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 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 156-161

An appraisal of intestinal stomas at a tertiary hospital in South Western, Nigeria


Department of Surgery, General Surgery Unit, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Surulere, Lagos, Nigeria

Date of Web Publication1-Nov-2018

Correspondence Address:
Dr. Adedapo Olumide Osinowo
Department of Surgery, General Surgery Unit, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Surulere, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_23_18

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  Abstract 


Background: Intestinal stomas are frequently constructed as part of abdominal surgeries in our center especially for colorectal cancer (CRC). There has been no previous documentation of the experience at our tertiary center. Objective: The objective of this study is to document the indications, types, and complications of intestinal stomas in our center to make necessary recommendations. Patients and Methods: This was a retrospective descriptive study of all patients who had intestinal stomas constructed during a 4-year period. The demographic data of patients, the information on indications, types, and complications of intestinal stomas were obtained from theatre records, and case notes. Data were analyzed using SPSS version 23. Results: A total of 85 intestinal stomas were constructed during the study period. Forty-four (51.8%) were males and 41 (48.2%) females with a male-female ratio of 1.07 to 1. The common indications were large bowel obstruction due to CRC (21.2%), anastomotic dehiscence (15.3%), and rectal/sigmoid injuries (12.7%). The intestinal stomas constructed in patients included defunctioning stomas (61.2%), decompression stomas (31.8%), permanent end colostomy following abdominoperineal resection of rectum for cancer (3.5%), and palliative sigmoid colostomy (3.5%) in patients with anal cancer. Sigmoid loop was the commonest stoma, constructed in 26 patients (30.6%). The common complications were peristoma skin excoriation (53.5%), retraction (11.6%) pouch leakage (9.3%), and prolapse (9.3%). Conclusion: Malignant intestinal obstruction due to CRC was the most common indication for stoma construction at our institution. Consequently, massive health education campaign to ensure early presentation of CRC is needed to reduce the need for stoma creation.

Keywords: Colorectal cancer, colostomy, ileostomy and colorectal cancer, ileostomy in typhoid perforation, intestinal stomas and colorectal cancer


How to cite this article:
Osinowo AO, Balogun OS, Olajide TO, Lawal OA, Adesanya AA. An appraisal of intestinal stomas at a tertiary hospital in South Western, Nigeria. J Clin Sci 2018;15:156-61

How to cite this URL:
Osinowo AO, Balogun OS, Olajide TO, Lawal OA, Adesanya AA. An appraisal of intestinal stomas at a tertiary hospital in South Western, Nigeria. J Clin Sci [serial online] 2018 [cited 2022 Jun 27];15:156-61. Available from: https://www.jcsjournal.org/text.asp?2018/15/3/156/244743




  Introduction Top


An intestinal stoma is a purposeful anastomosis between a segment of the gastrointestinal tract and the skin of the anterior abdominal wall.[1] Many a time, this addendum to a major surgery is a lifesaving procedure to reduce morbidity and mortality associated with the disease process. Despite being a lifesaving intervention, stomas are associated with significant complications, social isolation, and reduction in quality of life.[2] Well-known complications of stomas include necrosis, retraction, parastomal hernias, skin excoriation, fistula, diarrhea, soiling, pouch leakage, odor, and psychosocial complications (social restrictions).

Intestinal stomas are usually created to serve a temporary defunctioning role: when restoration of gastrointestinal continuity is not deemed safe or contraindicated, for resolution of intra-abdominal sepsis, to facilitate the healing of perianal sepsis and to protect low anastomosis below the peritoneal reflection (<5–7 cm from the anal verge).[3],[4] Furthermore, stomas are created for decompression of large bowel obstruction and a permanent end stoma in abdominoperineal resection (APR) of the rectum. The clinical scenario often dictates the segment of the bowel selected, temporary or permanent, the type of intestinal stoma and its external location in the anterior abdominal wall. The decisions to create stomas are usually made after judicious analysis of the intraoperative findings in emergencies.

