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Surgery of Colorectal Cancer
Principles of Colorectal Surgery
Dedrick Kok Hong Chan & Simon James Alexander Buczacki
Key Take Home Messages
• In spite of various surgical techniques and approaches, the
key tenets in oncologic colorectal surgery are adequate circumferential and longitudinal margins and lymphadenectomy.
• Colorectal surgeons tailor the approach to individual patient
circumstances; in some cases, this leads to more minimally
invasive surgery while other cases require more maximally
invasive surgery.
• Emerging technologies all enable the colorectal surgeon to
visualize the anatomy and planes better, and could enter widespread use to improve oncologic outcomes.
Introduction
Surgery remains the cornerstone in the treatment of colorectal
cancer, and advances in surgical techniques have contributed
to improvements in outcomes. The importance of surgery in
the management of colorectal cancer is evident given that
almost two-thirds of all patients diagnosed with colorectal
cancer undergo some form of surgical intervention. This
chapter first presents the established tenets of colorectal surgery, before discussing two key trends which have become
commonplace in contemporary practice. The first being a trajectory toward more minimally invasive surgery. The second,
diametrically opposite, pushes toward more aggressive and
maximally invasive surgery. The balance between these two
trends is intriguing, and the modern colorectal surgeon has
become adept at applying these seemingly differing surgical
philosophies depending on the nature of the cancer and
patient. Finally, we explore future technologies which have the
potential to shape colorectal surgical practice in the decades to
come.
Principles of Gastrointestinal Surgery
in Colorectal Cancer
Margins
Longitudinal surgical margins are critical in any oncologic surgery to ensure that microscopic tumor cells which may result
in local recurrence are removed. Microscopically positive, or
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R1 margins, are independently associated with metachronous
systemic disease, as well as reduced three-year recurrence free
survival (Schellenberg etal. 2022; Smith etal. 2022). The desire
to remove more bowel to reduce recurrence needs to be balanced against the sacrifice of unnecessary bowel length. A study
by Hashiguchi etal. demonstrated that there was no additional
benefit in overall survival in resections extending more than 5
cm from the proximal or distal margin (Hashiguchi etal. 2011).
These margins also impact on the extent of lymphadenectomy
subtended by the resection, and margins <5 cm may be associated with understaging (Rørvig et al. 2014). The American
Society of Colon and Rectal Surgeons (ASCRS) recommends a
longitudinal resection margin of 5–7 cm (Vogel etal. 2022).
This may however be challenging to achieve in rectal cancer,
given the need to preserve sphincter function, and ensure a safe
anastomosis. In rectal cancer, a resection margin of 1–2 cm is
therefore generally accepted, with the literature currently probing whether a sub centimeter margin might be safely performed.
Among patients who received neoadjuvant chemoradiotherapy,
resection margins <1 cm were associated with increased threeyear local recurrence rates, and was a significant risk factor for
local recurrence on multivariate analysis (Song et al. 2021).
Another meta-analysis conversely showed that a resection
margin of <1 cm did not result in increased risk of local recurrence, except in patients who received surgery alone. In this
subgroup, the relative risk for local recurrence was 1.76 times
higher in patients with a margin <1 cm, compared to patients
with resection margin of 1 cm or more (Yan etal. 2022).
Lymphadenectomy
A minimal number of 12 lymph nodes harvested during surgery has traditionally been considered to be the cut-off for adequate staging of colorectal cancer (Amin etal. 2017), and this
has also been used as a surgical quality indicator (Dillman etal.
2009). The origin of the number 12 can be traced to the 1990
World Congress of Gastroenterology in Sydney, where it was
calculated that harvesting 12 lymph nodes would allow the
pathologist to accurately stage a tumor as being N0 90% of the
time (McDonald etal. 2012; Scott and Grace 1989). Since then,
the use of 12 as an absolute cut-off has been controversial.
Opponents of the use of an absolute cut-off argue that this fails
to consider the effect of other factors which may impact on the
lymph node harvest, such as age <60, or sidedness of the cancer
(Shen etal. 2009). Furthermore, there is evidence that reduced
lymph node harvest may not be an indicator for poor surgical
technique, but rather, is a marker of reduced immune sensitivity and worse prognosis (Chan and Buczacki 2022; Lal etal.
