- Email: [email protected]
Stoma Prolapse
Stoma Prolapse Rahila Essani, MD Stoma prolapse after formation of an ileostomy or colostomy is a late complication. Prolapse is less common than parastomal hernia. This article reviews the incidence of prolapse, technical factors related to the construction of the stoma that may influence the incidence, and different options for repair. Stoma prolapse affects 2%-47% of individuals with ostomies. Transverse loop colostomy has the highest rate of stoma prolapse, especially because of the large redundant distal loop. Loop ileostomies were thought to have a higher prevalence rate in the past, but recent literature shows only a 2% prolapse rate for ileostomy as opposed to 47% for loop colostomy. The role of extraperitoneal stoma construction is uncertain. Fascial fixation and size of the fascial defect have not been proven to affect the incidence of prolapse. Local care of stoma prolapse is possible, especially if stoma is not incarcerated; however, reversal of stoma is preferable if possible. The options of surgical repair include reversal, resection, revision, and relocation. Semin Colon Rectal Surg 23:13-16 © 2012 Elsevier Inc. All rights reserved.
D
espite substantial advances in surgical technique and enterostomal therapy, complications after stoma creation remain extremely common. The rate of stoma-specific complications in the literature varies widely, ranging from 10% to 70%.1-5 Stoma complications can be divided into early and late complications. Of the late complications, parastomal hernias are more common than stoma prolapse. Predisposing factors for development of stomal prolapse can be identified as patient factors, technique, and location of ostomy. This review describes the incidence of prolapse and assesses the technical factors related to the construction of the stoma that may influence this incidence. The different methods of repair have also been outlined.
Definition and Clinical Features A stomal prolapse occurs when the bowel intussuscepts or “telescopes” from the skin opening, becoming longer. It is commonly seen in transverse colostomies, with the distal bowel being typically affected; however, both limbs of a loop stoma may potentially prolapse. Stomal prolapse always presents as a stomal mass, but other symptoms include dislodgement of the appliance, bowel obstruction, and pain due to venous engorgement of the constricted, prolapsed seg-
Division of Colon and Rectal Surgery, Department of Surgery, West Penn Allegheny Health System, Pittsburgh, PA. Address reprint requests to: Rahila Essani, MD, Division of Colon and Rectal Surgery, Department of Surgery, West Penn Allegheny Health System, 320 East North Avenue, Pittsburgh, PA 15212-4756. E-mail: [email protected]
1043-1489/$-see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1053/j.scrs.2011.10.004
ment. In severe cases, patients may present with necrotic stomal prolapse due to incarceration. The frequency and consequences of symptoms are important because minimally symptomatic, infrequent prolapse does not require repair. Diagnosis is ascertained by history and physical examination. When examining the abdomen, the prolapse should be reduced and a finger placed in the stomal orifice. Diligent inspection and palpation of the peristomal skin will determine the presence or absence of a hernia. If a hernia is present, its presence and symptoms should dictate the type of repair performed. The prolapse will, by necessity, be repaired during the process. Stoma prolapse can be divided into 2 types: fixed and sliding.6 Fixed prolapse is defined as permanent eversion of a greater than desired segment of bowel. This occurs because too much bowel has been everted at the time of stoma construction. It is uncommon and rarely requires treatment. Sliding prolapse occurs when a long segment of ileum or colon protrudes through the stoma orifice intermittently, usually in response to Valsalva maneuver or increased abdominal pressure.6
Incidence Stomal prolapse may develop in any type of abdominal stoma.1 Reported rates of stoma prolapse vary from 2% to 47%.1,2,5,7-9 In a review of the Cook County Hospital registry, including 1616 stomas, Park et al1 found the overall incidence of stomal prolapse to be 2%. Londono-Schimmer et al7 reported a cumulative risk of 11.8% at 13 years. There are conflicting reports in the literature regarding prolapse rate of 13
R. Essani
14 ileostomies versus colostomies. In 1991, Fleshman et al9 reported that ileostomies have a higher incidence of prolapse as opposed to colostomies. However, more recent literature points to a higher prolapse rate with colostomies.8,10 Of the colostomies, transverse loop colostomies has the highest rate of prolapse.2
Etiology Development of hernia is influenced by both general patient factors and technical factors.