There appears to be a recent increase in the number of stomas created especially for emergency colorectal cancer (CRC) surgeries in our center, and hence, the need to document the varied indications and associated stoma complications. Moreover, a number of patients had a hitherto uncommon stoma; an ileostomy in this center. An ileostomy was first advocated in ulcerative colitis in 1912 but was not widely used until Brooke demonstrated his everted ileostomy in 1952.[5] The average output for an ileostomy ranges from 500 to 1300 mL a day. During the early postoperative period and episodes of gastroenteritis, daily output can be 1800 mL or even higher.[6] Ileostomies were hitherto, unpopular in this center because it was assumed that patients would not be able tolerate ileostomy fluid losses and its associated electrolyte derangements in a tropical environment. All ileostomy patients were instructed to consume 1.5 L of oral rehydration fluid (balanced salt solution) per day. From the early 1980s, in Western countries, with the spread of sphincter-saving procedures for rectal cancer, there has been a dramatic increase of the number of ileostomy constructions and loop ileostomy has become the most popular technique to divert fecal stream.

In Western countries, there has been a decline in the number of intestinal stomas; however, in our center, there appears to be an increase, and there are no specialized enterostomal nurses. Preoperative counseling by an ostomy nurse specialist improves postoperative quality of life by helping patients psychologically adapt to the significant lifestyle changes associated with living with a stoma. Furthermore, the specialized nurses provide practical aspects (type of stoma bags), reassurance that life can continue as normal, and how to change bags and how to detect and manage common problems. This counseling is usually provided in a nonstructured manner by the surgeons or nurses in our center, and this is mediocre.


  Patients and Methods Top


This is a retrospective, descriptive study of all intestinal stomas performed by the General surgery unit of the Tertiary center between January 2013 and 2017. The demographic data of patients, the information on indications, types, and complications of intestinal stomas were obtained from theater records and case notes. The American Society of Anesthesiologist (ASA) Score and Mannheim Peritonitis Index (MPI) were also recorded. The penetrating abdominal trauma index (PATI) score was calculated as by Moore et al. for abdominal gunshot wounds.[7]

Statistical analysis was done using SPSS Statistics for Windows, Version 23.0 Armonk, NY: IBM Corp. to calculate means, standard deviation, and percentages for quantitative variables and frequencies for categorical data.


  Results Top


Eighty-five patients who had intestinal stomas during January 2013–2017 were included in the study. [Table 1] showed the characteristics of patients. About 44 (51.8%) were male and 41 (48.2%) female with a male-female ratio of 1.07 to 1. The mean age was 47.22 ± 20.4 years with a range of 14–104 years. Nearly 65 stomas (76.5%) were constructed during emergency surgery and 20 stomas (23.5%) selectively. About 77 stomas (90.6%) were temporary while 8 stomas (9.4%) were permanent (all malignant conditions). [Table 1] also revealed that 39 stomas (45.9%) had been reversed while 20 patients (23.5%) died before reversal, 10 patients (11.8%) on chemotherapy, 8 patients awaiting closure, and there were 8 (9.4%) permanent stomas.
Table 1: Patient characteristics (n=85)

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The indications for intestinal stomas are shown in [Table 2], and it revealed defunctioning colostomy was the most common indication, and the least common was a permanent end colostomy in APR of the rectum.
Table 2: Indications for Intestinal stomas (n=85)

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[Table 3] showed the types of intestinal stomas, with the most common stoma being sigmoid loop colostomy in 26 patients (35.2%), Hartmann's colostomy in 25 patients (30.9%), and the least common was a cecostomy 1 patient (0.10%). One patient had a laparoscopically assisted trephine defunctioning sigmoid loop as part of the repair of a benign rectovaginal fistula. Twelve ileostomies (14.1%) were constructed during the reviewed period, and the varied indications are shown in [Table 4].
Table 3: Type of stomas (n=85)

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Table 4: Case Series of Patients with Defunctioning Ileostomies