2022). Nonetheless, 12 lymph nodes are considered to be the de
facto minimal lymph node harvest in most surgical guidelines,
and remains surgical dogma.
Surgical Procedures for Colorectal Cancer
There is mostly consensus regarding the operation of choice for
cancers arising at different locations of the colon and rectum
(Figure 1). These operations take into account the abovementioned
Figure 1 Colonic resections are determined based on the resected vascular pedicle. A. In a right hemicolectomy, the ileocolic vessels, a branch of the
superior mesenteric bundle, are resected. The terminal ileum is anastomosed to the transverse colon. B. In a left hemicolectomy, the left colic vessels are
resected and the transverse colon is anastomosed to the sigmoid colon. C. In an anterior resection, the inferior mesenteric vessels are resected, and the
descending colon is anastomosed to the rectum. Created with biorender.com.
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principles regarding margins and adequate lymphadenectomy.
Tumors of the right colon are treated with a right hemicolectomy, while tumors of the left colon are treated with either a left
hemicolectomy or an anterior resection. Low anterior resections are defined as those in which the anastomosis is made
distal to the peritoneal reflection. An abdominal–perineal
resection occurs when the anal sphincter has to be sacrificed
based on the abovementioned oncologic principles.
There is however some controversy regarding cancers which
arise at the splenic flexure. Some considerations of surgical
choice in addition to the aforementioned surgical principles
include this location being perfused by the terminal supply
of both the superior and inferior mesenteric vessels, as well as
the length of bowel and its impact on function beyond what
is needed for oncologic clearance but instead to ensure a safe,
tension-free bowel anastomosis. An analysis of short-term outcomes using the American College of Surgeons (ACS) NSQIP
database showed no difference in lymph node yield between
a segmental splenic flexure resection and a formal left hemicolectomy (Pang et al. 2022). Segmental resection however
required a shorter operative time, and had equivalent postoperative morbidity. Another retrospective study compared
the three main operations offered for cancers at the splenic
flexure – extended right hemicolectomy, segmental splenic
flexure colectomy, and left hemicolectomy (Manceau et al.
2022). Only extended right hemicolectomy resulted in a significantly higher lymph node yield, but at the expense of increased
operative time and increased hospital length of stay. Notably,
all three approaches did not result in differences in disease-free
or overall survival. A trial designed specifically to address cancers at this challenging will remain difficult, given the paucity
of splenic flexure cancers, and the number of variables which
will need to be standardized to account for the multiple factors
affecting surgical choice.
Minimally Invasive Surgery – Smaller
Incisions to Scarless
Laparoscopic Colon and Rectal Surgery
In most elective settings, surgery for colorectal cancer is performed via a laparoscopic approach. In colon cancer, the benefits of the laparoscopic approach have been well established
through multiple randomized controlled trials. The MRC
CLASICC trial demonstrated equivalent short-term outcomes
such as positive margin and complication rates between the
open and laparoscopic approach (Guillou etal. 2005), as well as
equivalent long-term outcomes such as overall survival, and
recurrence rates over a follow-up period with a mean of five
years (Green etal. 2013). Similar findings have been corroborated with other studies, all with the additional benefit of laparoscopic surgery requiring a smaller incision, and therefore
leading to less pain, decreased opioid use, reduced hospital
length-of-stay, and earlier return to premorbid function (Lacy
etal. 2002; Clinical Outcomes of Surgical Therapy Study Group
etal. 2004).
Trials with the aim of establishing the safety and oncologic
efficacy of laparoscopic surgery in rectal cancer have also been
performed. The COLOR II trial demonstrated no difference in
short-term surgical outcomes (van der Pas et al. 2013), and
equivalent rates of oncologic outcomes such as locoregional
recurrence, disease-free survival and overall survival between
patients who had undergone a laparoscopic or an open
approach to surgery (Bonjer etal. 2015). Similar results have
been observed in other trials performed over a diversity of geographic regions, such as the ACOSOG Z6051 in the United
States (Fleshman etal. 2019), the COREAN trial in South Korea
(Park etal. 2021) and randomized controlled trials performed
in Hong Kong (Ng etal. 2014, 2009). Intriguingly, the ALaCart
trial performed in Australasia however failed to prove noninferiority of the laparoscopic approach in terms of oncologic
outcomes at median follow-up of 3.2 years, and the authors
continue to await longer term results (Stevenson etal. 2019).
