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408 Casey et al.
27. Resnick RH, Ishihara A, Chalmers TC, Schimmel EM, Boston Inter-Hospital
Liver Group. A controlled trial of colon bypass in chronic hepatic trial of
colon bypass in chronic hepatic encephalopathy. Gastroenterology 1968; 54:
1057–1069.
28. Eade MN, Alexander-Williams J, Cooke WT. Bleeding from an iloeostomy
caput medusae. Lancet 1969; 2:1166–1168.
29. Foulkes J, Wallace DM. Haemorrhage from stomal varices in an ileal conduit.
Br J Urol 1975; 47:630.
30. Conte JV, Arcomano TA, Naficy MA, Holt RW. Treatment of bleeding sto-
mal varices: report of a case and review of the literature. Dis Colon Rectum
1990; 33:308–314.
31. Kartheuser AH, Dozois RR, LaRusso NF, Wiesner RH, Ilstrup DM, Schleck
CD. Comparison of surgical treatment of ulcerative colitis associated with
primary sclerosing cholangitis: ileal pouch-anal anastomosis versus Brooke
iloeostomy. Mayo Clin Proc 1996; 71:748–756.
32. Grundfest-Broniatowski S, Fazio V. Conservative treatment of bleeding sto-
mal varices. Arch Surg 1983; 118:981–985.
33. Beck DE, Fazio VW, Grundfest-Broniatowski S. Surgical treatment of bleed-
ing stomal varices. Dis Colon Rectum 1988; 31:343–346.
34. Roberts PL, Martin FM, Schoetz DJ, Murray JJ, Coller JA, Veidenheimer
MC. Bleeding stomal varices: the role of local treatment. Dis Colon Rectum
1990; 33:547–549.
35. Morgan TR, Feldshon SD, Tripp MR. Recurrent stomal variceal bleeding:
successful treatment using injection sclerotherapy. Dis Colon Rectum 1986;
29:269–270.
36. Hesterberg R, Stahlknecht CD, Ro
¨
her HD. Sclerotherapy for massive enteros-
tomy bleeding resulting from portal hypertension. Dis Colon Rectum 1986;
29:275–277.
36. Colwell JC, Dasgupta KA. Primary sclerosing cholangitis: implications for
the ET nurse. J Enterostomal Ther 1990; 17:171–173.
38. Cameron AD, Fone DJ. Portal hypertension and bleeding ileal varices after
colectomy and iloeostomy for chronic ulcerative colitis. Gut 1970; 11:755–
759.
39. Adson MA, Fulton RE. The ileal stoma and portal hypertension: an uncom-
mon site of variceal bleeding. Arch Surg 1977; 112:501–504.
40. Fitzgerald JB, Chalmers N, Abbott G, Lee SH, Warnes TW, Youngs GR,
Wardle TD. The use of TIPS to control bleeding caput medusae. Br J Radiol
1998; 71:558–560.
41. Shibata D, Brophy DP, Gordon FD, Asnastopoulos HT, Sentovich SM, Ble-
day R. Transjugular intrahepatic portosystemic shunt for treatment of bleed-
ing ectopic varices with portal hypertension. Dis Colon Rectum 1999; 42:
1581–1585.
42. Sigler L, Jedd FL. Adenocarcinoma of the iloeostomy occurring after colec-
tomy for ulcerative colitis: report of a case. Dis Colon Rectum 1969; 12:
45–48.
43. Cuesta MA, Donner R. Adenocarcinoma arising at an iloeostomy site: report
of a case. Cancer 1976; 37:949–952.
Unusual Problems in Stoma Management 409
44. Roth JA, Logio T. Carcinoma arising in an iloeostomy stoma: an unusual
complication of adenomatous polyposis coli. Cancer 1982; 49:2180–2184.
45. Baciewicz F, Sparberg M, Lawrence JB, Potich SM. Adenocarcinoma of an
iloeostomy site with skin invasion: a case report. Gastroenterology 1983; 84:
168–170.
46. Stryker SJ. Primary stomal adenocarcinoma: an unusual complication of
iloeostomy. Dis Colon Rectum 1983; 26:47–49.
47. Bedetti CD, DeRisio VJ. Primary adenocarcinoma arising in an iloeostomy
site: an unusual complication after colectomy for ulcerative colitis. Dis Colon
Rectum 1986; 29:572–575.
