Cecostomy

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138 Pearl et al.

Table 1 Effectiveness of Loop Stomas in Diverting Fecal Stream

No. of patients

with complete

Series Year Type Method diversion (%)

Rombeau et al. [10] 1978 Colostomy Barium 25/25 (100)

Schofield et al. [11] 1980 Colostomy Chromium 51 10/10 (100)

Williams et al. [8] 1986 Ileostomy/ Chromium 51 10/10 (100)

colostomy

Fontes et al. [12] 1988 Colostomy Barium 53/62 (85)

Winslet et al. [13] 1991 Ileostomy Chromium 51 22/26 (85)

When retracted stomas were revised, defunctioning efficiency approached 100%.

Another important but frequently overlooked question is: How often

are diverting stomas actually temporary? Table 2 summarizes the results of

studies concluding that nearly half of all diverting stomas that were in-

tended to be temporary remain permanent. The usual causes for this change

to permanency include patient preference and overall medical condition,

nonresectability of the primary tumor, and limited life expectancy. These

observations underscore the importance of careful preoperative planning

and attention to technical detail in creating a “temporary” loop ostomy in

order to minimize long-term morbidity.

Once the decision has been made to create a diverting stoma, the ques-

tion arises about which type of loop stoma is best, colostomy or ileostomy.

The most common method used to defunction the distal colon and rectum

is the construction of a transverse loop colostomy. Although this type of

stoma is relatively easy to fashion, it has several disadvantages. First, a

traditional right-upper-quadrant transverse loop colostomy is often difficult

to cover properly with an ostomy device because of its relative bulk and

location. Second, the liquid consistency and corrosive nature of the effluent

often lead to skin irritation in a relatively flush loop colostomy. Third, the

TABLE 2 Change of Loop Stoma from Temporary to Permanent State

Patients with

permanent loop

Series Year stomas (%)

Winkler and Volpe [14] 1982 99/211 (47)

Boman-Sandelin and Fenyo [15] 1985 11/29 (38)

Rutegard and Dahlgren [16] 1987 35/56 (62)

Diverting Stomas 139

offensive odor of colostomy output is a frequent patient complaint. Finally,

closure of a transverse loop colostomy is associated with an overall compli-

cation rate of between 10 and 50%, with most complications secondary to

wound infections and anastomotic leaks.

In contrast, a properly everted loop ileostomy is a better choice for a

diverting stoma because it circumvents most of the problems noted here. In

a prospective controlled trial comparing loop ileostomy with loop trans-

verse colostomy, ileostomy was associated with significantly less odor, a

lower frequency of ostomy device changes, fewer complications of stoma

management, and a lower wound infection rate following ostomy closure

[8]. A retrospective case-matched study from the Mayo Clinic [9] identified

no difference in morbidity or mortality from the operations to form or re-

verse the respective ostomies. However, patients with loop colostomies did

have a statistically significant higher risk of skin irritation and leakage of

the stoma appliance. Surgeon preference is likely the overriding influence

in many of these cases; however, careful evaluation of the current literature

reveals loop ileostomies to be a better alternative for both the surgeon and

the patient.

With the advance of technology and increasing experience, the use of

laparoscopy has allowed for safe creation and closure of diverting stomas,

both ileostomy and colostomy.

CONCLUSION

In summary, the construction of a diverting stoma should be considered a

major part of the overall operative procedure. It should be performed by a

surgeon who is not only technically skilled but also understands the poten-

tial complications associated with an ileostomy or a colostomy. In the ma-

jority of cases, loop stomas do seem to effectively divert the fecal stream.

Almost half of all temporary loop stomas become permanent, a fact that

underscores the importance of placing them in an optimal location on the

abdominal wall and paying strict attention to technical detail. Finally, loop

ileostomy should be considered a potentially superior alternative to trans-

verse loop colostomy following various colorectal surgical procedures.

Cecostomy

Anthony J. Senagore

The Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A.

INTRODUCTION

Pillore performed the first right inguinal cecostomy in 1776 to provide de-

compression for an obstructing rectal carcinoma [1,2]. This technique was

not popularized until the 1950s, when cecostomy was advocated for several

clinical conditions: (1) distal colonic obstruction, (2) proximal diversion to

protect a distal anastomosis, (3) cecal volvulus, (4) decompression of toxic

megacolon, and (5) intestinal pseudo-obstruction [3,4]. It should be recalled

that cecostomy allowed for satisfactory colonic decompression with mini-

mal anesthetic requirements at a time when large bowel obstruction carried

a mortality of 12–56% [5–8]. Two other factors that increased the fre-

quency with which this diversion procedure was performed were the re-

liance on three-stage resections for complicated diverticular disease and

obstructing neoplasms and the perceived need to protect distal colonic anas-

tomoses.