Nonetheless, the evidence would suggest (with caution) that
the laparoscopic approach is favorable in rectal cancer, as in
colon cancer.
Robotic Surgery
The robotic approach to colorectal surgery has gained in
prominence amongst surgeons in recent years, though it has
not reached a level of acceptance achieved by the laparoscopic
approach. Proponents of the robotic approach argue that the
stable platform and decreased reliance on a competent
assistance enable better dissection deep into the pelvis, as well
as in circumstances which require precision, such as in lateral
pelvic side wall lymph node dissection (Baek et al. 2013).
Indeed, a randomized controlled trial performed in South
Korea showed that the robotic approach achieved similar
levels of total mesorectal excision (TME) quality, with similar
results in terms of postoperative morbidity, return of bowel
function, and quality of life scores (Kim etal. 2018). The
ROLARR trial compared evaluated similar short-term outcomes. Notably, this study was powered to compare the rates
of conversion to open approach as its primary endpoint, with
secondary end-points including postoperative complications,
circumferential resection margin positivity, and bladder and
sexual function (Jayne et al. 2017). Given that the study
showed no difference in the risk of conversion to the open
approach, the authors were critical of the robotic approach,
and did not deem it to be superior to laparoscopic surgery,
particularly given the much-increased costs associated with
robotic surgery. The surgical community eagerly awaits longer-term oncologic results from the trial.
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Natural Orifice Approaches for Early Rectal
Cancer
Early rectal cancers can be managed in a natural orifice
approach as the risk of lymph node metastasis is often so
limited as to not require lymphadenectomy. In the absence of
lymphovascular invasion and non-poorly differentiated
tumors, the risk of lymph node metastasis in pT1 cancers was
found to be 7.5% only (Chang etal. 2012). pT2 lesions significantly increased this risk to 23.1%. For this reason, pT1 lesions
in the absence of high-risk features can be considered adequately treated with local resection.
Transanal endoscopic microsurgical dissection (TEM) or transanal endoscopic microsurgery (TAMIS) are two different platforms with the aim of locally dissecting an early rectal cancer
without the need for more radical surgical approaches. These two
procedures are forms of natural orifice transluminal endoscopic
surgery (NOTES), in which no surgical scar is made for removal of
the lesion. Meta-analyses have confirmed that TEM is comparable
to formal surgical resection for early rectal cancers. In patients
who have undergone TEM compared with formal surgical resection for pT1 cancers, patients undergoing TEM reported lower
surgical morbidity and mortality, and shorter hospital stays (Allaix
etal. 2016). While Heintz etal. (Heintz etal. 1998) showed that
patients with TEM had higher local recurrence rates, all studies
have not shown that this translated into difference in long-term
oncologic outcome (Heintz etal. 1998; Lee etal. 2003).
Maximally Invasive Surgery – beyond
TME, CME, and Pelvic Exenteration
Total Mesorectal Excision (TME)
TME is unquestionably one of the key surgical techniques
which significantly improved oncologic outcomes in rectal
cancer. The principle of TME is that pararectal lymph nodes
drain into the mesorectum, such that excision of this mesorectum leads to adequate lymphadenectomy. This technique
therefore encompasses removal of the rectum together with its
enveloping mesorectum, by sharp dissection along the visceral
pelvic fascia, termed the “Holy Plane” (Heald 1988).
Application of this technique ensures that cancer tissue is
completely removed, and accords the patient the benefit of
having a negative resection margin. Involvement of the resection margin with tumor is associated with a drastic increase in
locoregional recurrence from 10% in uninvolved margins, to
78% in involved margins (Adam etal. 1994), and an increase
in distal metastases from 12% to 40% (Wibe et al. 2002).
Pathologic examination of the quality of TME is important as
the quality of TME is correlated with recurrence rates. In
patients who had an inadequate TME, recurrence was noted to
be significant higher compared with patients who received a
complete TME (Nagtegaal etal. 2002).
