Stoma-Related Complications: Frequency of Postoperative Morbid Events and Factors Related to Adverse Outcomes

Abstract

Introduction Stoma placement is a common surgical procedure that can be performed in the context of urgent and elective surgery for benign and malignant conditions, with an estimated morbidity ranging from 21% to 70%.

Methods A retrospective cohort analysis to determine the incidence of stoma placement postoperative-related complications and potential associated factors. This study was conducted at a single tertiary care center in Mexico City including all patients who underwent a stoma construction between January 2016 and October 2023.

Results A total of 276 patients underwent stoma construction. Eighty-one (29.3%) patients presented morbidity exclusively related to the ostomy.

The multivariate analysis showed the following risk factors: advanced age for developing stoma-related complications; obesity for developing parastomal hernia; strangulated hernia and complicated diverticular disease for developing mucocutaneous dehiscence; bowel obstruction and parastomal hernia for developing stomal prolapse; anastomotic leak and preoperative corticosteroid therapy for developing parastomal abscess; and end-colostomy and advanced age for reoperation.

Discussion Ostomy creation carries a high morbidity rate. Preoperative features such as advanced age, obesity, corticosteroid therapy, the indication of the surgery, as well as the type of the stoma created must be considered as they could significantly impact the development of adverse outcomes.

Keywords

stoma complications - stomas - colostomy - ileostomy

Introduction

Stoma placement (SP) is a common procedure in colorectal and general surgery practice. The indications for SP include benign and malignant conditions and could be performed under emergency and elective contexts. However, despite its frequency, the SP surgery is associated with postoperative complications ranging from 2.9% to 82%[1] [2] which contributes to prolonged hospitalization, hospital readmissions, and number of visits to outpatient clinics, resulting in substantial costs to health care systems and potentially affecting patient quality of life.

Some risk factors for developing postoperative complications following SP have been proposed, including age,[3] body mass index,[4] underlying medical conditions, indication of surgery, type of surgery (elective vs emergency), intraoperative factors such as the surgical approach, and operative time.[5]

Considering the significant negative impact of complications after SP, it is crucial to identify the risk factors that could be reduced prior to surgery. Therefore, this study aims to assess the patient risk factors for developing complications following stoma formation.

Materials and Methods

The study was approved by the corresponding Institutional Review Board (approval number: 04-37-2020) and performed in line with the principles of the Declaration of Helsinki. The competent authorities waived informed consent due to anonymized data and its retrospective nature.

A retrospective comparative analysis of medical records of patients admitted to our institution who underwent an SP due to benign and malignant conditions from January 2016 to October 2023 was performed. Patient data came from a single general hospital in Mexico City. All consecutive adult patients admitted to our institution complying with the previous specifications were included.

Outcomes

The primary outcomes were to evaluate the frequency of all specifically related stoma complications and the incidence of the specific complications regarding the stoma type. The secondary outcome was to assess potential associated factors related to stoma complications.

Data Collection

Variables, including patient demographics, indications for SP, intraoperative features, and those related to in-hospital postoperative follow-up were recorded in a digital database.

Statistical Analysis

Continuous variables were expressed as medians and ranges, and frequencies and proportions were used for categorical variables. The Chi-squared and Fisher’s exact test were used to evaluate categorical variables as appropriate. The student’s T test and the Mann-Whitney U test were employed to analyze the continuous data according to the data distribution. All clinically relevant variables with a p-value <0.1 in the univariate analysis were included in a multivariable regression analysis assessing potential factors associated with adverse events due to SP surgery.

The variables representing the lowest risk for each complication were considered in the reference group (OR = 1). Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for adverse events. A two-tailed P value <0.05 was considered statistically significant. Data analysis was performed using SPSS Statistics (version 25.0; Armonk, NY: IBM Corp.).

Results

Two hundred and seventy-six patients were analyzed, of which 174 were female (63%), with a median age of 50 years (115-100), a mean BMI of 26.61 (SD 6.01) kg/m², 109 (39.49%) were active smokers, and 141 (51.1%) had ASA ≥3.

Overall, most of the procedures were due to benign conditions (76.49%, n = 211), of which complicated diverticular disease represented the predominant cause (23.3%, n = 64), and the majority were urgent surgeries (88.8%, n = 245). The demographics and indications for surgery are summarized in [Table 1].