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The complications associated with stomas are shown in [Table 5], and it revealed peristoma skin problems (53.5%) as the most common complication. Other complications were retraction (11.6%), pouch leakage (9.3%), prolapse (9.3%), stenosis (2.3%), fistula (2.3%), suprafascial partial necrosis (2.3%) full thickness infrafascial necrosis (2.3%), paracolostomy hernia (2.3%) dehydration (2.3%), and stoma bleeding (2.3%). Stoma prolapse was seen in 4 patients (9.3%) with transverse loop colostomies. It caused a great deal of distress, as it was unsightly and alarming to the patients and relatives. Patients presented to the emergency room on account of the prolapse. One patient required surgical intervention on account of this complication because it was associated with paracolostomy herniation of the stomach and omentum. A double-barrel colostomy and narrowing of the defect in the anterior abdominal wall were the procedures carried out. Similarly, the patient with infrafascial necrosis of the colostomy also had refashioning. Stoma bleeding occurred in a patient with bleeding diathesis, and it stopped following the correction of the coagulopathy.
Table 5: Complications of intestinal stomas (n=43)

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  Discussion Top


Intestinal stomas and fecal diversion are frequently a critical component of surgical intervention for diseases of the bowel and in management of perianal wounds in our center. The most common stoma in our center was a sigmoid loop (%) and the least common was a cecostomy. This is in contradistinction to what obtains in other environments where surgeons considered loop ileostomy an effective form of fecal diversion. In this center, 12 ileostomies (14.1%) were constructed as a matter of necessity in exigent circumstances. However, in a study done in India by Safirullah et al.,[8] loop ileostomy was the most common stoma (43%) formed followed by loop colostomy (17.4%).[8] Ileostomy accounted for 70% of stomas in another study by Ghazi et al. followed by a colostomy in 30%.[9]

Defunctioning stomas were constructed in 52 patients, and the most common indication was for the management of anastomotic leak (AL) following CRC surgery. Nearly 13 stomas (24.5%) were constructed in the management of ALs. AL after colorectal surgery is a highly undesirable event that can lead to excess mortality, reoperative surgery, and increased length of stay. A subgroup analysis of these defunctioning stomas for ALs revealed 7 stomas were constructed during relaparotomy following initial emergency colorectal surgery for the left colonic obstruction. The initial surgery was segmental resection with on-table lavage and primary anastomosis that had been championed since 1967. Besides, primary anastomosis has been recently reconsidered as appropriate for left-sided lesions, particularly if the proximal colon is not severely dilated, and the patient is deemed to be “good risk.”[10],[11],[12] The cause of the AL in these circumstances is most likely the emergent nature of the colectomies in all the patients. In a prospective study of 9192 patients was done in 64 Michigan hospitals, multivariate analysis revealed that the following factors were significantly associated with a leak: male sex, obesity, chronic immunosuppression, length of operation, urgent surgery, smoking, and low platelet count (P < 0.001 for all).[13] Emergency is predictably, associated with higher AL rates compared with elective practice. Furthermore, five defunctioning stomas (transverse loop) were constructed to protect distal colorectal anastomosis in low anterior resection. In other climes, temporary loop ileostomy is preferred over colostomy for protecting a distal colorectal anastomosis, or coloanal anastomosis following a sphincter-saving rectal resection.[14],[15],[16],[17],[18] The defunctioning protective stomas (transverse loop) in two patients were constructed on account of preoperative hypoalbuminemia, anemia, and weight loss to reduce the morbidity of a possible leak. In a study done by Iancu et al.,[19] a serum protein level lower than 5.5 g/dl and serum hemoglobin lower than 9.4 g/dl were considered as host-related predictive markers for AL in large bowel resections for cancer. The use of a defunctioning stoma in low anterior resection has been considered to decrease the leakage rate and its fatal consequences by keeping the distal anastomosis relative “clean” and reducing the intraluminal pressure of the bowel.[20],[21] Moreover, a protective stoma can mitigate its inherent consequences.[22] Nonetheless, the value of a protective stoma has been the subject of controversy for many years. Other defunctioning stomas were constructed for the indications shown in [Table 3] to promote quiescence of the disease process in intra-abdominal sepsis, healing of perianal sepsis (Fournier's gangrene) and gluteal ulcers, and closure of nonmalignant fistulas.

