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Fat Grafting for Improved Ileostomy Ostomy Device Fit: A Case Report

Case Report

Fat Grafting for Improved Ileostomy Ostomy Device Fit: A Case Report

Index: Wound Management & Prevention 2019;65(3):38–44 doi: 10.25270/wmp.2019.3.3844

Abstract

For patients with an ostomy, a poor fitting appliance may cause leakage, peristomal dermatitis, and frequent appliance changes. PURPOSE: The purpose of this case study was to report the outcome of fat grafting to augment peristomal soft tissue and improve appliance fit. CASE STUDY: A 57-year-old woman with a history of Crohn’s disease presented with soft-tissue deficiency and uneven contour around her ileostomy site. She was unable to properly fit an ostomy appliance, which resulted in leakage, chronic skin irritation, and frequent appliance changes. The patient underwent 2 rounds of fat grafting using fat harvested from her medial thighs and knees infused with dilute lidocaine with epinephrine. The patient noted immediate improvement after 34 cc of processed fat was injected in the first round. Appliance change frequency decreased from daily to every 3 to 4 days. A second graft of 32 cc provided 3 months later further improved appliance fit, reducing appliance change frequency to every 5 to 7 days and obviating the need to use adjustment rings and glue. Pre- and postoperative computed tomography showed increased thickness of abdominal wall subcutaneous tissues. CONCLUSION: Fat grafting around an ostomy site presents a viable option to improve contour and appliance fit with reduced skin irritation and leakage. 

Introduction

Ostomy creation is a surgical procedure that has a major effect on patients’ lifestyle. Patients regularly1,2 report reduced quality of life and physical and psychosocial well-being in addition to the burden of ostomy care, particularly when experiencing leakage. Chronic skin irritation results in pain and discomfort, limiting daily activities and engagement in social settings and contributing to social isolation.1,2 In a nationwide survey1 of 783 patients with a permanent ileostomy, 72% reported adverse effects on daily life because of their stoma; specifically, stoma care problems, including parastomal hernia, stenosis, and prolapse, affected quality of life in 63% of patients. In a 2013 review of the literature, Kwiatt and Kawata2 found overall complication rates for all types of stomas to vary between 10% and 82%, with peristomal skin problems the most common source of patient dissatisfaction and reason for wound management nursing intervention. Musculoskeletal comorbidities (rheumatoid/osteoarthritis), immobility, poor American Society of Anesthesiologist rating, and surgery for cancer have been found to be independent risk factors for overall ostomy surgery complications; in addition, obesity contributes to poor outcomes, and respiratory comorbidities, smoking, diabetes, and malignancy associated with the highest risk of complications.2

Skin complications. Skin complications following stoma creation are common. A prospective group analysis by Persson et al3 that followed 180 patients for 2 years found a 41.2% incidence of peristomal skin complications; subgroup analysis showed persons with an ileostomy had the highest rate of skin complications (66.5%). An open-label, multinational trial by Meisner et al4 involving 3015 patients with a stoma found 57.7% had peristomal skin complications that included irritant dermatitis, mechanical trauma, infection, allergic reaction, and disease-related issues.

Irritant dermatitis. A review of stomal dermatology by Alvey and Beck5 described peristomal complications in further detail. Irritant dermatitis involves the breakdown of the most superficial layers of the skin due to the effluent that comes from the stoma, stool, or urine. This generally occurs within months of stoma formation (ie, an early complication). If not addressed, irritant dermatitis can incite local inflammation, which can inhibit stoma healing in general and lead to further effluent leakage. The drainage from ileostomies is particularly caustic and is the likely explanation as to why these stomas have a higher rate of complications.

Mechanical trauma. Mechanical trauma is a result of repeated removal and reapplication of ostomy devices; it typically occurs as a post ostomy month- to year-range complication.5 Mechanical trauma can peel off the superficial layers of the skin, causing damage and inflammation. Constant pressure of the device against the skin also can cause breakdown and the eventual development of an ulcer.5

Allergy. Allergic reactions to adhesives can occur. These reactions are not common and, due to newer adhesives, these reactions are becoming more infrequent.5 