Patient Factors Prolapse is more common when a stoma is formed in an emergency setting, and also when the patient is obese, elderly, or has poor-quality fascial tissue.11 Leenen and Kuypers3 reported an overall higher stoma complication rate in patients with body mass index ⬎30. Obesity predisposes patients to stoma complication mainly due to thicker abdominal wall, with difficulty in maturing a stoma, as well as increased intra-abdominal pressure and weakened abdominal musculature. Elderly patients are at an increased risk because of poor nutritional status and weakened abdominal wall as well.
Technique Technical factors that have been implicated in stoma prolapse include loop ostomy, intraperitoneal colostomy formation, transverse loop colostomy, inadequate fixation of colon mesentery, and size of fascial defect. Ileostomy Versus Colostomy There are conflicting reports in the literature regarding rates of stoma prolapse when comparing ileostomies with colostomies. In a review of the United Ostomy Association Registry, Fleshman et al9 found the prolapse rates to be 3% for ileostomy and 2% for colostomy. However, registries tend to include predominantly individuals with permanent stomas, and therefore underestimate the risk of complications associated with temporary stomas. In contrast, Gooszen et al8 reported in a randomized study prolapse rates of 42% and 2% for colostomy and ileostomy, respectively. Furthermore, Harris et al10 have recently reported a higher prolapse rate with loop colostomy as compared with ileostomy (17.4% vs 2%, P ⫽ 0.001). End Versus Loop Ostomy Prolapse is more common with a transverse colostomy than with an end colostomy,2 but transverse colostomy prolapse can be managed conservatively because the stoma is usually temporary. The distal defunctionalized limb is usually responsible. The reasons for this are unclear, but a large stoma aperture, particularly when stomas are created in an emergency setting, and a poorly fixed, redundant, distal transverse colon have been implicated. Transverse loop colostomy is also often constructed in the right upper abdomen using the right-side transverse colon, which could leave a redundant transverse colon distal to the stoma. Incidence varies, but
rates of prolapse as high as 47% have been found in association with loop colostomies.2 When prolapse develops in colostomies, a parastomal hernia may also be present. It is essential that any concomitant hernia be identified before treatment, as the presence of a parastomal hernia will dictate the type of repair required. Allen-Mersh and Thomson12 identified a 50% incidence of hernia associated with colostomy prolapse, most commonly with end colostomies. Extraperitoneal Versus Intraperitoneal Colostomy Since Goligher13 reported extraperitoneal colostomy in 1958, surgeons usually believed extraperitoneal colostomy was better than intraperitoneal colostomy with regard to postoperative complications. In 1976, Whittaker and Golighter14 compared the extraperitoneal technique with intraperitoneal ileostomy, and they concluded that the extraperitoneal technique was less likely to prolapse. However, in a meta-analysis comparing extraperitoneal colostomy with the intraperitoneal technique, the chance of prolapse was not significantly reduced after extraperitoneal colostomy.15 Two studies in this meta-analysis reported on colostomy prolapse, with an overall reduction from 5.7% to 3.4% in favor of the extraperitoneal group, a difference that did not reach statistical significance (OR, 0.61; 95% CI, 0.20-1.82; P ⫽ 0.38).15 Inadequate Fixation of Colonic Mesentery Inadequate fixation of the colonic mesentery to the parietal peritoneum has been reported to be associated with the prolapse of the stoma.16,17 In contrast, mesenteric fixation and sitting through oblique muscles or rectus abdominus have not been the risk factors to develop stomal prolapse in ileostomy.18 Fixation of the colonic wall to the parietal peritoneum is carried out at a 2- or 4-cm distance from the stoma with this method. However, in the author’s experience, fixation of the colon or the colonic mesentery is not routinely carried out to facilitate colostomy closure, especially in temporary stoma. Fascial Defect Fascial fixation at initial operation has been proposed by some surgeons to prevent prolapse, whereas others advocate creating a small fascial defect, but neither is universally practiced. Law et al19 suggested that a smaller fascial defect created for the colostomy might decrease the incidence of stomal prolapse when compared with the previous report.8
Complications The prolapse itself can appear distressing for the patient and can cause numerous management issues, such as bleeding, ulceration, ischemia, and strangulation. However, ⬍10% of prolapse will be complicated by incarceration and/or strangulation. In these situations, treatment is urgent. In viable incarcerated stomas, table sugar may be sprinkled (large amounts) on the stoma to draw out water and decrease edema. This may allow for reduction of the prolapse with subsequent elective operation.20 If this is unsuccessful or if viability is in question, then it will be necessary to proceed with operation.