Similar to what obtains in developed countries, CRC with or without obstruction was the most common indication for stoma formation as 38 (42.4%) stomas were constructed during the management of patients with CRC. A subgroup analysis of stomas for relieving CRC obstruction revealed that four cases were done for unresectable tumors with liver metastasis. This is a reflection of the late presentation of cases of CRC in this environment. In a study carried by Adesanya et al.,[23] nonresectional surgery was offered to 28% of the cases. The incidence of CRC in Nigeria is 3.4/100,000 compared with 35.8/100,000 each year in the USA.[24] However; the outcome of treatment for CRC in Nigeria still remains poor due largely to late presentation, ignorance, poverty, and superstition.[25] According to Adesanya et al.,[23] 50% of CRC cases occur in the rectum in Nigeria, affecting the distal one-third of rectum in two-thirds of cases. Three patients had APR of the rectum and permanent end colostomy following chemoradiation and neoadjuvant chemotherapy.

Twelve defunctioning ileostomies, a hitherto uncommon stoma in this center, were constructed during the period in review. All were fashioned in emergency settings and considered the most prudent option in the management of these patients. In all these circumstances, the ASA or MPI scores and PATI scores in cases of abdominal gunshot wounds precluded safe anastomosis. [Table 4] revealed the indications, complications, and outcome of the ileostomy cases. Ileostomy was constructed in the two patients with penetrating abdominal trauma secondary to gunshots because they had transection and devascularized injuries to the right colon (Grade V) in addition to other intra-abdominal injuries. The operative strategy adhered to damage control principles as the patients had a stapled resection of the devascularized right colon and exteriorization of the distal ileum as an end ileostomy in a timely efficient manner. The patients met more than three exclusion criteria for primary repair as defined by Stone and Fabian: presence of shock at admission to the hospital (blood pressure <90 mmHg); injury of two or more abdominal organs; >750 ml of blood in the peritoneal cavity; and presence of peritonitis.[26] For the patients with complications of typhoid perforation ileostomies were constructed under the following circumstances: reoperation for postoperative high-output enterocutaneous fistula with tertiary peritonitis and primary ileostomy in American Society of Anaesthesiologists (ASA) class IVE patient. This allowed for the resolution of intra-abdominal sepsis and ileus and consequently early commencement of enteral nutrition that will hasten the recovery of the patient.[27] Primary ileostomy is not customarily the treatment for typhoid perforation. However, in the setting of jaundice, hypoalbuminemia, ASA IVE and leathery edematous bowel, a defunctioning protective ileostomy is a lifesaving procedure.[28] Apart from reducing mortality, it plays a vital role in decreasing the incidence of complications such as fecal fistula.[28]

Stoma-related complications were common in this review, and it revealed pouch leakage and skin excoriation as the most common complication that was noted in 21 patients. peristoma skin complications affected about one-third of the patients and this could easily have been minimized by use of appropriate stoma bags and judicious use of barrier creams, gels, lotions sprays, and wipes in peristomal skin care. In addition, these peristoma skin complications can be minimized if there were specialized enterostomal nurses attending to patients perioperatively and availability of affordable stoma appliance. Prolapse developed in four patients with transverse loop colostomies and was managed electively except the prolapse with a herniation of stomach, which was treated urgently. It has been shown that prolapse is more prevalent in loop colostomies; particularly, those constructed using the transverse colon.[29],[30]

Furthermore, all patients with temporary stomas wanted their stomas closed as soon as possible because of the social restriction imposed by intestinal stomas. Patients who require an ostomy for fecal diversion often experience physical, psychological, and emotional stress related to misconceptions and fears regarding social acceptance, sexuality, and economic burden.[30] The social restrictions included inability to perform marital, breastfeeding, and economic functions, and in extreme cases being branded a witch by the spouse. Evidently some restrictions were due to misconceptions about stomas, which would have to be disabused and factored into consideration in future preoperative counseling.


  Conclusion Top


Malignant intestinal obstruction due to CRC was the most common indication for stoma construction at our institution. Consequently, massive health education campaign to ensure early presentation of CRC is needed to reduce the need for stoma creation. Furthermore, it has been shown that with adequate patient education on prevention of dehydration ileostomies can safely be constructed and stoma skin complications can be minimized by the availability of affordable stoma appliances and enterostomal nurses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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