What is a prolapsed colostomy in patients with a history of colorectal cancer or other conditions, particularly in older adults?

What is a Prolapsed Colostomy

A prolapsed colostomy is a late complication where the bowel protrudes through the stoma opening beyond the normal level of the abdominal wall, occurring most commonly when the stoma is created in an emergency situation or placed in a mobile portion of the colon. 1, 2

Definition and Mechanism

• Prolapse represents telescoping or protrusion of the bowel through the stomal opening, extending beyond the skin surface, sometimes dramatically (up to 20 cm in severe cases) 3
• This complication occurs more frequently with loop colostomies than end colostomies, particularly when created in mobile portions of the colon such as the transverse or sigmoid colon 2
• The condition is not immediately life-threatening but causes significant quality of life issues including difficulty with appliance management, skin irritation, and cosmetic concerns 3

Clinical Presentation

Typical features include:

• Visible protrusion of bowel through the stoma opening, ranging from mild (few centimeters) to extreme (>15-20 cm) 3, 4
• Marked redness, swelling, and erosion of the prolapsed segment in severe cases 3
• Difficulty with stoma appliance application and frequent leakage 2
• Peristomal skin breakdown from chronic irritation 1

Risk Factors

The following increase prolapse risk:

• Emergency stoma creation (most significant risk factor) 3, 2
• Placement in mobile portions of colon (transverse, sigmoid) rather than fixed portions (descending colon) 2
• Loop colostomies versus end colostomies 2
• Inadequate fixation of bowel to abdominal wall at time of creation 2

Management Approach

Non-Urgent Prolapse (Most Common)

For asymptomatic or minimally symptomatic prolapse:

• Manual reduction is the first-line approach - patients can be taught gentle reduction techniques 1, 5
• Conservative management with proper appliance fitting and skin barrier products while awaiting elective closure 6
• Referral to wound ostomy continence (WOC) specialist for pouching optimization 1

Urgent/Emergency Prolapse

Immediate surgical referral is required when:

• Painful, obstructed, or discolored (purple/black) stoma indicating ischemia or incarceration 1
• Signs of strangulation including fever, tachycardia, intense unremitting pain 7
• Inability to reduce the prolapse manually 3

Definitive Surgical Options

When surgical correction is necessary:

• Local revision using stapling devices (Proximate Linear Cutter) can be performed under mild sedation for patients too fragile for laparotomy 3, 4, 6
• This technique involves diagonal insertion of the stapler into the prolapsed stoma, applying it twice on both sides to divide and restaple the tissue 3
• Formal laparotomy with stoma revision or relocation for recurrent cases or when local repair fails 2
• Sugar as a desiccant can assist reduction of incarcerated prolapse in emergency situations, potentially avoiding urgent surgery 5

Prevention Strategies

Key preventive measures include:

• Creating stomas in fixed portions of colon (descending colon preferred) rather than mobile segments 2
• Using separated end stomas rather than loop stomas when feasible 2
• Adequate fixation of bowel to abdominal wall during initial creation 2
• Avoiding emergency stoma creation when possible through better preoperative planning 3, 2

Common Pitfalls

• Do not assume all prolapses require immediate surgery - most can be managed conservatively or with elective repair 6
• Do not delay emergency referral when signs of ischemia or incarceration are present (purple/black discoloration, severe pain, obstipation) 1
• Do not create loop colostomies in mobile colon segments as this significantly increases prolapse risk 2