Re-operative surgery for intestinal stoma complications

Seminars in Colon and Rectal Surgery 26 (2015) 200–205

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Re-operative surgery for intestinal stoma complications Laurence R. Sands, MD, MBA, FACS, FASCRSa,n, Carlos Sam Morales, MDa,b a b

Division of Colon and Rectal Surgery, University of Miami Miller School of Medicine, Miami, FL Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL

abstract Intestinal stomas remain a vital tool for the surgeon caring for patients with bowel disease. This article reviews stoma complications that may result in re-operative surgery to revise the stoma. It includes a comprehensive review of early- and late-stoma complications as well as an extensive review of the treatment and prevention of parastomal hernia. Surgical techniques, adherence to basic surgical principles, proper preoperative patient counseling, and pre-operative stoma marking, all of which may prevent many of these complications and enable the surgeon to create the perfect stoma, are also reviewed. & 2015 Elsevier Inc. All rights reserved.

Introduction The origins of the diverting stoma can be traced back to Dr. Littre where in 1710 he created a colostomy for a patient with an obstructing colon cancer.1 While the creation of the colostomy is over 300 years old, it still remains a vital tool for both the general and colorectal surgeon in order to treat a variety of gastrointestinal diseases. Most surgeons would like to believe that stomas are created without issue. However, the literature is replete with many articles describing the morbidity and complications of even the well-constructed stoma. These complications can be divided into physiologic issues, mechanical problems, and anatomic difficulties. When one decides to re-operate on a patient for stoma-related issues, it is best to consider these problems as acute or chronic problems. When grouped together, however, all stoma complications represent a considerable morbidity and mortality. In addition, they pose a large financial burden to our already stressed medical system.

Initial considerations—Stoma marking Stoma complications such as skin irritation and leakage may arise from a poorly placed stoma. Therefore proper preoperative counseling, education, and site marking may play a key role in preventing some basic stoma issues and re-operation (Figs. 1). The role of the enterostomal therapist has increased considerably today over the recent past. Many hospitals and medical n

Corresponding author. E-mail address: [email protected] (L.R. Sands).

http://dx.doi.org/10.1053/j.scrs.2015.09.006 1043-1489/& 2015 Elsevier Inc. All rights reserved.

institutions now hire an entire team of enterostomal therapists and wound care teams. The counseling they provide reinforces the patients need for the stoma. They are able to answer many questions for the patient about the surgery and the stoma in a non-threatening environment, as many patients will experience a great deal of anxiety related to the creation of a stoma. They may offer reading material, video presentations, and online websites in order to provide the patient with additional information and resources regarding the stoma. The enterostomal therapist may also show the patient the stoma appliances and related products in advance of the surgery, so they have a basic understanding of how these devices work. Another useful resource is to provide the patient the ability to speak to other willing patients in a similar situation who have a stoma so that many of their questions may be appropriately addressed. All of this is important since stoma counseling has been shown to play a major role in stoma acceptance. This has been confirmed in a study that used multiple regression analysis to show that stoma adjustment was related to learning how to care for the stoma by the patient, the interpersonal relationships that the patient has developed, and better stoma placement. The authors concluded that addressing the psychosocial concerns of the patient should become a part of the care routinely given to stoma patients and preoperative counseling plays a major role in this care.2 Another randomized controlled trial demonstrated far greater proficiency with the stoma, shorter hospital stays, and lower overall hospital costs if patients were educated about the stoma in advance of the surgery compared to postoperative stoma teaching.3 One of the most important roles of the enterostomal therapist is preoperative stoma marking. Proper stoma siting reduces stoma

L.R. Sands, C.S. Morales / Seminars in Colon and Rectal Surgery 26 (2015) 200–205

Fig. 1. Stoma irritation.

