Abstract
Background:
End colostomies are performed frequently in both emergency and elective abdominal surgery. The aim of this study was to assess early stoma-related complications and to identify risk factors for severe complications.
Methods:
All patients undergoing surgery with an end colostomy during 2018–2020 at Tampere University Hospital were identified. This was a single-center study based on a prospective stoma registry complemented with additional retrospective clinical data. A stoma-related complication was classified as severe (Clavien-Dindo grade ⩾3a) or mild (<3a).
Results:
The study comprises 360 patients (median age = 71, interquartile range = 64–78 years); 197 (55%) patients were male, and out of these 360 patients, 242 (67%) underwent elective operation and 118 (33%) underwent emergency surgery. There were 18/118 (15%) severe stoma-related complications in the emergency and 12/242 (5%) in the elective group. Stoma site was marked preoperatively for 53/118 (45%) in the emergency group and for 235/242 (97%) patients in the elective group. Most of the stomas were performed by a specialist or resident in gastrointestinal surgery (95%, 342/360). In univariate analyses, emergency surgery (odds ratio (OR) = 3.5, 95% confidence interval (CI) = 1.6–7.4, p = 0.002), smoking (OR = 2.9, 95% CI = 1.3–6.8, p = 0.01), lack of experience in gastrointestinal surgery of the operating surgeon (OR = 4.9, 95% CI = 1.6–14.8, p = 0.05, unmarked stoma site (OR = 2.3, 95% CI = 1.0–5.2, p = 0.04), and American Society of Anesthesiologists (ASA) score IV–V (OR = 2.7, 95% CI = 1.2–6.0, p = 0.01) showed increased risk of severe stoma complications. In multivariate logistic regression analysis, smoking (OR = 3.3, 95% CI = 1.3–7.9, p = 0.009) was associated with severe stoma complications.
Conclusion:
Morbidity associated with end colostomy is common, especially in emergency surgery. Smoking was the only independent risk factor for severe short-term stoma complications. Stoma site planning and cessation of smoking may reduce stoma-related complications.
Context and relevance
End colostomies are frequent in both emergency and elective surgery, yet early stoma-related complications are common and burdensome. Earlier studies have reported several risk factors, but their clinical significance is limited due to heterogeneous cohorts with various stoma types and both early and late complications. In this study, we analyzed a large prospectively collected data supplemented with clinical data, focusing on the incidence and predictors of early stoma-related complications. Severe stoma-related complications occurred in 8% of patients and were more common after emergency surgery. Smoking was identified as a risk factor for severe complications. Overall perioperative morbidity was higher in emergency procedures, whereas preoperative stoma site marking was associated with fewer complications. Reducing the complication risk requires smoking cessation guidance, preoperative stoma site planning, and adequate stoma formation training for all on-call surgeons.
Introduction
Surgical treatment of various diseases, such as colorectal malignancies, diverticular disease, or inflammatory bowel disease, may result in permanent or temporary end colostomy.1,2 Stoma-related complications are common, with an overall incidence of 10%–70%.1 –3 Stoma-related complications are associated with poor stoma function, which impairs the quality of life of colostomy patients.4 –6
While earlier studies have reported a wide range of complication rates and identified various patient- and surgery-related risk factors, these findings are often based on heterogeneous cohorts including multiple stoma types and both early and late complications, limiting the applicability of their results to specific clinical scenarios. Moreover, early postoperative complications—occurring within 30 days of surgery—are particularly relevant, as they may affect long-term outcome. Postoperative infection is a risk factor for parastomal hernia; stoma retraction and necrosis are associated with stoma stenosis and prolonged peristomal skin problems; they often require prompt intervention.1,2,3,7,8
This study aimed to assess early complications related to end colostomies, with severe postoperative complications defined as Clavien-Dindo grade ⩾3a as the primary outcome. The main exposure was emergency versus elective surgery, and outcomes were compared between these groups at a Finnish tertiary referral center.
Methods
Patients
All adult patients (⩾18 years) with operations resulting in an end colostomy performed at Tampere University Hospital between January 2018 and December 2020 were identified, and all end colostomies performed during any surgical procedure within the study period were included. Patients with a pre-existing stoma and ⩽18 years were excluded. The study was conducted according to the Helsinki Declaration, and institutional review board approval was obtained (ETL-code R20560).