Stoma prolapse
Management Treatment options vary from temporary, conservative measures to surgical intervention. When prolapse or any stoma complication develops, the first determination should be whether the stoma can be reversed and intestinal continuity can be reestablished. If this can be done safely, it should be the first surgical option, even if performed earlier than previously planned. If intestinal continuity in not an option, then appropriate surgical repair should be undertaken.
Local Care Stoma prolapse is usually managed expectantly until the time of the definitive stomal closure. Prolapse may be difficult to reduce, especially if longstanding, because of edema of the prolapsed segment. Patients are advised to ensure the aperture size on their appliance is cut adequately to prevent constriction. A protective paste or petroleum jelly is often recommended to prevent trauma to the stoma. A protective shield or guard can also be worn to the same effect. The prolapse can occasionally be manipulated back, although it is vital that this procedure is carried out with a good deal of caution and expertise.
Surgical Repair The techniques for surgical repair fall into 4 categories: reversal, resection, revision, and relocation of the stoma. Reversal When a patient presents with a complicated stoma prolapse, every effort should be made to determine whether reversal is an option. However, if reversal is not an option either due to patient factors or oncological factors, the surgeon then should consider alternative methods of surgical repair. Resection Resection is most commonly used for end ostomy. Resection simply involves mucocutaneous disconnection; care should be taken to prevent creating an oversized skin defect, eversion of the prolapsed segment, resection of any exteriorized bowel, and recreation of the stoma. This can be achieved using a stapling device; there are various techniques described in recent literature using a linear, circular, or contour stapler.21-23 Revision Revision is most appropriate for prolapse of the distal limb of a transverse loop colostomy. In this case, through peristomal skin incision, the distal limb is dissected free and separated from the proximal limb. The open end is then closed and returned to the abdominal cavity. The fascial and skin defects are then tailored to an appropriate size, and an end colostomy is created. Care should be taken to ensure proper orientation of the proximal and distal limbs, as dropping the proximal, functional end of a transverse colostomy into the peritoneal cavity will have predictable, devastating consequences.6 Zinkin and Rosin24 described a modification of an old procedure called “button colopexy” for patients who are not candidates for extensive revision. This procedure can be per-
15 formed on an outpatient basis. It is performed by pressing the proximal and distal loop of the bowel against the anterior abdominal wall by a finger inserted in the lumen, and then securing each loop against the abdominal wall with large nonabsorbable sutures tied over a button. Another option for transverse colostomy prolapse in high-risk patients is dividing the loop colostomy into 2 limbs. The prolapsing proximal or distal colon limb is dissected free, the redundant tip is resected, and a new end colostomy is fashioned with a long Hartmann pouch or a small mucous fistula.25 Relocation Relocation of a stoma to a new position on the abdominal wall may be achieved both with and without formal laparotomy. This approach is useful if the current stoma position is unsatisfactory. Possible relocation sites may be limited if the patient has had multiple operations.
