Enterostomas:
History
Recent advances
Complications
Valentine N. Nfonsam, MD,MS
Assistant Professor of Surgery
Colon and Rectal Surgery
University of Arizona
Introduction
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Over 500,000 in the US have some kind of functional
enterostomy
Annually 120,000 more are created
 36.1% colostomy
 32.2% ileostomy
 31.7% urostomy
Average age of a patient with ostomy is 68.3 years
Advances in stoma surgery, enterostomal therapy and ostomy
management led to better ostomates lives
Colorectal surgeons have pioneered new techniques and ostomy
management systems that have allowed the intestinal stoma to be
a barely noticeable alternative to perianal defecation
History
•The
Bible describes one of the
earliest accounts of visceral
injury in the old testament
when Eglon was stabbed by
Ethud:
“He (Eglon) could not draw the
dagger out of his belly and dirt came
out”
•350
BC – Praxagoras of Kos – has
a kind of stoma created by intestinal
injuries
History
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Hippocrates(460-377BC), Cornelius (53BC-AD7),
Galen(131-201AD) knew injuries to colon and small
intestine were often fatal – but did not know what to
do
14th Century: Artillery began to be used in wars, and
patients with GSW to abdomen – mostly died
Prior to WWI - French did pioneering work on stoma
surgery – which later spread to the rest of Europe
Between the Two world wars and after WWII –
Americans took the lead in the field of stoma.
History
•Soldier
George Deppe injured his back at the
Battle of Ramillies (The duke
of Marlborough beat the
French) – May 23rd 1706.
•He
sustained a wound to the
lower back – and developed
what today is known as a fisula
•He
lived with it for 14 years.
History
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Earliest stomas were not envisioned or created by
imaginative surgeons but by forces of nature
These patients managed these stomas on their own
It was only much later that physicians ponder the
surgical creation of an ostomy.
In 1757 Lorenz Heister (1683-1758) first recommended
the surgical creation of stomas for the treatment of
abdominal trauma.
History
After observing spontaneous stomas in individuals
with abdominal wounds, Heister wrote:
"As the lips of the intestines, so wounded,
would sometimes quite unexpectedly adhere to
the wound of the abdomen; and therefore it
seemed no reason why we should not take hints
from nature"
History
Time of barber surgeons such as John Bell and
Gene Palfin
"It is surely far better to part with one of the
conveniences of life than to part with life itself“
(Lorenz Heister)
History
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In 1710 Alexis Littre (1626-1726) suggested the
creation of an abdominal stoma in the treatment of
imperforated anus after observations made during the
autopsy of a six-day old infant.
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This idea remained untested for 66 yrs until in1777
when Pilore, a country surgeon from Rouen, France
performed a cecostomy for the treatment of an
obstructing rectal cancer. (histoire)
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“…..for a dressing, I applied burnt charcoal and towels.”
History
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Not until 1793 that the first successful stoma was
created.
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Duret, a naval surgeon at Brest performed the first
successful left iliac colostomy in the treatment of
imperforated anus on a three-day old infant.
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He practiced on a 15 day old dead child
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Pt. survived till age 45
History
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With the advent of surgical stomas, it became necessary to create
a means for the collection of feces.
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Pts left to their own devices
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First mention of collecting device was reported by Daguesceau
in 1795.
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He performed a left inguinal colostomy on a patient that impaled
himself on a wheat cart
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The Farmer created his own appliance and died at age 81
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“…he conveniently collected his feces in a small leather pouch”
History
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Until this time only loop stomas had been surgically created
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Prone to prolapse and often did not completely divert the fecal
stream.
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In 1881, Schitsinger and Madelung both described a procedure
for creating a proximal “single barreled” stoma while returning
the distal loop in to the abdominal cavity
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This was the start of the end colostomy
History
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Stomas also played an important role in early techniques for safe
intestinal anastomosis
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Primary anastomosis advocated in the late 1800s ---high
morbidity and mortality
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Johann Von Mikulicz-Radecki noted high leak rates led to
Morbidity and Mortality.
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He advocated a two-stage technique for intestinal anastomosis
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Resection with double-barreled stoma
Anastomosis 2 weeks later
Morality decreased from 50% to 12.5% in his first 100 pts.
History
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Colostomy also become important in the treatment of other
conditions like diverticular disease.
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In 1907 Mayo first described the use of the right transverse
colostomy in the treatment of diverticulitis with reversal after
resolution of inflammation
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In the 1930s, Mayo, Rankin and Braun independently described
a three stage approach consisting of
- diverting transverse colostostomy and drainage,
- a secondary sigmoid resection with anastomosis and
- finally a colostomy closure.
