminate colitis were diagnosed in one participant each. Out of the 33 ulcerative colitis patients, 25 identified their pre-operative abdominal pain as it was severe (75.8%) and this pain completely disappeared after surgical resection in 18 (72%). At analyzing the responses to question (3): (How do you feel in general?), it was found that those in the group with a longer elapsed time after diagnosis were more likely to feel better (p=0.042). But those in the older age group (>50years) were more likely to feel worse (p0.024); Patients in the older age group (>50 years) tended to experience more pain after creation (p=0.046); Patients with a longer elapsed time after diagnosis (>5 years) were more likely to say no at answering question (7): (Has your treatment changed the way you see yourself as a man/woman?) (p=0.039) and to say no at answering question (8) (Has your treatment caused any change in your sexual functioning (sex life)?) (p=0.007 ) as well; this group of patients were more likely to enjoy the things they used to before conducting the disease (p=0.025); there were no significant statistical differences were found between those who presented with an established stoma of less than five years old and those with stomas of more than five years old. Conclusion: Participants in the group with a longer elapsed time after diagnosis were more likely to feel better (p=0.042), to have better self-perception (p=0.039), to be more satisfied about their sexual performance (p=0.007), and to enjoy the things they used to before conducting the disease (p=0.025). However, the effect of self-perception on sexual act is significantly high in the two groups.

Routine defunctioning stoma after chemoradiation and total mesorectal excision: A single-surgeon experience

To investigate the 10-year results of treating low rectal cancer by a single surgeon in one institution. From Oct 1998 to Feb 2009, we prospectively followed a total of 62 patients with cT2-4 low rectal cancer with lower tumor margins measuring at 3 to 6 cm above the anal verge. All patients received neoadjuvant chemoradiation (CRT) for 6 wk. Among them, 85% of the patients received 225 mg/m(2)/d 5-fluorouracil using a portable infusion pump. The whole pelvis received a total dose of 45 Gy of irradiation in 25 fractions over 5 wk. The interval from CRT completion to surgical intervention was planned to be approximately 6-8 wk. Total mesorectal excision (TME) and routine defunctioning stoma construction were performed by one surgeon. The distal resection margin, circumferential resection margin, tumor regression grade (TRG) and other parameters were recorded. We used TRG to evaluate the tumor response after neoadjuvant CRT. We evaluated anal function outcomes using the Memorial Sloan-Kettering Cancer Center anal function scores after closure of the defunctioning stoma. The median distance from the lower margin of rectal cancer to the anal verge was 5 cm: 6 cm in 9 patients, 5 cm in 32 patients, 4 cm in 10 patients, and 3 cm in 11 patients. Before receiving neoadjuvant CRT, 45 patients (72.6%) had a cT3-4 tumor, and 21 (33.9%) patients had a cN1-2 lymph node status. After CRT, 30 patients (48.4%) had a greater than 50% clinical reduction in tumor size. The final pathology reports revealed that 33 patients (53.2%) had a ypT3-4 tumor and 12 (19.4%) patients had ypN1-2 lymph node involvement. All patients completed the entire course of neoadjuvant CRT. Most patients developed only Grade 1-2 toxicities during CRT. Thirteen patients (21%) achieved a pathologic complete response. Few post-operative complications occurred. Nearly 90% of the defunctioning stomas were closed within 6 mo. The local recurrence rate was 3.2%. Pathologic lymph node involvement was the only prognostic factor predicting disease recurrence (36.5% vs 76.5%, P = 0.006). Nearly 90% of patients recovered sphincter function within 2 year after closure of the defunctioning stoma. Neoadjuvant CRT followed by TME, combined with routine defunctioning stoma construction and high-volume surgeon experience, can provide excellent surgical quality and good local disease control.

Different Surgeons Find Same Solution for Minimally Invasive Stoma Construction

Diseases of the Colon & Rectum: July 2012 - Volume 55 - Issue 7 - p e302 doi: 10.1097/DCR.0b013e3182542383