Stoma-related data were collected from a prospective stoma registry updated by trained stoma nurses during the patient’s hospital stay and at the routine 30-day follow-up visit. Additional clinical data—including comorbidities, perioperative details, laboratory results, postoperative recovery, and readmissions—were collected retrospectively from the Tampere University Hospital medical records to obtain relevant information on outcome assessments not systematically recorded during prospective follow-up. In our hospital, the stoma sites are marked preoperatively by a trained stoma nurse.
A stoma-related complication was considered early if it occurred within the first 30 days of the index operation and severe if it required urgent re-operation or caused a life-threatening condition with hospital readmission (Clavien Dindo ⩾3a). Any other adverse outcomes, such as skin irritation, mucocutaneous separation, conservatively treated wound infection, superficial stoma necrosis, and mild, conservatively treated retraction of the stoma, were classified as mild early complications. The operating surgeon was identified and recorded.
The primary outcome was early stoma-related complications and associated risk factors, including differences between patients undergoing emergency and elective procedures. Secondary outcomes were early mild stoma-related complications (Clavien Dindo <3a), independence in stoma care at 30 days. Emergency versus elective surgery was the main exposure variable. Additional exposure variables included smoking, comorbidity burden, and surgeon’s experience in gastrointestinal surgery.
In the elective group, cancer was the primary indication associated with increased overall comorbidity. To balance the comorbidity assessment between the emergency and the elective groups, cancer was excluded from the Charlson Comorbidity Index (CCI) when calculating comorbidity burden. Other covariates included age, sex, Body Mass Index (BMI) (<30 or ⩾30 kg/m2), American Society of Anesthesiologists (ASA) classification (ASA I–III or IV–V), smoking status (non-smoker for ⩾1 year/current smoker), timing of the surgery (emergency versus elective), indication for operation (intestinal malignancy diverticular disease, surgical complication, other intestinal diagnosis, gynecological malignancy, other), surgeon’s specialization (gastrointestinal surgery and resident in gastrointestinal surgery or non-gastrointestinal surgeon), and preoperative stoma site marking (yes/no). Age was analyzed as a continuous variable, whereas all the other variables were treated as categorical. The following variables were considered potential confounders and included in the multivariable adjustment set: age, sex, BMI, ASA class, smoking, and CCI.
All the elective patients making an uneventful recovery after surgery had a follow-up appointment with a gastrointestinal surgeon and a stoma care nurse approximately 30 days after the operation, where possible complications and independence in stoma care were recorded. Patients with delayed postoperative recovery or undergoing emergency operation were retrieved retrospectively from the medical records, including documentation on stoma care nurses’ visits to the hospital ward. Missing data were handled by complete-case analysis.
Statistical analyses
Associations between categorical variables were examined using Pearson’s chi-square test, and associations between stoma care independence and age were examined by Mann–Whitney U test. A significant p value was defined as p < 0.05. The number of predictors included in the multivariable model was restricted to four to avoid overfitting. Therefore, only variables with a significant p value of <0.05 in univariable analysis were included in the multivariable analysis. Malignancy was excluded from the multivariable analysis, as cancer was present predominantly in elective cases. Statistical analyses were performed using SPSS software (IBM Corp., Version 28.0.1.1.).[
Results
There were 360 patients with an end colostomy during the study period. The patient flowchart is presented in Fig. 1, and the baseline characteristics are presented in Table 1. Median age at surgery was 71 (interquartile range: 64–78) years, including 197 (55%) male patients. Out of these 360 patients, 118 (33%) underwent emergency surgery and 242 (67%) underwent elective operation. The colostomy was performed in most cases by a gastrointestinal surgeon specialist or gastrointestinal surgical resident (342/360, 95%). Preoperative stoma marking was done for 288 (80%) patients, in 53/118 (45%) and 235/242 (97%) of the patients in emergency and elective surgery groups, respectively (p < 0.001). Fifteen patients (4%) died before their follow-up visit, and three of these had experienced a stoma complication.