Table 1 Patients characteristics and preoperative features

	All patients (N = 276)	Group w/o morbid events related to ostomy placement (N = 195)	Group with morbid events related to ostomy placement (N = 81)	p
Age	50 (15-100)	50 (15-100)	51 (16-89)	0.361
>65 years old	63 (22.82%)	34 (17.4%)	29 (35.8%)	0.001*
Sex
Female	174 (63%)	125 (64.1%)	49 (60.5%)	0.586
Male	102 (37%)	70 (35.9%)	32 (39.5%)
BMI (kg/m2) [a]	26.61 (SD 6.01)	25.89 (SD 5.53)	28.37 (SD 6.7)	0.002*
BMI ≥30[a]	65 (23.6%)	44 (22.6%)	21 (25.9%)	0.086
Active smoking	109 (39.49%)	74 (38.1%)	35 (43.8%)	0.417
Diabetes mellitus	71 (25.7%)	48 (24.6%)	23 (28.4%)	0.547
SAH[b]	58 (21)	39 (20%)	19 (23.5%)	0.627
Cancer	40 (14.5%)	29 (14.9%)	11 (13.6%)	0.853
Cardiopathy	9 (3.3%)	7 (3.6%)	2 (2.5%)	0.731
Others	62 (22.46%)	43 (22.2%)	19 (23.5%)	0.874
ASA Classification[c]
ASA I-II	134 (48.6%)	93 (47.7%)	41 (50.6%)	0.693
ASA > III	141 (51.1%)	102 (52.3%)	39 (48.1%)	0.597
Preoperative use of corticosteroids	15 (5.4%)	11 (5.6%)	4 (4.9%)	0.537
Serum albumin (g/dL)	3.07 (SD 1.02)	2.99 (SD 1.06)	3.02 (0.96)	0.841
Hypoalbuminemia (<3.5 g/dL)	159 (57.6%)	110 (59.1%)	49 (64.5%)	0.486
Indications for stoma placement
Benign disease	211 (76.49%)	146 (74.9%)	65 (80.2%)	0.356
Bowel obstruction	21 (7.6%)	18 (9.2%)	3 (3.7%)	0.087
Complicated acute appendicitis	21 (7.6%)	12 (6.2%)	9 (11.1%)	0.211
Complicated diverticular disease	64 (23.2%)	42 (21.1%)	22 (27.8%)	0.348
Strangulated hernia	14 (5.1%)	8 (4.1%)	6 (7.4%)	0.365
Strangulated inguinal hernia	7 (2.5%)	3 (1.5%)	4 (4.9%)	0.115
Strangulated ventral hernia	7 (2.5%)	5 (2.6%)	2 (2.5%)	1
Sigmoid volvulus	4 (1.4%)	3 (1.5%)	1 (1.2%)	1
Abdominal Trauma	14 (5.1%)	9 (4.6%)	5 (6.2%)	0.764
Blunt trauma	7 (2.5%)	6 (4.6%)	1 (1.2%)	0.340
Penetrating tauma	7 (2.5%)	3 (1.5%)	4 (4.9%)	0.200
Fournier’s gangrene	19 (6.9%)	15 (7.7%)	4 (4.9%)	0.453
Bowel perforation	13 (4.7%)	9 (4.6%)	4 (4.9%)	1
Mesenteric ischemia	10 (3.6%)	9 (4.6%)	1 (1.2%)	0.290
Incidental bowel injury	9 (3.3%)	7 (3.6%)	2 (2.5%)	0.731
Pancreatitis	7 (2.5%)	5 (2.6%)	2 (2.5%)	1
Other benign indications[d]	11 (4%)	7 (3.6%)	4 (4.9%)	0.736
Colon and rectum malignant disease	66 (23.9%)	50 (25.6%)	16 (19.8%)	0.353
Elective procedure	12 (4.3%)	11 (22%)	1 (6.3%)	0.266
Emergency procedure	54 (19.56%)	39 (76.5%)	15 (93.8%)	0.165
Malignancy conditioning bowel obstruction	41 (14.9%)	29 (58.0%)	12 (75%)	0.254
Malignancy with bowel perforation	13 (4.71%)	10 (19.6%)	3 (18.8%)	1
Malignancy with anastomotic leak[e]	7 (2.53%)	5 (10%)	2 (12.5%)	1
Anastomotic leak including benign and malignant disease	30 (10.9%)	16 (8.2%)	13 (16%)	0.082

^a BMI: body mass index.

