ABBREVIATIONS
CD
Crohn’s disease
EBD
endoscopic balloon dilation
EI
end ileostomy
IBD
inflammatory bowel disease
IPAA
ileal pouch-anal anastomosis
IQR
interquartile range
LI
loop ileostomy
NSAID
nonsteroidal antiinflammatory drugs
RPC
restorative proctocolectomy
STX
strictureplasty
UC
ulcerative colitis
INTRODUCTION
Fecal diversion with the construction of jejunostomy, ileostomy, or colostomy may be required for the treatment of refractory distal colorectal or perianal diseases as a temporary or permanent measure. The construction of an ostomy is performed for the protection of freshly fashioned anastomosis distally. Stoma complications including stenosis, fistula, abscess, prolapse, retraction, and hernia often occur. Contributing factors for the complications include underlying disease, abdominal wall anatomy, obesity, comorbidities, and the lack of surgical expertise. The majority of complications can be managed by proper stomal care and, in severe cases, by surgical intervention. Stoma care therapy and surgical treatment of stoma complications are discussed in separate chapters ( Chapters 19 and 21 ). Some of these complications may be treated with endoscopic approaches. Endoscopy plays a key role in the evaluation of surgically altered bowel (including stomas) in inflammatory bowel disease (IBD), as well as other colorectal disorders. However, endoscopic treatment of stomal complications is an evolving field, and there is limited literature. The content of this chapter is largely based on the author’s personal experience.
COMMONLY CONSTRUCTED STOMAS
Fecal diversion with the construction of ileostomy is an effective way to treat refractory Crohn’s disease (CD) in the downstream bowel or perianal area. Ileostomy is commonly constructed, followed by colostomy and, rarely, jejunostomy. An ileostomy is created as a temporary or permanent treatment modality for CD. , However, the initially intended temporary ileostomy may become permanent due to persistent distal bowel or perianal diseases. In a nationwide cohort of 18,815 incident CD patients with a minimum of 5 years of follow-up, 652 (3.5%) had stoma surgery for the treatment of disease or protection of ileocolonic anastomosis, of whom only 44% of patients were able to have stomas closed. In staged restorative proctocolectomy (RPC) and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), total proctocolectomy, subtotal colectomy, completion proctectomy, and subsequent IPAA is often combined with temporary end ileostomy (EI) or loop ileostomy (LI). EI or LI has also been constructed for the treatment of pouch failure or for staged pouch revision surgery. ,
Fecal diversion with ileostomy or colostomy has also been performed for other colorectal diseases, such as severe fecal incontinence, colonic inertia, megacolon, colon volvulus, severe ischemic colitis or colorectal cancer with or without resective surgery. The fecal diversion can be temporary or permanent. Temporary fecal diversion with ileostomy or colostomy is performed in those with distal bowel anastomoses at risk for leaks, such as colorectal or coloanal anastomosis after surgical resection in those with malnutrition, comorbidities, or pelvic radiation.
The ostomy can be classified into (1) ileostomy, colostomy, and jejunostomy, based on the bowel segment used; (2) end, loop, or loop end, based on the configuration; (3) temporary and permanent, based on the intention of creation and duration; and (4) special stomas, such as mucus fistula and continent ileostomy. There can be a diverted bowel segment distally, such as the left-side colon, rectum, or ileal pouch.
STOMAL COMPLICATIONS AMENABLE TO ENDOSCOPIC THERAPY
Various complications can occur at the site of the stoma, peristomal skin area, and bowel segment leading to the stoma. Stomal care and the management of peristomal skin lesions are discussed in Chapter 19 . Endoscopic therapy has been applied for the treatment of stomal bleeding, strictures, fistulas, and abscesses.
STOMAL BLEEDING
The true incidence or prevalence of stoma hemorrhage is not known. Bleeding can occur at the stoma site, the bowel segment or anastomosis in the neo-small bowel or colon, proximal to the stoma. Bleeding is usually visible through an ileostomy bag, resulting in tremendous mental stress for the patient ( Fig. 20.1 ). Bleeding may result from granular tissue, friable mucosa, or ulcers. In the clinic or endoscopy suite, silver nitrate is commonly used for the treatment of stomal bleeding from granular tissue or ulcers ( Fig. 20.2 ). Mucosal bleeding from active inflammation from underlying CD can be managed by proper medical therapy with agents such as antitumor necrosis factor agents (e.g., infliximab and adalimumab), antiintegrin agents (e.g., vedolizumab), antiinterleukin agents (e.g., ustekinumab and risankizumab), or small molecule agents (e.g., upadacitinib). However, endoscopic therapy may be applied for the treatment of bleeding ulcers, bleeding polyps, or bleeding vessels at the neo-ileum or neo-colon, the anastomosis, or strictureplasty site proximal to the stoma ( Figs. 20.3 – 20.5 ).
Commonly used techniques to control bleeding are clipping (e.g., the use of through-the-scope clips) ( Figs. 20.3 and 20.5 ), injection (e.g., hypotonic glucose) ( Fig. 20.4 ), spray (e.g., hemostatic foam or gel), or polypectomy ( Fig. 20.6 ). The author found that the injection of epinephrine or application of cauterization may exacerbate bleeding with the underlying inflammatory process. Radiation enteritis-associated bleeding may be treated with the luminal administration of hypertonic glucose via endoscopy.
