|Year : 2018 | Volume
| Issue : 1 | Page : 1-6
Impact of suturing of stoma edges directly to skin without peritoneal fixation
Sandhya Padmanabhan Iyer, Pranal Sahare, Prabhakar Subramaniyan
Department of General Surgery, LTMM College, Mumbai, Maharashtra, India
|Date of Submission||17-Jul-2018|
|Date of Decision||29-Apr-2019|
|Date of Acceptance||30-Sep-2019|
|Date of Web Publication||20-Jan-2020|
Dr. Prabhakar Subramaniyan
LTmmc and LTMGH, Sion, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Enterostomies are one of the common surgical procedures performed in a general surgery unit. Enterostomies are fixed to the peritoneum/abdominal wall, before being sutured to the skin. This results in prolongation of operative time and dense adhesions between the bowel wall and the abdomen at the site of stoma. This is a comparative study between the commonly followed methods of maturation with our method of direct suturing of the stoma to the skin. Materials and Methods: A prospective randomized study to compare the traditional method of maturation of stoma with direct suturing of the stoma edges to the skin without a peritoneal fixation was carried out in a tertiary health-care hospital. Results: Skin complications and stomal prolapse were the most common type of complication seen. Most of the stoma-related complications were managed conservatively. There was no difference in stoma-related complications between the two methods of stoma construction in our study. However, during stoma closure, dense adhesions were seen in 90% of cases in Group A (peritoneal hitch) as compared to 7% in Group B (direct skin fixation). There was a significantly high 16.7% incidence of iatrogenic perforation of bowel in Group A during stoma closure. Conclusions: Thus, additional rectus and/or peritoneum fixation does not add any benefit in preventing stoma-related complications over intestinal stomas, which are constructed with fixation only to skin. In the group, where the stoma was fixed to abdominal wall, the higher incidence of dense adhesions between the stoma and the abdominal wall resulted in longer operative time during stoma closure and increased risk of iatrogenic bowel trauma.
Keywords: Colostomy, ileostomy, intestinal stoma
|How to cite this article:|
Iyer SP, Sahare P, Subramaniyan P. Impact of suturing of stoma edges directly to skin without peritoneal fixation. Niger J Surg Sci 2018;28:1-6
| Introduction|| |
Enterostomies are one of the most common surgical procedures performed in a general surgery unit. Enterostomas are fixed to the peritoneum/abdominal wall to prevent prolapse, retraction, and leakage of the bowel contents into the peritoneal cavity. Fixation of the bowel to the abdominal wall prolongs the operative time and also causes dense adhesions to the abdominal wall, which renders stoma closure a difficult operation. This study aims to determine the impact of suturing the stoma edges to the skin directly without peritoneal fixation.
| Materials and Methods|| |
A randomized study was initiated at a teaching hospital between May 1, 2012, and April 30, 2014, after obtaining clearance from the hospital ethics committee. A total of 60 cases were included in the study. They were randomized into two groups of 30 each. This study was performed to compare the traditional method of maturation of stoma (fixation of the bowel wall to peritoneum and edges to the skin) with direct suturing of bowel edges to skin without peritoneal fixation. The parameters compared were operative times, blood loss, stomal complications, and leak rates after stoma closure.
- Group A: (traditional and conventional teaching): During construction of stoma, stomas were fixed to the peritoneum and/or rectus sheath as traditional teaching, before being fixed to the skin
- Group B: Stomas were directly fixed to the skin as described in review of literature.
Sixty participants needing temporary stoma, fulfilling inclusion criteria were included in the study after informed consent. Surgeries were performed by a consultant or under their supervision. The screening and recruitment were done by the first or second author, and the recording of time was done by the consultant performing or assisting the surgery. The endpoint was the last suture of the stoma to skin.
The age, gender and indications, operative time for stoma maturation were recorded. Various complications and their management were noted during the postoperative hospital stay and subsequently during the follow-up till stoma closure. Complications encountered during stoma closure and operative time in each group were recorded.
- Age between 15 and 60 years either sex
- All temporary stomas-emergency and elective
- Temporary stomas: loop and double-barrel stoma.
- Permanent end stomas
- The presence of comorbid conditions such as DM, HTN, and IHD
- Pregnant patients
- Extremes of ages
- Nonconsenting patient
- Previously operated patients were not excluded from the study.
