Why is a stoma created before another surgery?

Indications for Creating a Stoma Before Another Surgery

A stoma is created before another surgery primarily in cases of delayed diagnosis, significant peritonitis, left-sided perforations, or when the patient is hemodynamically unstable, as this staged approach reduces morbidity and mortality by controlling contamination and inflammation before definitive treatment. 1

Primary Indications for Stoma Creation

1. Colorectal Emergencies

• Iatrogenic Colonoscopy Perforation (ICP):

  • Delayed surgery (>24 hours from colonoscopy)
  • Extensive peritoneal contamination
  • Important comorbidities
  • Deterioration of patient's general status (hemodynamically unstable or sepsis) 1

• Rectal Cancer with Obstruction:

  • For locally advanced rectal cancers requiring neoadjuvant chemoradiotherapy
  • Stoma creation (preferably transverse colostomy) allows for proper staging and appropriate oncologic treatment
  • Avoids premature resection that would compromise oncologic outcomes 1

2. Patient-Related Factors

• Risk Factors for Anastomotic Complications:
  • Patients with ≥2 risk factors (sepsis, widespread peritoneal contamination, hemodynamic instability, need for inotropes, poor nutrition/low albumin, presence of abscess, immunosuppression, smoking) should receive a stoma rather than primary anastomosis 2
  • Allows for bowel healing and resolution of inflammation before definitive surgery

3. Disease-Specific Indications

• Fournier's Gangrene:
  • Common indications for colostomy include anal sphincter involvement, fecal incontinence, and continued fecal contamination of the wound
  • Protects the perineal wound from fecal contamination during healing 1

Types of Stomas and Selection Criteria

Loop vs. End Stoma

• Loop Transverse Colostomy: Often preferred because:

  • Can be left in place to protect future anastomosis
  • Easier to fashion due to mobility of transverse colon
  • Avoids damage to marginal arcade
  • Preserves left abdominal region if permanent end colostomy becomes necessary 1

• End Sigmoid Colostomy: Preferred when abdominal-perineal resection is anticipated 1

• Loop Ileostomy: Viable option only if:

  • Obstruction is incomplete OR
  • Ileocecal valve is patent (otherwise colonic distension would not be resolved) 1

Timing Considerations

• Immediate Stoma Creation: Required in cases of:

  • Hemodynamic instability
  • Severe sepsis/septic shock
  • Massive intestinal bleeding
  • Toxic megacolon
  • Severe peritonitis 2

• Delayed Decision: Some evidence suggests postponing stoma creation for 48 hours after initial surgery to:

  • Allow acute inflammation and edema regression
  • Enable correct evaluation of sphincters and perianal tissues 1

Benefits of Staged Approach with Stoma

1. Source Control: Immediate control of contamination source
2. Reduced Operative Time: Shorter initial surgery in critically ill patients
3. Improved Outcomes: Allows for resolution of inflammation before definitive surgery
4. Oncologic Benefit: In rectal cancer, permits proper neoadjuvant therapy without compromising treatment schedules 1

Potential Drawbacks

• Temporary stoma formation significantly increases healthcare costs without affecting mortality rates and hospital length of stay in some studies 1
• Requires a subsequent surgical procedure for stoma closure
• Potential for stoma-related complications

Practical Considerations

• Stoma site marking by a stoma care nurse is crucial to prevent complications, though often not possible in emergency settings 1
• The absence of preoperative stoma site marking and emergency surgery are risk factors for problematic stoma development 1
• Nursing care and education are vital components of successful stoma management 1

Decision Algorithm

1. Assess patient stability:

   • If unstable (septic, hemodynamically compromised) → Create stoma
   • If stable → Proceed to next step

2. Evaluate contamination:

   • If extensive peritoneal contamination → Create stoma
   • If minimal contamination → Proceed to next step

3. Consider timing since injury/perforation:

   • If >24 hours → Create stoma
   • If <24 hours with good bowel preparation → Consider primary repair

4. Assess anatomical location:

   • For rectal cancer requiring neoadjuvant therapy → Create stoma
   • For left-sided perforations → Higher likelihood of needing stoma

5. Evaluate risk factors for anastomotic leak:

   • If ≥2 risk factors present → Create stoma
   • If <2 risk factors → Consider primary anastomosis

The decision to create a stoma should be made by a multidisciplinary team whenever possible, tailoring the approach to the individual clinical circumstance 1.