Transanal TME (TaTME) is a recent modification of the TME
technique. In TaTME, the TME is performed transanally instead
of trans-abdominally. This technique usually requires two surgical teams operating concurrently – one focusing on the transabdominal part of the surgery, while another dissects the TME
plane by making a full-thickness incision through the anus distal
to the cancer. Both teams “meet-up” on completion of the TME.
One of the clear advantages of this approach is that the distal
margin is always assured. Although some retrospective studies
have consistently shown no difference in short-term surgical
outcomes, and long-term oncologic outcomes [39–41], there has
been significant concern regarding the technical challenges of
this procedure and a pattern of multifocal local recurrence
unique to TaTME (van Oostendorp etal. 2020). In Norway, a
prospective registry of TaTME showed higher anastomotic leak
rates as well as higher local recurrence rates compared with standard laparoscopic TME (Wasmuth etal. 2020), leading to a moratorium on the procedure (Larsen etal. 2019). COLOR III is an
international, multi-center, superiority RCT which has been
designed to compare TaTME with laparoscopic TME, and will
hopefully provide surgeons with more confidence in deciding
between both approaches (Deijen etal. 2016).
Complete Mesocolic Excision (CME)
Success with the TME technique in dramatically improving
oncologic outcomes has led to the consideration of a similar
surgical approach in cancers of the right colon. Hohenberger
described a similar technique in the right colon, using sharp
dissection to remove the visceral peritoneum off the retroperitoneum, combined with central vascular ligation to maximize the lymph node harvest (Hohenberger et al. 2009).
The main advantage of this technique is in the increased
lymph node harvest, particularly lymph nodes situated close
to the root of the vasculature, which have been associated
with worse outcomes. In a study by Zenger etal., three-year
overall survival and disease-free survival were significantly
worse amongst stage III patients with metastases to the
central vascular lymph nodes (Zenger etal. 2021). Thus far,
there has only been one randomized controlled trial which
has compared conventional right hemicolectomy with CME
right hemicolectomy (Di Buono et al. 2021). This study
showed that CME right hemicolectomy was associated with
a greater lymph node harvest with no increase in surgical or
postoperative complications. While longer-term oncologic
outcomes have yet to be published, meta-analyses of retrospective studies have indicated improved oncologic outcomes
amongst patients who have undergone CME right hemicolectomy [49–51]. In one meta-analysis, three-year overall
survival and five-year disease-free survival were both found
to be significantly improved in patients who had undergone
CME right hemicolectomy (Anania etal. 2021).
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Pelvic Exenteration
Pelvic exenteration is surgery performed for locally advanced
and recurrent pelvic cancers. These complex surgical procedures often entail multi-visceral resections to achieve clear margins, and commonly involve multiple surgical specialties
including colorectal, urology, gynecology, plastic surgery, and
orthopedics. This is particularly important as achieving a R0
resection has been found to be the most important factor in predicting overall survival (Koh etal. 2022). Given the complexity
of these procedures, pelvic exenteration is often performed only
at high-volume centers of excellence, which concentrate expertise to ensure the best outcomes.
Modern Adjuncts to Oncologic
Colorectal Surgery
Surgeons are ultimately limited in our ability to visualize
anatomy, and modern adjuncts have been developed which
have helped surgeons to see better during an operation. This
could potentially lead to the recognition of danger before it has
occurred, and lead to reduced morbidity and mortality. In this
section, cutting-edge technology which is still in the nascent
stage will be explored.