During the creation of stoma
All standard preoperative protocols were followed. These included adequate hydration, hemodynamic stability, and preoperative resuscitation for emergency patients. The bowel preparation was done with preoperative polyethylene glycol solution 24 h before surgery. Prophylactic antibiotics (amoxyclavulanic acid) 1.2 g was administered at the time of induction of anesthesia. While creating a temporary stoma, all standard steps were followed, as mentioned in literature for all patients. All surgeries were performed or supervised by a consultant. The variations in the construction of stomas were as follows:
- Group A: Bowel loop was first fixed to rectus and/or peritoneum by four stitches at 12, 3, 6, 9 O' clock positions and later hitched to skin with eight stitches
- Group B: Bowel loop was fixed only to skin with eight stitches
- Supporting rod or bridge was used only for transverse colostomies in both the groups
- Suture material used was absorbable polyglactic acid 2–0/3–0
- None of the patients underwent laparoscopic surgery
- Operative time was recorded for this step in each group.
Complications were noted immediate postoperative for 24 h, 48 h, 7 days during the hospital stay, at 3 months, and till stoma closure in our follow-up outpatient department (OPD) and managed accordingly. The follow-up interval was monthly.
Patients were considered for stoma closure once they regained optimum health, and the purpose of temporary stoma was served. Preoperative hemoglobin and serum albumin were considered. Preanesthetic check-up was done on OPD basis. Distal bowel was checked with water-soluble contrast and in some cases, with colonoscopy. All patients were admitted 1 day prior to surgery. They were advised to clear liquids and were kept on intravenous fluids. Bowel preparation was given to patients undergoing colostomy closure. All patients were kept nil per-oral for 8 h before surgery. Antibiotic prophylaxis with third-generation cephalosporin (ceftriaxone 1 g) and metronidazole 100 cc was given to all patients at the time of induction of anesthesia.
Peristomal incision was made. The enteric mucosal–cutaneous junction was taken down, and the adhesions between the bowel and the anterior abdominal wall were freed with sharp and blunt dissection. Continuity was then restored using either of the following two techniques depending on findings.
- Enterostomy closure of anterior wall after refreshioning of edges in two layers
- Resection of proximal and distal loop and end-to-end anastomosis in two layers.
Suture material used was 2-0 silk.
Soft abdominal drain was kept near anastomosis.
After replacing the bowel into the abdominal cavity, the abdominal wall defect was closed with delayed absorbable polydioxanone no. 1; the subcutaneous tissue and skin were closed. Nasogastric tube was passed in all patients postoperatively. Postoperatively, nasogastric tube was removed, and oral feeds were started on confirmation of the return of bowel function. This was, however, delayed in some patients when they had ileus or suspected anastomotic leak. The abdominal drain was removed on the 3rd postoperative day in most of the patients.
Patients' complications and hospital stay were documented on discharge.
Findings, complications, and operative time for dissection of stoma from abdominal wall and total operative time for stoma closure from peristomal incision to skin closure were noted in each group.
All patients were followed up for 3 months. The follow-up interval was monthly.
Descriptive statistics comprising of means percentages and proportions was used to describe the data. Randomization was done using online random number generators. The investigator who was aware of the method used to fix the stoma was not part of the stoma closure team.
Chi-square and Student's t-tests of proportion were used to compare the statistical significance of differences in two groups between the various parameters such as age, gender, complications, and indication for surgery. The level of significance was fixed at 95% (error 5%). P<0.005 was considered statistically significant.
| Results|| |
A total of 60 patients were included in the study who underwent temporary intestinal stoma. They were divided into two different groups who underwent surgery by two different techniques at a tertiary care hospital in Mumbai from 2012 to 2014.
In our study, the age of patients requiring stoma ranges from 15.5 to 60 years with a mean average age of 36.1 years in Group A and 37.12 years in Group B.
Of 60 patients, 37 were male and 23 were female; thus, there was a male preponderance in this study with a ratio of 1.6:1 male: female. In our study, 48 patients required stoma in an emergency setting, and 12 stomas were created during elective surgeries. Tubercular ileal perforations, typhoid perforations, gangrene, and bowel trauma were the most common indications for stoma creation in our study [Table 1].
The common types of stoma performed are double barrel ileostomy 17 cases (28.3%) and loop ileostomy 14 cases (23.3%). In the present study, loop transverse colostomy and double-barrel ileocolostomy have 11 cases each 18.3%, followed by loop sigmoidostomy 6.7% and double-barrel colostomy 5%. Thus, ileostomies are most commonly performed stoma followed by colostomy in our study. In our study, 19 patients had ileostomies in Group A (traditional method), while 23 patients had ileostomies in Group B (only skin).
