A Retrospective Analysis of Factors Affecting Early Stoma Complications
Despite advances in surgical techniques and products for stoma care, stoma-related complications are still common. A retrospective analysis was performed of the medical records of 462 consecutive patients (295 [63.9%] female, 167 [36.1 %] male, mean age 55.5 ± 15.1 years, mean body mass index [BMI] 25.1 ± 5.2) who had undergone stoma creation at the Gastroenterological Surgery Clinic of Turkiye Yuksek İhtisas Teaching and Research Hospital between January 2008 and December 2012 to examine the incidence of early (ie, within 30 days after surgery) stoma complications and identify potential risk factors.
Variables abstracted included gender, age, and BMI; existence of malignant disease; comorbidities (diabetes mellitus, hypertension, coronary artery disease, chronic respiratory disease); use of neoadjuvant chemoradiotherapy; permanent or temporary stoma; type of stoma (loop/end stoma); stoma localization; and the use of preoperative marking of the stoma site. Data were entered and analyzed using statistical software. Descriptive statistics, chi-squared, and Mann-Whitney U tests were used to describe and analyze all variables, and logistic regression analysis was used to determine independent risk factors for stoma complications. Ostomy-related complications developed in 131 patients (28.4%) Of these, superficial mucocutaneous separation was the most frequent complication (90 patients, 19.5%), followed by stoma retraction (15 patients, 3.2%). In univariate analysis, malignant disease (P = .025), creation of a colostomy (P = .002), and left lower quadrant stoma location (P <.001) were all significant indicators of stoma complication. Only stoma location was an independent risk factor for the development of a stoma complication (P = .044). The rate of stoma complications was not significantly different between patients who underwent nonemergent surgery (30% in patients preoperatively sited versus 28.4% not sited) and patients who underwent emergency surgery (27.1%). Early stoma complication rates were higher in patients with malignant diseases and with colostomies. The site of the stoma is an independent risk factor for the development of stoma complication. Preoperative marking for stoma creation should be considered to reduce the risk of stoma-related complications. Prospective, randomized controlled studies are needed to enhance understanding of the more prevalent risk factors.
Many colorectal operations involve stoma formation. Despite advances in surgical techniques and products for stoma care, complications are still common; they range between 25% and 60%, affect patient quality of life, and increase the financial cost to the health system, as shown in prospective research and audits.1-5 According to a prospective analysis of stoma-related complications (N = 408),6 the consequences of complications can be complex and life-threatening.
Complications are classified as early or late. Early complications are defined as those occurring in the first postoperative month; the most common are superficial or deep stoma necrosis, retraction, mucocutaneous separation, dermatitis, bleeding, and parastomal abscess.7-10 Late complications appear after this period and may include parastomal hernias, stenosis, or stomal prolapse.10
Patient-related and surgery-related factors contribute to the risk of stomal complications.11 However, although several prospective analyses12-15 (total number of patients = 5913) have attempted to identify definite risk factors associated with stoma complication, the results are contradictory with regard to the impact of gender, body mass index (BMI), emergency surgery, and preoperative stoma siting.
The main purpose of the present study was to analyze the incidence of early stoma complications and determine risk factors that may predict stoma complication.
Material and Methods
Patients. After approval of the local ethical committee of Turkiye Yuksek .Ihtisas Teaching and Research Hospital, medical chart data for 462 consecutive patients admitted to the Gastroenterological Surgery Clinic for a stoma creation between January 2008 and December 2012 were collected and retrospectively analyzed. Patients undergoing both emergency and elective procedures were included in the study and compared as to gender, age, and BMI; existence of malignant disease; comorbidities (diabetes mellitus, hypertension, coronary artery disease, chronic respiratory disease); use of neoadjuvant chemoradiotherapy; permanent or temporary stoma; type of stoma (loop/end stoma); stoma localization; and the use of preoperative marking of the stoma site.
Data abstraction. Patient demographics and details of the stoma complications up to 30 days after surgery were abstracted by a stoma care nurse specializing in ambulatory care. Data were collected to a spreadsheet and entered into a software program (SPSS Inc, Chicago, IL). Patients usually were seen 2 times during the first month following surgery. Patients needing reminders for follow-up visits received a call from the stoma nurse.
