Stoma formation: An underestimated challenge in emergency surgery

Intestinal stomas are frequently burdened with complications. ¹ Several risk factors have been identified, one being emergency surgery. ² Two cohort studies in the current issue investigated stoma construction in the acute care surgery setting^3,4—one focusing on preoperative stoma site marking and the other one on risk factors for stoma complications specifically between elective and emergency surgery.

Preoperative stoma site marking might reduce stoma complications, but it is difficult in the emergency setting. ⁵ Nozawa et al. ³ achieved stoma site marking in the majority of their emergency cases by improving hospital routines. The study encompasses a large cohort, but significant differences in stoma complications between marked and unmarked patients were limited to bleeding and peristomal dermatitis. ³ The long study period might have affected the results as stoma techniques and stoma equipment may have changed. Laparoscopic surgery might have negative effects on stoma construction, especially if the bowel is extracted through the stoma site. ⁶

Ayik et al. ⁴ compared stoma outcomes in elective versus emergency surgery and included more than 800 patients. In this study, bleeding and stoma necrosis were more prevalent in acute cases in line with previous studies. To prevent both herniation and obstruction, the stoma passage needs to be just wide enough but not too wide, which is difficult to achieve in the acute setting with bowel edema, peritonitis, and a lack of adequate bowel length contributing to bad outcomes. However, even larger differences between elective an emergency surgeries could have been expected.

Both articles highlight the fact that emergency stoma creation needs more attention. Although marking might improve outcomes, it does not seem to be a major variable in the emergency setting. The skill of the surgeon might be a very important factor. After a long-lasting emergency operation at night hours, it is only human to be more prone to overlook a stoma you are not completely happy with by assuring yourself that it will be ok. A good advice is to complete the stoma before closing the abdomen, keeping a low threshold for refashioning the stoma as there is no proven effect on surgical site infection rates by completing the stoma before abdominal closure. Variants of these principles could also be applied in laparoscopic surgery.