Patient selection.
Patients’ baseline characteristics.
BMI: body mass index; CCI: Charlson Comorbidity Index; ASA: American Society of Anaesthesiologists.
The indications for emergency and elective surgical procedures are presented in Table 2. In the emergency surgery group, the main indication was diverticular disease (53/118, 45%), whereas in the elective surgery group, the most common indication was colorectal cancer (186/242, 77%). There was no difference between the groups in BMIs or smoking status. The prevalence of coexisting conditions (CCI ⩾ 4) in the emergency surgery versus elective groups was 53% versus 48%, p = 0.5. Statistically significantly higher ASA classifications were observed in the emergency patients compared with the elective patients (ASA IV–V = 47% versus 6%, p < 0.001).
Indications for emergency and elective surgery.
Out of the 360 patients, stoma-related complications were observed in 130 (36%) patients, with 30 (8%) severe and 100 (28%) mild complications. Patients who underwent emergency surgery had more severe stoma-related complications compared with the elective group, 18/118 (15%) versus 12/242 (5%), p = 0.001. The most common severe stoma-related complication was necrosis (5%). Severe stoma-related complications are presented in detail in Table 3.
Severe stoma-related complications.
Incidence of mild complications was 28% (100/360). Mild complications showed no statistically significant associations with BMI, age, gender, smoking, independence in stoma care, preoperative stoma planning, or CCI. The most frequent mild complications were peristomal skin complications in 24 patients (7%) and ostomy leakage in 64 (18%). A total of 18 (5%) patients had more than one mild complication. Mild complications are listed in Table 4.
Mild stoma-related complications.
Out of the 360 patients, 183 (51%) patients had learned to independently care for their stoma at the 30-day stoma nurse follow-up visit. Patients who were independent in stoma care were mainly men, 113 (62%, p = 0.018), and most of them had undergone an elective operation, 143 (78%, p < 0.001). Those who needed help with stoma care had more coexisting conditions than the independent patients (CCI ⩾ 4: 64% versus 36%, p < 0.001). Stoma site was planned for independent stoma patients compared with the patients who needed help, 163 versus 115 (90% versus 72%, p < 0.001). Independent stoma patients were younger than those needing help (median age: 67 versus 74 years, p < 0.001).
Predisposing factors
Emergency surgery (odds ratio (OR) = 3.5, 95% confidence interval (CI) = 1.6–7.4, p = 0.002), smoking (OR = 2.9, 95% CI = 1.3–6.8, p = 0.01), lack of experience in gastrointestinal surgery of the operating surgeon (OR = 4.9, 95% CI = 1.6–14.8, p = 0.05), unmarked stoma site (OR = 2.3, 95% CI = 1.0–5.2, p = 0.04), benign indication for surgery (OR = 3.2, 95% CI = 1.5–6.8, p = 0.003), and ASA score IV–V (OR = 2.7, 95% CI = 1.2–6.0, p = 0.01) showed increased risk of severe stoma-related complications in univariable analysis. In multivariable logistic regression analysis, smoking (OR = 3.3, 95% CI = 1.3–7.9, p = 0.009) was significantly associated with severe stoma-related complications. Table 5 presents the predictors of severe postoperative complications.
Predictors for early end-colostomy severe complications.
Discussion
In this prospective cohort study, morbidity associated with end colostomy was common, especially in emergency surgery, with stoma necrosis being the most common severe complication requiring re-operation. Smoking was the only risk factor for severe end-stoma complications with independent prognostic significance in the multivariable analysis. In this study, the incidence of early stoma-related complications was 36%, which is comparable to those in earlier studies.8,9 In concurrence with the stoma necrosis in this study, a large cohort study reported a similar incidence of 4.8%, with higher rates after emergency surgery. 10 We observed a severe retraction rate of 2%, which is slightly lower than in earlier reports, ranging from 3.2% to 7.7%.2,10,11
Earlier studies have identified obesity, unmarked stoma site, and colostomies as risk factors for stoma-related complications, and emergency procedures have been linked to higher rates of severe stoma complications.1,7,12 –15 In this study, 118 (33%) stomas were created in emergency operations. In concurrence with earlier data, patients undergoing emergency operations had more severe stoma-related complications than those in the elective group (15% versus 5%, p = 0.001). Also, in univariable analysis, the surgeon’s lack of experience in gastrointestinal surgery appeared to suggest an increased risk for major severe complications (p = 0.05). This may to some extent explain the increased complication risk associated with emergency surgery, as surgeons’ training backgrounds may be more heterogeneous during on-call hours. The most significant patient-related risk factor was smoking, with smokers having over three times higher risk for severe complications. However, obesity, age, or high CCI did not have a statistically significant impact on early stoma-related outcomes. In this study, benign disease was the main indication for emergency surgery, which explains why malignancy was not found to be a risk factor for severe stoma-related complications.
