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308 Rosen
Figure 1 Stoma prolapse.
Table 1 Incidence of Stomal Prolapse
No. of Follow-up End Loop End Loop
Author Date patients (months) ileostomy ileostomy colostomy colostomy
Chandler [2] 1978 491 2.4% 26%
Porter [3] 1989 126 35 3.2%
Londono-
Schimmer [4] 1994 203 156 11.8%
Cheung [5] 1995 316 38 4.3% 38.5%
Makela [6] 1997 156 104 12.5% 3.7%
Gooszen [7] 1998 76 3.1% 42.1%
Edwards [8] 2001 70 36 0% 5.6%
Stomal Prolapse 309
According to most authors, prolapse tends to present within the first
year of stoma creation [2,10]. This may reflect the temporary nature of
stomas in some patients or the short life expectancy of other patients upon
whom they were performed (i.e., palliation for metastatic cancer). Nonethe-
less, patients with ostomies are continually susceptible to new prolapse.
In general, loop colostomies tend to prolapse more often than do end
colostomies [2,5], and the distal limb is more often involved than the proxi-
mal limb. It is postulated that this results from an appropriately sized fascial
defect at the time of operation becoming disproportionately enlarged as the
distal limb atrophies. Incidence reported in the literature ranges from 5–
47% [2,5,7,8].
A commonly associated finding with colostomy prolapse is parasto-
mal hernia. In a series by Allen-Mersh, 50% of the patients with colostomy
prolapse had concomitant parastomal hernia [10]. This may occur because
the fascial and skin apertures for colostomies are larger than for ileosto-
mies. This is especially true for end colostomies because they are often
created at the time of obstruction, mandating overly large fascial and skin
openings at the time of surgery. Although parastomal hernias can occur
with end or loop ileostomies or loop colostomies, they are most often asso-
ciated with end colostomies.
SYMPTOMS
Prolapse can cause unsightly bulging of the stoma, which can adversely
affect the ostomy patient’s acceptance of the stoma. The presence of this
bulge, especially if associated with a parastomal hernia, commonly results
in difficulties with proper fitting of the ostomy management system. The
mere bulk of the prolapsed colon may result in dislodgement of the pouch
from the parastomal skin. As a result of an improperly fitted appliance,
leakage and parastomal skin irritation can ensue (Fig. 2). Thus pain or
bleeding from skin excoriation and a poorly fitting ostomy management
system may be a symptom of prolapse. The prolapsed colon itself is suscep-
tible to trauma, including mucosal ulceration and bleeding. Although it is
usually easily reduced, maintenance of reduction is often difficult or impos-
sible [11]. Ultimately obstruction from incarceration or even strangulation,
leading to possible peritonitis, can occur. Although these complications are
unusual, they do require immediate recognition and treatment [2 ]. The man-
agement of incarceration is addressed further on in this chapter.
It is important to recognize that the ostomy patient’s overall quality
of life can be severely hampered by a poorly functioning stoma. In a pro-
spective, randomized study of 76 patients, Gooszen and colleagues [12]
followed patients after either loop ileostomy or loop colostomy, evaluating
quality of life with questionnaires at scheduled visits. Patients were catego-
310 Rosen
Figure 2 Peristomal skin irritation.
Stomal Prolapse 311
rized into various groups, ranging from “socially interactive” to “socially
isolated.” Prolapse was rarely seen in patients seeking “social isolation less
than once per week” (2 of 33; 6%), but was quite common in patients
seeking “complete isolation” (3 of 8; 38%). The authors concluded that
prolapse was a contributing factor to social isolation and decreased quality
of life for these patients.
RISK FACTORS
The development of stomal prolapse is usually insidious rather than acute.
Certain circumstances are thought to predispose to the development of pro-
lapse, but the level of evidence in the literature is often inadequate. There
are both patient- and surgery-related factors (Table 2).