^b SAH: systemic arterial hypertension

^c ASA classification: American Society of Anesthesiologists Classification.

^d Other benign indications included: eleven, 3 were infectious colitis (one case due to Clostridioides difficile, and two cases due to Entamoeba histolytica), 3 were secondary to ulcerative colitis; 2 cases were due to necrosis of the ileum, and one due to a mesenteric torsion, one rectal prolapse, and one colovesical fistulae.

^e Malignancy with anastomotic leak refers to those patients that on the first intervention had some kind of anastomosis and the indication for the stoma created was the anastomosis leak.

^* p values ≤0.05.

The procedures were mainly performed through an open approach. (233 open procedures, 88.4%; 31 laparoscopic procedures, 11.2%; and six robot-assisted procedures, 2.2%). And colostomies were the most frequent type of stoma (147 colostomies and 129 ileostomies). Intraoperative features and ostomy distribution are shown in [Table 2].

Table 2 Intraoperative and postoperative features

	All patients (N = 276)	Group w/o morbid events related to ostomy placement (N = 195)	Group with morbid events related to ostomy placement (N = 81)	p
Emergency surgery	245 (88.8%)	172 (88.2%)	73 (90.1%)	0.684
Type of surgical approach
Open	233 (84.4%)	160 (82.1%)	73 (90.1%)	0.103
Laparoscopic	31 (11.2%)	25 (17.9%)	6 (7.5%)	0.215
Robot assisted	6 (2.2%)	5 (2.6%)	1 (1.3%)	0.673
Type of stoma
Ileostomy	129 (46.7%)	96 (49.2%)	33 (40.7%)	0.233
End Ileostomy	88 (31.9%)	61 (31.3%)	27 (33.3%)	0.777
Loop Ileostomy	30 (10.9%)	25 (12.8%)	5 (6.2%)	0.106
Double barrel Ileostomy	10 (3.6%)	9 (4.6%)	1 (1.2%)	0.155
Colostomy	147 (53.3%)	99 (50.8%)	48 (59.3%)	0.124
End Colostomy	109 (39.5%)	72 (36.1%)	37 (45.7%)	0.180
Loop Colostomy	35 (12.7%)	25 (12.8%)	10 (12.3%)	1
Double barrel Colostomy	4 (1.4%)	3 (1.5%)	1 (1.2%)	1
Mortality	30 (10.9%)	19 (8.9%)	11 (13.6%)	0.237
Hospitalization (days)	11 (1-172)	10 (1-120)	15 (1-172)	0.020*

^* p values <0.05 were considered statistically significant.

Primary Outcomes

Postoperative adverse events related to SP occurred in 29.3% (n= 81), of whom 60.5% (n = 49) were women, 43.8% (n = 35) were active smokers, and 48.1% (n = 39) had ASA ≥3. The group developing postoperative morbidity had a higher BMI than the group with no morbidity (p = 0.002). The more frequent morbid events were parastomal hernia (9.7%, n = 27), followed by mucocutaneous dehiscence (7.9%, n = 22), parastomal abscess (6.8%, n = 19), and ostomy retraction (3.6%, n = 10). Morbid events regarding the type of stoma are listed in [ Table 3 ].