48. Vasilevsky C-A, Gordon PH. Adenocarcinoma arising at the ileocutaneous
junction occurring after proctoc ole ct omy for ulce rat iv e colitis. Br J Surg 1986;
73:378.
49. Longo WE, Stephan RN, True LD, August DA, McCullough WB. Recurrent
ileal mucinous adenocarcinoma in an iloeostomy. J Clin Gastroenterol 1986;
8:192–194.
50. Carter D, Choi H, Otterson M, Telford GL. Primary adenocarcinoma of the
iloeostomy after colectomy for ulcerative colitis. Dig Dis Sci 1988; 33:509–
512.
51. Roberts PL, Veidenheimer MC, Cassidy S, Silverman ML. Adenocarcinoma
arising in an iloeostomy: report of two cases and review of the literature.
Arch Surg 1989; 124:497–499.
52. Starke J, Rodriguez-Bigas M, Marshall W, Sohrabi A, Petrelli NJ. Primary
adenocarcinoma arising in an ileostomy. Surgery 1993; 114:125–128.
53. Johnson WR, McDermott FT, Pihl E, Hughes ESR. Adenocarcinoma of an
iloeostomy in a patient with ulcerative colitis. Dis Colon Rectum 1980; 23:
351–352.
54. Schlippert W, Mitros F, Schulze K. Multiple adenocarcinomas and premalig-
nant changes in “backwash” ileitis. Am J Med 1979; 66:879–882.
21
Technical Tips
for the Difficult Stoma
Peter A. Cataldo
University of Vermont College of Medicine,
Burlington, Vermont, U.S.A.
The creation of an intestinal stoma is a nearly purely technical endeavor.
In most situations it is relatively simple and can be well performed by any
experienced surgeon. However, under some circumstances, creating a well-
perfused, properly placed colostomy or ileostomy can be very difficult.
These include the placement of stomas in patients who are morbidly obese,
those who have had multiple surgeries, those requiring two intestinal sto-
mas, and patients with spinal cord injury.
This chapter suggests preoperative planning strategies and technical tips
that will hopefully make even difficult stoma creation safe and satisfying.
In creating temporary stomas, thoughtful considerations of future sto-
mal take-down will make the ensuing surgery safer and less difficult. This
chapter offers insight into the creation of temporary stomas, which do not
require subsequent laparotomy for take-down. In addition, it offers several
methods of making a “Hartmann take-down,” often a very challenging en-
deavor, less difficult.
Even in the best of circumstances, some stomas will develop postoper-
ative ischemia. This chapter includes methods of assessment for evaluating
the degree of the ischemia in the early postoperative period. Treatment al-
gorithms are also included, which will help determine appropriate treatment
for various degrees of stomal ischemia.
Overall, this chapter offers some relatively simple, straightforward
technical advice that will lead to the creation of the well-perfused, properly
placed intestinal stomas which, if necessary, will last a lifetime.
INTRODUCTION
On having read this chapter, the reader should be able to understand situa-
tions where the creation of an intestinal stoma is technically challenging.
411
412 Cataldo
Further he/she should be aware of many technical tips which will make
difficult stoma creation simpler and safer.
TECHNICAL TIPS FOR THE DIFFICULT STOMA
An intestinal stoma, commonly created at the end of a long and complex
operation, is often the greatest predictor of long-term postoperative quality
of life. They are often left to be completed by junior residents with little
functional knowledge of stoma creation and even less clinical experience.
Each stoma represents an intestinal anastomosis and all principles that
apply to creating any intestinal anastomosis similarly apply to stoma cre-
ation. The need to avoid tension and preserve blood supply is no less im-
portant in stoma creation. Keeping that in mind, the following chapter
hopefully elucidates techniques for creating properly placed, well-vascular-
ized stomas without undue tension, even under difficult circumstances.
Many times the creation of a well-vascularized stoma without tension
is a relatively simple process. However, in the obese patient, the patient
with multiple surgical scars, or in individuals with a short, thick mesentery,
it can be very challenging. The following paragraphs provide a summary
of technical tips for creating healthy, functional stomas in these adverse
situations. In addition this chapter also details other technical pearls for
creating temporary stomas, which will lead to easier stoma take-down and
often avoid the need for a second laparotomy.
