Why Stomas Are Created Before Another Surgery
A stoma is created before another surgery primarily in emergency situations to control contamination and inflammation, allowing for resolution of sepsis before definitive treatment, which significantly reduces morbidity and mortality in critically ill patients. 1
Main Indications for Preoperative Stoma Creation
Emergency Situations
- Delayed diagnosis with significant peritonitis
- Left-sided perforations
- Hemodynamically unstable patients
- Extensive peritoneal contamination
- Intra-abdominal abscesses that fail percutaneous drainage 2
- Toxic megacolon or severe peritonitis 2
Disease-Specific Indications
- Refractory Crohn's disease colitis (defunctioning stoma to delay or avoid colectomy) 2
- Colorectal cancer with obstruction or perforation 2
- Locally advanced rectal cancers requiring neoadjuvant chemoradiotherapy 1
Benefits of Creating a Stoma Before Definitive Surgery
- Source control: Immediate control of contamination source in perforated cases
- Reduced operative time: Shorter initial surgery in unstable patients
- Improved outcomes: Resolution of inflammation before definitive surgery
- Reduced risk of anastomotic complications: Particularly important in high-risk patients
- Avoidance of emergency colectomy: In cases of refractory IBD colitis 2
Decision-Making Algorithm for Stoma Creation
Right-Sided Pathology
- Stable patient: Right colectomy with primary anastomosis if feasible
- Unstable patient: Right colectomy with terminal ileostomy 2
- Severely unstable patient: Loop ileostomy alone 2
Left-Sided Pathology
- Stable patient: Consider primary resection with anastomosis
- Unstable patient: Hartmann's procedure (resection with end colostomy) 2
- Severely unstable patient: Loop transverse colostomy 2
Risk Factors That Favor Stoma Creation
When two or more of these factors are present, stoma formation is recommended 1:
- Sepsis or septic shock
- Widespread peritoneal contamination
- Hemodynamic instability requiring inotropes
- Poor nutritional status (low albumin)
- Presence of intra-abdominal abscess
- Immunosuppression
- Active smoking
Stoma Types and Selection
Loop transverse colostomy: Often preferred in emergency settings because it:
- Can protect future anastomosis
- Is technically easier to create
- Preserves the left abdomen for potential permanent stoma 1
End colostomy (Hartmann's procedure): Preferred for:
- Left-sided perforations
- When abdominal-perineal resection is anticipated 1
Loop ileostomy: Considered for:
- Incomplete obstruction
- Patent ileocecal valve
- Defunctioning stoma for non-acute refractory Crohn's disease colitis 2
Preoperative Optimization
- Nutritional assessment: Critical before IBD surgery 2
- Anemia correction: Preoperative intravenous iron for iron deficiency anemia 2
- Abscess drainage: Percutaneous drainage of abscesses >3cm as a bridge to surgery 2
- Stoma site marking: Should be performed by stoma therapists or specialist nurses 2
Important Considerations
- In Crohn's disease, a defunctioning stoma may delay or avoid the need for colectomy, with initial remission rates of up to 90% reported 2
- Successful stoma reversal rates are lower when perianal disease is present (29-42%) 2
- Preoperative stoma counseling and marking by specialists significantly improves outcomes 2
- Enhanced recovery pathways should be implemented for all IBD surgical patients 2
Potential Complications
- Stoma complications occur in up to 70% of cases 3
- Risk factors for permanent stoma after "temporary" diversion include:
- Anastomotic leakage
- Positive circumferential resection margins
- Advanced cancer stage 4
Creating a stoma before definitive surgery is a critical decision that balances the need to control sepsis against the morbidity of multiple operations. When performed appropriately in the right clinical scenarios, this staged approach significantly improves patient outcomes.