Conclusions Stoma prolapse is more common with loop ostomies, and of these, transverse loop colostomy has the highest rate of prolapse. There are patient and technique factors associated with stoma prolapse. When possible, reversal of a stoma should be attempted first. Local care is possible, but cosmetic effects of prolapse can be distressing for the patient, along with ulceration and bleeding. Surgical repair of prolapse can be done locally and seems to work the best.
References 1. Park JJ, del Pino A, Orsay CP, et al: Stoma complications: The Cook County Hospital experience. Dis Colon Rectum 42:1575-1580, 1999 2. Cheung MT: Complications of an abdominal stoma: An analysis of 322 stomas. Aust N Z J Surg 65:808-811, 1995 3. Leenen LP, Kuypers JH: Some factors influencing the outcome of stoma surgery. Dis Colon Rectum 32:500-504, 1989 4. Duchesne JC, Wang YZ, Weintraub SL, et al: Stoma complications: A multivariate analysis. Am Surg 68:961-966, 2002 5. Arumugam PJ, Bevan L, Macdonald L, et al: A prospective audit of stomas—Analysis of risk factors and complications and their management. Colorectal Dis 5:49-52, 2003 6. Gordon PH, Nivatvongs S: Intestinal stomas, in Principles and Practice of Surgery for the Colon, Rectum and Anus, 3rd ed. New York, NY, Informa Healthcase, 2006, pp 1053-1054 7. Londono-Schimmer EE, Leong AP, Phillips RK: Life table analysis of stomal complications following colostomy. Dis Colon Rectum 37:916920, 1994 8. Gooszen AW, Geelkerken RH, Hermans J, et al: Temporary decompression after colorectal surgery: Randomized comparison of loop ileostomy and loop colostomy. Br J Surg 85:76-79, 1998 9. Fleshman JW, Lewis MG: Complications and quality of life after stoma surgery: A review of 16,470 patients in the UOA data registry. Semin Colon Rect Surg 2:66-72, 1991 10. Harris DA, Egbeare D, Jones S, et al: Complications and mortality following stoma formation. Ann R Coll Surg Engl 87:427-431, 2005 11. Black P: Managing physical postoperative stoma complications. Br J Nurs 18:S4-S10, 2009 12. Allen-Mersh TG, Thomson JP: Surgical treatment of colostomy complications. Br J Surg 75:416-418, 1988 13. Goligher JC: Extraperitoneal colostomy or ileostomy. Br J Surg 46:97103, 1958 14. Whittaker M, Goligher JC: A comparison of the results of extraperitoneal and intraperitoneal techniques for construction of terminal iliac colostomies. Dis Colon Rectum 19:342-344, 1976
R. Essani
16 15. Lian L, Wu XR, He XS, et al: Extraperitoneal vs. intraperitoneal route for permanent colostomy: A meta-analysis of 1,071 patients. Int J Colorectal Dis (in press) 16. Doberneck RC: Revision and closure of the colostomy. Surg Clin North Am 71:193-201, 1991 17. Mäkelä JT, Turku PH, Laitinen ST: Analysis of late stomal complications following ostomy surgery. Ann Chir Gynaecol 86:305-310, 1997 18. Leong AP, Londono-Shimmer EE, Phillips RK: Life-table analysis of stomal complications following ileostomy. Br J Surg 81:727-729, 1994 19. Law WL, Chu KW, Choi HK: Randomized clinical trial comparing loop ileostomy and loop transverse colostomy for faecal diversion following total mesorectal excision. Br J Surg 89:704-708, 2002 20. Coburn WM III, Russell MA, Hofstetter WL: Sucrose as an aid to man-
21.
22.
23.