PREOPERATIVE PREPARATION
A significant percentage of stoma-related complications are due to im-
proper placement. Peristomal hernias and stomal prolapse are more com-
monly associated with stomas placed outside the rectus abdominis, while
peristomal leakage and poorly fitted appliances are associated with stomas
placed too close to incisions, bony prominences, or large skin folds. Nearly
all these complications can be prevented by proper preoperative marking
and stoma placement. Elective cases allow the luxury of time; therefore
an enterostomal therapist, if available, can mark patients preoperatively.
Emergency cases require urgent marking either in the emergency room or
the patient’s hospital room. In all but the most unstable of patients, a few
minutes to identify an appropriate site for an intestinal stoma will go a long
way toward avoiding postoperative complications.
The marking sequence should require 1 or 2 min (see Fig. 1). The
anterosuperior iliac spine, pubic tubercle, and umbilicus are identified, as
is the lateral aspect of the rectus muscle. Following this, the patient’s belt
line is marked. With this information, a stomal site (right side for ileos-
tomy, left side for colostomy) can be identified. The stoma should pass
The Difficult Stoma 413
Figure 1 Ostomy triangle, bordered by the anteriosuperior iliac spine, pubic tu-
bercle, and umbilicus.
through the rectus abdominis muscle and be 5 cm away from bony promi-
nences, skin folds, old incisions, and the umbilicus. If possible, once the
site is marked, the patient should be asked to sit up, to ensure that large
skin folds do not develop at the previously marked site. Individuals with
disabilities should be marked in the position in which they spend the major-
ity of their time. For example, a patient with a spinal cord injury who is
wheelchair-dependent should be marked while seated in his or her chair.
Often these individuals, as well as individuals with significant abdominal
obesity, will be better served with a stoma above the umbilicus.
Stoma marking is particularly important in patients who require multi-
ple stomas, who have had prior stomas, or who have had multiple abdomi-
nal incisions. It is important to remember that the both the left and right
upper quadrants are potential stoma sites as well as the umbilicus and the
midline in the suprapubic region. These are all much less commonly em-
ployed than the right- and left-lower-quadrant transrectus stoma sites but
may in some circumstances allow the creation of a well-functioning stoma
in an individual with a difficult abdominal wall. In rare instances the often
forgotten but once popular lumbar colostomy can also be used (see Fig. 2).
414 Cataldo
Figure 2 Alternative stoma sites, which include those that are now rarely used
as well as one commonplace lumbar colostomy.
CHOOSING THE APPROPRIATE INTESTINAL SEGMENT
Many times the intestinal segment is dictated by the surgical pathology,
such as a sigmoid colostomy following abdominoperineal resection for rec-
tal cancer or an ileostomy following total proctocolectomy for inflamma-
tory bowel disease. However in some cases, particularly with temporary
stomas, several intestinal segments may be available for stoma creation.
Regarding both the small intestine and the colon, the more distal the stoma,
the better the function (i.e., and a sigmoid colostomy is superior to a right
transverse colostomy). However this is not always true. For example, an
ileostomy may be tolerated far better than a right transverse colostomy. The
following principles should serve to help determine stoma placement:
1. If the stoma is temporary and re-establishment of continuity is
likely, the preservation of bowel length should take precedence
over creating the optimal stoma—i.e., if a left colectomy is per-
formed for an obstructing descending colon carcinoma, it is pref-
erable to create a midtransverse colostomy with plans for later
The Difficult Stoma 415
anastomosis between the transverse colon and the rectosigmoid
rather than excising the remaining colon and creating an end
ileostomy.
2. If the stoma is likely to be permanent (based on clinical judgment
at the time of the operation), emphasis should be placed on creat-
ing a stoma that will function well for the remainder of the pa-
tient’s life; i.e., in an elderly individual undergoing left colectomy
for ischemic colitis, it is often wiser to perform a total abdominal
colectomy with end ileostomy than to preserve the right colon
and leave the patient with a right-side transverse colostomy.
Finally, when a diverting stoma is required, often to protect a low
pelvic anastomosis or to treat an anastomotic leak, a loop ileostomy is far
superior to a transverse loop colostomy. Transverse loop colostomies are
associated with substantially higher complication rates and substantially
lower patient satisfaction than are loop ileostomies [1,2]. Transverse loop
colostomies are to be avoided at nearly all costs as they are prone to stoma-
related complications such as prolapse and hernia, are difficult to pouch,
and are often associated with odor and leakage problems.