complications and may reduce the chances that re-operative surgery will be needed for a poorly placed stoma. It may also allow patients to be more independent and to more readily adapt to their new way of life if the stoma is properly placed (Figs. 2). Stoma siting should be a collaborative effort among the patient, family members, enterostomal therapist, and surgeon in order to achieve a secure stoma appliance devoid of leakage. A leaking stoma can cause severe skin irritation and maceration which leads to a tender raw area that makes the application of a stoma appliance very difficult. This leads to a vicious cycle of poor apposition of the stoma wafer, further leakage, high cost due to over utilization of stoma supplies, and possibly social isolation due to fear of stoma leakage. In a recent Israeli study of 105 patients half of whom were marked preoperatively by an enterostomal therapist, the quality of life of those patients marked preoperatively for a stoma site was significantly better than those who were not marked even though 43% of the stomas were temporary. In addition, the marked group had a statistically significant lower incidence of stoma complications and greater independence. They concluded that preoperative marking by a qualified enterostomal therapist was advantageous to the patients undergoing surgery that required a stoma.4 Other studies have confirmed better patient outcomes as well in those

Fig. 2. Demonstrates a well-formed stoma.

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undergoing preoperative assessment and stoma markings by an enterostomal therapist.5 Certain factors for proper stoma siting such as body habitus, abdominal wall contour (observed in both the sitting and standing position), abdominal girth, prior abdominal incisions, belt line, skin folds, and bony prominences need to be considered. The stoma should be approximately 5 cm away from other incisions and should optimally lie below the umbilicus. Stoma sites should be modified to avoid scars, skin creases, and other skin disorders. The site must be checked to ensure skin folds or crevices do not interfere with appliance fitting. In the morbidly obese individual, it may be best to place the stoma above the level of the umbilicus due to the large pannus and to facilitate visualization of the stoma for the patient. One should also take into account the patient's flexibility, capabilities, and activity when properly siting a stoma. An adequate stoma location should be placed lateral to the midline and should be exit through the rectus abdominus muscle for additional support and to minimize hernia risk. Siting a stoma through the umbilicus should, in general, be avoided. However, when a reasonable alternative does not exist, Raza and his colleagues, felt that this was a good option based on their series of 101 patients whereupon only four needed stoma revision. They also noted that none of their patients developed a parastomal hernia or stoma prolapse.6 Another study showed that there was excellent cosmesis in infants and children after closure of an umbilical stoma.7 The stomas site should be marked and the appliance ideally worn by the patient after being marked for 24–48 h in order to properly test the location selected. Once proper placement is ascertained, the spot is marked with indelible ink. This may be done with a water resistant marker if the marking is done close to the surgery date or it may be done by using ink and then puncturing the skin under the ink thereby forming a permanent tattoo.8 Therefore, assessing and teaching patients preoperatively and postoperatively helps them gain confidence and better experiences in self-stoma care reducing the psychological, physical, emotional, social, and sexual problems that may otherwise arise. In this era of high health costs, adequate patient education has also resulted in reduced cost to both the patient and the institution.9

Incidence The incidence of stoma complications has been reported as ranging from 10% to 70%.10 This range is very broad and in reality the true incidence of stoma-related issues is largely underreported. In a study conducted at Cook County Hospital that included over 1600 patients with either a colostomy or ileostomy, a complication rate of 34% was reported. Furthermore, these complications were divided into early ( o30 days after surgery) complications and late complications. The early complication rate was much higher at 28% compared to 6% of patients who experienced later complications. Certain factors have been implicated in influencing stoma complications (Table 1).11,12 In the acute setting, body mass index (BMI), emergency surgery, the presence of bowel ischemia found at the time of initial operation and underlying Crohn's disease have all been implicated as the strongest risk factors contributing to early complication rates.13,14 Patients with a large BMI tend to have a short mesentery. This, when coupled with a large amount of subcutaneous tissue surrounding the stoma can compromise blood flow causing bowel ischemia and retraction of the stoma. Emergency surgery has always posed a great challenge due to its high morbidity and mortality. In addition, fecal diversion has been regarded as a way out of an abdominal catastrophe. Due to the

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Table 1 Risk factors for stoma complications (most relevant factors indicated by n). Age of patient Body mass indexn Emergentn vs. elective surgery Contour of abdominal wall Preoperative stoma siting Grade of operating surgeon Diabetesn Type of stoma Type of suture material used in stoma creation Smoking

inherent nature of emergency surgery with the possibilities of encountering a perforated viscous or intra-abdominal contamination there are many challenges with the creation of a well-formed and adequately functioning stoma. For the purposes of this narrative, re-operative surgery for stoma complications will be divided into early and late complications requiring surgery.