24. 25.
ual reduction of incarcerated rectal prolapse. Ann Emerg Med 30:347-349, 1997 Hata F, Kitagawa S, Nishimori H, et al: A novel, easy, and safe technique to repair a stoma prolapse using a surgical stapling device. Dig Surg 22:306-310, 2005 Maeda K, Maruta M, Utsumi T, et al: Local correction of a transverse loop colostomy prolapse by means of a stapler device. Tech Coloproctol 8:45-46, 2004 Tepetes K, Spyridakis M, Hatzitheofilou C: Local treatment of a loop colostomy prolapse with a linear stapler. Tech Coloproctol 9:156-158, 2005 Zinkin LD, Rosin JD: Button colopexy for colostomy prolapse. Surg Gynecol Obstet 152:89-90, 1981 Agrez MV: Revision of transverse colostomy prolapse without stoma resiting. Ann R Coll Surg Engl 79:383-384, 1997
D
espite substantial advances in surgical technique and enterostomal therapy, complications after stoma creation remain extremely common. The rate of stoma-specific complications in the literature varies widely, ranging from 10% to 70%.1-5 Stoma complications can be divided into early and late complications. Of the late complications, parastomal hernias are more common than stoma prolapse. Predisposing factors for development of stomal prolapse can be identified as patient factors, technique, and location of ostomy. This review describes the incidence of prolapse and assesses the technical factors related to the construction of the stoma that may influence this incidence. The different methods of repair have also been outlined.
Definition and Clinical Features A stomal prolapse occurs when the bowel intussuscepts or “telescopes” from the skin opening, becoming longer. It is commonly seen in transverse colostomies, with the distal bowel being typically affected; however, both limbs of a loop stoma may potentially prolapse. Stomal prolapse always presents as a stomal mass, but other symptoms include dislodgement of the appliance, bowel obstruction, and pain due to venous engorgement of the constricted, prolapsed seg-
Division of Colon and Rectal Surgery, Department of Surgery, West Penn Allegheny Health System, Pittsburgh, PA. Address reprint requests to: Rahila Essani, MD, Division of Colon and Rectal Surgery, Department of Surgery, West Penn Allegheny Health System, 320 East North Avenue, Pittsburgh, PA 15212-4756. E-mail: [email protected]
1043-1489/$-see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1053/j.scrs.2011.10.004
ment. In severe cases, patients may present with necrotic stomal prolapse due to incarceration. The frequency and consequences of symptoms are important because minimally symptomatic, infrequent prolapse does not require repair. Diagnosis is ascertained by history and physical examination. When examining the abdomen, the prolapse should be reduced and a finger placed in the stomal orifice. Diligent inspection and palpation of the peristomal skin will determine the presence or absence of a hernia. If a hernia is present, its presence and symptoms should dictate the type of repair performed. The prolapse will, by necessity, be repaired during the process. Stoma prolapse can be divided into 2 types: fixed and sliding.6 Fixed prolapse is defined as permanent eversion of a greater than desired segment of bowel. This occurs because too much bowel has been everted at the time of stoma construction. It is uncommon and rarely requires treatment. Sliding prolapse occurs when a long segment of ileum or colon protrudes through the stoma orifice intermittently, usually in response to Valsalva maneuver or increased abdominal pressure.6
Incidence Stomal prolapse may develop in any type of abdominal stoma.1 Reported rates of stoma prolapse vary from 2% to 47%.1,2,5,7-9 In a review of the Cook County Hospital registry, including 1616 stomas, Park et al1 found the overall incidence of stomal prolapse to be 2%. Londono-Schimmer et al7 reported a cumulative risk of 11.8% at 13 years. There are conflicting reports in the literature regarding prolapse rate of 13
R. Essani
14 ileostomies versus colostomies. In 1991, Fleshman et al9 reported that ileostomies have a higher incidence of prolapse as opposed to colostomies. However, more recent literature points to a higher prolapse rate with colostomies.8,10 Of the colostomies, transverse loop colostomies has the highest rate of prolapse.2
Etiology Development of hernia is influenced by both general patient factors and technical factors.