While comparing mean operative time in both groups for performing stoma, we found that Group B requires meantime 8.73 min, which is significantly less than in Group A, where meantime was 13.8 min. This difference is statistically significant [Table 2].
|Table 2: Comparison of mean operative time for stoma construction between the two groups|
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In the present study of 60 cases [Table 3], 29 cases developed one or more stoma-related complications, in which skin complication accounts for 26.7% ranging from mild skin irritation, dermatitis and eczema to skin excoriation. All were managed conservatively with proper stoma care and use of stoma accessories. Patients were counseled with an endostoma therapist. Stomal edema accounted for 10% of the complications. This complication was, however, asymptomatic and reduced with time. Stomal prolapse was seen in 8.3% of which one case developed stomal bleeding for which revision surgery was required. Rest of the cases were managed conservatively. When these cases (stomal prolapse – five cases) were compared in both groups, Group A had four cases and Group B had one case. This finding was comparable but not statistically significant (P = 1.00). Thus, it can be assumed that fixing stoma to rectus and/or peritoneum does not provide any additional benefit in preventing prolapse. There may be many other factors which may influence stoma prolapse.
|Table 3: Profile of total complications of stoma during the study (n=60)|
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Two patients in Group A developed stomal retraction of which one also developed stomal necrosis for which revision surgery and refashioning of stoma were required. About 3.3% of the cases (two cases in Group A) developed parastomal hernia, which was a late finding, observed at 3 months. Both patients were asymptomatic and were managed conservatively.
Other complications encountered in our study were fistula (5%), parastomal infection (3.3%), and stomal stenosis (3.3%) which were mild in nature and were managed effectively by conservative management. Complications in both groups were comparable but were not statistically significant, and thus, fixing stoma to the rectus did not add any benefit in preventing complications, especially stoma retraction, prolapse, or parastomal hernia.
Meantime for considering closure in both Groups A and B was 21.7 weeks and 22.2 weeks, respectively. Surgeons prefer to close temporary stoma mostly by 8–12 weeks. Long-time lag in our study was mostly due to limited availability of resources, poor patient follow-up, and large number of patients requiring elective surgeries.
All our patients were optimized to good health prior to closure and mean serum albumin and hemoglobin in Group A and B were 3.39 g/dl and 11.75 mg%, 3.44 g/dl and 11.69 mg% which were comparable.
During stoma closure, we found dense and cohesive adhesions while separating stoma from the abdomen in 90% cases in Group A and 7% in Group B which was statistically significant [Table 4]. These dense adhesions between the stoma and the abdominal wall may be attributed to the inflammatory reaction, and serositis caused due to the fixing of the bowel to the rectus and/or peritoneum. Flimsy, easily dissectible adhesions were found in Group B in 76.7% in whom the bowel was not fixed to the rectus sheath and/or peritoneum. During stoma closure in Group A, 26.7% of patients had iatrogenic serosal tears and 16.7% of cases had iatrogenic perforations while in Group B, there were serosal tears in 6.7% patients. This difference was statistically significant (P = 0.038). During stoma closure, nine patients in Group A required resection anastomosis due to the iatrogenic bowel trauma which was significant when compared to Group B (P = 0.038) [Table 4]. Thus, additional stoma fixation to rectus and/or peritoneum increased complications during the closure, in our study.
|Table 4: Comparison of the proportion of cases with findings and complications during closure between the two groups|
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We compared the operative time for dissection of stoma which was significantly higher in Group A (30.53 min) than in Group B (17.4 min) which influenced the total mean operative time for stoma closure. The total mean operative time for stoma closure in Group A was 94.5 min which is significant when compared to Group B which is 68.5 min [Table 5] (P = 0.001).
|Table 5: Comparison of mean total operative time for stoma closure between two groups|
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In all patients who underwent stoma closure in our study, paralytic ileus was seen in 23% of patient in Group A and 6.7% of patients in Group B. It was managed conservatively. Anastomotic leak with peritonitis was seen in one patient in each group for which both the patients were re-explored, and a stoma was re-created which was closed at a later date. Wound infection developed in a total of 9 patients (15%) who were managed with drainage of discharge, course of antibiotics, and daily cleaning and dressing. Enterocutaneous fistula developed in four cases in Group A which is significant when compared to Group B, where none of the patients had such a complication [Table 6]. Three out of four cases of enterocutaneous fistula were low output. Patients were hemodynamically stable and could be managed by conservative management (course of antibiotics and supplementary diet) and spontaneous closure of fistula occurred by the end of 14 weeks.
|Table 6: Comparison of the proportion of cases with complications postclosure between two groups|
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One patient with enterocutaneous fistula had to be explored due to fever and 6increasing total counts. On exploratory laparotomy, the opening in the bowel was found to be distal to the anastomotic site and was a site of a missed iatrogenic perforation at the time of stoma closure. This patient expired 25 days after the stoma closure.