Infection. Infection-related complications can occur at any time in a patient with a stoma. The most common infectious agent is Candida albicans, but folliculitis due to Staphylococcus aureus can occur as well.5 An uncommon but often reviewed disease-related complication is pyoderma gangrenosum, defined as an ulcer with a distinct violaceous border. This type of ulcer is considered a late skin complication, occurring many years after the formation of the stoma2; it has an 0.6% incidence for ostomies overall.2 Pyoderma gangrenosum has no diabetic, venous, or pressure etiology; it is thought that disease processes such as inflammatory bowel disease may contribute to ulcer formation owing to the fact that patients with stomas created due to Crohn’s disease have an increased incidence (3.8%).2 

Contour. Contour irregularities around the stoma may impair appliance fit and duration of adherence. Multiple etiologies may contribute to this, including preexisting abdominal skin rolls and poor scar formation of midline incisions that distort tissue proximal to the stoma. Additionally, patients may experience parastomal herniation, stomal retraction, and prolapse, which also can cause peristomal skin irregularities.6 

Herniation. The incidence of parastomal herniation (PH), a type of incisional hernia, has been reported to range from 14.1% to 40% in persons with ileostomies.2 Herniation does not only cause contour problems; a hernia can become a surgical emergency if the contents of the hernia sac become incarcerated or (worse) strangulated. Current treatment options for PH involve surgery and include tissue repair, stoma relocation, and repair with mesh.2 Unfortunately, these options do not guarantee good outcomes; recurrence rates of 46% to 100%, 24% to 40%, and 6.9% to 17.8%, respectively, have been reported.2 

Prolapse. Stomal prolapse has a general incidence in ostomies of 2% to 22%; it occurs in approximately 2% of ileostomies² and can be treated medically or surgically. Common medical options are usually aimed at reducing bowel edema and include manual reduction, use of topical table sugar, and hyaluronidase injection; surgical options include local repair with stapler devices.2 No studies have assessed the long-term effectiveness of these techniques.

Retraction. Stomal retraction alters the skin and affects ostomy device fit. Researchers and clinicians do not agree whether to categorize stomal retraction as an early or late complication, but the overall incidence (ie, for all ostomy types) for this complication is 32.2% to 40.1%.2 Stomal retraction increases the chances of stoma leakage, leading to skin-related complications. Because a common underlying cause is increased tension on the bowel, most treatments attempt to reduce this tension, usually by surgery.2 Successful repair is not always possible through the ostomy opening; a laparotomy often is necessary, which brings its own complications and compounds the chances of a negative outcome for the patient.2

Fat grafting. Fat grafting involves harvesting adipose tissue via a cannula for injection into other sites and has been found to be an effective and reliable tool, used extensively in reconstructive and aesthetic plastic surgery to correct volume deficits and augment soft tissues and contour. It has been described in multiple reviews and randomized clinical trials7-11 to aid in the reconstruction of the breast, extremities, and craniofacial areas, and reports of its safety have been published extensively. A recent literature review by Simonacci et al9 found the overall complication rate for fat grafting in breast reconstruction to be 8.4%. A prospective, randomized study that compared fat grafting for pedal fat pad atrophy to supportive care in 25 patients found persons who underwent fat grafting had significantly reduced pain and improved foot function as compared with the supportive care group.11 

Fat grafting to improve peristomal contour irregularity and consequently appliance fit appears to be effective with low morbidity and minimal down time.12 Fewer device changes result in improved quality of life and a significant positive financial impact. A cohort study12 involving 164 patients with ostomies showed that using better fitting appliances with less leakage results in improvement of secondary skin inflammation. Although multiple fat grafting procedures may be required to achieve the desired result, this procedure is simpler and safer than further gastrointestinal surgery such as relocating the stoma, especially in patients who have had multiple prior surgical procedures. Fat grafting may be contraindicated if the patient were to have insufficient donor site adiposity; however, the vast majority of patients have sufficient tissue. Relocating the stoma may be reserved as a later option. 

Because many approaches to peristomal complications and securing appliance fit come with challenges, the authors pursued fat grafting as a viable option to treat contour irregularity around the stoma in an eligible patient, thereby improving appliance fit and quality of life.

Case Report

History. Ms. L, a 57-year-old woman with Crohn’s disease, presented with contour irregularity around her permanent ileostomy, situated in the right midabdomen. At the onset of her Crohn’s diagnosis, Ms. L was treated with steroids, sulfadiazine, and antibiotics; when she was 26 years old, she underwent a total proctocolectomy and a permanent ileostomy was created. Additional comorbidities included recurrent acute pancreatitis of unclear etiology, asthma, anxiety, and gastric reflux. Her body mass index was 27.5 (overweight.). Since her permanent ileostomy, she no longer takes medications for Crohn’s disease.

