PERISTOMAL HERNIA: THE CASE FOR EXTRAPERITONEAL COLOSTOMYGarnet Blatchford, M.D.
I have no disclosures to report
EXTRAPERITONEAL COLOSTOMYOLD CONCEPT, BUT FORGOTTEN?
Principles and Practice of Surgery for the Colon, Rectum and Anus, Gordon/Nivatvongs – role of extraperitoneal colostomy uncertain
Complications of Colon & Rectal Surgery, Hicks/Beck – no mention
Colon and Rectal Surgery - Corman – no mention for colostomy, only ileostomy
ASCRS textbook-extraperitoneal “extreme” lateral mesenteric closure
FACTORS IN PARACOLOSTOMY HERNIA
Poor technique
Lateral to rectus
Trephine size
Fascial fixation
Closure of lateral space
High intra-abdominal pressure
Obesity
Constipation
Chronic cough
Prostate enlargement
INTRAPERITONEAL COLOSTOMY
EXTRAPERITONEAL COLOSTOMY
EXTRAPERITONEAL VS INTRAPERITONEAL COLOSTOMY
Goligher 1958: Br J Surg Vol 46,196:7-8
Goligher 1976 DCR: 19:342-366 251 patients
Complications Intraperitoneal n=162
Extraperitoneal n=89
Pericolostomy hernia
28 8
Prolapse 10 2
Recession 1 0
Stenosis 6 3
Fistula 1 0
Total 46 13
PROBABILITY OF COLOSTOMY COMPLICATION IN INTRAPERITONEAL COLOSTOMIES
# of patients
Crude Rate (%)
Actuarial Rate (%)
Years
Paracolostomy hernia
43 21.2 36.7 10
Skin 24 11.8 17.4 11
Prolapse 11 5.4 11.8 13
Obstruction
11 5.4 13.7 13
Stenosis 10 4.9 7.3 10
Retraction 3 1.5 NA -
Fistula 2 1.0 NA
Life Table Analysis of Stomal Complications Following Colostomy, Phillips RKS DCR 37:916-920 (1994)
META-ANALYSIS OF EXTRA VS INTRA
Seven retrospective studies with a combined total of 1,071 patients (250 extraperitoneal colostomy and 821 intraperitoneal colostomy)
There was a significantly lower rate of parastomal hernia (odds ratio, 0.41; 95% confidence interval, 0.23-0.73, p = 0.002) in the extraperitoneal colostomy group
the occurrences of bowel obstruction and prolapse were not significantly different between the two groups.
Int J Colorectal Dis. 2012 Jan;27(1):59-64
LAPRASCOPIC EXTRAPERITONEAL COLOSTOMY 12 patients with lap extraperitoneal
colostomy No peristomal hernias
10 patients with lap intraperitoneal colostomy 4 peristomal hernias (33%), occurred at
24, 36, 48 and 72 months
Laparoscopic extraperitoneal colostomy in elective abdomino-perineal resection. Leroy J, Colorectal Dis (2012)
OMAHA EXPERIENCE
223 Patients undergoing APR for cancer Open APR in 209(94%), robotic/lap in
14(6%)
June 2001-July 2013, seven colorectal surgeons
Retrospective chart review Males 123 (55%), Females 100 (45%) 183 had intraperitoneal colostomy made 40 had extraperitoneal colostomy made
OMAHA STOMA STUDY
Demographic
IP (n=183 EP (n=40) P value
Age (yr) 66.2 62.8 NS
Gender (M/F) 102/89 21/19 NS
BMI 28.0 24.6 0.002
Comorbidity
IP (%) EP (%) P value
Smoker 64(34.9) 12(30) NS
COPD 12(6.5) 1(2.5) NS
DM 25(13.7) 1(2.5) NS
Other hernia 15(8.2) 1(2.5) NS
BPH 9(4.9) 2(5) NS
Hypothyroid 19(9.8) 2(5) NS
OMAHA STOMA STUDY
Surgeon
APR n IP n (%)
BMI EP n (%)
BMI
1. 43 26 (60) 28.1 17 (40) 24
2. 49 34 (69) 25.7 15 (31) 24.9
3. 35 34 (97) 25.7 1 (3) 26.5
4. 40 37 (92) 28.8 3 (8) 25.6
5. 17 16 (94) 28.2 1 (6) 23.1
6. 28 27 (96) 20.4 1 (4) 19.7
7. 10 7 (70)
25.1 2 (10) 29.1
OMAHA STOMA STUDY
Variable IP n=183 EP n=40 P value
Stoma complications
45 2 0.006
-Prolapse 2 0 NS
-Stoma necrosis
2 0 NS
-Obstruction 0 1 NS
-Diverticulitis 0 1 NS
-Peristomal hernia
41 0 <0.001
time to dx (mos)
25.7 (3-108)
op repair 17/41 (41%)
recurrent hernia
4/17 (24%)
Bowel Obstruct.
7 0 NS
OMAHA STOMA STUDYINTRAPERITONEAL GROUP
Variable Hernia (n=41)
No hernia (n=142)
P value
Age 65.5 66.4 NS
BMI 29.5 (20-52) 27.5 (15-50) NS
Smoking/COPD
18 (43%) 58 (41%) NS
DM 3 (7.3%) 22 (15.5%) NS
Gender (M/F) 25/16 77/65 NS
BPH 1 (2.4%) 8 (5.6) NS
Hypothyroid 2 (4.9%) 16 (11.3%) NS
OMAHA EXPERIENCEINTRAPERITONEAL COLOSTOMYCOMPLICATIONS
Peristomal hernia- 41 patients Colostomy prolapse – 2 pts at 18, 28 months Colostomy necrosis requiring revision – 2
patients (2 days postop and at 1 month)
Overall colostomy complication rate of 24.6%(45/183)
OMAHA EXPERIENCEEXTRAPERITONEAL COLOSTOMY Complications in 2 (5%) p<0.001
compared to intraperitoneal group
Bowel obstruction at 2 months related to small bowel entering extraperitoneal space
Diverticulitis of extraperitoneal segment required revision at 64 months
No stomal prolapse/necrosis
CONCLUSIONS
Phillips “When surgeons who devote a substantial amount of their time to colorectal surgery and who have extensive personal experience of stomal surgery are also found to have a high rate of stoma related complications (cumulative risk of 58.1% at 13 years) it is time to question some of the tenets that are currently accepted as a sene qua non of good stomal surgery”
CONCLUSION OMAHA EXPERIENCE
Extraperitoneal colostomy should be the preferred technique for permanent stoma
We need to be teaching this technique to our residents when making permanent stomas
CONCLUSIONS CONT.
FOR DISCUSSION: ? If the colon is not amenable to extraperitoneal approach should we do a sugerbaker technique at the original surgery with biologics?
Should this technique be done for permanent ileostomies?