Data relevant to the incidence of stoma complications and potential risk factors associated with them as previously noted1-18 were abstracted. The postoperative complication variable was obtained from the charts as diagnosed at that time. An early postoperative stoma complication was defined as occurring within the first 30 postoperative days.
Statistical analysis. Data analysis was performed using SPSS 18 for Windows software (SPSS Inc, Chicago, IL), and descriptive statistics were used to summarize the data. The statistical significance of the data was evaluated by applying the Pearson’s chi-squared test for the relationship between categorical variables. The Mann-Whitney U test was used to analyze the difference between the measured values of 2 groups of patients (those undergoing emergent versus those having nonemergent surgery) after confirming with the Kolmogorov-Smirnov test whether the 2 random samples had the same statistical distribution. Logistic regression analysis was used to determine the independent risk factors for stoma complication. A P value <.05 was considered to be statistically significant.
Of the 462 patients, 295 were female (63.9%) and 167 were male (36.1%); the mean age was 55.5 ± 15.1 years, and mean BMI was 25.1 ± 5.2. The BMI was <18.5 in 55 patients (11.9%), between 18.5 and ≤29.9 in 186 patients (40.3%), and ≥30 in 221 patients (47.8%).
The most common indications for stoma creation were colorectal carcinoma (344 patients, 74.1%) and inflammatory bowel disease (56 patients, 12.1%). The most frequently performed surgical interventions were low anterior resection with diverting (loop) ileostomy (178 patients, 38.5%), followed by total colectomy with end ileostomy (71 patients, 15.3%). Other less common types of surgery and indications for stoma creation are listed in Table 1.
Ostomy-related complications developed in 131 patients (28.4%). Superficial mucocutaneous separation was the most frequent complication (90 patients, 19.5%), followed by stoma retraction, which developed in 15 patients (3, 2%) (see Table 2).
Age, gender, BMI, comorbidity, neoadjuvant chemoradiotherapy, emergency surgery, smoking, and preoperative site marking had no significant effect on the occurrence of stoma complication (see Table 3). However, stoma complications were significantly more likely to occur in patients with malignant (31.1%) compared to benign disease (20.3%, P = .0025) and after colostomy rather than ileostomy surgery (P = .002). The complication rate was also significantly higher in patients with a stoma located in the left lower abdominal quadrant (39%) when compared to right lower abdominal quadrant (23.1%, P = .001).
The complication rate was 24.2% in patients with loop ileostomy, 19.2% in patients with end ileostomy, 35% in patients with loop colostomy, and 37.7% in patients with end colostomy. No significant difference was found in complication rates when comparing loop to end ileostomy (P = .341), loop colostomy (P = .206), and end colostomy (P = .803) (see Table 4).
Factors with significant differences in the rate of complications (malignant disease, creation of colostomy, and stoma location) were further analyzed in multivariate logistic regression analysis. Of these variables, the only independent risk factor was found to be the location of the stoma (P = .016), with the complication rate increasing 1.8 fold when the stoma was in the left lower rather than in the right lower abdominal quadrant (see Table 5).
Elective and emergency surgery patients were evaluated separately for any effect of preoperative marking of the stoma location. In the elective surgery group, the complication rate was 30% in patients who underwent preoperative marking versus 28.4% in patients who were not preoperatively sited. Only 1 patient in the emergency group underwent preoperative marking; the stoma complication rate was 27.1% and did not significantly differ from the elective surgery group (P = .81) (see Table 6).
The present study demonstrated a high incidence (28.4%) of a variety of stoma problems, with significant risk factors identifiable for complications. In a prospective multicenter study13 in the UK including 3970 stomas, a strong association was noted between female gender and higher rates of stoma complications. In the present study, although the stoma complication rate was slightly higher in women (30.5%) than in men (27.1%), the difference was not statistically significant (P = .433). Obesity is frequently cited in some prospective studies12,13 as having an impact on the development of stoma complications. In the present study, the stoma complication rate also was higher in obese patients (30, 8%). However, on comparison with nonobese patients (BMI<30), no significant difference was found.