Patient Factors Prolapse is more common when a stoma is formed in an emergency setting, and also when the patient is obese, elderly, or has poor-quality fascial tissue.11 Leenen and Kuypers3 reported an overall higher stoma complication rate in patients with body mass index ⬎30. Obesity predisposes patients to stoma complication mainly due to thicker abdominal wall, with difficulty in maturing a stoma, as well as increased intra-abdominal pressure and weakened abdominal musculature. Elderly patients are at an increased risk because of poor nutritional status and weakened abdominal wall as well.
Technique Technical factors that have been implicated in stoma prolapse include loop ostomy, intraperitoneal colostomy formation, transverse loop colostomy, inadequate fixation of colon mesentery, and size of fascial defect. Ileostomy Versus Colostomy There are conflicting reports in the literature regarding rates of stoma prolapse when comparing ileostomies with colostomies. In a review of the United Ostomy Association Registry, Fleshman et al9 found the prolapse rates to be 3% for ileostomy and 2% for colostomy. However, registries tend to include predominantly individuals with permanent stomas, and therefore underestimate the risk of complications associated with temporary stomas. In contrast, Gooszen et al8 reported in a randomized study prolapse rates of 42% and 2% for colostomy and ileostomy, respectively. Furthermore, Harris et al10 have recently reported a higher prolapse rate with loop colostomy as compared with ileostomy (17.4% vs 2%, P ⫽ 0.001). End Versus Loop Ostomy Prolapse is more common with a transverse colostomy than with an end colostomy,2 but transverse colostomy prolapse can be managed conservatively because the stoma is usually temporary. The distal defunctionalized limb is usually responsible. The reasons for this are unclear, but a large stoma aperture, particularly when stomas are created in an emergency setting, and a poorly fixed, redundant, distal transverse colon have been implicated. Transverse loop colostomy is also often constructed in the right upper abdomen using the right-side transverse colon, which could leave a redundant transverse colon distal to the stoma. Incidence varies, but
rates of prolapse as high as 47% have been found in association with loop colostomies.2 When prolapse develops in colostomies, a parastomal hernia may also be present. It is essential that any concomitant hernia be identified before treatment, as the presence of a parastomal hernia will dictate the type of repair required. Allen-Mersh and Thomson12 identified a 50% incidence of hernia associated with colostomy prolapse, most commonly with end colostomies. Extraperitoneal Versus Intraperitoneal Colostomy Since Goligher13 reported extraperitoneal colostomy in 1958, surgeons usually believed extraperitoneal colostomy was better than intraperitoneal colostomy with regard to postoperative complications. In 1976, Whittaker and Golighter14 compared the extraperitoneal technique with intraperitoneal ileostomy, and they concluded that the extraperitoneal technique was less likely to prolapse. However, in a meta-analysis comparing extraperitoneal colostomy with the intraperitoneal technique, the chance of prolapse was not significantly reduced after extraperitoneal colostomy.15 Two studies in this meta-analysis reported on colostomy prolapse, with an overall reduction from 5.7% to 3.4% in favor of the extraperitoneal group, a difference that did not reach statistical significance (OR, 0.61; 95% CI, 0.20-1.82; P ⫽ 0.38).15 Inadequate Fixation of Colonic Mesentery Inadequate fixation of the colonic mesentery to the parietal peritoneum has been reported to be associated with the prolapse of the stoma.16,17 In contrast, mesenteric fixation and sitting through oblique muscles or rectus abdominus have not been the risk factors to develop stomal prolapse in ileostomy.18 Fixation of the colonic wall to the parietal peritoneum is carried out at a 2- or 4-cm distance from the stoma with this method. However, in the author’s experience, fixation of the colon or the colonic mesentery is not routinely carried out to facilitate colostomy closure, especially in temporary stoma. Fascial Defect Fascial fixation at initial operation has been proposed by some surgeons to prevent prolapse, whereas others advocate creating a small fascial defect, but neither is universally practiced. Law et al19 suggested that a smaller fascial defect created for the colostomy might decrease the incidence of stomal prolapse when compared with the previous report.8
Complications The prolapse itself can appear distressing for the patient and can cause numerous management issues, such as bleeding, ulceration, ischemia, and strangulation. However, ⬍10% of prolapse will be complicated by incarceration and/or strangulation. In these situations, treatment is urgent. In viable incarcerated stomas, table sugar may be sprinkled (large amounts) on the stoma to draw out water and decrease edema. This may allow for reduction of the prolapse with subsequent elective operation.20 If this is unsuccessful or if viability is in question, then it will be necessary to proceed with operation.