Patients with primary sclerosing cholangitis or portal hypertension may develop stomal varices. Varix-associated stomal bleeding may be treated with endoscopic injection sclerotherapy. Bleeding from stomal varices usually requires interventional radiology or surgical intervention, with transjugular intravascular transhepatic shunts, surgical shunts, or liver transplantation. ,
STRICTURES
Stricture is a common complication in patients with ileostomy or colostomy. The stricture in these settings can be classified into (1) benign or malignant; (2) mild, moderate, or severe; (3) short (<4–5 cm) or long (≥5 cm); (4) single or multiple; (5) primary or secondary (e.g., use of nonsteroidal anti-inflammatory drugs [NSAID] and anastomotic); (6) intraluminal (e.g., inflammatory polyps, prolapse, and foreign bodies), intramural (e.g., transmural fibrosis and muscular hyperplasia), or constrictive (e.g., adhesions and compression from the contracted abdominal wall muscles and facia or placement of mesh); and (7) simple or complex (e.g., those associated with prestenotic dilation, fistula, or abscess). Strictures at ileostomy or colostomy can occur at the tip of the stoma, skin level, fascia level, or small bowel or large bowel segments proximal to the stoma.
For patients with CD who had ileostomy or colostomy, recurrent inflammatory, fibrostenotic, or penetrating CD can occur in the neo-distal ileum or distal neo-colon. The disease activity of CD can reliably be assessed by a careful endoscope via the stoma. Ulcer, stricture, or fistula of the ileum at or distal to fascia level are likely caused by technical factors, such as ischemia and mesh placement. Inflammation, strictures, or fistulae at the segment of the ileum proximal to the fascia, in the absence of the use of NSAIDs, usually result from recurrent CD. The Rutgeerts Score was designed for the monitoring of disease recurrence at the neo-terminal ileum in those with ileocolonic resection and anastomosis has been used to evaluate disease recurrence in patients with ileostomies.
Patients with ileostomies for CD may also have additional small bowel surgeries proximal to the stoma, including small bowel resection, anastomosis, and strictureplasty. The anastomosis or strictureplasty (especially at the inlet or outlet of surgical strictureplasty). Patients with CD occasionally may carry end or loop colostomies. Strictures at the colostomy site are less common than ileostomy. Endoscopists can use a gastroscope or pediatric colonoscope to assess the proximal colon and ileum via the stoma. Primary or anastomotic strictures can occur in the colon, ileocecal valve, ileocolonic anastomosis, or terminal ileum.
Approximately 20% of patients with UC would require total proctocolectomy for their medically refractory disease or colitis-associated neoplasia. Restorative proctocolectomy with IPAA is the preferred surgical procedure for the majority of patients with UC or familial adenomatous polyposis undergoing colectomy. A few patients may elect to have permanent Brooke EI without an attempt to have an ileal pouch, as IBD hardly ever recurs in those patients. While IPAA surgery significantly improves patients’ quality of life, structural, inflammatory, or functional adverse sequelae are common. , Patients with abscess, pouch sinus, vaginal fistula, chronic pouchitis, or CD of the pouch may develop pouch failure with pouch excision or permanent fecal diversion. Patients with secondary ileostomies due to pouch failure are at risk of developing complications such as strictures and fistulas at the stoma or small bowel proximal to the stoma. Contributing factors to these complications include CD, surgical ischemia, or mesh placement.
Stricture complications are not common in patients who had ileostomy or colostomy for other benign or malignant colorectal diseases, although there is limited literature.
Endoscopy via stoma can deliver therapy in selected patients with strictures in the stoma or neo-small or large bowel. Endoscopic therapy may be attempted for the treatment of simple, short, benign, intramural, primary or anastomotic strictures or the removal of lumen-blocking lesions or materials. It is important to characterize the number, degree, length, and location by cross-sectional imaging (such as computed tomography and magnetic resonance imaging) or gastrografin enema via the stoma.
Commonly used endoscopic treatment modalities for the treatment of strictures are balloon dilation and endoscopic stricturotomy. Occasionally, a temporary covered metallic stent may be used. The author’s team performed endoscopic balloon dilation (EBD) of 25 consecutive patients with CD-associated strictures via stoma using ileoscopy ( Figs. 20.7 and 20.8 ). A total of 75 sessions of EBD were performed. There was a median of two endoscopic sessions (interquartile ratio [IQR]: 1.0–4.5) and three cumulative strictures dilated (IQR: 1.5–9.5) for each patient. The median size of the balloon was 19 mm (IQR: 16–20 mm). Of the 75 EBD procedures, technical success, as measured by the passage of the gastroscope after dilation, was achieved in 70 (93.3%) sessions. Of the 25 patients undergoing the initial dilation, seven (28.0%) did not require endoscopic re-intervention or surgical intervention, during a mean follow-up of 21.6 ± 26.1 months (range, 5 days–94 months). Sixteen patients (64.0%) required further EBD and two (8.0%) had surgery for newly developed fistulas in one patient or bowel perforation from EBD in another patient. The majority of patients tolerated the procedure and EBD-associated perforation occurred in two patients (2.7%), requiring hospitalization or urgent surgery. Although EBD has been routinely used for the treatment of primary or anastomotic strictures in IBD, there is limited literature specifically analyzing outcomes of EBD therapy of bowel strictures in patients with ostomies.
Related posts:
Endoscopy-Associated Complications in Colorectal Diseases: Clinical Presentation and Diagnostic Evaluation
Anastomoses and Complications in Inflammatory Bowel and Colorectal Diseases
Endoscopic Therapy of Fistulas from Chronic Anastomotic Leaks
Stoma Complications: Surgical Management
Closure of Endoscopy- and Surgery-Associated Colonic Defects: From Animal Lab to Endoscopy Suite
Corrective Surgery for Surgery-Associated Vaginal Fistula
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