Early stoma complications Stoma ischemia and necrosis The most immediate and most dreaded complication of stoma creation is the ischemic or necrotic stoma. This can occur from 2.3% to 17%, with frank necrosis occurring in o 3% of cases.15,16 The best method of correcting this problem is to avoid the problem upon the initial creation of the stoma. Care must be taken to create a perfect stoma from the outset. Several principles must be adhered to upon stoma creation in order to make the perfect stoma (Table 3). First the surgeon must ensure adequate colonic or small bowel mobilization in order to avoid tension of the bowel approaching the skin and subcutaneous tissues. This may require mobilization of the splenic flexure as well as dividing some of the mesenteric vasculature in order to allow the bowel to reach the skin easily. If the surgeon is pulling the bowel firmly to the skin in order to get it to reach for stoma creation, this is often a sign that there is too much tension on the bowel wall. Second, the bowel wall must not be skeletonized or stripped of its mesenteric blood supply in order to ensure adequate blood flow. In order to obtain mobility, it is best to ligate vessels near the root of the mesentery rather than near the bowel edge in order to prevent stoma ischemia. Third, a formal disc of skin must be removed at the stoma site rather than simply making a skin incision. Removing a disc of skin will prevent wound contraction, which would ultimately cause stoma stenosis as a later complication. Fourth, upon opening the bowel end for stoma maturation, the surgeon should see bleeding from the edges of the bowel wall. In addition, one should be conscious that there is no evidence of venous thrombosis in the mesentery adjacent to the stoma. This often indicates a devascularization of the bowel and may ultimately cause stoma ischemia and necrosis. In the morbidly obese patient, a wound protector may facilitate exteriorization of the bowel from the abdominal cavity.17 Even though stoma creation is often the last part of a major operation, the surgeon must not rush this part of the procedure in Table 2 Indications for repair parastomal hernia. Incarcerated bowel with compromise Poor fitting appliance Severe parastomal skin irritation Intestinal obstruction Severe parastomal pain

Table 3 Steps to create the perfect stoma. Avoid tension on the bowel as it reaches the abdominal wall Avoid stripping of the mesentery of the stoma Remove a disc of skin from the abdominal wall at the site of the stoma Assure an adequate sized fascial opening for the segment of bowel to be exteriorized Notice bleeding edges of the bowel upon maturation of the stoma