Table 3 Morbid events according to the stoma type

	All patients (N = 276)	End Ileostomy (N = 88)	Defunctioning Ileostomy[a] (N = 40)	End Colostomy (N = 109)	Defunctioning Colostomy[b] (N = 39)	p
Morbidity events	81 (29.3%)	27 (30.7%)	6 (15%)	37 (33.94%)	11 (28.2%)	0.063
Mucocutaneus dehiscence	22 (7.9%)	6 (7.4%)	2 (5.0%)	13 (13.5%)	1 (2.56%)	0.186
Bowel obstruction	8 (2.8%)	5 (5.68%)	0 (0.0%)	3 (3.1%)	0 (0.0%)	0.405
Parastomal hernia	27 (9.7%)	6 (7.4%)	3 (7.5%)	12 (12.5%)	6 (15.38%)	0.188
Incarcerated parastomal hernia	2 (0.72%)	1 (1.2%)	0 (0.0%)	0 (0.0%)	1 (2.56%)	0.184
Stomal prolapse	6 (2.17%)	2 (2.5%)	1 (2.5%)	1 (0.91%)	2 (5.12%)	0.373
Stomal retraction	10 (3.6%)	3 (3.40%)	0 (0.0%)	6 (6.3%)	1 (2.56%)	0.452
Peristomal dermatitis	2 (0.7%)	1 (1.13%)	1 (2.5%)	0 (0.0%)	0 (0.0%)	0.286
Stomal necrosis	6 (2.17%)	3 (3.40%)	1 (2.5%)	2 (2.1%)	1 (2.56%)	0.836
Parastomal fascitis	3(1.08%)	0 (0.0%)	0 (0.0%)	2 (2.1%)	1 (2.56%)	0.455
Parastomal abscess	19 (6.8%)	4 (4.9%)	2 (5.0%)	2 (2.1%)	0 (0.0%)	0.636
Ostomy fistula	3 (1.08%)	3 (3.40%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0.253
Reoperation[c]	48 (17.4%)	16 (18.18%)	1 (2.5%)	25 (22.93)	6 (15.38%)	0.010*
Mortality	30 (10.1%)	9 (10.2%)	1 (2.5%)	14 (12.84%)	6 (15.38%)	0.136

^a Includes loop and double barrel ileostomies.

^b Includes loop and double barrel colostomies.

^c Indications for reoperations due stoma complications include: Fifteen 15 (31.25%) mucocutaneous dehiscences, 8 (16.6%) stomal retractions, 7 (14.5%) parastomal abscesses, 6 (12.5%) stomal necrosis, 5 (10.4%) stomal stricture, 3 (6.25%) peristomal necrotizing fasciitis, 2 (4.16%) stoma fistulas, and 2 (4.16%) parastomal incarcerated hernias.

^* p values <0.05 were considered statistically significant.

The median overall hospitalization was 11 (1-172) days, and the postoperative mortality rate was 10.9% (n = 30) due to causes unrelated to the SP procedure.

Secondary Outcomes

The multivariate analysis showed the following risk factors: advanced age (>65 years old) (OR 2.708; 95% CI 1.480 to 4.953, p = 0.001) for developing stoma related complications; obesity (OR 3.177; 95% CI 1.184 to 8.525, p = 0.022) for developing parastomal hernia; strangulated hernia (OR 07.022; 95% CI 1.646 to 29.961, p = 0.008) and complicated diverticular disease (OR 3.081; 95% CI 1.063 to 8.930, p= 0.038) for developing mucocutaneous dehiscence; bowel obstruction (OR 13.455; 95% CI 1.739-109.030, p = 0.014) and parastomal hernia (OR 12.444; 95% CI 1.852 to 83.590, p= 0.009) for developing stomal prolapse; anastomotic leak (OR 5.477; 95% CI 1.67 to 23.886, p = 0.003) and preoperative corticosteroid therapy (OR 5.477; 95% CI 1.765 to 16.993, p = 0.031) for developing parastomal abscess; and end-colostomy (OR 1.874; 95% CI 1.951 to 3.342, p= 0.033) and advanced age (OR 2.293; 95% CI 1.223 to 4.296, p= 0.010) were associated with the necessity of reoperation.

The variables regarding skin complications, stomal retraction, stomal necrosis, parastomal fasciitis, and fistula of the ostomy were also analyzed; however, the multivariate analysis did not show significant results. The multivariate analysis is shown in [ Table 4 ].