Peristomal skin complications are the most common stoma-related issues, with reported incidences ranging from 14% to 43%, including both early and late complications.2,3 In the 30-day follow-up, only 24 (7%) patients experienced peristomal irritation, and an additional 18 (5%) patients had more than one mild complication. Carlsson et al. found that one or more stoma-related complications were observed in 35% of patients during a 1-year follow-up. We observed that mild complications, including stoma leakage (reported in 64 cases,18%), occurred in 100 (28%) patients, with no significant associations found with BMI, age, gender, smoking status, independence in stoma care, preoperative stoma site planning, or coexisting diseases.
Previous studies have shown that preoperative stoma site marking significantly reduces stoma-related complications and improves quality of life and independence in stoma care.8,9,16,17 However, for emergency patients, the availability of a qualified stoma nurse or a nurse with gastrointestinal training able to properly plan the stoma site preoperatively may be limited. Reflecting this, the reported preoperative stoma site markings on emergency patients range between 48% and 63%.8,18 In addition, many studies about stoma-related complications do not even report the rate of stoma site planning. 2 In this study, stoma site was planned preoperatively for the majority of patients (288, 80%), and 53 (45%) emergency stomas were marked. An unmarked stoma site had over twofold risk for severe complications in the univariable analysis. Independence in stoma care was significantly more infrequent after emergency surgery, when preoperative stoma education is likely to be more cursory. In addition, patients having fewer coexisting diseases, a planned stoma site, younger age, and male gender were more likely to achieve independence in stomacare.
This study has several limitations. First, although the stoma-related data originated from the prospective stoma registry maintained by trained stoma nurses, the supplementary clinical data were retrospectively collected from patient databases and may, therefore, be more biased. Although multiple data sources were used, not all relevant variables were available. Residual confounding cannot be excluded, since clinically relevant features, such as patient frailty, social support, and comprehensive lifestyle factors, could not be assessed. The small number of severe complications (30/360) and the relatively small number of patients in the treatment groups reduced the statistical power, which may explain why comorbidity, BMI, and emergency surgery were not statistically significant independent risk factors in this study. Missing data were handled by complete-case analysis, and this may also have impaired the precision of the analyses. Center-specific practices may influence outcomes and limit the generalizability of the findings. Data were comprehensive, and we successfully focused on a single stoma type, colostomy, and were able to distinguish both early severe and mild complications.
Conclusion
Morbidity associated with end colostomy was common, especially in emergency surgery. Smoking was the only independent risk factor for severe short-term stoma complications. Only half of the patients had learned to care independently for their stoma at 30-day follow-up. Stoma site planning and cessation of smoking may reduce stoma-related complications.
Footnotes
Author contributions
Conceptualization: I.H. and A.V.
Methodology: I.H., E.W., A.V., and H.H.
Formal analysis: H.H. and A.V.
Investigation: A.V., I.H., K.L., and E.W.
Resources: M.H.
Writing—original draft preparation: A.V.
Visualization: A.V.
Supervision: M.H. and I.H.
Funding acquisition: A.V.
All authors were involved in writing the final version and gave their approval to submit the article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: A.V. was supported by research grants from the EVO Foundation (government research grant) and from the Finnish Cultural Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Data availability statement
The data sets generated and/or analyzed during this study are not publicly available due to the Finnish legislation on the protection of privacy. The sharing of data will require approval from the relevant ethics committees.