order to expedite and complete the operation. It is a good practice to adequately prepare the segment of bowel to be used well in advance. In emergency cases where there has already been a perforated viscous or spillage of enteric material within the abdominal cavity due to the disease state being corrected with surgery, it is the author's preference to create the stoma and mature the bowel prior to fascial closure in order to allow more time for the bowel to be observed and thereby ensure viability before the surgery is concluded. The most reliable indicator of a well-vascularized stoma is noting bowel viability in the operating room at the end of the surgical case. Sometimes the surgeon may leave the operating room with a slightly dusky stoma and feel that this will improve over the next day or so. This is a common misconception. The stoma is often never better within the ensuing days of the operation unless the patient was on high-dose pressors at the time of the initial surgery due to an abdominal catastrophe. Often the stoma will look worse as time progresses if it was dusky from the outset. In cases of hemodynamic instability requiring pressor agents, the surgeon may opt for a second look procedure to assess bowel viability in 24–48 h after the initial operation and after the patient has been adequately resuscitated. In those cases, it may be best to delay creation of the stoma until the second look procedure has been performed. If frank stoma necrosis is noted in the postoperative period, the patient should be immediately returned to the operating room for stoma revision. However, if the stoma is simply ischemic, the bowel should be assessed at the patient's bedside in order to determine how extensive the process is. This can be done by simply using a glass blood drawing tube, removing the rubber stopper, and inserting the blunt side of it into stoma while looking down the tube with a flashlight in order to assess the length of the ischemia. Alternatively, endoscopic evaluation of the stoma can also be done. If the ischemia extends to the fascial level, the patient should be returned to the operating room for stoma revision due to fear of bowel wall breakdown and spillage of intestinal contents into the abdominal cavity. If the ischemia is limited to the superficial surface only and is above the fascial level, then observation may be an acceptable alternative. If the patient develops parastomal cellulitis, skin breakdown, then re-operation should be strongly considered in order to prevent a necrotizing fasciitis and gross infection. If mucocutaneous separation occurs this can often be handled by providing good stoma care with adequate pouching by a skilled ostomy nurse. If the stoma was designed as a temporizing measure then the patient should ultimately be returned to the operating room in a timely manner in order to reverse the stoma and correct the issue related to the bowel ischemia. If the stoma was designed as a permanent stoma and stenosis ultimately occurs due to ischemia, then reoperation should be done in order to correct the problem and create a well functioning stoma.

High stoma output High stoma output is another issue that may require reoperation in the early phases after stoma creation. Ostomy output

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is clearly related to the placement of the stoma with more proximal stomas draining more effluent than more distal stomas. Initial attempts to control stoma output may be accomplished by initiating a regular diet and then adding bulking and anti-diarrheal agents such as loperamide or lomotil as needed. If output remains high the patient will develop a severe electrolyte abnormality unless they are maintained on supplemental intravenous fluids. Although not ideal, in some cases patients may be maintained on nightly IV fluids for supplementation to prevent dehydration. In the healthy individual, nearly 1000–2000 mL of fluid passes through the ileocecal valve on a daily basis. This is reduced by 80– 90% to 100–200 mL of fluid volume in normal stool as it passes through the colon. Unless the patient has diarrhea, left sided colostomy output is similar to the feces that would be passed trans-anally, and there is little loss of total body fluid or sodium.18 If the ileocecal valve has been removed or if there has been significant small bowel resected then the volume of stool will clearly increase. Total body water and sodium reductions may become chronic conditions in ileostomy patients and may lead to mild or severe dehydration.19–21 These patients become uremic which may lead to severe nausea with concomitant loss of appetite and propagation of the dehydrated state. These patients will require hospitalization and ultimate intravenous re-hydration best accomplished with fairly large amounts of normal saline.18 Stoma output should be controlled with bile salt binders, anti-diarrheal agents, or opiates. Injectable somatostatin may also be helpful in controlling high stoma output. Radiographic studies with CT scanning should also be considered in the postoperative patient with high stoma output to rule out an intra-abdominal collection, which could cause bowel irritation and high stoma output. While there is no specific surgical procedure that may be done for high stoma output, the procedure of choice would be early stoma reversal if feasible after appropriate correction of fluids and electrolytes. Late stoma complications Stoma stenosis Stoma stenosis most commonly occurs at the fascial level or at the skin as a late complication of stoma creation in approximately 2–14% of cases.22 The stenosis may be due to a variety of reasons such as ischemia, adhesions, infection, chronic stoma retraction, prior radiation to the abdominal wall and bowel, or chronic inflammatory processes such as Crohn's disease. Techniques that may be employed to prevent stenosis include ensuring that one chooses a viable, tension free segment of bowel for the stoma. As previously mentioned, the surgeon must excise an adequate disc of skin at the selected site of stoma creation rather than simply incising the skin. The latter choice may result in wound contracture and ultimate stenosis. Patients may present with a partial or complete bowel obstruction depending on the degree of stoma stenosis. In mild cases, the patient may experience bloating and difficulty with evacuation of stool. In more severe case, patients may experience excessive liquid output via the stoma as more solid material may not be able to be eliminated. Fortunately, complete intestinal obstruction from a stenotic stoma is rare; however, this situation would require urgent surgical intervention with stoma revision after appropriate fluid resuscitation for the patient. Mild to moderate stoma stenosis may be managed by dietary changes and stoma irrigation. As the stenosis worsens or if it is more severe, serial dilations may be required. This may be done in a GI unit under sedation or may require a general anesthesia in an operating room. It is the author's preference to use serial Hegar dilators for this purpose. A small plastic anoscope may be sent home with the patient so that they may continue the dilations as