Indocyanine Green (ICG)
Indocyanine green is a water-soluble dye which has a short
half-life of three to five minutes (Keller etal. 2017). This dye
absorbs light at an excitation wavelength of 750 to 800 nm,
and emits light at a higher wavelength of 830 nm (Alander
et al. 2012). These characteristics make it suitable for use
during surgery as a modality to increase the visibility of critical structures. One key area in which ICG may be used is to
visualize perfusion to an anastomosis made following a major
resection. Given that anastomotic leaks are major sources of
morbidity and mortality in colorectal surgery, the use of ICG
as an adjunct to assessing perfusion to the anastomosis has
been shown in meta-analyses to significantly reduce this risk
(Chan etal. 2020). Another major morbidity during surgery
is ureteric injury, particularly during repeat surgery in which
natural planes have been disrupted. Fluorescent ureterography has been used to aid in the visualization of the ureter
during colorectal surgery (Satish etal. 2022). Finally, ICG has
also been applied to the identification of lymph nodes outside
the usual resection plane, such as at the inguinal region or
lateral pelvic side wall. Such surgery is usually performed
laparoscopically, precluding the use of tactile sensation to
identify lymph nodes. As it can often be challenging to pick
out a single enlarged lymph node, ICG can help in the visual
identification of enlarged lymph nodes as they would tend to
concentrate ICG relative to its surroundings (Sun etal. 2022;
Zhou etal. 2019).
HoloLens
HoloLens (Microsoft Corporation, Redmond, WA) is a headmounted display which provides 3-dimensional (ED) visualization of the surgical field. This technology provides the
surgeon with a mixed reality, given that a 3D image is superimposed onto the surgical field. This 3D image can take the form
of the patient’s vasculature, and could potentially help guide the
harvesting of lymph nodes which might have been seen on
computed tomography imaging. This technology has thus far
been described in the resection of colorectal liver metastases
(Saito etal. 2020). Users of this technology have described the
key advantages being no reliance on a sterilized display monitor, improved spatial awareness of key anatomic structures, as
well as shared image among all surgeons of the surgical field.
This technology will need to be validated and explored in a
spectrum of other surgical applications, but has the potential to
revolutionize how surgical teams function together, and how
surgery is performed.
3D Printing
Another novel technology which has been used to augment the
surgeon’s appreciation of anatomy is the use of 3D printing
technology. Already, current CT scanning machines are able to
perform 3D reconstruction of images. Using 3D printing technology, a physical render of the reconstruction can be constructed. There have been a number of authors who have
with the bulk of applications being for use in the pre-operative
planning phase. Some specific examples of its use include 3D
models of the pelvis for use in low rectal cancer, reconstruction
of the pelvic side wall to facilitate lateral pelvic lymph node dissection, and to delineate the anatomy in the setting of recurrent
disease at the infrarenal region (Przedlacka etal. 2021). 3D
models have also been useful to teach surgical trainees and
medical students about pelvic anatomy (Hassinger etal. 2010).
Areas for Further Research
The next frontier of colorectal cancer research will involve
bringing the proverbial bench and bedside together. Colorectal
surgeons today continue to rely on predominantly clinical
parameters to stage cancer, or to prepare a patient for surgery.
There is however increasing evidence that colorectal cancer can
and should be subtyped beyond the four broad stages. For
example, the recent efficacy of dostarlimab, an anti-PD-1
monoclonal antibody, in achieving complete response of mismatch repair deficient, locally advanced rectal cancer, suggests
that patients who have been molecularly subtyped can get tailored treatment (Cercek etal. 2022). In this study, inclusion criteria for the trial rested on molecular subtyping, and not on the
stage of disease. Our ability to go beyond clinical parameters
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and to characterize a patient’s cancer based on the molecular
signatures will herald an era of truly personalized medicine.
This will not only require the identification of new molecular
markers, but will also require increased scalability of current
technologies to meet the needs of the global patient community,
while addressing important factors such as bioethical ramifications which may arise based on the technology involved.
Conclusion
This chapter has highlighted the breadth and depth of surgical
approaches which are available to treat colorectal cancer. We
have structured this chapter by highlighting two opposing
trends of minimally invasive and maximally invasive
approaches, which although diametrically distinct in surgical
philosophy, are similarly undergirded by the principles of clear
surgical margins and adequate lymphadenectomy. The future
of colorectal surgery must continue to evolve by tapping into
other broader surgical and technological trends, with the ultimate aim of improving short-term surgical and long-term
oncologic outcomes for patients.