Table 4 Univariate and multivariate analysis of clinical factors associated to adverse events after ostomy placement

Variable evaluated for outcome	Outcomes evaluated
	Univariate analysis		Multivariate analysis
	OR (95% CI)	p	OR (95% CI)	p
Adverse events
>65 years old	2.641 (1.470-4,744)	0.001	2.708 (1.480-4.953)	0.001*
Parastomal hernia
Obesity	3.236 (1.414-7.405)	0.005	3.177 (1.184-8.525)	0.022*
Parastomal abscess
Anastomotic leak	4.134 (1.134-11.919)	0.009	5.477 (1.67-23.886)	0.003*
Preoperative use of steroid	4.583 (1.128-18.619)	0.033	5.477 (1.765-16.993)	0.031*
Mucocutaneous dehiscence
Strangulated hernia	6.056 (1.662-22.062)	0.006	07.022 (1.646-29.961)	0.008*
Complicated diverticular disease	2.864 (1.151-7.125)	0.024	3.081 (1.063-8.930)	0.038*
Stoma prolapse
Bowel obstruction	6.618 (1.130-38.755)	0.036	13.455(1.701-106-425)	0.014*
Parastomal hernia	10.000 (1.903-52.553)	0.007	12.444 (1.852-83.590)	0.009*
Reoperation
End colostomy	2.776 (2.188-6.486)	0.018	2.562 (1.087-6.040)	0.032*
>65 years old	2.740 (1.408-5.330)	0.003	2.543 (1.297-4.987)	0.010*

The reference category has an odds ratio of 1.0. For multivariable backward logistic regression analysis, odds ratio (OR) and 95% confidence interval (CI) are presented.

^* p values <0.05 were considered statistically significant.

Discussion

Our overall rate of complications related to SP was 29.3%, which is similar to that reported in recent series ranging from 25.6% to 50.5%.[4] [6]

A study of 180 patients with a 2-year follow-up reported a high incidence of postoperative complications after stoma creation; 53% of patients with colostomies, 79% with loop ileostomies, and 70% of patients with end ileostomies experienced postoperative morbidity.[7] In our series, lower morbidity rates were recorded when evaluating the stoma subtypes: 33.94% and 28.2% for terminal and loop colostomies, respectively, and 30.7% and 15% for terminal and loop ileostomies, respectively, with no significant difference between subtypes. Some studies have shown a relationship between older age and increased morbidity.[3] Consistent with this, in our series, the multivariate analysis showed age >65 years as a risk factor for developing morbid events (0.001).

In our study, stomal necrosis occurred in 2.17%, with no difference when comparing stoma subtypes (p= 0.0836). Some studies report similar incidence rates ranging from 1% to 10% in colostomies and 1% to 5% in ileostomies.[8] [9] Others have reported rates as high as 20% to 29% for this complication, being more frequent in patients with colostomies.[6] [10] This outcome has been associated with an inadequate surgical technique, including, tension on the mesentery, excessive dissection, obesity, and emergency surgeries.[11] In contrast, no risk factors associated with this outcome were found in our study.

Mucocutaneous dehiscence occurred in 7.9% of our patients, less than that reported in other studies.[4] [12] Some studies have reported a history of diabetes mellitus, the presence of a septic process, preoperative corticosteroid use, malnutrition, excessive stress on the stoma, and obesity as risk factors for developing this outcome.[12] [13] In our study, the history of strangulated hernia and complicated diverticular disease as indications for surgery where the stoma was created were risk factors for this outcome (0.008 and 0.038, respectively), these being potential scenarios leading to inflammatory and septic processes.

The incidence of stomal prolapse ranges from 2% to 26%,[12] [14] 2% to 3% in ileostomies, 2% to 10% in colostomies, with transverse loop colostomies carrying the highest risk.[13] Our study showed an overall incidence 2.17% for this outcome, in concordance to that reported in the literature; however, the type of stoma registering the highest rate of prolapse was the loop colostomy (5.12%). The risk factors for stoma prolapse described include advanced age, obesity, chronic obstructive pulmonary disease (COPD), constipation, redundant bowel, and fascia weakness, as well as factors related to surgical technique, including inadequate SP sites, fascia oversized aperture, redundancy of the bowel at the stoma site, and the space between the abdominal wall and the stoma.[15] Our analysis showed bowel obstruction and para-stomal hernia as risk factors for this complication (p= 0.014 and p= 0.009, respectively), being bowel obstruction a condition capable of generating an episodic increase in intra-abdominal pressure, and the parastomal hernia a possible consequence of an oversized opening of the fascia.