Henry Hartmann (1860-1952)
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Born in France and graduated from the university of Paris
Medical school in 1877
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Performed more than 30,000 operations
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Somewhere between 1909 and 1923 devised the “Hartmann
procedure” for obstructing sigmoid cancer. Unknown if he ever
performed this for diverticulitis
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Unknown surgeon in the 1930s first performed this two-staged
resection and anastomosis for diverticulitis
History
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Though the first colostomy was performed in 1776, the first
ileostomy was performed more than a century later.
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In 1879, Baum, in Germany, performed the first diverting
ileostomy for treatment of obstructing right colon cancer
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In 1883 Maydl, of Vienna, performed the first successful
ileostomy in combination with a colonic resection
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J. M. T. Finney described the flush-loop ileostomy for treatment
of SBO- Much complications, skin irritation
History
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In 1888, the support rod was introduced to prevent retraction of
the loop stoma until it has granulated to the abdominal wall
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Major advancement. Produced protruding stoma. Provided almost
complete diversion of fecal stream.
Widespread use of Ileostomy came as a result of the work of
John Y. brown, a St. Louis Surgeon in 1912.
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Reported experience with 10 pts
Ileostomy at lower pole of laparotomy incision
Stoma protruded 2-3 inches beyond abdominal wall and was emptied by a
catheter sewn in place
Catheter removed eventually and stoma matured by itself.
History
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The single most important
advance in ileostomy history
was described by Bryan
Brooke, university of
Birmingham, London
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In a 1952 article, entitled
“Management of Ileostomy
and its Complications”,
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Brooke in a single sentence,
dramatically advanced
surgical treatment and life
with an ileostomy.
Bryan Brooke
History
‘A more simple device is to evaginate the ileal end
at the time of operation and suture the mucosa
to the skin; no complications have occurred
from this’
- Bryan Brooke (1952)
History
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Crile in 1942 also suggested the
"mucosal grafted ileostomy" to
prevent ileostomy dysfunction.
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He recommended removing the
distal 3 to 4 cm of serosa and
muscle from the ileostomy and
folding over and suturing the
redundant mucosa to the
abdominal skin in order to
"mature" the ileostomy at the time
of surgery.
Dr George Crile – Co
founder of Cleveland
Clinic
History
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Turnbull and Crile (Cleveland
clinic) and Brooke made advances
in ileostomy surgery
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Turnbull and Gill coined the term
“enterostomal therapist” in 1958
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Turnbull opened the first school of
enterostomal therapy in 1961
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First real pouch was created in
1944 by Henry Koenig
(ileostomate)
Rupert Turnbull
History of Ileostomy
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Ileostomy – relatively newer
terminology
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First recorded Ileostomy – 1879 by
Wilhem Baum, a German Surgeon
from Danzig – created a ileostomy
in a patient with malignant tumor –
Patient died 9 weeks later
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Successful recovery after ileostomy
– reported by Maydi from Vienna
in 1883
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Lauenstein (1894) created the first
protruding ileostoma.
Wilhem Baum
Types of Stomas
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Colostomy
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Ileostomy
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End colostomy
Loop colostomy
End Ileostomy
Loop ileostomy
End Loop ostomy
Cecostomy
Urostomy
Types of Ostomy
Stoma types
End ostomy types
(A) End stoma (inset shows everting maturation); (B) double-barrel stoma: End stoma
and mucous hop-Koop stoma; and (F) fistula are divided and brought through the
same incision (inset shows closed mucus fistula sutured to abdominal wall); (C) loop
stoma; (D) decompressing blowhole stoma; (E) Bis Santulli stoma
Indications
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To provide fecal diversion for both elective and
emergent procedures
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Colonic obstruction
Bowel perforation with peritonitis
Trauma
Protection of low colorectal/coloanal anastomosis
Perianal sepsis
Radiation proctitis
Rectovaginal fistula
incontinence
Preoperative Considerations
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Preoperative Counseling
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Stoma nurse/therapist
Assuage anxiety
Explain post op care
Stoma site selection
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Visibility (pt. able to care for stoma)
Colostomy vs ileostomy
Assess pt supine, sitting, standing and bending forward
Individualized
Pass through Rectus abdominis muscle ( parastomal hernia)
Superior aspect of the infra-umbilical fat fold in the lower quadrant (pt. visibility)
Obese pts –better located in upper abdomen
Avoid skin creases, bony prominences, scars, drain sites and belt lines.
Mark site
Advances
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Improvement in Stoma creation – Laparoscopic
/ Single port techniques
Placement of mesh at the time of ostomy
construction
Improvements in stoma appliances including
Laparoscopic options
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Laparoscopic colostomy
/ Ileostomy
3 ports usually, SILS
Operative time usually ~
<1 hour
Lap Transverse Colostomy
Advantages of Laparoscopy
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Better selection of stoma site – as no midline
incision is involved
Early post operative recovery
Better pain control
Short length of hospital stay
Cosmesis
Stoma and recreation
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Can swim – without
harming the stoma
/spillage. Bag and
adhesive are waterproof.