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Fig. 3. Stoma prolapse.

an outpatient. The effects of serial dilatations are often short lived due to scarring, fibrosis, and eventually restenosis, thus ultimately requiring definitive treatment with surgical stoma revision on an elective basis. Stoma prolapse The most common late stoma complications requiring surgery include the prolapsing stoma and parastomal hernia. These two conditions often go hand in hand; in most every case of stoma prolapse there is a concomitant parastomal hernia that allowed the prolapse to occur in the first place. Once again, the best surgical solution for both of these issues would be stoma reversal if feasible. When stoma reversal is not possible, the surgeon needs to consider when and if repair should be undertaken. Stoma prolapse most often occurs in patients with loop stomas that were created due to a distal bowel obstruction in order to relieve the obstruction (Fig. 3). This scenario required the surgeon to design a fascial opening wide enough to accommodate two loops of dilated obstructed bowel. Over the course of time as the obstruction resolves, the bowel will decompress, become smaller, less dilated, and will ultimately return to normal caliber. The large fascial opening initially made at the time of surgery remains, however, thereby giving rise to a hernia. The lack of fixity of the bowel proximally facilitates stoma prolapse through this large hernia. The transverse loop colostomy is known to have the highest risk of prolapse estimated at 30%.23 Stoma prolapse is often a chronic condition that will require proper enterostomal care and pouching of the enlarged stoma. Various support garments may be tried in order to reduce the size and unsightliness of the prolapse. Consideration should be given to resect the disease process that necessitated the loop stoma and attempt should be made at reversal of the stoma. If stoma reversal is not feasible then the patient should be considered for

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re-operation and conversion to an end stoma with a separate mucous fistula if a resection of the obstructed bowel is not feasible. Acute stoma prolapse and incarceration of the bowel should be handled by placing sugar on the prolapsed stoma and then applying gentle manual reduction similar to the handling of acute rectal prolapse. The sugar will allow a decrease in bowel wall swelling and ultimately allow reduction of the prolapse. If the bowel is not able to be reduced and shows signs of ischemia, then urgent repair will need to be done. This may be accomplished via a peri-stoma incision and would include resection of the ischemic portion of the bowel and creation of an end stoma and a distal mucous fistula.

