INTRODUCTION
Loop ileostomies and colostomies are generally used by general and colorectal surgeons for fecal diversion in order to protect an anastomosis or to decompress a dilated colon. Though placement of a rod is relatively simple, complications may occur and some may require surgical revision. The reported prevalence of such complications varies; the largest series we found reported a stoma complication rate of 34% in 1616 patients.1-3 The most frequent complications are stomal necrosis or retraction, parastomal hernia, and peristomal skin irritation.3-5
In order to avoid stoma retraction, which may lead to devastating consequences such a generalized peritonitis, many surgeons propose use of a stoma rod acting as a bridge for additional stoma support.4 Among the different techniques that have been described to create a stoma rod, the most frequent are a plastic rod, a local skin flap, a Jackson-Pratt drain, a Robinson catheter, subcutaneous sutures, or fascial bridges.6-9 We searched the literature and found no guidelines concerning the use of a stoma bridge or rod and limited evidence regarding outcomes or complications of patients managed with or without a stoma rod or bridge. The objective of this systematic review was to evaluate the impact of the use of a stoma rod during confection of a diverting loop ileostomy or colostomy on stoma retraction.
METHODS
A systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analyses) statement.10 The MEDLINE (through PubMed), EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched using combinations of terms including "rod" and "ileostomy" or "colostomy" or "ostomy." The exact search strategy is summarized in Table 1. All studies, in English or French, including adult patients undergoing a loop ileostomy or colostomy, irrespective of the underlying pathology and the surgical indication, were considered as eligible. The search was performed up to December 4, 2019. Articles were initially screened based on titles and abstracts. Two authors (E.G. and J.M.) performed the database searches. Potentially relevant papers were explored after their full texts had been obtained. Any discrepancies were resolved by consensus.
The population we studied included adults undergoing ostomy surgery. The intervention was use of a rod versus no use of a rod. Our primary outcome was stoma retraction. Other postoperative complications, as well as need for reoperation, were evaluated as secondary outcomes.
FINDINGS
The inclusion process is reported in the Figure. One hundred eighty-two publications were identified via database search, and 2 additional references were identified through search. One hundred three articles underwent additional scrutiny after duplicates were removed. Title and abstract review resulted in exclusion of 82 records. Among the 21 original publications describing the use of rod during ostomy formation selected for full-text review, 15 were excluded for not comparing the rod and no-rod groups and one was excluded for not reporting the main or secondary outcomes according to our predefined protocol. Five publications were included in our qualitative analysis; we were unable to perform meta-analysis of pooled findings due to the limited number of studies included and heterogeneity in findings.
Table 2 summarizes the main features of the 5 studies that met inclusion criteria4,6,11-13; 4 were prospective randomized controlled trials (RCTs)4,6,11,12 and one was a prospective cohort study.13 The pooled sample of 1058 participants included 529 who underwent placement of a rod (bridge) and 529 with no rod. Four studies reflect data collected from a single facility, and one study was multicentered.6 Indications for ostomy creation varied in 4 studies.6,11-13 In one study, the population was limited to patients with ulcerative colitis undergoing total proctocolectomy, ileal J-pouch, and diverting loop ileostomy.4 Plastic rods were used as a bridge in 4 studies,6,11-13 and a metallic rod was used in one study.4 Three studies reported the day that the stoma rod was removed. Uchino and colleagues4 and Speirs and associates11 reported leaving the rod in place for 1 week, while Franklyn and coworkers12 reported leaving the rod in for 10 to 14 days. The follow-up period was identified in 3 of the 5 studies.11-13
Outcomes
Table 3 summarizes pertinent research outcomes. The incidence of stoma retraction (our main outcome) was reported in all 5 studies; it ranged from 0.0% to 8.0% in patients with rod versus 0.78% to 8.2% in patients managed without a rod.4,6,11-13 Analysis indicated no statistically significant difference in stoma retraction between patients based on placement of a rod.
Several studies reported statistically significant differences in stomal or peristomal complications. Franklyn and colleagues12 reported a significantly higher rate of edema in participants managed by a rod (22.7% vs 3.9%). Evidence concerning the incidence of stoma necrosis between the 2 groups differed. Franklyn and colleagues12 and Zindel and colleagues6 reported a higher incidence of participants managed by rods. In contrast, Whiteley and colleagues13 reported a higher mean incidence of stoma necrosis, but the difference was not statistically significant, and Speirs and associates11 reported equal incidence in each group.
