Challenging Stomas

  • Ryan S. Williams
  • Victor W. Fazio


Permanent ostomy creation is a life-changing event and ostomy construction deserves careful attention. Even under the best of circumstances, problems may occur and this is more so when ostomy creation is difficult. Many of these problems can impact patients’ daily routines and decrease quality of life. They may be minor, ranging from pseudoepitheliomatous hyperplasia and skin irritation, to major, such as peristomal hernia or ischemic necrosis. A significant number of patients with these complications will require reoperation. This chapter will present techniques to minimize the possibility of complications when ostomy construction is difficult and will propose solutions if the surgeon is presented with specific difficult ostomy complications.


Ileal Pouch Anal Anastomosis Rectus Abdominus Middle Colic Artery Pseudoepitheliomatous Hyperplasia Thick Abdominal Wall 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Londono-Schimmer EE, Leong APK, Phillips RKS. Life table analysis of stomal complications following colostomy. Dis Colon Rectum. 1994;37(9):916–20.PubMedCrossRefGoogle Scholar
  2. 2.
    Makela JT, Niskasaari M. Stoma care problems after stoma surgery in Northern Finland. Scand J Surg. 2006;95:23–7.PubMedGoogle Scholar
  3. 3.
    Park JJ, Del Pino A, Orsay CP, Nelson RL, Pearl K, Cintron JR, et al. Stoma complications: the cook county hospital experience. Dis Colon Rectum. 1999;42(12):1575–80.PubMedCrossRefGoogle Scholar
  4. 4.
    Leong APK, Londono-Schimmer EE, Phillips RKS. Life-table analysis of stomal complications following ileostomy. Br J Surg. 1994;81:727–9.PubMedCrossRefGoogle Scholar
  5. 5.
    O’Toole GC, Hyland JM, Grant DC, Barry MK. Defunctioning Loo ileostomy: a prospective audit. J Am Coll Surg. 1999;188:6–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Gooszen AW, Geelkerken RH, Hermans J, Lagaay MB, Gooszen HG. Quality of life with a temporary stoma: ileostomy vs. colostomy. Dis Colon Retum. 2000;43:650–5.CrossRefGoogle Scholar
  7. 7.
    Tsunoda A, Tsunoda Y, Narita K, Watanabe M, Nakao K, Kusano M. Quality of life after low anterior resection and temporary loop ileostomy. Dis Colon Rectum. 2008;51:218–22.PubMedCrossRefGoogle Scholar
  8. 8.
    O’Leary DP, Fide CJ, Foy C, Lucarotti ME. Quality of life after low anterior resection with total mesorectal excision and temporary loop ileostomy for rectal carcinoma. Br J Surg. 2001;88:1216–20.PubMedCrossRefGoogle Scholar
  9. 9.
    Wu JS, Fazio VW. Difficult stomas. Persp Colon Rectal Surg. 1998;10:33–60.Google Scholar
  10. 10.
    Gooszen AW, Geelkerken RH, Hermans J, Lagaay MB, Gooszen HG. Temporary decompression after colorectal surgery: randomized comparison of loop ileostomy and loop colostomy. Br J Surg. 1998;85:76–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Winslet MC, Barsoum G, Pringle W, Fox K, Keighley MRB. Loop ileostomy after ileal pouch-anal anastomosis—Is it necessary? Dis Colon Rectum. 1991;34:267–70.PubMedCrossRefGoogle Scholar
  12. 12.
    American Society of Colon and Rectal Surgeons and the Wound Ostomy Continence Nurse Society. Joint position statement on the value of preoperative stoma marking for patients undergoing ostomy surgery. J Wound Ostomy Continence Nurs. 2007;34:627–8.CrossRefGoogle Scholar
  13. 13.
    Engel J, Kerr J, Schlesinger-Raab A, Eckel R, Sauer H, Holzel D. Quality of life in rectal cancer patients. Ann Surg. 2003;238:203–13.PubMedGoogle Scholar
  14. 14.
    Nugent KP, Daniels P, Stewart B, Patankar R, Johnson C. Quality of life in stoma patients. Dis Colon Rectum. 1999;42:1569–74.PubMedCrossRefGoogle Scholar
  15. 15.
    Rozen BL. The value of a well-placed stoma. Cancer Pract. 1997;5(6):347–52.PubMedGoogle Scholar
  16. 16.