Conditions that increase intra-abdominal pressure likely predispose to
stomal prolapse. Chronic coughing (i.e., patients who smoke) and straining
(i.e., frequent constipation) are believed to be associated with stoma pro-
lapse. Neonates and infants are felt to have higher rates of prolapse (13–
30%) not only because stomas are usually placed during obstruction (i.e.,
Hirschsprung’s disease, imperforate anus) but also secondary to frequent
crying and screaming episodes, which cause increased intra-abdominal
pressure [13,14]. Although never demonstrated in a prospective trial, many
surgeons believe obese patients are at a higher risk for developing a variety
of stomal complications, including prolapse, parastomal hernia, and retrac-
tion. Efforts by the patient to lose excess weight, quit tobacco habits, and
improve bowel regimen may be rewarded with lower incidences of pro-
lapse.
Table 2 Factors Contributing to Stomal Prolapse
Patient-Related Factors Surgery-Related Factors
Higher Level of Evidence
Age—i.e., pediatric and elderly Loop > end stomas
Bowel obstruction Oversized aperture—i.e., trephine tech-
nique
Increased intra-abdominal pressure Proximal > distal colon
Pregnancy Improper site—i.e., lateral to rectus muscle
Spinal cord injury No preoperative marking by stoma nurse
Failure of mesenteric fixation
Lower Level of Evidence
Obesity
Bowel redundancy
Weak fascia
Sources: Refs. 2, 13 –16.
312 Rosen
Creation of an abdominal wall aperture that is too large is likely to
lead to prolapse and herniation. Following the “two finger” rule can obviate
this technical error. If the aperture accepts two fingers placed through the
internal opening, so that both interphalangeal joints are at the level of the
skin defect, an adequate opening has been achieved. An abdominal wall
opening that is too large, especially in the presence of other predisposing
factors, will lead to the development of prolapse. Extra care must be taken
in forming an end-sigmoid colostomy for an obstructing distal lesion be-
cause the colon proximal to the obstruction will be very dilated. Patients
who undergo surgery while obstructed have a significantly higher risk of
prolapse (38 vs. 7%) [2]. Although dilation and bowel wall edema resolve
rapidly after diversion, the aperture remains as large as was necessary to
permit exteriorization of the divided colon. Golladay described using a
purse-string technique in pediatric patients to avoid this problem [17]. Two
purse strings of absorbable suture are used to fasten the seromuscular layer
of the bowel to both layers of fascia in a running fashion and then
“cinched” to reduce the diameter of the greatly dilated bowel to a more
normal size (Fig. 3). With resolution of edema, the stoma remains widely
patent but does not prolapse. The authors used this technique in 85 patients
and reported no episodes of prolapse.
It is not uncommon for pregnant women to notice increased protrusion
of their stomas during the last trimester of pregnancy. Gopal reviewed 67
ostomates during 82 pregnancies in order to determine the risk of gestation
and labor to stomal prolapse; 4 prolapses occurred (4.8%) [16]. Pregnancy
may increase risk of prolapse via an enlarging uterus, hyperemesis [18],
or changes in the abdominal wall. Often, surgical correction is unnecessary,
as the condition resolves after delivery with the return to normal intra-
abdominal pressure. When surgery is required, it should be deferred until
after delivery.
Patients with spinal cord injuries may require the creation of a colos-
tomy. Arun et al. reviewed ostomy prolapse in paraplegic patients in an
acute spinal cord injury unit. They concluded that prolapse is more likely
to occur in paraplegic patients with an injury at or above the T-10 level [19].
The exact reason for this association is unknown.
PREVENTION
The single most important factor in the prevention of stomal prolapse is
adherence to sound surgical technique. Technical aspects have a direct ef-
fect on the ultimate outcome of the stoma, its function, and its propensity
for complications. Factors that directly affect the predilection for prolapse
include selection of the stomal site, creation of the abdominal wall aperture,
and the technique of fixation.
Stomal Prolapse 313
Figure 3 Purse-string technique. (Adapted from Ref. 17.)
