The structure of parastomal complications, predictors of their development: regional experience of the Center of Coloproctology of the Surgut District Clinical Hospital

Introduction

Scientific and technological progress has allowed medical science, in particular surgery, to reach a high level of development due to the introduction of modern methods of diagnosing diseases, as well as minimally invasive surgical techniques and various types of instruments and suturing devices. Due to the increase in cases of gastrointestinal diseases, there is a tendency towards an increase in the frequency of surgical interventions on the small and large intestines worldwide. Therefore, there is no tendency to reduce the number of operations ending in the formation of a temporary or permanent artificial intestinal fistula. The most common causes of stoma formation are malignant tumors of the colon and rectum. Much less common causes are complications of diverticular disease, inflammatory bowel disease, and injuries.

According to the World Health Organization, the number of patients with stoma worldwide is at least 100–150 people per 100 thousand population, of which 38.2–50.8% are people of working age. The number of patients with a stoma in the Russian Federation is estimated at 100–140 thousand people [1]. In the UK, about 20 thousand operations ending in the formation of a stoma are performed annually, in the USA – from 87 to 135 thousand [2][3]. The consequences of surgery with the formation of a temporary or permanent stoma induce moral and physical discomfort. The uncomplicated intestinal fistula is known to be a problem, and complications associated with a stoma significantly reduce the quality of life and successful social rehabilitation. In some cases, reconstructive and restorative intervention becomes impossible for a number of reasons, such as age, severe comorbid pathology, and fear of repeated surgery. Publications devoted to this issue indicate that in 21.3–45.0% of cases, temporary stomas become permanent [4].

The results of analysis of domestic and foreign studies demonstrate a different frequency of parastomal complications – from 15.9 to 90.1% of cases [1–10]. The most common complications include parastomal hernias, their share fluctuates from 4 to 48%. According to the American Association of Colorectal Surgeons, parastomal hernias are developed in 48–78% of patients. The second most common complication is parastomal dermatitis, which is diagnosed in 1.8–55.0% of patients with a stoma. Evagination and failure of the myenteric suture occur in 2–26% and 2.3–17% of patients, respectively. The share of other complications does not exceed 10–15% in patients with colo- and ileostomies. For this category of patients, there is a need not only for stoma care, but also for treatment of complications that have arisen [5][7][8].

According to literature data, repeated surgical intervention to manage parastomal complications is required in 30.1–58.5% of patients. This makes the problem of treating parastomal complications relevant and requires searching for significant mechanisms and predictors of their development and effective methods of conservative and surgical treatment [1–11].

The study was aimed at investigating the structure of parastomal complications and predictors of their development in patients with an artificial intestinal fistula.

Materials and methods

A single-center retrospective analysis of treatment outcomes was performed in 770 (100.0%) patients with colo- and ileostomies included in the registry of patients with the ostomy (the OSO registry) of the District Center of Coloproctology of the Surgut District Clinical Hospital for the period from 2019 to 2023. The inclusion criteria for the study were age over 18 years, an intestinal fistula on the anterior abdominal wall, and permanent residence in the Khanty-Mansi Autonomous Area – Yugra during the study. Exclusion criteria included the patient's permanent residence outside the district, as well as the patient's unwillingness to participate in the study.

The group of patients under analysis included 353 (45.8%) women and 417 (54.2%) men. The average age of patients was 62 [ 55; 68] years, the minimum age – 27 years, and the maximum age – 92 years. The number of young patients with an ostomy was 70 (9.1%), the middle age group included 244 patients (31.7%), and the elderly were 389 (50.5%) patients. The proportion of patients with an ostomy over 75 years old was 64 (8.3%) patients, and long-livers were 3 (0.4%) patients.

By the nature of the surgical intervention, planned operations were predominant (528 patients, or 68.6%); emergency interventions were performed in 242 patients (31.4%). In most cases, the indications for surgery were malignant tumors of the intestine and pelvic organs — in 617 patients (80.1%). Benign diseases were detected in 153 cases (19.9%): acute and chronic complications of diverticular disease — in 49 (6.4%) patients, intestinal trauma and perforation of various etiologies as the cause of stoma formation — in 38 (4.9%) patients, inflammatory bowel diseases — in 27 (3.5%) patients, purulent-destructive diseases of the abdominal organs and hepatobiliary zone, acute vascular disorders of the intestine, as well as benign tumors of the colon and rectum — in 39 (5.1%) patients (Table 1).

Surgical treatment, one of the stages of which was the formation of an end stoma, was performed in 581 (75.5%) patients, and a loop stoma was developed in 189 (24.5%) patients. Therapeutic colonic fistula was created in 637 (82.7%) patients, ileostomy was performed in 133 (17.3%) patients.

In the analyzed group, laparoscopically assisted interventions were performed in 169 (21.9%) patients, and open interventions were performed in 601 (78.1%) patients. In 515 (66.9%) patients, the interventions were combined and accompanied by resection of adjacent organs (Table 2).

In order to describe the epidemiology of complications associated with the artificial fistula on the anterior abdominal wall, the classification proposed by the Association of Coloproctologists of Russia was used. It is based on a multifactorial approach and simultaneously considers etiopathogenetic factors, localization of the process, and clinical manifestations, and also allows determining the tactics of management and treatment of patients with a stoma. According to this classification, complications should be divided into two groups: complications of the stoma intestine and peristomal skin complications. The first group includes bleeding, necrosis, eventration, failure of the skin-intestinal suture, parastomal abscess or phlegmon, stoma retraction, evagination, parastomal hernia, stenosis of the stoma orifice, fistulas, mucosal hyperplasia and recurrence of a tumor in the stoma area. Peristomal skin complications are characterized by changes only in the skin, these are contact peristomal dermatitis, allergic dermatitis, folliculitis, gangrenous pyoderma, and hyperkeratosis. Specific, including fungal or psoriatic, skin changes also refer to peristomal complications.