Stoma prolapse
Management Treatment options vary from temporary, conservative measures to surgical intervention. When prolapse or any stoma complication develops, the first determination should be whether the stoma can be reversed and intestinal continuity can be reestablished. If this can be done safely, it should be the first surgical option, even if performed earlier than previously planned. If intestinal continuity in not an option, then appropriate surgical repair should be undertaken.
Local Care Stoma prolapse is usually managed expectantly until the time of the definitive stomal closure. Prolapse may be difficult to reduce, especially if longstanding, because of edema of the prolapsed segment. Patients are advised to ensure the aperture size on their appliance is cut adequately to prevent constriction. A protective paste or petroleum jelly is often recommended to prevent trauma to the stoma. A protective shield or guard can also be worn to the same effect. The prolapse can occasionally be manipulated back, although it is vital that this procedure is carried out with a good deal of caution and expertise.
Surgical Repair The techniques for surgical repair fall into 4 categories: reversal, resection, revision, and relocation of the stoma. Reversal When a patient presents with a complicated stoma prolapse, every effort should be made to determine whether reversal is an option. However, if reversal is not an option either due to patient factors or oncological factors, the surgeon then should consider alternative methods of surgical repair. Resection Resection is most commonly used for end ostomy. Resection simply involves mucocutaneous disconnection; care should be taken to prevent creating an oversized skin defect, eversion of the prolapsed segment, resection of any exteriorized bowel, and recreation of the stoma. This can be achieved using a stapling device; there are various techniques described in recent literature using a linear, circular, or contour stapler.21-23 Revision Revision is most appropriate for prolapse of the distal limb of a transverse loop colostomy. In this case, through peristomal skin incision, the distal limb is dissected free and separated from the proximal limb. The open end is then closed and returned to the abdominal cavity. The fascial and skin defects are then tailored to an appropriate size, and an end colostomy is created. Care should be taken to ensure proper orientation of the proximal and distal limbs, as dropping the proximal, functional end of a transverse colostomy into the peritoneal cavity will have predictable, devastating consequences.6 Zinkin and Rosin24 described a modification of an old procedure called “button colopexy” for patients who are not candidates for extensive revision. This procedure can be per-
15 formed on an outpatient basis. It is performed by pressing the proximal and distal loop of the bowel against the anterior abdominal wall by a finger inserted in the lumen, and then securing each loop against the abdominal wall with large nonabsorbable sutures tied over a button. Another option for transverse colostomy prolapse in high-risk patients is dividing the loop colostomy into 2 limbs. The prolapsing proximal or distal colon limb is dissected free, the redundant tip is resected, and a new end colostomy is fashioned with a long Hartmann pouch or a small mucous fistula.25 Relocation Relocation of a stoma to a new position on the abdominal wall may be achieved both with and without formal laparotomy. This approach is useful if the current stoma position is unsatisfactory. Possible relocation sites may be limited if the patient has had multiple operations.
Conclusions Stoma prolapse is more common with loop ostomies, and of these, transverse loop colostomy has the highest rate of prolapse. There are patient and technique factors associated with stoma prolapse. When possible, reversal of a stoma should be attempted first. Local care is possible, but cosmetic effects of prolapse can be distressing for the patient, along with ulceration and bleeding. Surgical repair of prolapse can be done locally and seems to work the best.