Prognostic Factors for Traumatic Bowel Injuries: Killing Time

Intestinal rupture/perforation after abdominal trauma is a rare complication, but it is related to significant morbidity and mortality. Our objective is to identify determinants of prognosis in patients surgically treated for a bowel injury (small bowel and colon) after abdominal trauma. The present study is a retrospective analysis of 102 patients seen at our hospital during a 10-year period in whom laparotomy for traumatic bowel injury was performed. Predictors for morbidity and mortality were assessed in univariate and multivariate analysis models. Mean age at diagnosis was 40years, and most patients were male. There was a slight preponderance of blunt abdominal trauma, and the most frequent mechanism of injury was motor vehicle accident. In 75% of patients there was a small bowel lesion, and the colon was affected in 47%. There was no statistical relation between stoma construction and mortality, but an increase in morbidity was ultimately dependent on the severity of the underlying trauma. The univariate determinants of mortality were the new injury severity score (NISS) and American Society of Anesthesiologists (ASA) scores, the presence of blunt trauma and multiple intestinal or extra-abdominal lesions, and the elapsed time to surgery. The occurrence of postoperative complications was related to all these factors, as well as to tachycardia, hypotension, and bleeding. In multivariate analysis ASA score (p=0.015), NISS (p=0.002), time to surgery (p=0.007), and presence of colonic lesions (p=0.02) were identified as independent prognostic factors for postoperative morbidity. The only modifiable determinant of morbidity seems to be the time to surgery. Only an expeditious evaluation and diagnosis and prompt surgical intervention can improve the prognosis of these patients.

Educational support for patients with intestinal provisional stoma: a descriptive study

Method: A descriptive exploratory study that will be developed in the abdomino-pelvic ambulatory surgery of Cancer Hospital I, located in the municipality of Rio de Janeiro. The study subjects will be surgery patients who have received treatment for colorectal neoplasia with the construction of temporary intestinal stoma. Aims: 1- Develop an educational protocol of nursing care for patients undergoing surgery for the treatment of colorectal neoplasia with the construction of temporary intestinal stoma; 2- Apply the protocol; 3- Discuss the educational protocol of nursing care with patients undergoing colorectal surgery with the construction of temporary intestinal stoma, focusing on self-care. The results will be collated, categorized and analyzed according to Orem’s Self-Care Theory and the work of other authors. The project was approved by the Ethics Committee in Research of the National Cancer Institute on 07.19.2011 under No. CAAE-0008.0.007.007-11.

The indications for a diverting stoma in low anterior resection for rectal cancer: a prospective multicentre study of 222 patients from Japanese cancer centers

The aim of the study was to determine the present state of diverting stoma construction in Japanese cancer centres and to investigate the relationship between symptomatic leakage and diverting stoma after low anterior resection for rectal cancer. Two hundred and twenty-two consecutive patients undergoing low anterior resection for rectal cancer located within 10 cm from the anal verge were investigated in a prospective, multicenter study. The overall leakage rate was 9.0% (20/222). Of 31 cases with an anastomosis within 2.0 cm from the anal verge, 22 (71%) had a diverting stoma. Of cases anastomosed within 5.0 cm, the absence of a diverting stoma and tumour size were significantly related to an increased rate of leakage [leakage in 13 (12.7%) of 102 cases without a diverting stoma; in three (3.8%) of 80 cases with a diverting stoma]. Among anastomoses within 2.0 cm from the anal verge, leakage occurred in four (44.4%) of nine cases without and in none (0%) of 22 cases with a diverting stoma. We recommend a diverting stoma for an anastomosis within 5.0 cm of the anal verge and strongly recommend it for a very low anastomosis within 2.0 cm.

Surgical resection in Crohn’s disease: is immunosuppressive medication associated with higher postoperative infection rates?

The aim of this study was to analyse postoperative infection in patients undergoing surgery for Crohn's disease (CD) according to the use of preoperative immunosuppressants, including infliximab. With IRB approval, the records of all patients with CD who underwent abdominal surgery between 2001 and 2008 were reviewed for comorbidity, preoperative medication, type of surgery, stoma construction and postoperative complications. Patients were divided into three categories according to the preoperative medication within 90 days of surgery as follows: infliximab (IFX), other drugs including steroids and/or immunosuppressive agents (OD) and no drugs (ND). Two hundred and twenty-five patients were identified. Preoperative comorbidity, surgical indication and type of surgery were not significantly different among the three groups. Ileocolic resection was the most common procedure [50.8%, IFX group; 61.2%, OD group; 41.3%, ND group (P = 0.09)]. Other procedures included total colectomy (16%), protectomy (15%) and others (18%). Laparoscopic surgery was performed in 47.7%, 45.9% and 29.3% of patients in the IFX, OD and ND groups, respectively (P = 0.04). There were no differences in postoperative rates of infection [pneumonia (P = 0.14), wound infection (P = 0.35), abscess (P = 0.34) or anastomotic leakage (P = 0.44)]. Reoperation was needed in 3.0%, 8.2% and 2.6% of patients in the IFX, OD and ND groups, respectively. Multiple logistic regression found no relationship between infliximab use and infection. There was no difference in the rate of postoperative complications among the groups of patients undergoing surgery for CD pretreated with IFX or other immunosuppressive drugs.