In the present study, the complication rate in patients with malignant disease was significantly higher than in patients with benign disease (20.3% and 31.1%, respectively). Similar results have been reported in the retrospective cohort study by Nastro et al.14
Some retrospective and prospective studies2,19,20 including a total of 602 patients have shown the stoma complication rate is lower following ileostomy than following colostomy surgery. Similarly, in the present study, the stoma complication rate was significantly higher among patients with a colostomy than patients with an ileostomy.
In the present study, although not statistically significant, the complication rate after loop colostomy was higher than after loop ileostomy surgery. This result is in accordance with several prospective randomized and nonrandomized studies.21,22
A prospective study,8 a meta-analysis,23 and a white paper24 found stoma site is another factor affecting stoma complications. In the present study, stoma location was the only independent risk factor for the development of stoma complications. Ileostomies are ultimately created in the right lower and colostomies are usually localized in the left lower abdominal quadrant. A review by Pine and Stevenson10 found early complications such as ischemia and necrosis are more common following colostomy than ileostomy formation. Excessive tension on the bowel secondary to insufficient mobilization of the exteriorized distal portion or a large abdominal pannus in an obese patient with a narrow parietal opening through which the colon passes negatively affects the blood supply, with potential ischemic insults. In the retrospective study by Hsu et al,25 risk factors significantly associated with early complications were stoma location, diameter, and height, as well as peristomal skin condition. Furthermore, in logistic regression analysis, these authors also found stoma diameter and stoma height were predictors for the incidence of early complications. According to several randomized and nonrandomized studies,22,26,27 higher enlargement capacity and intraluminal pressure of the colon leads to more frequent stoma herniation in the long term, but it also brings a higher risk of incisional hernia after colostomy than after ileostomy closure.
The results of the present study show comorbidity, neoadjuvant chemoradiotherapy, type of surgical procedure, and smoking had no significant effect on the development of stoma complication.
Several retrospective studies27-31 have demonstrated preoperative marking of the site for stoma creation can reduce the complication rate and facilitate optimal stoma care for the patient during everyday activities. In the present study, only 13.2% of the patients underwent preoperative marking but no significant statistical difference was noted in the rate of stoma complications when persons with and without presurgical marking were compared. This may be a reflection of the small sample size. However, the authors recommend preoperative marking, which they have used routinely in their clinic in recent years.
The present study has some limitations. First, because it is retrospective in nature, the data may have inherent flaws unknown to the current researcher. Secondly, stomas were created by different surgeons, which may have had an effect on the complication rates.
The results of a retrospective review of patient data indicate early stoma complication rates are higher in patients with malignant diseases and after the creation of colostomies and permanent stomas. The site of the stoma is an independent risk factor for the development of stoma complication. Preoperative marking for stoma creation should be considered to reduce the risk of stoma-related complications. Prospective, randomized controlled studies to enhance understanding of the factors influencing stoma complication rates are warranted.
The authors are grateful to Claire Olmez, BEd, MSc for proofreading of and language corrections to the manuscript.
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Potential Conflicts of Interest: none disclosed
Dr. Koc is an Associate Professor, Antalya Teaching and Research Hospital, Department of General Surgery, Antalya, Turkey. Dr. Karaman is an Associate Professor, Sakarya University Faculty of Medicine, Department of General Surgery, Sakarya, Turkey. Dr. Gomceli is an Associate Professor, Antalya Teaching and Research Hospital. Dr. Dalgic is a gastrointestinal surgeon; and Dr. Ozer and Dr. Ulas are Associate Professors, Turkiye Yuksek Ihtisas Teaching and Research Hospital, Department of Gastroenterological Surgery, Ankara, Turkey. Dr. Ercan is an Associate Professor; and Dr. Bostanci and Dr. Akoglu are Professors, Sakarya University Faculty of Medicine, Department of General Surgery. Please address correspondence to: Dr. Umit Koc, Antalya Eğitim ve Araştırma Hastanesi, Varlık Mah, Kazım Karabekir Caddesi, 07100 Soğuksu /Muratpaşa/Antalya Turkey; email: firstname.lastname@example.org.