© Springer-Verlag Berlin Heidelberg 2017Alexander Herold, Paul-Antoine Lehur, Klaus E. Matzel and P. Ronan O’Connell (eds.)ColoproctologyEuropean Manual of Medicine10.1007/978-3-662-53210-2_30
30. Stomas and Stomatherapy
Chair of Surgical Oncology, Sigmund Freud Medical School, Freudplatz 1, 1020 Vienna, Austria
Harald R. Rosen
Fecal diversion by constructing a stoma is a common procedure in colorectal surgery. While a permanent stoma as a treatment for rectal cancer has decreased markedly since the introduction of sphincter-saving techniques, a variety of indications still lead to the construction of intestinal stomas. While the first historical reports about the treatment of penetrating abdominal injuries date back to the thirteenth century, the eighteenth and nineteenth centuries saw a change from mere exteriorizations of intestinal lacerations to elective formations of ileostomies, cecostomies, and left inguinal colostomies for large bowel obstructions . Following the next “milestone” of a rod introduced by Maydl, which led to the creation of the loop colostomy in 1884, it took more than 60 years until mucocutaneous sutures and the immediate opening of a stoma were accepted as the method of choice . At the same time, Koernig, a German student studying chemistry and suffering from the side effects of an ileostomy performed because of ulcerative colitis, developed a bag made of rubber and fixed to the skin with a latex preparation, thus leading to the emergence of modern stoma appliances. While the principle of the “Koernig bag” remained a standard for many years, more effective sealing materials – first karaya gum and later Stomahesive and similar hydrocolloids – have led to the present state of the art of stoma appliances.
30.2 Definitions and Indications
Stomas may be permanent or temporary and can be created either as a loop, double barrel, or end stoma using a part of the small (ileostomy) or large (colostomy) bowel.
30.2.1 Indications for a Permanent Stoma
Abdominoperineal excision of the rectum for rectal cancer, recurrent anal cancer, or severe inflammatory bowel disease of the anorectum
Untreatable persistent fecal incontinence
30.2.2 Indications for a Temporary Stoma
Contrary to previous applications, when a temporary stoma was used as the first step of treatment in emergency situations (colonic obstruction, acute diverticulitis, fulminant ulcerative colitis), most patients today will be treated by definitive surgical resection immediately [12, 13]. Therefore, forming a temporary stoma as a sole procedure should be reserved only for those few patients with a massive obstruction and in such a general condition that they cannot tolerate a resection.
Formation of a temporary stoma is limited to those patients in whom either a primary anastomosis might be not desirable (Hartmann procedure, double-barrel stoma following resection in selected patients) or in whom it would serve as a so-called protective or covering stoma. However, stoma reversion should be feasible within an acceptable time period .
Protection of low rectal or anal anastomoses
Need to delay primary anastomoses until a later time (Hartmann procedure, double-barrel stoma)
Complicated perianal and/or rectal fistula
Penetrating colorectal injuries
Extensive trauma to the pelvic floor
Congenital malformations (anal atresia)
18.104.22.168 Efficacy of a Protective Stoma
There is controversy regarding the efficacy of a protective stoma today. Experimental and clinical data show evidence that the fecal stream has an important beneficial effect on anastomotic healing, leading to a higher anastomotic strength and increased collagen synthesis . It is widely accepted that loop stomas in particular do not result in a complete fecal exclusion of the bowel, which should be covered; therefore the use of a temporary stoma for protective purposes is being questioned. Furthermore, recent data show the safety of elective colorectal surgery, even without bowel preparation, with the introduction of early feeding and activation of peristalsis [14, 15].
In contrast to these observations, low rectal anastomoses are regarded as being at higher risk for leakage. Data from randomized trials suggest that although covering stomas do not influence the insufficiency rate, serious life-threatening infections might be prevented [2, 4, 8].
However, it must be taken into account that in large series only two-thirds of all temporary stomas were closed, whereas more than 30 % of all patients kept their stoma permanently (e.g., because of the underlying primary disease, old age, a poor general condition) or died before closure . In addition, closure of a stoma is not a procedure devoid of problems; the complication rate ranges form 16 to 35 %, with a mortality of 0–4 % [16, 21]. The most common complications are wound infections, fistulas, and incisional hernia; bowel obstruction and peritonitis have also been observed.
22.214.171.124 Loop Ileostomy or Loop Colostomy?
In the 1980s many surgeons started to favor loop ileostomies to avoid problems associated with colostomies (i.e., higher incidence of parastomal hernias and/or stoma prolapse, incisional hernias following stoma closure, easier application of appliances with ileostomies). While some controlled studies with a limited number of patients showed evidence of a lower complication rate associated with the formation and subsequent closure of ileostomies (lower rates of infections and incisional hernias) , other data show a decrease in the number of obstruction problems following reversal of colostomies . Furthermore, it must be emphasized that for the mere decompression of an obstructing process in the colon or rectum, an ileostomy (if the ileocecal valve is still competent) can sometimes be insufficient. However, construction of a transverse loop colostomy or loop sigmoidostomy is technically so difficult – especially in obese patients – that an ileostomy is preferable.
30.3 Stoma Construction
30.3.1 Stoma Site and Preoperative Counseling
The optimal location for a stoma is a prerequisite for satisfying function and an acceptable application of stoma appliances. The site depends on the anatomic position and type of stoma, scars, and the patient’s build and dressing habits.
Anatomic sites of stomas (present surgical standard):
Ileostomy: over the right rectus muscle, halfway between the umbilicus and the anterior superior iliac spine, lying just below the midline and well away from the symphysis pubis and costal margin. If the right side is not accessible (e.g., scars after previous operations), a trephine can be performed in the left rectus muscle.
Transverse colostomy: usually brought through the rectus muscle just right of the midline, well above the umbilicus but a safe distance from the costal margin.
Sigmoidostomy: Through the left rectus muscle away from the inguinal ligament, midway between the umbilicus and the anterior superior iliac spine.
In elective stoma formation (or even when there is a possibility for the need of a stoma), it is mandatory to define the site preoperatively using ink and a stoma bag.
The optimal position should be marked while the patient is sitting and standing, and with regard to the patient’s usual clothing. A specialized stoma therapist should counsel the patient and the surgeon during this step to achieve an optimal position.
Preoperative counseling by a stoma therapist who also follows the patient postoperatively and after hospital discharge is mandatory to reduce the negative effects of a stoma on quality of life (QOL). This includes introducing stoma appliances, irrigation sets (if applicable), and dietary recommendations to the patient and his/her relatives as well as communicating with the patient, the family doctor, and the surgeon during follow-up. Organized “patient stoma groups” are also available in some countries and have been proven to be beneficial to allay patients’ concerns and fears preoperatively and to reduce postoperative problems, especially with regard to health care providers (e.g., insurance problems).