In foreign publications, an alternative classification of complications associated with the presence of an artificial intestinal fistula can also be found. It is based on the time of their development and pathogenesis [9][10]. Thus, in 2014, Pittman presented an algorithm for the formation of parastomal complications, identifying three groups of factors in it. Based on this theory, he developed the idea of classifying complications identified up to 30 days after surgery as early. These include bleeding, necrosis, failure of the skin-intestinal suture, retraction, as well as an abscess or phlegmon in the stoma area. Complications that occur 30 days post-surgery are classified as late, including stenosis of the stoma orifice, its prolapse, the development of a parastomal hernia, injuries to the mucous membrane of the stoma intestine with the development of hypergranulations [11].

Statistical analysis was performed using the StatTech v. 4.0.6 software (developer — StatTech LLC, Russia). Quantitative indicators were assessed for compliance with normal distribution using the Shapiro-Wilk test (for a sample of less than 50 subjects) or the Kolmogorov-Smirnov test (for a sample of more than 50 subjects). Quantitative indicators with normal distribution were described using arithmetic means (M) and standard deviations (SD), and 95% confidence interval limits (95% CI). In the absence of normal distribution, quantitative data were described using the median (Me) and lower and upper quartiles (Q1–Q3). Categorical data were described using absolute values and percentages. A comparison of two groups by a quantitative indicator with a non-normal distribution was performed using the Mann-Whitney U test. A comparison of percentages in the analysis of four-field contingency tables was performed using Pearson’s chi-squared test (for values of the expected phenomenon greater than 10), and Fisher’s exact test (for values of the expected phenomenon less than 10). A comparison of percentages in the analysis of multi-field contingency tables was performed using Pearson’s chi-squared test.

Results

In the analyzed group, complications were defined in 457 (59.4%) people. One parastomal complication was identified in 310 (67.8%) patients, two complications – in 128 (28.0%) patients, three complications – in 17 (3.7%) patients, and a combination of four complications – in 2 (0.4%) patients. Various peristomal skin complications were noted in 160 (35.0%) patients, and complications of the stoma intestine – in 297 (65.0%) patients. The most common complication was maceration, it was identified in 111 (24.3%) people. Peristomal skin dermatitis in the erythema phase was diagnosed in 48 (10.5%) patients, and folliculitis – in 43 (9.4%) people. Allergic dermatitis and peristomal skin dermatitis in the ulcerative lesion phase were diagnosed in 10 (2.2%) patients. The most frequent complication in the late postoperative period was the formation of parastomal hernia, which was found in 142 (31.1%) patients. Retraction, stenosis of the stoma orifice, and granulation of the mucous membrane were detected in 73 (16.0%), 70 (15.3%), and 63 (13.8%) patients, respectively. Other types of complications of the stoma intestine were less common: evagination was diagnosed in 26 (5.7%) patients, single fistula or multiple parastomal fistulas – in 15 (3.7%) patients, failure of the skin-intestinal suture – in 7 (1.5%) patients, polyps at the stoma orifice – in 6 (1.3%) patients with a stoma.

The analysis revealed statistically significant differences in the risks of complications in elderly and senile patients (p = 0.035); the average age of individuals with stoma complications was 63 [ 56;69] years (p = 0.003), while the average age in the group without complications was 60 [ 53;66] years. Another statistically significant risk factor for complications in the analyzed group was the presence of a loop stoma (p = 0.018). The odds of complications in the group of patients with a loop stoma were 1.511 times higher; the differences in odds were statistically significant (95% CI: 1.071–2.131). According to the results of the statistical analysis of this group, it was noted that the risks of developing complications did not depend on the patient’s gender (p = 0.309, 95% CI: 0.871–1.550) and the order of surgical treatment (p = 0.941, 95% CI: 0.732–1.399).

Discussion

Contrary to the data of modern publications, the analysis of complications between patients with malignant tumors and patients with other non-malignant pathologies provided in this study revealed no statistically significant differences (p = 0.086), the differences in odds were also not statistically significant (95% CI: 0.955–1.988). When comparing the incidence of complications in patients with colo- and ileostomy, no statistically significant differences (p = 0.071) were established. In the group of patients with ileostomy, the odds of developing complications were 1.438 times higher, but the differences in odds were not statistically significant (95% CI: 0.968–2.134).

Conclusion

Therefore, parastomal complications occur in 59.4% of patients. The most common peristomal skin complication is considered to be maceration. It was noted in 111 (24.3%) people, and the most common complication of the ostomy intestine is the formation of a parastomal hernia which was detected in 142 (31.1%) patients. It has been found that in patients over 63 years old, i.e. in elderly and senile people, the risk of complications is higher (p = 0.003). Another statistically significant risk factor for complications is loop stoma development (p = 0.018). In this group of patients, the odds of complications are 1.511 times higher, the differences in odds are statistically significant (95% CI: 1.071–2.131). Therefore, the search for mechanisms of development and risk factors for complications associated with the stoma requires further scientific research.