References 1. Park JJ, del Pino A, Orsay CP, et al: Stoma complications: The Cook County Hospital experience. Dis Colon Rectum 42:1575-1580, 1999 2. Cheung MT: Complications of an abdominal stoma: An analysis of 322 stomas. Aust N Z J Surg 65:808-811, 1995 3. Leenen LP, Kuypers JH: Some factors influencing the outcome of stoma surgery. Dis Colon Rectum 32:500-504, 1989 4. Duchesne JC, Wang YZ, Weintraub SL, et al: Stoma complications: A multivariate analysis. Am Surg 68:961-966, 2002 5. Arumugam PJ, Bevan L, Macdonald L, et al: A prospective audit of stomas—Analysis of risk factors and complications and their management. Colorectal Dis 5:49-52, 2003 6. Gordon PH, Nivatvongs S: Intestinal stomas, in Principles and Practice of Surgery for the Colon, Rectum and Anus, 3rd ed. New York, NY, Informa Healthcase, 2006, pp 1053-1054 7. Londono-Schimmer EE, Leong AP, Phillips RK: Life table analysis of stomal complications following colostomy. Dis Colon Rectum 37:916920, 1994 8. Gooszen AW, Geelkerken RH, Hermans J, et al: Temporary decompression after colorectal surgery: Randomized comparison of loop ileostomy and loop colostomy. Br J Surg 85:76-79, 1998 9. Fleshman JW, Lewis MG: Complications and quality of life after stoma surgery: A review of 16,470 patients in the UOA data registry. Semin Colon Rect Surg 2:66-72, 1991 10. Harris DA, Egbeare D, Jones S, et al: Complications and mortality following stoma formation. Ann R Coll Surg Engl 87:427-431, 2005 11. Black P: Managing physical postoperative stoma complications. Br J Nurs 18:S4-S10, 2009 12. Allen-Mersh TG, Thomson JP: Surgical treatment of colostomy complications. Br J Surg 75:416-418, 1988 13. Goligher JC: Extraperitoneal colostomy or ileostomy. Br J Surg 46:97103, 1958 14. Whittaker M, Goligher JC: A comparison of the results of extraperitoneal and intraperitoneal techniques for construction of terminal iliac colostomies. Dis Colon Rectum 19:342-344, 1976
R. Essani
16 15. Lian L, Wu XR, He XS, et al: Extraperitoneal vs. intraperitoneal route for permanent colostomy: A meta-analysis of 1,071 patients. Int J Colorectal Dis (in press) 16. Doberneck RC: Revision and closure of the colostomy. Surg Clin North Am 71:193-201, 1991 17. Mäkelä JT, Turku PH, Laitinen ST: Analysis of late stomal complications following ostomy surgery. Ann Chir Gynaecol 86:305-310, 1997 18. Leong AP, Londono-Shimmer EE, Phillips RK: Life-table analysis of stomal complications following ileostomy. Br J Surg 81:727-729, 1994 19. Law WL, Chu KW, Choi HK: Randomized clinical trial comparing loop ileostomy and loop transverse colostomy for faecal diversion following total mesorectal excision. Br J Surg 89:704-708, 2002 20. Coburn WM III, Russell MA, Hofstetter WL: Sucrose as an aid to man-
21.
22.
23.
24. 25.
ual reduction of incarcerated rectal prolapse. Ann Emerg Med 30:347-349, 1997 Hata F, Kitagawa S, Nishimori H, et al: A novel, easy, and safe technique to repair a stoma prolapse using a surgical stapling device. Dig Surg 22:306-310, 2005 Maeda K, Maruta M, Utsumi T, et al: Local correction of a transverse loop colostomy prolapse by means of a stapler device. Tech Coloproctol 8:45-46, 2004 Tepetes K, Spyridakis M, Hatzitheofilou C: Local treatment of a loop colostomy prolapse with a linear stapler. Tech Coloproctol 9:156-158, 2005 Zinkin LD, Rosin JD: Button colopexy for colostomy prolapse. Surg Gynecol Obstet 152:89-90, 1981 Agrez MV: Revision of transverse colostomy prolapse without stoma resiting. Ann R Coll Surg Engl 79:383-384, 1997