Ms. L subsequently underwent multiple gastrointestinal surgical interventions, including multiple lysis of adhesions procedures. She initially consulted with the authors’ group in 2008 to address a contour irregularity that impaired appliance fit. At that time, she underwent scar excision and local tissue rearrangement with successful adjustment of the abdominal contour and subsequently achieved good appliance fit (see Figure 1a–c). 

In 2015, Ms. L underwent ostomy revision, and in 2016 sought the authors help. She described her inability to properly fit an appliance due to contour irregularities around her ileostomy site as well as leakage of small bowel contents and chronic skin irritation and breakdown (see Figure 2a,b). Ms. L required daily appliance changes despite using different skin barriers and adhesives, including a convex pouching system designed to help with concave abdominal planes and reinforcing adhesive rings. She complained of pain, distress, poor quality of life, and social isolation due to fear of leakage in public; essentially, she was housebound. Her colorectal surgeon offered to reposition the stoma to the contralateral side. The authors offered her the option of fat grafting to build up soft tissue around her ileostomy and create an even contour on which to fit an appliance. 

Treatment. Ms. L was agreeable to fat grafting, and informed consent was obtained. Two (2) episodes of fat grafting were performed under general anesthesia, and intravenous metronidazole and ciprofloxacin were administered before surgery began. Donor sites (her medial thighs and knees in the first round, and medial thighs in the second) were prepped separately from the abdomen. The appliance was left in place around the ileostomy until after the fat harvest to maximize sterility. 

Donor sites were infused with dilute lidocaine with epinephrine. Fat was harvested with handheld syringes under negative suction and processed using the Coleman method to minimize injury to the adipocytes using a 3-mm, blunt-edged bucket-handle cannula connected to a 10-cc Luer-lok syringe.7,8 Centrifugation of the extracted fat was performed at 3000 rpm for 3 minutes using a smaller centrifuge with a small rotor to ensure sterility to separate the harvested components based on density, with oil, fatty tissue, and aqueous elements comprising the upper, middle, and lowest layers, respectively. The oil layer was decanted and the aqueous layer released by temporarily removing the Luer-lok plug. Refined fat then was transferred into 1-cc syringes for injection.7

The appliance then was removed, and the abdomen was prepped with betadine solution. The surgeon’s finger remained in the stoma to guide fat graft placement. Blunt-tipped cannulas were used to place the graft material (34 cc of fat), injected upon withdrawal into the subcutaneous tissue of the deficient areas (see Figure 3). At the end of the case, the stoma was assessed and had no evidence of injury. Ms. L was discharged in good condition with follow-up at 10 weeks.

Outcomes and follow-up. Following the first procedure, Ms. L had noticeable improvement: she utilized a smaller appliance that needed to be changed every 3 days by the 10-week follow-up, compared with daily pregrafting. However, she continued to experience leakage around the 2 o’clock area, which was noted to be underfilled. The authors provided a second round of fat grafting (32 cc), and by 3 months after the second procedure, the interval between appliance changes was extended to every 5 to 7 days. Currently, Ms. L uses a malleable appliance with moldable ostomy barrier rings, feels confident leaving the house, and her quality of life has greatly improved. 

Aside from minor bruising at the donor sites as expected, no postoperative complications occurred after either round of fat grafting. Postoperative computer tomography, performed 3 months after the second round of grafting, confirmed retention of the fat grafts around the ileostomy site (see Figure 4a–f). Measurements comparing pre- and postoperative abdominal wall thickness show an approximate 10% increase in volume along with a difference in the abdominal wall contour, with decreased concavity and a more even contour (see Figure 5).

Discussion

Studies report different approaches taken to improve appliance fit. Smith et al6 reported the case of a 29-year-old man who underwent an ileostomy secondary to complications of ulcerative colitis. The patient encountered difficulty with stoma bag application due to contour irregularity and striae. The patient was surgically provided injected porcine dermal collagen (Permacol; Covidien, Minneapolis, MN), with complete resolution of leakage maintained through the patient’s 2-year follow-up. This cross-linked porcine dermal collagen is sterilized by gamma irradiation and resistant to collagenase, with few reported adverse effects.13 Although a more permanent collagen filler may present a more promising, off-the-shelf therapy, the product’s longevity in vivo has been challenged: a review14 of 9 articles found 66.7% of the studies included did not show any appreciable changes in anal manometry after using this collagen product, and a prospective study15 of 10 patients found this dermal collagen product used as a bulking agent improved patient fecal incontinence scores, but these scores regressed almost to baseline by 6 weeks.