Parastomal hernia Parastomal hernia, while listed as a stoma complication, is truly an expected outcome of stoma creation. It is perhaps the most common late complication of stoma creation. In normal circumstances, creating a stoma requires that the fascia be opened in a non-anatomic location within the abdominal wall. In effect this creates an actual hernia whereupon a segment of bowel exits through the created defect. While the surgeon tries to limit the abdominal wall opening to fit just that segment of bowel there is no standard measurement that is used and over the course of time the abdominal wall defect will enlarge. A retrospective study evaluating 43 patients who underwent permanent stoma creation tried to address the issue of the “ideal” size of fascial defect required for stoma creation. While this study showed an overall 58% incidence of parastomal hernia, the authors noted that when the abdominal wall defect of the stoma site was less than 25 mm, there were no cases of parastomal hernia. However, the median abdominal wall aperture of the stoma in those patients with a parastomal hernia was 35 mm while it was noted to be 22 mm in those without a hernia.24 This study allows one to have some basic understanding that the size of the defect created for stoma creation may have some bearing on parastomal hernia formation. In general, the literature suggests that parastomal hernias occur in up to 50% of patients regardless of which techniques, open or laparoscopic, are used for stoma creation.25–28 There has been a flurry of interest to reinforce the abdominal wall with a piece of mesh every time a stoma is made. While not considered a standard practice, one must envision that every patient with a stoma will ultimately develop a hernia at that site and therefore consideration of employing this technique must be entertained. Studies have shown cost-effectiveness in placing a mesh prophylactically in those patients requiring a permanent stoma.29 There have also been studies that suggest that incisional hernias are significantly more common in those patients with a concomitant parastomal hernia and as such there may be additional advantages in preventing parastomal hernia formation.30 Simple interventions such as restricting patient activity particularly heavy lifting in the postoperative period for one full year, combined with requiring patients to wear various support garments in lieu of regular underwear have shown some promise in reducing the risk of developing parastomal hernias as well as improving the quality of life for these patients.31 A recent randomized patient and third party assessor-blind study comparing 58 controls to 55 patients undergoing prophylactic sublay placement of non-cross-linked porcine-derived acellular dermal matrix at the time of permanent stoma construction showed similar safety and quality of life data from both groups but failed to show any advantage in reduction of parastomal hernia in the mesh group. This study combined both ileostomies and colostomies, however, and may have been limited by including such a small number of patients.32

Other studies, however, have shown some benefit with prophylactic mesh placement. A systematic review of three randomized control trials, three prospective observational series, and one retrospective study showed a parastomal hernia rate in the mesh group of 7.82% compared to 55% in the control group.33 Another meta-analysis and systematic review of three trials with 129 patients substantiated these results showing a hernia formation rate of 12.3% in the mesh group vs. 54.7% in those without mesh. They also demonstrated that if a parastomal hernia formed in the mesh group, those patients were less likely to require surgical intervention.34 Other studies have also supported the use of prophylactic mesh in the sublay position.35–37 The real issue at hand, however, is deciding which patients with a parastomal hernia need surgical repair especially since the incidence of recurrence can be as high as 50%. Clearly the mere presence of a parastomal hernia is not an indication for repair. Indications for repair of a parastomal hernia can be found in Table 2. The patient who presents with acute incarceration of bowel within a parastomal hernia will require urgent surgical intervention. Repair may be done with a midline incision with reduction of bowel contents and resection of compromised bowel if necessary along with repair of the hernia defect. This repair would be ideally done with a biologic mesh especially in the face of an infected operative field. Laparoscopic exploration and repair may be done if the surgeon is skilled in this technique although this may not be possible to do in the urgent setting. Fortunately, most parastomal hernias are repaired in the elective setting. Once the surgeon and the patient have decided to undergo elective repair of a parastomal hernia, the surgeon is then faced with the decision of which method of repair is best. Once again, if feasible, stoma reversal and repair of the abdominal wall defect with or without mesh would certainly be best for the patient. This scenario would of course eliminate the parastomal hernia altogether. The best method of parastomal hernia repair has been debated over the years. Early on, Thoralkson reported on his direct technique of parastomal hernia repair. In his original description, he advocated a direct suture repair of the hernia defect. While this seemed to address the immediate problem, the hernias frequently recurred often within weeks of the repair.38 Goligher advocated relocation of the stoma to the opposite side or another site. While this technique is certainly feasible and may be done with relative ease in some cases through the site of the current parastomal hernia, it does not address the issues that caused the hernia in the first place and oftentimes it may result in a recurrence of the hernia at the site of the previous ostomy and may also result in a new parastomal hernia at the site of the new stoma.39 The Sugarbaker technique of parastomal hernia repair has gained popularity due to its high success rate. This technique employs the use of a prosthetic mesh that is placed subfascially and closes the hernia defect while allowing an additional 10 cm of bowel within the abdominal cavity to be covered by the mesh in a “pocket like sleeve.” The author claims that the abdominal forces and tension placed on this mesh and the bowel do not allow for recurrence of the hernia.40,41 This technique while initially described as an open surgical procedure has also been adapted to a laparoscopic technique with excellent results. In addition, the laparoscopic technique also demonstrated concomitant hernias in many cases that may be addressed and had an overall recurrence rate of 6.6% in one study.42–44 Hansson and his colleagues performed a systematic review of 30 largely retrospective studies looking at parastomal hernia repair. They found that direct suture repairs resulted in higher recurrence rates than mesh repairs and that mesh repairs were associated with a recurrence rate between 6.9% and 17%. They also