Mini bags , Stoma caps
are available
Diving: Yes. A suit
including the bag would
be better
Sauna: Yes. Sauna belts
are available
Complications
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20-41% of patients will have complications
Nearly 50% of these will require a revision
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Ileostomy vs colostomy
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Early complications
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Ischemia, hemorrhage, stenosis, fistula and retraction. Technical
Late complications
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6% -76% incidence
Prolapse, obstruction, hernia and skin irritation
Complication due to poor technique and poor care and management.
Could also be due to recurrent disease.
Stoma Ischemia/Necrosis
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2.3-17% incidence
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Ranges from harmless mucosal
sloughing to frank Necrosis
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Causes
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Aggressive stripping of mesentery
Stenotic fascia defect
Extensive tension
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Assess depth of necrosis
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Necrosis beyond fascial defect warrants
immediate reconstruction
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Consider End loop
Hemorrhage
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Mild hemorrhage common and self limiting.
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Usually mucosal.
Apply pressure
Active bleeding
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Implies failure to ligate a mesenteric vessel
Identify and ligate prior to leaving OR
Stomal Stenosis/Stricture
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2-14% incidence
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Could manifest early or late
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Ischemia is usual underlying factor
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Other causes: -Infection and
retraction
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R/o Crohn’s or recurrent
malignancy
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Treat initially with dilation
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Definitive Stoma revision
Mucocutaneous Separation
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Separation along mucocutaneous
border
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Occurs to some extent in many
patient
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Caused by underlying tension and
or separation of sutures
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Supportive care usually resolve
problem
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Could lead to eventual stricture,
serositis or infection
Infection/Fistula
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Incidence of 2-14.8%
Peristomal abscess
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infected hematoma
Stoma revision
Foliculitis for mature stomas
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I &D
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Fistula may form from Abscess
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Beyond immediate post op, fistula
formation or infection could be
signs of recurrent Crohn’s disease
Stoma Retraction
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1-6% for colostomy and 3-17% for
ileostomy
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Most common reason for re-operation
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Tension:
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Tension
Obesity
Steroids use. Poor wound healing
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Can lead to leakage and severe skin
problem, more in ileostomy
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Convex stoma plate or use of protective
barrier helps
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Most eventually need revision
Prolapse
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2-26% incidence
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Seen mostly in transverse loop
colostomy (30%)
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May occur with parastomal hernia
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Managed by reduction and
supportive care until definitive
surgery
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Convert to end colostomy if need
be
Ileostomy Prolapse
Parastomal Hernia
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“ It doesn’t matter if God Himself made
your ostomy. If you have it long enough
you have a 100% risk of a parastomal
hernia”
J Byron Gathright, 1996
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50% of patients
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Predisposing factors
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Stoma placement lateral to rectus
Large stoma aperture
Obesity
Prior abdominal incisions
Malnutrition
Wound infection
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Minor cases- Abdominal binder
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Symptomatic – Repair with mesh,
Relocation
Acute Parastomal hernia/Bowel
obstruction
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Incidence 4.6-13% in early post op
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Causes
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Technical
Too large fascial defect
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Rarely seen in mature stomas
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Signs of bowel obstruction
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Repair hernia with mesh
Skin Complication
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3-42% Incidence
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Range from mild skin dermatitis to full- thicknes
skin necrosis and ulceration
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More common with illeostomy
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Skin Erosion from constant exposure to stoma
effluent
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Contact dermatitis
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Fungal infection
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Intervention
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Contact Dermatitis
Better fitting appliance
Improve cleaning of peristomal skin
Application of desents and skin barriers
Anti fungals and antibiotics
Stoma paste
Effluent Irritation
Edema
Skin Complications
Candida albicans infection
Foliculitis
Skin Complication
(Pyoderma Gangrenosum)
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First described associated
with Crohn’s in 1970
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Diagnosis mainly by physical
exam (80%)
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“Cookie cutter” appearance
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Treatment conflicting
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Wound debridement
Steroids injection
Systemic therapy
Skin Complications
(Pyoderma Gangrenosum)
Skin Complications
(Granulomas)
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Granulomas are lumpy
lesions due to inflammation
in the dermis.
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Stomal granulomas may be
due to:
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Granulation tissue (poor
wound healing and infection)
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Bowel metaplasia (stomal skin
morphing into bowel tissue)
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Crohn's disease
Stoma warts
Stoma Appliances
Conclusion
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In the last century, there have been dramatic
improvements in surgical techniques for the creation of
stomas

Life with a stoma has also changed dramatically

The development of enterostomal therapy and the
improvement of ostomy management systems have
made life with a stoma nearly as routine as life with an
anus.
Conclusion
“care and expertise are important in creating
intestinal stomas because some patients must
live with the technical result for the rest of their
lives”
Thank you