    Rullier E, Le Toux N, Laurent C, Garrelon J, Parneix M, Saric J. Loop ileostomy versus loop colostomy for defunctioning low ­anastomoses during rectal cancer surgery. World J Surg. 2001;25:274–8.PubMedCrossRefGoogle Scholar
  17. 17.
    den Dulk M, Smit M, Peeters K, Kranenbarg E, Rutten H, Wiggers T, et al. A multivariate analysis of limiting factors for stoma reversal in patients with rectal cancer entered into the total mesorectal excision (TME) trial: a retrospective study. Lancet Oncol. 2007;8:297–303.CrossRefGoogle Scholar
  18. 18.
    Peeters KC, Tollenaar RA, Marijnen CA, Klein KE, Steup WH, Wiggers T, et al. Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg. 2005;92:211–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Tilney HS, Sains PS, Lovegrove RE, Reese GE, Heriot AG, Tekkis PP. Comparison of outcomes following ileostomy versus colostomy for defunctioning colorectal anastomoses. World J Surg. 2007;31:1142–51.PubMedCrossRefGoogle Scholar
  20. 20.
    Tjandra JJ, Chan MK. A sprayable hydrogel adhesion barrier facilitates closure of defunctioning loop ileostomy: a randomized trial. Dis Colon Rectum. 2008;51:956–60.PubMedCrossRefGoogle Scholar
  21. 21.
    Tang CL, Seow-Chen F, Fook-Chong S, Eu KW. Bioresorbable adhesion barrier facilitates early closure of the defunctioning ileostomy after rectal excision: a prospective, randomized trial. Dis Colon Rectum. 2003;46:1200–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Salum M, Wexner SD, Nogueras JJ, Weiss E, Koruda M, Behrens K, et al. Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (seprafilm) decrease operative time for loop ileostomy closure? Tech Coloproctol. 2006;10:187–90; discussion 190–1.PubMedCrossRefGoogle Scholar
  23. 23.
    Harris DA, Egbeare D, Jones S, Benjamin H, Woodward A, Foster ME. Complications and mortality following stoma formation. Ann R Coll Surg Engl. 2005;87(6):427–31.PubMedCrossRefGoogle Scholar
  24. 24.
    Arumugam PJ, Bevan L, Macdonald L, Watkins AJ, Morgan AR, Beynon J, et al. A prospective audit of stomas—analysis of risk factors and complications and their management. Colorectal Dis. 2003;5(1):49–52.PubMedCrossRefGoogle Scholar
  25. 25.
    Duchesne JC, Wang Y, Weintraub SL, Boyle M, Hunt JP. Stoma complications: a multivariate analysis. Am Surg. 2002;68(11):961–6; discussion 966.PubMedGoogle Scholar
  26. 26.
    Demetrios D, Murray J, Chan L, Ordonez C, Bowley D, Nagy KK, et al. Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma. 2001;50:765–75.CrossRefGoogle Scholar
  27. 27.
    Remzi FH, Fazio VW, Gorgun E, Ooi BS, Hammel J, Preen M, et al. The outcome after restorative proctocolectomy with or without defunctioning ileostomy. Dis Colon Rectum. 2006;49:470–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Wexner SD, Taranow DA, Johansen OB, Itzkowitz F, Daniel N, Nogueras JJ, et al. Loop ileostomy is a safe option for fecal diversion. Dis Colon Rectum. 1993;36:349–54.PubMedCrossRefGoogle Scholar
  29. 29.
    Senapati A, Nicholls RK, Ritchie JK, Tibbs CJ, Hawley PR. Temporary loop ileostomy for restorative proctocolectomy. Br J Surg. 1993;80:628–30.PubMedCrossRefGoogle Scholar
  30. 30.
    Carlsen E, Bergan AB. Loop ileostomy: technical aspects and complications. Eur J Surg. 1999;165:140–3.PubMedCrossRefGoogle Scholar
  31. 31.
    Pokorny H, Herkner H, Jakesz R, Herbst F. Predictors for complications after loop stoma closure in patients with rectal cancer. World J Surg. 2006;30:1488–93.PubMedCrossRefGoogle Scholar
  32. 32.
    Pokorny H, Herkner H, Jakesz R, Herbst F. Mortality and complications after stoma closure. Arch Surg. 2005;140:956–60.PubMedCrossRefGoogle Scholar
  33. 33.