Trusted Websites for Further Reading
https://www.cancer.gov/types/colorectal/hp/colon-treatment-pdq
https://www.cancer.gov/types/colorectal/hp/rectal-treatment-pdq
https://www.cancer.gov/types/colorectal/hp/colorectal-genetics-
pdq
https://www.acpgbi.org.uk/resources/354/guidelines_for_
the_management_of_cancer_of_the_colon_rectum_and_
anus_2017
https://fascrs.org/ascrs/media/files/downloads/2022-colon-
cancer-cpg.pdf
https://fascrs.org/ascrs/media/files/downloads/rectal-cancer-
cpg-2020.pdf
https://www.nccn.org/guidelines/guidelines-detail?category=
1&id=1428
https://www.nccn.org/guidelines/guidelines-detail?category=
1&id=1461
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Stoma
Theophilus Anyomih, Mudassar Majeed & Justin Davies
Definition
The term “ostomy” comes from the Greek “stoma” and means
“mouth.” In medical terms, a stoma/ostomy refers to a communication, natural or artificial, temporary or permanent between
a body cavity and the external environment. An enterostomy is
a surgically fashioned intestinal opening or diversion of bowel
continuity of which ileostomy or colostomy are the most
common.
Brief History
Surgical formation of intestinal stomas was rare in the preanesthetic era. The earliest report of formation of surgical
stoma was by Littre – he created a stoma in a diseased child
with imperforate anus (Littre 1732). It was not until 1793 when
the first successful colostomy on a three-year-old with imperforate anus was undertaken – the patient lived up to the age of 45
years (Cataldo 1999; Duret 1798).
The advent of anesthetic techniques made intestinal stoma
formation safer, practical and more common. An ileostomy
was first advocated in ulcerative colitis in the early 1900s but
became widely accepted after Dr Bryan Brooke made surgical
maturation the standard of care for ileostomy. Shortly thereafter,
surgical maturation became the standard of care for colostomy
construction as well (Cataldo 1999; Hardy 1989; Weakley 1994).
Types/Classication of Intestinal Stoma
Stomas can be classified based on the anatomical parts of the
involved structure; ileostomy, colostomy, jejunostomy or less
commonly caecostomy, and appendicostomy. A urostomy (or
ileal conduit) is quite commonly fashioned to serve as a conduit
for urinary diversion after cystectomy.
A stoma can also be classified as either a loop or an end stoma.
A loop stoma is formed by externalizing a loop of bowel and creating a proximal and distal opening. Intestinal content empties
via the proximal/afferent opening. The distal loop is adjacent
to the proximal loop and makes for a technically more simple
closure by mobilizing the two ends, anastomosing them, and
placing the joined bowel back in the abdominal cavity through
the same opening. A loop stoma is mainly indicated to protect
a distal anastomosis, thereby reducing the risk of anastomotic
leak. Some studies have demonstrated fewer complications with
loop defunctioning ileostomy compared to a loop colostomy
(Saunders and Hemingway 2008; Williams etal. 1986).
An end stoma is formed from the proximal end of the divided
bowel. The usual location of a sigmoid end colostomy is the left
iliac fossa – as performed during a Hartmann’s procedure (classically described as a sigmoid resection, end colostomy, and
remaining closed rectal stump). Sometimes a mucus fistula
may be created in addition to an end colostomy by bringing out
the distal end of the divided colon, either through the same
opening as the colostomy (forming a double-barrel stoma) or
through a separate incision. Mucus fistulas are created if there
is high risk that the distal stump closure might break down.
An end ileostomy is usually sited in the right iliac fossa and is
commonly fashioned from the most distal viable ileum. Reversal
of end stomas can be via a minimally invasive or open approach.
Based on functional purposes a stoma can be temporary or
permanent. Temporary diverting stomas are usually created to
protect a distal anastomosis, to relieve an obstruction or to rest
the distal bowel. Permanent stomas are typically indicated
when a primary anastomosis is not possible (e.g. very low rectal
cancer involving the sphincter complex requiring an abdominoperineal excision of the rectum – APER), not safe (e.g. in a
patient with significant comorbidity who would not be able to
tolerate potential septic complications from an anastomotic
leak) or not appropriate (e.g. a patient with pre-existing poor
bowel function/continence).
Indications
There are several indications for the different types of stomas.
End ileostomies are indicated after panproctocolectomy (single
procedure or staged, according to indication) for hereditary
bowel cancer – FAP/HNPCC (especially when in association
with low rectal cancer), ulcerative colitis refractory to medical
therapy or refractory Crohn’s colitis.
