Efforts to reduce the incidence of stoma ischemia, retraction, and stricture are primarily focused on attempts to technically mitigate tension and ischemia at the intestinal cutaneous anastomosis. A number of techniques may be helpful and are listed in Table 42.2, but several deserve some comment. First, it is critical to recognize that the creation of a healthy stoma is crucial to the success of the operation and at times can be very challenging. As such, it demands the same degree of attention, time, and effort as the other important components of a gastrointestinal operation. Unfortunately, this essential understanding can be commonly lost, particularly at the end of a complex and difficult operation where there is an “emotional letdown” once a challenging resection is complete. A number of specific technical steps may require consideration to create a healthy ostomy, particularly in difficult circumstances, and each of these may take some time and careful thought. The overall technical goal is to be able to reach a well-vascularized piece of intestine to the skin surface without tension. To do so, the bowel should first be fully mobilized and rotated on its mesentery to the midline. For the left colon, this may involve fully dividing the lateral attachments (White line of Toldt), in some cases fully mobilizing the splenic flexure and the posterior mesenteric attachments to the retroperitoneum. For the terminal ileum, this may involve fully freeing the entire distal small bowel mesentery off of the retroperitoneum to the level of the duodenum. Upon completion of these maneuvers, the bowel should not be tethered by anything other than its mesentery. It should be kept in mind that full mobilization and freeing the associated mesentery off the retroperitoneum can often add substantial mobility to the intestine and be all that is required. In many cases, this mobilization alone is sufficient to be able to bring the bowel to the skin without tension and is ideal because significant mesenteric blood flow had not been divided. If the bowel is still not adequately mobilized at this point, it will be tethered by its mesenteric blood supply alone, and decisions regarding mesenteric division will need to be made. Careful identification of the major feeding vessels as well as the marginal, pericolic vessels should be made prior to any division. If the mesentery requires division, this division should be done close to the root of the mesentery, central to the marginal or pericolic vessels that will ultimately be the source of the blood supply to the stoma. Mesenteric diversion in the periphery close to the bowel wall will sacrifice the marginal vessels’ perfusion of the bowel leading to ischemia. If these mobilization measures are still inadequate, consideration of the use of a transverse colostomy or terminal ileostomy might be appropriate, as these structures tend to have longer, more mobile mesenteries. Furthermore, positioning the ostomy aperture in the upper abdomen may be helpful, as the abdominal wall of even very obese patients is usually much thinner in the upper rather than mid- or lower abdomen. Finally, as noted previously, if there is undue tension on a loop ostomy, consideration of converting it to an end ostomy with some mesenteric division may be of benefit. Additional mobility may also be achieved by conversion of the loop ostomy to an “end loop” as described by Hebert [13], which creates the ostomy aperture on the antimesenteric side of the bowel, rather the end, which is less tethered by the mesenteric vessels. Table 42.2 highlights the technical considerations and the order in which I think about them when creating an ostomy under difficult circumstances.

When concern about stoma ischemia and retraction arises in the early postoperative period, the first question that needs to be considered is the possibility of full thickness intestinal ischemia proximal to the fascia. A glass test tube may be gently inserted into the stoma aperture and often is quite helpful in differentiating superficial mucosal sloughing from full thickness ischemia involving bowel deep to the fascia. Additionally, progressive peristomal inflammation or signs of systemic sepsis may indicate full thickness stomal necrosis. If full thickness necrosis to the fascia is suspected, the patient requires urgent reoperation with laparotomy and recreation of the ostomy to prevent intraabdominal intestinal perforation and sepsis. Ostomy revision should be done with the technical considerations discussed in the “Prevention” section in mind. If the ischemia is more superficial or distal to the fascia, usually expectant management is warranted, although the more severe the ischemia or retraction, the more likely the need for eventual elective ostomy revision. Occasionally, in the absence of full-thickness ischemia proximal to the fascia, a decision for early revision is made with the goal of reducing the likelihood of future stenosis requiring later revision. Factors which may influence the decision to return for early ostomy revision under these circumstances include the clinical state of the patient and the difficulty of the initial stoma creation. Furthermore, if the stoma is temporary, expectant management with acceptance of temporary poor ostomy function that will resolve with ostomy closure may be a reasonable alternative to early reoperation. In general, in the absence of deep full-thickness ischemia mandating urgent reoperation, non-operative, expectant management is usually undertaken in the immediate postoperative period.

Perioperative ischemia or tension not severe enough to require urgent early reoperation may result in chronic problems with stoma stenosis or retraction. Initial non-operative interventions may be tried. Bowel slowing and thickening medications and the use of convex pouching may improve minor-to-moderate pouching difficulties related to retraction. Some authors have advocated the use of catheterization for stenotic colostomies as a mean of controlling partial obstruction or pouching difficulties [14]. Serial dilations of strictured stomas has been suggested, but the literature is quite mixed on the long-term effectiveness of dilation, and many authors do not advocate it [14,15]. I personally have not found this to be effective for most patients with strictured stomas.