Fat grafting to address stoma contour has been previously described; this case16 involved the care of a 56-year-old man who underwent proctocolectomy with permanent ileostomy for Crohn’s disease and developed an abdominal wall abscess requiring ileostomy takedown and resiting. The patient began experiencing significant issues with stoma flange and adhesion, changing the appliance every 1 to 3 days despite use of multiple adhesives. Further skin damage was endured due to leakage of small bowel effluent. The patient underwent fat grafting around the ileostomy site using a very small amount of fat (4–8 cc) in 2 rounds of injection; the second round was performed in conjunction with rematuration of the ileostomy and followed by 2 “touch-ups” at 4 and 10 months postoperatively. By contrast, the case presented here was performed as a stand-alone procedure, independent from the stomal surgery, and involved a much larger volume of graft material. By using a larger volume of grafted fat, the need for further stomal manipulation may be obviated. Moreover, radiographic data show the change in soft tissue configuration. 

Financial implications involved in ostomy care are significant. One case series17 proposed using a betel leaf (a food consumed mostly in Asia) as a cost saving measure for ostomy care. A randomized controlled trial18 involving 125 patients found as many as 16% of patients have difficulty paying for ostomy supplies. Financial concerns have been shown to significantly affect quality of life in a survey study19 conducted among 239 Veteran’s Administration patients. Current estimates find ostomy care costs to range between $100 and $300 per month or up to $3600 per year. Differences in device change frequency can have significant impact. Changing a device daily, compared with every 6 days, has been shown by CostHelper, Inc,20 a company of professional journalists who pool consumer information about thousands of consumer goods and services, to cost $8736 versus $1440, respectively, for the ostomy bag alone.

Limitations

Limitations of this study include the inherent exclusiveness of a case study and associated bias. Patients benefitting from fat grafting for an ostomy to address poor fit are of a specific population — that is, it is most appropriate for persons with contour deficiencies. However, as acknowledged in the literature, skin-related problems are likely underreported, and more patients than anticipated might benefit from this approach.2 Additionally, a potential drawback of this method is the unpredictable nature of fat graft survival.8 A recent case report and literature review of fat grafting by Wu et al16 showed a wide range of graft survival rates (from 32% to 52%) depending on how long the patients were followed. This may lead surgeons to counsel patients that they may require multiple rounds of fat grafting for correction, as in this study and the other reported in the literature.16 Patients should be followed-up in the more immediate postoperative period following fat grafting (within 3-6 weeks and at the 3-month period). At that time, if the fat graft correction is insufficient, a repeat procedure may be considered. When correction is sufficient, follow-up can be scheduled only as needed, and results may be considered permanent.

Conclusion

A case study illustrated the outcome of fat grafting to improve contour for better ostomy device fit in 1 patient. The patient underwent 2 rounds of fat grafting with considerable improvement in the ostomy device fit and reduction in skin complications with no adverse effects. Grafting around an ostomy site appears to be a safe and effective tool in improving contour, thereby improving appliance fit. Subsequently, patients may benefit from improved quality of life, including optimized appliance changing schedules and reduced skin irritation and leakage. One procedure may provide some improvement, but patients may require multiple episodes of grafting. These case studies should continue to be reported to the literature to optimize patient selection and increase knowledge about short- and long-term outcomes. 

Affiliations

Dr. Czerniak, Dr. Gusenoff, and Dr. MacIsaac are plastic surgeons; Mr. Bram is a medical student; Dr. Amar is a plastic surgeon; Dr. Seynnaeve is a radiologist; Dr. Medich is a general surgeon; and Dr. Coleman and Dr. Rubin are plastic surgeons, University of Pittsburgh Medical Center, Department of Plastic Surgery, Pittsburgh, PA. 

Correspondence

Please address correspondence to: J. Peter Rubin, MD, University of Pittsburgh Medical Center, Department of Plastic Surgery, 3500 Terrace Street, 6B Scaife Hall, Pittsburgh, PA 15261; email: rubipj@upmc.edu.