During construction of the stoma, strict attention to technical detail is
imperative. A common factor in the development of prolapse is improper
location of the stoma site. The ideal location for a stoma is away from bony
prominences, skin creases, old scars, the umbilicus, the belt line, and future
incision sites. The stoma should be brought out through the rectus abdomi-
nis muscle. If the stoma is located outside the rectus abdominis, it is more
prone to prolapse and herniation. In the series by Weaver et al., parastomal
hernia and prolapse were associated with an improperly sited stoma in 10
of 17 patients [20]. Fleshman and Lewis reported malpositioning of the
314 Rosen
stoma in 12% of patients with stomal prolapse [1]. Preoperative marking of
the stoma site by an enterostomal therapist allows for proper site selection.
Many authors hold that failure to fix the bowel mesentery at the level
of the internal opening can contribute to prolapse. This remains a debatable
point and is not universally accepted [21,22]. There is good evidence sug-
gesting that fixation of the mesentery to the abdominal wall will prevent
prolapse. Makela et al. evaluated patients with stomas for “late complica-
tions” in order to elucidate potential contributing factors. Of the 13 pro-
lapsed stomas in 156 patients, 10 were nonfixed and 3 were fixed [6]. Fur-
ther evidence is provided by Ng et al., who performed a prospective,
randomized controlled trial of 55 pediatric patients to evaluate the efficacy
of distal colon tethering in preventing prolapse of a loop colostomy. Using
specific criteria for successful tethering (length of mesentery tethered to
abdominal wall being greater than three times the width of the fascial aper-
ture), it was demonstrated that no patient with successful tethering suffered
a prolapse, while patients without tethering experienced higher rates of pro-
lapse (26 and 7%, respectively) [23].
Although the stoma can be secured to the posterior rectus sheath and
peritoneum or to the anterior rectus sheath, neither of these adjunctive ma-
neuvers obviates stomal prolapse. Moreover, the use of seromuscular su-
tures for fascial fixation may encourage subsequent fistula formation. More
important than the number of levels through which sutures are placed is the
size and location of the aperture in the abdominal wall.
Whittaker and Goligher favored the use of the extraperitoneal approach
for the construction of the stoma [24]. In their experience, this technique was
associated with a decreased incidence of complications, including prolapse,
when compared to a standard intraperitoneal colostomy. However, despite
the authors’ enthusiasm, these differences were not statistically significant.
Ein reported his experience with the creation of a divided-loop colostomy
in 13 infants by using a modification of the extraperitoneal approach. Dur-
ing the 3-year study period, no prolapse was observed [25].
Patients who undergo stoma construction via a trephine approach may
have an increased incidence of prolapse [15]. This is thought to be second-
ary to enlarging the fascial defect during the procedure while attempts are
made to improve visualization, usually while mobilizing mesenteric attach-
ments. The tendency to create an oversized stoma must be avoided because
it is both unnecessary and inadvisable.
Laparoscopy-assisted stoma formation may help overcome the ten-
dency to stretch the fascial defect. Kini followed patients for up to 18
months after laparoscopy-assisted trephine stoma formation, with no evi-
dence of prolapse or hernia [26]. Fuhrman reviewed 17 rectal cancer pa-
tients who underwent laparoscopic intestinal stomas. Only one patient de-
veloped prolapse and subsequently died from complications of metastatic
disease within weeks of developing prolapse. Fuhrman stated, “the laparos-
Stomal Prolapse 315
copic method does not compromise the surgeon’s ability to choose a loca-
tion for the stoma, nor does it impair the ability to mobilize and prepare the
intestine for exteriorization” [27]. Ludwig published the Cleveland Clinic
experience with 24 laparoscopic procedures, with no reoperations for stoma-
related complications [28]. Although no large study has been published to
analyze long-term complication rates of laparoscopic stomas, there is no
current evidence that stomas created using laparoscopic techniques are more
prone to complications or specifically to prolapse.
The design of a rodless end-loop stoma is felt to protect against pro-
lapse of the distal limb, since only a small portion of the stapled antimesen-
teric border is brought out and matured through the abdominal wall opening
(Fig. 4). Over a 7-year period, 229 patients had end-loop stomas created at
the University of Illinois, lasting for 3 months to 7 years; only 1 prolapse
(0.4%) occurred [29].