Uchino and colleagues4 reported higher rates of peristomal skin necrosis and abscess in participants managed with rods, but the difference did not differ significantly. In contrast, they reported significantly higher rates of peristomal irritant dermatitis. Three studies compared stoma bleeding, mucocutaneous separation, and stoma prolapse and reported no differences between participants managed with or without rods.11-13 Stoma bleeding was reported in 3 participants managed by rods.
Three research groups indicated that the number of participants who required reoperation was equivalent in both groups.11-13 Franklyn and colleagues12 reported that 9 participants required additional surgical management for ostomy-related complications; 2 directly were attributed to the presence of a stoma bridge (perforation of the posterior wall with insertion).12
DISCUSSION
Stoma retraction is a frequent complication of loop stoma formation; incidence rates vary from 0% to 40%.3,14,15 Retraction may occur during the early postoperative period (first 30 days following surgery) or later.4 Agreement regarding the definition of stoma retraction varies, but most authors define it as a lowering of the mucosa of at least 5 mm from the skin surface for 50% or more of the stoma circumference.4,11,13,16 Placement of a rod has been advocated as preventive intervention, but pooled findings from the studies included in the review suggest the use of rods or bridges does not prevent stoma retraction.
While use of ostomy rods did not reduce the likelihood of stoma retraction during the early postoperative period, the use of rods was associated with higher rates of other complications or adverse outcomes. For example, Speirs and associates11 reported small intestine perforation attributed to the placement of a rod in addition to higher rates of stomal edema, peristomal irritant dermatitis, and abscess in participants managed with rods. Though not evaluated in this systematic review, the use of rods has been found to create complexity with the application pouching system with associated risks of leakage and peristomal moisture-associated skin irritation.6,11,13,17 Adding complexity to the stoma pouching also may increase anxiety among patients learning to manage a new ostomy.
Based on this evidence, we question the use of rods for prevention of stoma retraction in patients undergoing loop ostomy creation. Zindel and colleagues6 used the Stoma Specific Morbidity Score to evaluate the number and severity of stomal and peristomal complications including edema, bleeding necrosis, peristomal skin irritation, suture dehiscence/abscess formation, stenosis, retraction, fistula, prolapse, parastomal hernia, and incomplete diversion. Items were scored on a scale of 1-2 or 1-4; higher scores indicated a greater number and severity of complications. The higher possible score was 42 points. No differences were found between patients managed with rods and those managed without rods. Zindel and colleagues6 used multivariate analysis to identify risk factors for stoma-related complications; this analysis indicates that higher body mass index is an independent risk factor for stoma-related complications and, more specifically, stoma retraction. Nevertheless, the potential role of stoma rods in obese patients is not known.4,11
Considered collectively, the evidence we identified related to the use of protective rods to prevent stoma retraction is sparse. The small number of studies and the cumulative number of participants were not sufficient to enable meaningful meta-analysis of pooled findings. Analysis of these studies also identified a relatively low incidence of stoma retraction (our primary outcome). For example, Whiteley and colleagues13 reported 4 stoma retractions in 515 participants. Thus, we cannot exclude the possibility of type II statistical error. Only 2 of the 5 studies reported the use of a power analysis to identify needed sample size.4,6 We also observed heterogeneity among the included studies in terms of the surgical techniques used to create an ostomy and differences in techniques for identifying complications. Finally, the follow-up period in all studies was rather short with a maximum of 3 months.11 Given these limitations, we recommend an adequately powered prospective RCT to provide more definitive evidence. Using current evidence, we recommend avoiding the use of rods whenever possible, given the lack of evidence supporting their efficacy in preventing stoma retraction in conjunction with evidence suggesting they may increase rates of other stoma-related complications from stoma retraction and may be related to further complications.
CONCLUSION
The use of rods in order to prevent stoma retraction remains controversial. We systematically reviewed the literature and extracted 5 studies comparing the use of rods for loop ostomies to studies that did not use rods. We found that stoma rods do not reduce the risk of retraction and may lead to an increased likelihood of complications. While the limited available evidence did not allow us to reach strong conclusions, we discourage the use of rods to prevent stoma retraction.
KEY POINTS
* Stoma retraction is a frequent complication of stoma formation.
* Evidence suggests that the placement of a rod does not significantly reduce the likelihood of stoma retraction.
* Evidence also suggests that the use of rods may increase the likelihood of other complications.
REFERENCES