    Mansfiel SD, Jensen C, Phair AS, Kelly OT, Kelly SB. Complications of loop ileostomy closure: a retrospective cohort analysis of 123 patients. World J Surg. 2008;32(9):2101–6.CrossRefGoogle Scholar
  34. 34.
    Mackay G, Goldberg J. Self-everting ileostomy. Colorectal Dis. 2007;9:763–4.PubMedCrossRefGoogle Scholar
  35. 35.
    King RF, Norton T, Hill GL. A double-blind cross-over study of the effect of loperamide hydrochloride and codeine phosphate on ileostomy output. Aust N Z J Surg. 1982;52:121–4.PubMedCrossRefGoogle Scholar
  36. 36.
    Newton CR. Effect of codeine phosphate, lomotil and isogel on ileostomy function. Gut. 1978;19:377–83.PubMedCrossRefGoogle Scholar
  37. 37.
    Modlin M. Urinary calculi and ulcerative colitis. Br Med J. 1972;3(821):292.PubMedCrossRefGoogle Scholar
  38. 38.
    Fukushima T, Sugita A, Masuzawa S, Yamazaki Y, Takemura H, Tsuchiya S. Prevention of uric acid stone formation by sodium bicarbonate in an ileostomy patient: a case report. Jpn J Surg. 1988;18:465–8.PubMedCrossRefGoogle Scholar
  39. 39.
    Christl SU, Scheppach W. Metabolic consequences of total colectomy. Scand J Gastroenterol Suppl. 1997;222:20–4.PubMedGoogle Scholar
  40. 40.
    Carlsen E, Bergan AB. Technical aspects and complications of end-ileostomies. World J Surg. 1995;19:632–6.PubMedCrossRefGoogle Scholar
  41. 41.
    Fleshman Jr JW. Ostomies. In: Hicks TC, Beck DE, Opelka FG, Timmcke AE, editors. Complications of colon and rectal surgery. Baltimore: Williams and Wilkins; 1996. p. 357–81.Google Scholar
  42. 42.
    Kann BR, Cataldo TE. Early stomal complications. Clin Colon Rectal Surg. 2002;15:191–8.CrossRefGoogle Scholar
  43. 43.
    Pearl RK. Parastomal hernias. World J Surg. 1989;13:569–72.PubMedCrossRefGoogle Scholar
  44. 44.
    Martin L, Foster G. Parastomal hernia. Ann R Coll Surg Engl. 1996;78:81–4.PubMedGoogle Scholar
  45. 45.
    Williams JG, Etherington R, Hayward MWJ, Hughes LE. Paraileostomy hernia: a clinical and radiological study. Br J Surg. 1990;77:1355–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Steel MCA, Wu JS. Late stomal complications. Clin Colon Rectal Surg. 2002;15:199–207.CrossRefGoogle Scholar
  47. 47.
    Turnbull Jr RB, Weakley FL. Atlas of intestinal stomas. St. Louis: Mosby; 1967.Google Scholar
  48. 48.
    Sjodahl R, Anderberg B, Bolin T. Parastomal hernia in relation to the site of the abdominal stoma. Br J Surg. 1988;75:339–41.PubMedCrossRefGoogle Scholar
  49. 49.
    Thorlakson RH. Technique of repair of herniations associated with colonic stomas. Surg Gynecol Obstet. 1965;120:347–50.PubMedGoogle Scholar
  50. 50.
    Kim H, Bruen K, Vargo D. Acellular dermal matrix in the management of high-risk abdominal wall defects. Am J Surg. 2006;192:705–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Patton Jr JH, Berry S, Kralovich KA. Use of human acellular dermal matrix in complex and contaminated abdominal wall reconstructions. Am J Surg. 2007;193:360–3.PubMedCrossRefGoogle Scholar
  52. 52.
    Young MJ. Convexity in the management of problem stomas. Ostomy Wound Manage. 1992;38:53–60.PubMedGoogle Scholar
  53. 53.
    Taylor Jr RL, Rombeau JL, Turnbull Jr RB. Transperitoneal relocation of the ileal stoma without formal laparotomy. Surg Gynecol Obstet. 1978;146(6):953–8.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Department of Colorectal Surgery, Digestive Diseases InstituteCleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic FoundationClevelandUSA

Personalised recommendations