The use of cecostomy as an initial decompressive procedure for distal

colonic obstruction has been very successful for decompression of the colon

and subsequent preparation of the colon for definitive surgery [9]. How-

ever, in most series the mortality rate following decompressive cecostomy

was alarmingly high (21.5%) [2–9]. This situation is more a reflection on

differences in perioperative care of the patient with large bowel obstruction

rather than a specific disadvantage of cecostomy. At the time of cecostomy

placement, as many as 10% of patients in these series had cecal perforations

that would have been unnoticed if a blind transverse loop colostomy had

been chosen as the diversion procedure [9]. Conversely, complementary

cecostomy placement performed to protect a difficult distal colonic anasto-

mosis has been associated with few complications. However, it is discon-

certing that leakage, with subsequent mortality, occurred as frequently (2%)

at the cecostomy site and at the distal anastomosis. Such leakage is a factor

that discourages wide application of this form of proximal diversion [1].

143

144 Senagore

The treatment of nongangrenous cecal volvulus has included cecal resec-

tion, cecopexy, detorsion alone, and cecostomy with or without cecopexy

[10–14]. A preference for nonresectional therapy with viable bowel has

been noted, and the lowest recurrence rate appears to be associated with

cecopexy and cecostomy tube placement [10]. In such cases cecostomy is

most readily achieved through the appendicular stump unless the stump was

previously resected. Overall, an approach involving cecostomy and ceco-

pexy is highly successful and is associated with lower operative mobility

and mortality than resectional therapy [15].

The use of surgical cecostomy for intestinal pseudo-obstruction had

been associated with operative mortality ranging from 25–44%, even with

adequate decompression [16–18]. Mortality increases significantly with de-

lay in diagnosis and associated full-thickness necrosis of the bowel wall,

usually in the face of significant associated medical illnesses [20,21]. How-

ever, the morbidity rates associated with endoscopic decompression are

minimal compared to those of surgical cecostomy.

TUBE PLACEMENT

Throughout the years a number of techniques and tubes have been advo-

cated for cecostomy. The two most frequently recommended techniques

are exteriorization and blind tube cecostomy [9,22–26]. Typically the tube

placement procedure is performed through a right-lower-quadrant incision,

although Hughes [27] has advocated a formal laparotomy with placement

of the cecostomy through a separate stab incision.

The procedure can be performed with the patient under local infiltra-

tive anesthesia, although general anesthesia and regional blocks have been

used, depending on the patient’s medical condition. A transverse (McBur-

ney) incision is made in the right lower quadrant to allow access to the

peritoneal cavity (Fig. 1A). On entry to the peritoneal cavity, the distended

cecum should be readily identifiable. The cecum is carefully and gently

inspected for perforations or serosal tears, which can occur in as many as

3% of patients with cecal distention greater than 10 cm [2]. If the surgeon

encounters a collapsed cecum, bloody peritoneal fluid, or purulent exudate,

the procedure should be terminated in favor of a formal laparotomy, which

allows for clearer identification of the pathological condition and definitive

treatment. After the cecum has been identified, the cecotomy can be per-

formed by exteriorization or the blind tube technique (Fig. 1B). When exte-

riorization is used, the cecal pouch is allowed to protrude from the abdomi-

nal cavity to skin level. A row of seromuscular sutures is placed prior to

opening the cecum to prevent spillage of cecal contents into the peritoneal

cavity. A cecotomy is made, and the cecum is sewn to the skin circumferen-

tially with seromuscular sutures (Fig. 1B and C), completing the cecotomy.

Cecostomy 145

Figure 1 A. A transverse (McBurney) incision is made in the right lower quad-

rant to expose the distended cecum, which is brought out to skin level through this

incision. The peritoneal cavity is then closed circumferentially with seromuscular

interrupted sutures. B. After the peritoneum has been approximated circumferen-

tially, a cecotomy is performed. C. The cecotomy is matured by circumferential

placement of full-thickness sutures through the cecum to the dermis.