When the bowel is exteriorized though the stoma site, attention should
be directed toward creating a well-vascularized stoma. Redundant bowel
proximal to the stoma should be resected to lessen stomal prolapse. The
spout should be of proper length after eversion and maturation: 2 cm for
an ileostomy and <2 cm for a colostomy.
Clearly a variety of techniques are available for the creation of a stoma.
Adherence to sound surgical judgment, proper selection of the site, and care-
ful creation of the aperture are most important in preventing stomal prolapse.
Furthermore, adjunctive techn iqu es such as fixation of the mesentery or exte-
riorization of the segment and alternative stomas such as the rodless end-loop
stoma may have a role in the prevention of stomal prolapse.
MANAGEMENT
The physician caring for the patient with stomal prolapse must decide
which course of therapy to pursue. Indications for surgery are based on
degree of inconvenience experienced by the patient balanced against fitness
to undergo surgery and probability of achieving a successful outcome [10].
If the prolapse is minimal and asymptomatic, an expectant course is indi-
cated. If the patient has significant comorbid diseases, the risks of surgery
may outweigh the potential risks associated with ostomy prolapse. If the
patient is a reasonable surgical candidate and nonoperative means fail, sur-
gical options should be considered. There are two surgical approaches to
the management of stomal prolapse: local parastomal procedures and intra-
abdominal procedures. The choice of surgical procedure should be tailored
to the individual patient and to the type of stoma. It is recognized that those
patients who undergo surgical repair for prolapse have a higher rate of recur-
rent surgery than patients with other ostomy complications, such as hernia
and stenosis [10].
316 Rosen
Figure 4 Rodless end-loop stoma. (Adapted from Ref. 29.)
Stomal Prolapse 317
Ileostomy
A variety of local techniques are available for the management of a pro-
lapsed ileostomy. Local repair of the prolapse can be performed by dividing
the mucocutaneous junction. Some advocate leaving a rim of mucosa on
the skin of the mucocutaneous junction, thereby eliminating the need for
further skin excision and further widening of the skin aperture. Others ad-
vocate excising only a small amount of parastomal skin with the mucocuta-
neous junction. Once mucocutaneous division is accomplished, the bowel
is dissected and delivered through the skin aperture, thus eliminating any
excess proximal redundancy. The redundant bowel is resected, and a new
primarily everted stoma is created. Nonabsorbable mesh can be secured
around the stoma at the level of the posterior rectus sheath. This option is
reserved for patients with concomitant parastomal hernias. Another surgical
approach to the prolapsed ileostomy is laparotomy with relocation of the
ileostomy. This is usually reserved for patients with associated large para-
stomal hernias or for those in whom a local approach has already failed.
End Colostomy
Several options are available in the management of the prolapsed perma-
nent end colostomy, including local revision and laparotomy with reloca-
tion. If the stoma is temporary, re-establishment of intestinal continuity may
be preferable to surgical repair of the prolapse. Those who undergo early
closure secondary to prolapse symptoms or sequelae do not suffer increased
rates of operative complications [2]. If the stoma is permanent, local mea-
sures should be attempted whenever possible. Gauderer and Izant described
a technique of postreduction intraluminal bowel fixation. After reduction of
the prolapsed segment, the reduced bowel is attached to the parietal perito-
neum with the use of large U sutures several centimeters away from the
stoma. The sutures are bolstered to the skin with latex tubing. The authors
used this technique on four children with prolapsed colostomies [30]. But-
ton colopexy has also been described by Berzin and Canil (Fig. 5) [31,32].
This involves fastening a button in the stoma (below fascia level) to another
button adjacent to the stoma (on the skin), thus fixing the reduced stoma.
After 1 month, during which adhesions have presumably formed, the but-
tons may be removed. This technique has been described in 12 patients
with no complications reported.
Abulafi described a modification of the Delorme procedure for pro-
lapsed colostomy [33]. A mucosal dissection is performed with a redundant
seromuscular layer left behind. Several pleating sutures are placed in the
muscular coat, precluding the need for resection. Good results were re-
ported in two patients. This option might be appropriate in elderly patients
or those considered unfit for major surgery.