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concluded that in the patients undergoing laparoscopic repair, the Sugarbaker technique was associated with a lower recurrence than the keyhole technique and that the overall infection rate with mesh repair was low.45 Another review article evaluated 27 articles comparing open parastomal repair with and without mesh reported substantially lower recurrences in the mesh repair group over the non-mesh groups (7.9–14.8% vs. 50%).46 Other repair techniques with mesh have now gained popularity especially with many of the newer biologic agents that are currently available. Fistulous disease at stoma site Peristomal fistulae can be a difficult issue to deal with as it may cause severe disability for the patient. This condition is often due to Crohn's disease. If the fistulae are in close proximity to the stoma and can be easily pouched with an appliance, then the patients should ideally be managed by a gastroenterologist with optimization of medications for Crohn's disease as well as a wellqualified enterostomal therapist. If this is not adequate therapy, then stoma revision should be considered. Preoperative studies should include endoscopy via the stoma as well as imaging studies to assess the extent of the inflammatory bowel disease in order to plan the surgery adequately. If the disease were limited to the segment of bowel of the stoma then resection and new stoma creation at a different site would be ideal. If there is more extensive disease present, then a formal laparotomy or laparoscopic approach may be needed to in order to resect the involved segment of bowel.

Conclusions The best method of treatment for stoma issues is prevention and construction of a well-formed stoma. However, despite welldone and well-planned surgery stoma complications still occur and may present in the early- or late-postoperative period. These complications cause a significant morbidity and mortality. If possible, the best method of treating a stoma complication is reversal of the stoma. If this is not feasible, then the surgeon must be aware of the indications and procedures for re-operative stoma surgery. These operations may be quite difficult since the surgeon is likely to encounter adhesions and other technical challenges. A multi-disciplinary approach is key and a qualified enterostomal therapist as well as skilled nursing is required to help patients overcome the many challenges of this type of surgery. References 1. Bryant TA. Case excision of a stricture of the descending colon through an incision made for a left lumbar colostomy: with remarks. Proc R Med Chir Soc. 1882;9:149–153. 2. Simmons KL, Smith JA, Bobb KA, et al. Adjustment to colostomy; stoma acceptance, stoma care self efficacy and interpersonal relationships. J Adv Nurs. 2007;60(6):627–635. 3. Chaudhri S, Brown L, Hassan I, et al. Preoperative intensive, community-based vs. traditional stoma education: a randomized, controlled trial. Dis Colon Rectum. 2005;48(3):504–509. 4. Person B, et al. The impact of preoperative stoma site marking on the incidence of complications, quality of life, and patient's independence. Dis Colon Rectum. 2012;55(7):783–787. 5. Hocevar B, Gray M. Intestinal diversion (colostomy or ileostomy) in patients with severe bowel dysfunction following spinal cord injury. J Wound Ostomy Continence Nurs. 2008;35(2):159–166. 6. Raza SD, Portin BA, Bernhoft WH. Umbilical colostomy: a better intestinal stoma. Dis Colon Rectum. 1977;20(3):223–230. 7. Fitzgerald PG, Lau GY, Cameron GS. Use of the umbilical site for temporary ostomy: review of 47 cases. J Pediatr Surg. 1989;24(10):973. 8. Pittman J, Rawl SM, Schmidt CM, et al. Demographic and clinical factors related to ostomy complications and quality of life in veterans with an ostomy. J Wound Ostomy Continence Nurs. 2008;35(5):493–503. 9. Danielsen AK. Life after stoma creation. Dan Med J. 2013;60(10).

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