Figure 1 Loop ileostomy.
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Defunctioning loop ileostomy is typically formed to protect
a distal rectal anastomosis (e.g. low anterior resection), relieve
a distal obstruction (e.g. malignant/inflammatory stricture) or
to defunction an intestinal fistula. It can be fashioned to prevent contamination and allow healing of anorectal trauma or
anal sphincter injury. In the presence of severe perianal sepsis
(e.g. Crohn’s disease), a defunctioning loop stoma to prevent
worsening of sepsis and relieve symptoms is particularly useful
(see Figure 1).
An end colostomy is used in a Hartmann’s procedure, after a
low rectal cancer resection or anal cancer salvage surgery where
sphincter complex excision is necessary (APER) or in rectal
cancer surgery where a low colorectal or coloanal anastomosis
is deemed inappropriate, often to avoid the risks of potential
anastomotic leak or if the functional sequelae of a low anastomosis are not acceptable. It can also be useful in cases of intractable faecal incontinence.
Defunctioning loop colostomy may be indicated in relieving
distal obstruction (e.g. malignant/inflammatory stricture causing
a distal large bowel obstruction), defunctioning complex perianal
fistulas, and in the setting of Fournier’s gangrene in conjunction
with extensive perineal debridement. Some patients with locally
advanced and symptomatic rectal cancer may require a defunctioning loop stoma prior to commencing neoadjuvant chemoradiotherapy. Finally, in inoperable rectal carcinoma, it can be
performed as a palliative procedure, although palliative radiotherapy may offer more appropriate symptom relief.
Stoma Siting
Patients who undergo stoma surgery face multiple challenges
and lifestyle changes (WOCN Society Clinical Guideline:
Management of the Adult Patient With a Fecal or Urinary
Ostomy-An Executive Summary 2018). Appropriate siting of a
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stoma is critical as an error can result in significant impact in
the patients’ quality of life after surgery. Correct stoma siting/
marking and meticulous construction of the stoma are factors
that reduce complications from stomas and peristomal skin
complications and are important in allowing for stoma self-care,
independence and resumption of normal activities (Hendren
et al. 2015). Whenever possible, the stoma site should be
selected and marked by a specialist stoma nurse. They should
be involved early on as among other things, they discuss the
principles and practicalities of living with a stoma and counsel
the patient in advance of surgery. Sometimes, the patient may
choose to discuss lifestyle issues with other ostomates to help
with shared decision making, and the specialist stoma nurse is
often able to facilitate this.
The stoma site should be on a flat, smooth area of the skin
devoid of scars, skin creases and bony prominences. The selected
area should be visible to the patient and accessible so they can
manage it appropriately after surgery. When planning for a
stoma site, the patient should ideally be dressed in their normal
clothes and should be assessed standing, sitting and lying down.
Another factor to consider when choosing a site for stoma
formation is when surgery involves multiple sites; fecal and
urinary stomas (e.g. after a pelvic exenteration) should be sited
at different horizontal levels, and generally on opposite sides of
the abdomen.
Complications of Stoma Formation
A poorly constructed stoma can impact a patient’s outcome, and
result in difficult management issues. Moreover, complications
such as hernia, prolapse, retraction, and stenosis can occur
despite the best circumstances. It is important to understand
how to avoid and manage these issues (Strong Scott 2016).
Early Complications
Ischemia/necrosis
This is more common following colostomy formation than ileostomy. Incidence ranges from 1.6–11% (Cross et al. 2017;
Franklyn etal. 2017; Whiteley etal. 2016; Zindel etal. 2017).
Signs of ischemia usually arise within 24 hours of surgery,
although delayed ischemia can also occur due to underlying
medical conditions causing hypoperfusion. The causes of
ischemia/necrosis are mainly associated with surgical technique
in creation of the stoma and include tension on the mesentery
or ligation of the primary blood vessel/damage to blood supply
of the distal end of the stoma. The latter is typically due to extensive mesenteric dissection or skeletonization of the distal bowel.