Mean hospital stay from stoma closure to discharge in Group A and Group B was 9.67 and 7.87 days, respectively. The hospital stay was more in patients who developed major complications such as anastomotic leak.
| Discussion|| |
The findings of male preponderance in our study are comparable with a study carried out in Lahore  which also showed a male preponderance with a ratio of 3:1.
Unlike carcinoma and ulcerative colitis in the western world  the most common indication requiring ileostomy or colostomy, in our study, was abdominal tuberculosis (17 cases – 28.3%) [Table 2]. These cases which presented to our hospital were either previously diagnosed cases for tuberculosis taking antitubercular treatment or were defaulters or were newly diagnosed after surgery. They presented with a variety of findings such as ileocaecal mass with stricture presenting as subacute intestinal obstruction or stricture perforations requiring emergency or elective surgery. The next common indication was viscus perforation (13 cases – 21.7%). Most of these cases were due to typhoid ileal perforations presenting late in the disease course. Thus, abdominal tuberculosis and enteric perforations as indications for stoma creation in patients seem to be unique to our setting.
Intestinal obstructions with gangrene (10 cases – 16.7%) were the next common indications for stoma in our study. As these patients presented late in the course of their illness, anastomosis was not feasible. Abdominal trauma forms 11.7% of cases needing stoma, while malignancies were indications in 10% of cases. This is in contrast to Hassan Aya and Mohammed Redha et al. where 37.5%of stomas were performed for malignancy. This difference can be explained by the fact that our center is a tertiary level trauma center.
The shorter operative time in Group B gives an advantage in emergencies, especially during damage control surgeries in hemodynamically unstable patients.
The incidence of stoma-related skin complications is 26.7% and is comparable to 16% in study by Ratliff et al.
There have been studies supporting the fixation of the bowel to the fascia in addition to the skin by Maeda et al. Park et al., in their study, found that loop ileostomies have the maximum incidence of prolapse, while Mäkelä et al., in their study mention the role of mesenteric fixation in the prevention of prolapse.
The latter studies state that fixation to the recti/fascia is not a factor for the occurrence of stomal prolapse.
All patients were optimized to normal serum albumin and hemoglobin levels before stoma closure. Mileski et al. advised caution in patients with hypoalbuminemia who were planned for colostomy closure.
The total operative time for stoma closure, in our study, was mainly dependent on various factors such as dense adhesions, the time required for repair of serosal tears and resection and anastomosis for iatrogenic bowel trauma, which was significantly higher in Group A as compared to Group B. Hence, we also observed that an additional fixing stitch between the bowel and sheath/peritoneum does not provide any additional benefit in preventing the complication of stoma but instead increases the operative time and morbidity during stoma closure. To the best of our knowledge, there are no studies in literature comparing the above variables during stoma closure. Our anastomotic leak rate (3.3%) was comparable to other studies conducted, which ranges from 0% to 7%. The wound infection rate in our study (15%) is comparable to the study by Phang et al. who had a wound infection rate of 14.2%.
There is a significant increase in operative time, enterocutaneous fistulae, and paralytic ileus in Group A compared to that of Group B.
Thus additional rectus sheath and/or peritoneum fixing of stoma to the sheath can add to complications during stoma closure, which if missed may cause significant morbidity and mortality to patients.
Although stoma has many complications and morbidity, a correctly created stoma can help in reducing complication rates and further morbidity. The patient factors beyond the control of the surgeon, such as comorbid conditions, nutritional status, and obesity, are also predictors of morbidity.,,
Thus, in our study, we have found that fixing stomas to the rectus and/or peritoneum has no added benefit but adds to the complications during stoma closure. However, our study has a limited sample size, and larger randomized studies are required to derive a better conclusion and solution towards stoma techniques.
| Conclusions|| |
There was no difference in the postprocedure complications between the two methods of stoma construction in our study. Thus, additional rectus and/or peritoneum hitching sutures do not add any benefit in preventing stoma-related complications such as stomal retraction, stomal prolapse, and parastomal hernia over intestinal stomas which are constructed with hitching only to skin. The mean operative time for stoma construction and stoma closure was found to be increased when the stoma is fixed to the rectus/peritoneum. The hitching of the bowel to the peritoneum/sheath led to increase in adhesions and iatrogenic trauma to the bowel during stoma closure leading to increased morbidity.
We are thankful to the department of surgery for their help and cooperation during this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]