PREPARING FOR OSTOMY TAKE-DOWN
Except for those performed as planned diversions proximal to intestinal
anastomoses, most temporary stomas are created under emergency condi-
tions, often in the presence of intra-abdominal sepsis and/or hemorrahage.
This can lead to extensive intra-abdominal adhesions making repeat lapa-
rotomy and subsequent stoma takedown exceedingly difficult. The classic
example of this is a Hartmann take-down following sigmoid resection and
end descending colostomy for emergency surgery for complicated diverti-
cular disease. At the time of original stoma creation, thoughtful consider-
ation of the second stage can often make reoperation easier. The thought
process should be as follows:
1. Can an intestinal stoma be safely avoided?
2. What maneuvers can be performed at the time of this operation
to increase the ease with which the second operation can be per-
formed?
3. Can a stoma be created in which laparotomy is not required to
re-establish intestinal continuity?
The issues surrounding avoidance of a stoma are beyond the scope of
this chapter and have been thoroughly discussed in the literature on colon
and rectal surgery. They are not further discussed here.
Several maneuvers can be performed to improve the ease of stoma
take-down and decrease operative complications. The most challenging
416 Cataldo
cases of this nature involve establishing continuity after a Hartmann proce-
dure, usually performed in the emergency treatment of diverticulitis or ob-
structing rectosigmoid cancer.
At the first operation, several maneuvers can make the second stage
simpler and safer:
1. The extraperitoneal planes surrounding the rectum should not be
dissected.
2. If possible, the distal rectal stump should be brought to the ante-
rior abdominal wall.
3. If it is long enough, the rectal segment should be placed under-
neath the abdominal wall adjacent to the end sigmoid colostomy.
4. If this is not possible due to the segment ’s length, the rectal stump
should be sewn to the underside of the inferior aspect of the ab-
dominal incision.
5. Often the rectal stump is too short to reach anywhere on the ab-
dominal wall. In that case, one should consider tacking the rectal
stump up to the sacral promontory. Following a Hartmann proce-
dure, the rectal stump often recedes low into the pelvis and is
adherent to the sacral hollow. This makes its identification diffi-
cult. In addition, it is often impossible to advance the endoluminal
stapler to the proximal portion of the rectum due to tortuosity.
Suturing the upper portion of the rectosigmoid to the sacral prom-
ontory prevents the regression of the rectal stump into the sacral
hollow, making it easier to identify. In addition, the rectal stump
is often less tortuous and allows for easier transanal passage or
the endoluminal stapler. Finally, the rectosigmoid staple line
should be marked with long, nonabsorbable sutures in order to
allow for easier identification. It is common at the second-stage
operation to find multiple loops of small bowel adherent to the
pelvis. Identification of the rectal stump via these marking sutures
often minimizes the extent of pelvic dissection, decreasing the
risk of injury to the small bowel.
The performance of these additional maneuvers at the time of the pri-
mary surgery is simple, safe and not time-consuming. These maneuvers
will bring substantial benefits later on, in minimizing the complexity and
complications associated with subsequent stoma take-down.
AVOIDANCE OF SUBSEQUENT LAPAROTOMY
End loop stomas [3] have been used for both simple upstream diversion of
intestinal anastomoses and also for the creation of a single stoma using
remote intestinal segments. Creation of an end loop stoma allows for subse-
The Difficult Stoma 417
quent take-down without the need for laparotomy. An example would be a
patient who has sustained a right colon injury necessitating right hemicolec-
tomy. Because of extensive fecal soilage, a primary anastomosis is not felt
to be appropriate. Under these circumstances, an end loop stoma can be
created following intestinal resection. This is done by preparing the termi-
nal ileum as for standard end ileostomy. The hepatic flexure and proximal
transverse colon are mobilized as well. At a previously chosen stoma site,
a slightly oversized stoma trephine is created. The terminal ileum is brought
through the abdominal wall, as in creation of a standard ileostomy. Follow-
ing this, the antimesenteric corner of the previously stapled proximal trans-
verse colon is brought through the upper aspect of the same stoma site
(see Fig. 3). Subsequently the ileostomy is matured in routine fashion. The
antimesenteric corner of the staple line is excised, and the entrotomy subse-
quently created in the antimesenteric corner of the transverse colon is ma-
tured primarily to the skin without eversion (see Fig. 4). The creation of an
end loop stoma has two significant advantages: (1) The patient recovers
Figure 3 End loop stoma. Both proximal and distal limbs are brought through
one stoma site.