A large abdominal pannus in obese patients and a tight abdominal wall opening through which the stoma passes can also precipitate ischemia. It is essential in the early postoperative period
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to perform daily assessment of any formed stoma looking for
ischemia. It can be difficult to differentiate between necrosis
and hematoma.
Revision of a necrotic stoma depends on the level of necrosis
in the abdominal wall. A stoma that is necrotic proximal to the
fascial opening requires revisional surgery. Early, less critical,
and more distal stoma ischemia can lead to stenosis as a later
complication.
Fluid and Electrolyte Imbalances
These imbalances are more common in patients with an ileostomy. A newly formed ileostomy usually functions within
24 hours, producing an average of 1200 ml of stool daily.
Subsequent ileostomy adaptation (body’s compensatory
response to prevent dehydration by increasing mean plasma
aldosterone) maintains ileostomy output to about 300–700
ml daily. Despite this compensatory mechanism, dehydration
from high output stomas (>1000 ml daily) occurs in 16% of
ostomates (Arenas Villafranca etal. 2015; Baker et al. 2011).
Several factors contribute to this, including incomplete bowel
obstruction, intra-abdominal sepsis, prokinetic drugs, sudden
withdrawal of steroids or opiates, enteritis with Clostridium
difficile infection, diuretics, coexisting diabetes mellitus and
total proctocolectomy.
Intravenous fluid and electrolyte resuscitation, oral fluid intake
restriction, avoiding hypotonic drinks and triggering drugs are
recommended management strategies. Also, close monitoring of
body weight, fluid balance, serum biochemistry, and electrolytes
is mandatory in the immediate postoperative period.
Mucocutaneous Separation
Retraction
Retraction is the inversion of the mucocutaneous junction
toward the abdominal wall musculature and is often the
consequence of insufficient length of intestine or inadequate
mobilization at the time of operation, especially in obese
patients (see Figure 2). It can also be a sequelae of stoma
ischemia and necrosis. The incidence is 2.9–5.4% (Güenaga
etal. 2007; Miyo etal. 2017; Mohan etal. 2019). Traditionally,
stoma rods have been used to prevent retraction in loop stomas,
although a meta analysis showed that its use for loop stomas
did not prevent retraction but was associated with higher incidence of peristomal dermatitis and stoma necrosis (Mohan
etal. 2019). The definitive management is stoma revision with
adequate bowel length and blood supply.
Other early complications of stoma formation include
bleeding, hematoma formation, edema of the stoma and cutaneous irritation, sometimes with ulceration. “Twisting” of the
stoma will present in the early postoperative period as bowel
obstruction. The “twist” may be because of failure to orient the
stoma appropriately at the time of surgery or could be related to
a volvulus of, for example, small bowel around the ileostomy.
Late Complications
Parastomal Hernia (PSH)
This is an incisional hernia at the stoma site. The reported incidence ranges from 3–50% and increases over time. The risk
factors for PSH can be patient related or due to surgical technical
factors (Krishnamurty etal. 2017; Osborne etal. 2018).
Patient factors include obesity, malnutrition, advanced age,
smoking, collagen abnormalities, corticosteroid use and any
Mucocutaneous separation (MCS) is characterized by partial or
circumferential detachment of the mucosa from the peristomal
skin. The disruption can trigger wound breakdown and appliance leakage in the early postoperative period. A combination
of factors that can lead to MCS include infection, diabetes
mellitus, corticosteroids, malnutrition, excessive tension on the
stoma, and stoma necrosis (Kim and Kumar 2006; Steinhagen
etal. 2017). The incidence of MCS is 3.7–9.7% (Franklyn etal.
2017; Miyo etal. 2017; Sung etal. 2010).
It is generally treated conservatively with local wound care
and fastidious pouching technique. The separated area is irrigated with saline, and skin barrier powder is used to absorb exudates and fill the defect before applying the pouching system. If
the separation is deep, it may be effective to fill the separation
using alginate or gelling fiber and cover it with a solid hydrocolloid or the pouch’s skin barrier (WOCN Society Clinical
Guideline: Management of the Adult Patient With a Fecal or
Urinary Ostomy-An Executive Summary 2018). Circumferential
MCS is treated in a similar fashion but may predispose to eventual retraction and stenosis.
Figure 2 Stoma Retraction.
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