Transcutaneous implant evacuation system: a new approach to continent stoma construction

Several attempts have been made to construct a mechanical continent stoma without success. A system based on a titanium implant has been developed in an animal model. Following evaluation of this device in animals, the transcutaneous implant evacuation system (TIES) has now been tested in humans. The implant consists of a titanium cylinder including a mesh and a plastic cap. This design allows the intestine and subcutaneous tissue to grow into the device. Four patients with inflammatory bowel disease underwent surgery. The indications for surgery were malfunctioning pouches or skin problems around the stoma. Following abdominal surgery, implantation of the device was made behind the external fascia with diversion of the ileum through the device to create a permanent stoma. Primary surgery was uncomplicated. Skin tissue growth into the implant was delayed in one case and one patient had impaired healing between intestine and the device. In these cases minor surgical correction was necessary. The tested cap design in the current device was inconvenient and needs to be further developed. No local infections occurred. This first clinical study of the TIES device has shown few device-related complications and no significant safety concerns. In our experience bridging of connective tissue between the intestine and skin is crucial for healing. Further development of the lid, the implant and the implantation method within clinical trials is necessary before the device can be introduced in general practice.

UP-03.002 Application of Method of Continent Urinary Stoma Construction Using Diagonal Tubularization of Ileum Segment

UP-03.002 Application of Method of Continent Urinary Stoma Construction Using Diagonal Tubularization of Ileum Segment

The Malone antegrade continence enema procedure: the Amsterdam experience

Background The Malone antegrade continence enema (MACE) procedure has been previously described as a safe and effective option for the treatment of children with chronic defecation disorders when maximal medical therapy and conventional treatment have failed. Purpose To evaluate clinical success, complications, and quality of life of children with chronic defecation disorders with a MACE stoma. Methods A retrospective analysis of 23 patients who underwent the construction of a MACE stoma was performed. Preoperative and postoperative data were evaluated. A specific questionnaire was used to assess patient satisfaction. Results A significant increase was found in defecation frequency (1.0 [range, 0-4] pretreatment vs 5.5 [range, 0-28] posttreatment per week; P < .006) and a significant decrease in fecal incontinence frequency (10 [range, 0-14] pretreatment vs 0 [range, 0-14] posttreatment per week; P < .034). Postoperative complications of the MACE procedure were fecal leakage (43%), wound infection (52%), and stomal stenosis (39%). A total of 86% of the patients were satisfied with the results of the Malone stoma (n = 21). Conclusions The MACE procedure is an effective treatment in children with intractable defecation disorders. Postoperative complications are, however, not uncommon. Further refinement of the technique focused to reduce the complication rate is necessary to expand the application of this approach.

Ostomy Literature Review 2010

Ostomy Literature Review 2010

CT and MRI Features of Ileostomies

The purpose of this article is to describe CT and MRI features of normal anatomy, variants, and pathologic conditions of different ileostomies. Multiplanar imaging techniques are useful to identify the complications related to stoma construction and preexisting disease. Understanding the indications for ileostomy construction, surgical techniques, and postoperative anatomy is important for differentiating normal and abnormal imaging features.

Transcatheter arterial embolization for hemorrhage from the inferior epigastric artery injured after stoma construction

We report a rare case of life-threatening hemorrhage from the inferior epigastric artery that was injured after stoma construction. It was successfully controlled by transcatheter arterial embolization from both the external iliac arterial site and the internal thoracic arterial site.

Enhanced recovery is feasible in bariatic patients: Early outcomes of enhanced recovery following laparoscopic roux-en-y gastric bypass

Enhanced recovery is feasible in bariatic patients: Early outcomes of enhanced recovery following laparoscopic roux-en-y gastric bypass

Laparoscopic Parastomal Hernia Repair

Parastomal hernia is a common complication after stoma formation. Its reported incidence varies from 30% to 50%. Loop ileostomy has the lowest risk (0%-6.2%), followed by end ileostomy, and loop colostomy with a similar risk of 28% to 30%. End colostomy carries the highest risk for parastomal hernia of 48%. Even though most hernias occur within the first 2 years after stoma construction, the risk of herniation extends up to 20 years. Theoretically, parastomal hernia occurs as a result of mechanical factors, an intrinsic defect in collagen metabolism, and wound repair. Parastomal hernia is asymptomatic most of the time, but it may be associated with serious complications such as strangulation and perforation; hence, elective repair is mandatory for carefully selected cases and surgical approaches. Primary closure of the aponeurosis at the hernia site, either via peristomal approach or through midline incision, is a simple procedure, but it carries a recurrence rate of 38% to 100%. Stoma relocation may result in a zero recurrence rate at the same hernia site, but the risk of a parastomal hernia after new stoma formation is still expected. In addition, an incisional hernia at the previous colostomy site closure may also occur. Similar to other sites of hernia repair, prosthetic mesh has been used to reinforce the hernia defect intraperitoneally through open incision and recently via the laparoscopic approach. Mesh repair has demonstrated the lowest risk of recurrence for parastomal hernia of 0% to 33%.