Peristomal dermatitis is usually reported to have an incidence of 5% to 34%.[9] Although a lower incidence of this condition was recorded in our patients, it may be underestimated due to the underreporting of the complication by the patient during subsequent consultations.

Parastomal infections and abscesses incidence range from 2% to 14.8%,[16] being obesity, operative time, and emergency surgery risk factors for this outcome.[17] Our study registered an incidence of 6.8% for this condition, with no difference between stoma subtypes. Similarly, a retrospective study with 360 patients requiring emergency surgery with SP, reported parastomal infections in 5.6%, 6.7% of descending colostomies, 6.1% in transverse colostomies, and 3.2% of ileostomies, with no association between this complication and the location of the stoma.[17] Interestingly, anastomotic leakage as the indication for SP and perioperative corticosteroid use were risk factors for this outcome (p= 0.003 and 0. 031, respectively); anastomotic leakage being a setting that implies a septic process that can potentially seed bacteria at the time of stoma creation, and the perioperative therapy with corticosteroids a factor that predisposes to immune system suppression and immune response impairment.[18]

Stoma retraction has been reported in 1 to 6% after SP due to inadequate bowel mobilization.[15] Our data showed an overall incidence of 3.6% with no differences between stoma subtypes (p= 0.452), and no risk factors related to this outcome were found. A meta-analysis found no difference in the incidence of this outcome when comparing ileostomies and colostomies (1.6% vs. 3.1%, respectively).[19]

Parastomal hernias occur in up to 50% of patients with stomas, being more frequent in ileostomies than in colostomies and terminal stomas. The incidence of this complication is variable due to differences in follow-up in the studies. Risk factors for this complication include obesity, advanced age, malnutrition, COPD, steroid use, and SP lateral to the rectus abdominis.[15] In our study, only preoperative obesity was a risk factor for this complication (p = 0.022).

Some studies have noted age[3] and the type of stoma[8] as risk factors for adverse outcomes in general. Our analysis showed that age > 65 years (0.010) and the creation of a terminal colostomy (0.038) increase the risk of reoperation for stoma-related complications. This could be explained because patients older than 65 years tend to have more comorbidities, and it has been observed that terminal colostomies are among the types of stomas with higher adverse outcomes. In our study, the highest number of reoperations was registered in the group of terminal colostomies, which also recorded the highest rate of mucocutaneous dehiscence and stomal retraction. Therefore, it is mandatory to give appropriate importance to the technical aspects during the creation of stomas to minimize complications.

This study has limitations inherent to its retrospective design, being a study performed in a single center, as well as having a limited sample size, which limits the power of the analysis. Addressing these complications requires a collaborative and multidisciplinary approach. The absence of standardized guidelines and the variable definitions between studies show the need for international efforts to clarify definitions and identify specific risk factors for adverse events to promote better understanding, develop preventive measures, and improve outcomes. Future research should seek to implement these measures to achieve more uniform and reliable outcomes reporting.

In conclusion, ostomy creation has a high postoperative morbidity rate despite being a frequent procedure. This study showed that preoperative features such as advanced age, obesity, corticosteroid therapy, the indication of the surgery, and the type of the stoma created must be considered by the surgical team, as these, in addition to surgical technique, could significantly impact the outcomes.

Declaration of Conflicting Interests

The authors declare no conflicts of interest regarding the research, authorship, and/or publication of this article.

Authors' Contributions

Asya Zubillaga-Mares, Francisco Emmanuel Alvarez-Bautista, Eduardo Cárdenas-Lailson, and Alberto Nájera-Saldaña designed this work, collected and interpreted the data, and drafted the manuscript. Alejandra Núñez-Venzor, Javier Andrés Meza-Hernández, Minnet Serrano-Sánchez, and Mario Trejo-Ávila interpreted data, critically revised the manuscript, and performed overall supervision. All authors contributed to the final approval of the manuscript and agree to be accountable for all aspects related to the accuracy or integrity of the work.

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Publikationsverlauf

Eingereicht: 12. Juni 2024

Angenommen: 24. Oktober 2024

Artikel online veröffentlicht:
18. Dezember 2024