What are the potential complications of a colostomy and how are they managed?

Colostomy Complications

Colostomy complications occur in approximately 30-48% of patients and include both early complications (bleeding, infection, high output) and late complications (parastomal hernia, prolapse, stenosis), with an overall mortality rate of approximately 2%. 1

Mortality

• Perioperative mortality is approximately 2% for colostomy procedures 1
• Mortality increases to 12% for emergency Hartmann's procedures performed in critically ill patients 1
• Risk factors for mortality include age >60 years, presence of shock on admission, and previous episodes of volvulus 1
• Sepsis-related deaths can occur following colostomy closure, particularly with anastomotic dehiscence 2

Early Postoperative Complications

Bleeding and Cardiopulmonary Events

• Bleeding occurs in the immediate postoperative period related to anesthesia and surgical technique 1
• Cardiopulmonary events are related to anesthesia and occur more frequently in elderly patients with comorbidities 1

High Ostomy Output

• Early high output (>1.5 L/day) is rare with colostomy but requires prompt evaluation for infection (C. difficile, postoperative abscess), ileus, or medication effects 1
• Management requires intravenous hydration to prevent renal failure, often necessitating hospital admission 1
• Medical treatments include antidiarrheal agents and dietary modifications 1

Ostomy Leakage

• Leakage is one of the most common and dreaded complications, occurring more frequently with obesity, placement within skin creases, loop configuration, and flush stomas 1
• Prevention through preoperative marking by a stomatherapist and meticulous surgical technique is critical 1
• Management involves thickening stool with antidiarrheals, convex appliances, ostomy belts, paste, or barrier rings 1
• The appliance opening should be cut one-eighth inch larger than the stoma to prevent mucosal irritation while limiting skin exposure 1

Surgical Site Infection

• Surgical site infections occur in 23-43% of patients, representing the most common complication 1, 3
• Wound infections complicate 13% of colostomy closures 2
• Prevention requires meticulous technique, avoiding contamination, and perioperative antibiotics 4

Late Complications

Parastomal Hernia

• Parastomal hernia occurs in up to 50% of ostomates within 5 years 1
• Risk factors include obesity, smoking, steroid use, and transverse colostomies 1
• Stomas should be placed through the rectus muscle to minimize hernia risk 1
• Transverse colon should be avoided when possible due to significantly increased hernia and prolapse risk 1
• Incarcerated hernia presents as a painful hernia requiring urgent intervention 1

Prolapse

• Prolapse occurs in 119 cases (8.4%) in large series, predominantly in mobile portions of the colon 5
• Loop colostomies have higher prolapse rates than end colostomies 5
• Prevention involves creating colostomies in fixed portions of the colon (descending colon) or fixing the bowel to the abdominal wall 5

Stenosis and Retraction

• Stenosis occurs in 42 patients (3%) and retraction in 29 patients (2%) in large series 5
• These complications can interfere with appliance application and stool passage 5

Stomal Problems

• Major long-term problems include rashes, leakage, and ballooning 1
• Peristomal skin excoriation results from repetitive leakage and frequent appliance changes 1

Colostomy Closure Complications

Overall Morbidity

• Colostomy closure carries a 17-30% complication rate 2, 6
• Patients with initial colon injury experience 55% morbidity after closure, compared to only 12.5% for those with rectal injuries 2
• Combined morbidity from both colostomy creation and closure reaches 35% 6

Specific Closure Complications

Intestinal Obstruction:

• Small bowel obstruction occurs in 7-47% of closures, primarily from adhesions 2, 4
• Temporary anastomotic dysfunction can occur with severe size discrepancy between proximal and distal segments 4

Anastomotic Complications:

• Anastomotic dehiscence occurs in 7% of closures 2
• Anastomotic stricture develops in some patients requiring intervention 2
• Fecal fistula formation is a major complication requiring prolonged management 2

Wound Complications:

• Incisional hernia occurs in 11% of closures 2, 4
• Wound dehiscence affects 7.8% of patients 3

Prolonged Ileus:

• Prolonged ileus is the most common minor complication, affecting 25% of patients 2

Predictors of Closure Complications

• Colon injury as initial indication increases risk 7.7-fold (p=0.009) 2
• Operative time >2 hours increases risk 2.8-fold 2
• Blood loss >150cc increases risk 2.77-fold 2
• Delayed closure >11 months significantly increases complications compared to closure at 6 months 2
• Age >30 years increases risk 2.71-fold 2
• End colostomy increases risk 2.33-fold compared to loop colostomy 2

Prevention Strategies

At Creation

• Use separated stomas in the descending colon rather than loop colostomies to minimize complications 5
• Avoid Hartmann's procedure in anorectal malformations (contraindicated) 5
• Place stomas through the rectus muscle in fixed portions of the colon 1, 5
• Avoid transverse colon location due to high hernia and prolapse rates 1
• Ensure adequate stoma height to prevent flush stomas and leakage 1

At Closure

• Perform meticulous surgical technique including: packing proximal stoma, plastic drape immobilization, careful hemostasis, avoiding contamination, 2-layer end-to-end anastomosis with long-term absorbable sutures, generous irrigation, and layer-by-layer closure 4
• Administer IV antibiotics during induction and continue for 48 hours 4
• Perform proximal stoma irrigations 24 hours prior to operation 4
• Avoid drains and nasogastric tubes 4
• Consider timely closure (6-8 months) rather than prolonged delays to reduce complications 2

Special Considerations

Mislocation Complications

• Mislocation occurs in 282 cases (20%), including stomas too close together (116), too distal in rectosigmoid (97), inverted (30), too far apart (21), and right upper sigmoid (18) 5
• Mislocated stomas lead to appliance application problems, interference with pull-through procedures, megasigmoid, distal fecal impaction, and urinary tract infections 5

Hospital-Acquired Complications

• Hospital-acquired pneumonia occurs in 10.5% of colostomy patients 3
• Aggressive resuscitation, early operation, and close postoperative follow-up are essential 3