Hypothesis / aims of study
Stoma formation in constipation is considered controversial and a radical approach, however, it may be considered in a carefully selected subset of patients whose lives are significantly impacted by symptoms of constipation refractory to all forms of non-surgical treatment This involves colostomy or ileostomy formation with or without a bowel resection where options include ileorectal anastomosis, proctocolectomy or end-stoma formation. Stoma surgery, both with or without resection is associated with surgical complications and also has both psychological and social impacts on patients. We assessed patient-reported outcomes to gauge their satisfaction with the decision to undergo stoma formation and also assessed morbidity associated with the surgical procedure.
Study design, materials and methods
Clinical records of patients who underwent stoma formation for constipation were collected retrospectively between 2012-2024. Data included baseline characteristics, investigations, details of the surgery, postoperative outcomes, and subsequent stoma or complications-related surgeries. Furthermore, patients were assessed regarding their satisfaction with undergoing stoma surgery by asking them to fill decision regret scale (DRS).
Results
So far, data has been collected for 22 patients, with a median age of 51 years and a female predominance (86%). At least one psychological co-morbidity was reported by 54.5% of patients while 22.7% reported fibromyalgia. The median length of postoperative follow-up was 44.4 months.
Demographics are further shown in Table 1.
The median duration of symptoms was 13.5 years. Before surgery, all patients underwent bowel function retraining and biofeedback. All patients had tried laxatives, 81.8% tried glycerine suppositories, prokinetics were used by 72.7%, and 90.9% had used rectal irrigation.
Indication for surgery was determined by results from investigations where 72.7% underwent stoma surgery for slow transit constipation (STC), 4.5% for evacuation difficulties, 13.6% for both STC and evacuation difficulties, and 13.6% for other reasons such as autonomic neuropathy, pseudo-obstruction, and colonic inertia.
Loop-Ileostomy was formed in 17 patients, while loop-colostomy was formed in 5. Laparotomy and stoma were performed in 3 (13.6%) patients while laparoscopic stoma was formed in 19 (86.4%). Concomitant bowel resection (sub-total colectomy with ileorectal anastomosis) was performed in two (9.1%) patients with loop ileostomy.
The median postoperative stay was 11 days. Early postoperative stoma complications were reported by 6 (27.3%) patients and these included high stoma output (18.2%), retraction of stoma (4.5%), cellulitis around the stoma (4.5%). Other complications included urinary tract infection, adhesive bowel obstruction and paralytic ileus.
Subsequent surgery was performed in 72.7% of patients where 13 patients (59%) underwent definitive surgery including bowel resection while 3 required further surgery for complications such as enterocutaneous fistula, incisional hernia, and prolapse of stoma. The number of further surgical procedures after initial stoma surgery ranged from 1 – 4 which were further associated with post-operative complications.
Further details of procedures are shown in Table 2.
One patient was lost so follow-up. Out of 21 patients, the return of symptoms of constipation was reported by 33.3% of patients and parastomal hernia by 52.4%.
A total of 18 patients completed DRS scale. No regret was reported by (7,39%), mild regret by (5,28%), and moderate to severe regret by (6, 33%) patients. Mean score was 21.39 with (median 7.5, interquartile range 1 – 31.25) (Figure 1).
Interpretation of results
- High morbidity associated with stoma formation and requires further operations
- Less than half of patients had no regret
- 1/3rd of patients had a relapse of symptoms
- Severe regret was associated with the return of symptoms and those operated for STC