When tube cecotomy is chosen, the cecum is initially sutured to the

peritoneum circumferentially to prevent peritoneal soiling. Two concentric

purse-string sutures of 2-0 silk are then placed in the cecum (Fig. 2A). A

small colotomy is made in the center of the inside purse string, with suction

readily available to aspirate the effluent. An important technical point is to

place the suction tip at the opening of the colostomy rather than to insert it

into the cecum, because collapse of the cecum through suction may prevent

adequate removal of the more distal contents. Once the effluent has been

controlled, a 22 or 24F soft rubber catheter is inserted through the cecotomy

and both purse strings are tied securely. A variety of catheters can be em-

ployed, including a de Pezzer catheter, Foley catheter, endotracheal tube,

or even a soft rubber chest tube [9–28]. A water-filled balloon catheter has

the advantage of being more readily interchangeable, if a change should

become necessary, than the de Pezzer catheter. In addition, the water bal-

loon catheter offers a security advantage over a non–balloon-type catheter

146 Senagore

Figure 2 The cecum is exteriorized through a right-lower-quadrant incision. The

peritoneum may or may not be approximated to the seromuscular layer, according

to the surgeon’s preference. Prior to performing a cecotomy, a double row of sero-

muscular purse-string sutures is placed around the proposed tube site for the cecos-

tomy. A 24F Foley catheter should be used as the cecostomy tube. First the inner

purse-string sutures and then the outer ones are tied securely to hold the cecotomy

around the tube and keep it firmly in position B. The skin is closed around the

tube. The tube should also be secured at skin level with a separate stay suture.

in that the balloon tends to retard accidental dislodgment. After the tube

has been secured, the fascial skin layers are closed loosely around the cath-

eter and a light dressing is applied (Fig. 2B).

In recent years, percutaneous cecostomy guided by computed tomog-

raphy (CT) has been described [29,30]. For this technique, the patient is

rolled to the left lateral decubitus position. Only local infiltrative anesthesia

is required at the site of tube insertion. A small incision is made, and, under

CT guidance, a needle is placed through the retroperitoneum into the cecal

lumen. The track can then be gently dilated via the Seldinger technique to

allow catheter placement for decompression. Although most reports have

involved a relatively small group of patients, the technique has resulted in

successful rapid decompression of the cecum. Such decompression usually

Cecostomy 147

is achieved with the use of a 12F catheter. In addition to the significant

advantage of requiring only a local anesthetic, there have been no reported

cases of major morbidity or procedure-related mortality with this approach

[29,31,32]. Subsequently, Morrison et al. [33] have described a transperito-

neal approach that excludes the need for CT guidance. This technique re-

quires only fluoroscopy, thereby making the procedure readily available

at most institutions. In addition, there are limitations associated with the

retroperitoneal approach via CT guidance: (1) what appears to be an extra-

peritoneal cecum actually may be intraperitoneal because of a thin veil of

peritoneal reflection that encircles the cecum and (2) the posterior approach

via CT guidance presents difficulties when the cecum is tremendously di-

lated or when it has twisted anteriomedially on its mesentery [16,34]. When

the transperitoneal approach is used, the dilated cecum is located fluoro-

scopically and an area central to the cecum is identified. A 2-in. square of

skin and abdominal wall is anesthetized with a local infiltrative anesthetic

agent. A specially designed 18-gauge introducer needle loaded with a plas-

tic T fastener is carefully inserted into the cecal lumen. The T fastener is

launched from the introducer and used to secure the cecum against the ante-

rior abdominal wall. This step is repeated at each of the four corners of the

selected site for tube insertion. After the cecum has been attached to the ab-

dominal wall, the transcutaneous needle track to the cecal lumen is progres-

sively dilated via the Seldinger technique to allow a 24–34F tube to be

placed at the initial setting. This technique has been advocated primarily

for patients with cecal volvulus or those with distal colonic obstruction. In

a small group of patients, the technique has been very successful, with no

procedure-related morbidity or mortality reported [33].

For the first 12–24 hr after placement of a cecostomy tube, the tube

should be gently irrigated with 30 mL of normal saline every 2 hr. Use of

larger volumes may disrupt the seal between the cecum and the abdominal

wall, increasing the chance of peritoneal contamination. During ensuing

days, the irrigation solution can be increased steadily to 500–1000 mL [9].

As the volume is increased, turning the patient in different positions can

allow adequate preparation even as far distally as the descending colon.

Between irrigation intervals, the tube must be carefully inspected to ensure

that no obstruction has occurred as a result of accumulation of stool or

kinking. If unrecognized obstruction occurs, the cecum may burst [9].

TUBE MANAGEMENT

Tube management depends on the indication for placement of the tube.

When the cecostomy is placed as protection for distal anastomosis, it should

be left for 7–10 days. After this time, adequate integrity of the colonic

anastomosis should be ensured and the tube can be removed readily. In

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