Stoma Complications Following Intestinal Diversion: Frequency and Associated Risk Factors at a Tertiary Care Centre in Pakistan

A stoma is a surgically constructed aperture between a hollow organ and the body's exterior, indicated when primary anastomosis is unfeasible due to an elevated risk of failure or a lack of viable distal tissue for attachment.(1) An intestinal stoma, also known as fecal diversion, is defined as the surgical creation of an opening that connects the bowel to the surface of the abdominal wall.(2)Stoma creation is indicated for a spectrum of clinicopathological conditions, involving either temporary or permanent intestinal diversion. While the objective is to improve quality of life, inadequate stoma placement, suboptimal care, and complications can adversely impact patients, potentially leading to reduced quality of life, social withdrawal, and elevated medical costs and utilization. Consequently, patients often face substantial lifestyle modifications and challenges following stoma surgery.

 Tuberculosis, inflammatory bowel disease, and anastomotic leakage are frequent indications for loop ileostomy. In contrast to Western nations, typhoid fever remains a prevalent cause of intestinal perforation necessitating stoma formation within this region. Reported stoma complication rates range from 5% to 100%, with such variability likely attributable to differences in the duration of postoperative follow-up. (3)

 Wound infection, hematoma, anastomotic leakage, small bowel obstruction at the stoma site, iatrogenic bowel injuries, local abscess formation, and peristomal dermatitis are widely documented complications associated with the formation of an intestinal stoma. (4,5)Stoma formation is linked to various clinical morbidities and can negatively impact a patient's quality of life by causing physical discomfort and psychological distress related to disfigurement. (6) Stoma prolapse happens when the stoma is displaced, causing the proximal bowel to protrude through the lateral aspect of the stoma opening. Stoma retraction occurs when the stoma recedes approximately 5 cm below the skin surface; this is a late complication often associated with weight gain. Furthermore, stoma retraction may result from adhesions, sepsis, intestinal radiation, or specific surgical techniques. Bowel obstruction represents a frequent complication that commonly requires surgical intervention. (7,8)

 Jonkers et al. (9) reported that 82% of patients experienced at least one stoma-related complication. Skin irritation, fixation problems, and leakage were identified as the most prevalent issues, while superficial necrosis, bleeding, and stoma retraction were observed in 20%, 14%, and 9% of patients, respectively. (9)

The primary objective of this study is to assess the incidence of complications following stoma formation in our local population. Previous research (5,6,8) has largely relied on retrospective data, which often results in the under-registration of complications. This pragmatic, prospective study aims to offer a comprehensive overview of all complications arising from stoma construction within the daily clinical practice of a large teaching hospital.

 OBJECTIVE: To determine frequency of complication of intestinal stoma in Ayub Teaching hospital Abbottabad.

Demographic and Baseline Characteristics

A total of 126 patients who underwent intestinal stoma formation were enrolled. The mean age was 40.16 ± 14.4 years (range: 20–70 years), as detailed in Table 1.

Table 1: Age distribution of the study population (n=126)

Males constituted 55.6% of the cohort (n=70) and females 44.4% (n=56) (Table 2). Hypertension was present in 32.5% of patients (n=41), diabetes mellitus in 49.2% (n=62), obesity in 38.9% (n=49), and smoking in 37.3% (n=47). Middle socioeconomic class was the most prevalent group (49.2%), and the majority had matriculation-level education or above (38.1%).

Table 2: Gender distribution of the study population

 Frequency of Stoma Complications

Superficial necrosis was the most common complication (59.5%), followed by stoma retraction (53.2%), bleeding (46.0%), skin irritation (15.9%), fixation problems (8.7%), and leakage (7.9%). The full breakdown is presented in Table 3 and illustrated in Figure 1.

Table 3: Frequency of stoma complications among enrolled patients (n=126)

Figure 1. Distribution of stoma complications among 126 patients. Values represent percentage of total study population. Multiple complications could co-exist in the same patient.

Stratified Analysis of Stoma Complications

Data were stratified by age group, gender, hypertension, diabetes, smoking, obesity, socioeconomic status, and educational level. Table 4 summarises all statistically significant associations identified (p < 0.05).

Younger patients (20–45 years) showed a significantly higher frequency of skin irritation (85.0% vs. 15.0%; p=0.035) and fixation problems (100.0% vs. 0.0%; p=0.010). Superficial necrosis was significantly more prevalent in the older age group (p=0.019). Hypertension was significantly associated with higher rates of superficial necrosis (40.0% vs. 21.6%; p=0.030) and stoma retraction (43.3% vs. 20.3%; p=0.006), while skin irritation was paradoxically less frequent in hypertensive patients (5.0% vs. 37.7%; p=0.004). Among diabetic patients, leakage was substantially more common (90.0% of leakage cases; p=0.007). Leakage also showed a significant association with educational level, with 80.0% of cases occurring in patients with matriculation or above (p=0.033). Gender, smoking, obesity, and socioeconomic status showed no significant association with any of the studied complications.

Table 4: Statistically significant associations between patient characteristics and stoma complications

Intestinal stoma creation is established as one of the most frequently performed life-saving surgical procedures globally, serving a vital role in the management of both congenital and acquired gastrointestinal disorders. (10) Stoma formation is primarily indicated for fecal diversion, the protection of anastomotic sites, bowel decompression, or a combination of these clinical objectives  (11,12). While colostomies and ileostomies represent the most frequently performed ostomy procedures in surgical settings, less common variations like jejunostomies are also employed for the decompression, lavage, and diversion of intestinal contents. (13,14) Pediatric indications for intestinal stoma differ from those in adults. Unlike the adult population, stoma creation in children is typically performed as a temporary measure to manage congenital intestinal malformations. (13) Hirschsprung’s disease and anorectal malformations represent primary indications for pediatric stoma formation.. (15) Additionally, stoma formation in adults is sometimes necessary for the management of conditions such as trauma, diverticulitis, volvulus, and malignancies (11,15). Although intestinal stoma creation is a life-saving intervention for the management of numerous gastrointestinal conditions, its associated morbidity and mortality have been the focus of extensive research (12,15). Inadequate construction of a stoma may impede or delay the definitive repair of these malformations, which can, in severe cases, be fatal. (16) Numerous complications have been documented regarding the construction and closure of intestinal stomas (12,16). Stoma-related complications, observed in 20–70% of patients, are broadly classified into early events—including ischemia, hemorrhage, and infection—and late sequelae, such as stenosis, fistula development, prolapse, hernia formation, bowel obstruction, and peristomal skin denudation (14,16,17). Factors that favor the creation of an abdominal stoma over primary closure include significant blood loss, shock, fecal contamination of the abdominal cavity, and the presence of multiple perforations (18) .This study aimed to evaluate stoma-related complications within our patient population. A total of 126 patients were enrolled, with a mean age of 40.16 ± 14.4 years. The cohort consisted of 55.6% males and 44.4% females. Regarding comorbidities, hypertension was identified in 32.5% of patients, diabetes mellitus in 49.2%, obesity in 38.9%, and smoking in 37.3%. Socioeconomic status was distributed as follows: 49.2% middle class, 34.9% low class, and 15.9% high class. Educational attainment levels included primary education (13.5%), secondary education (31.7%), and matriculation or higher (38.1%). The most frequent stoma-related complications observed were superficial necrosis (59.5%), stoma retraction (53.2%), bleeding (46.0%), skin irritation (15.9%), fixation problems (8.7%), and leakage (7.9%). These findings are consistent with broader literature, which generally reports high rates of stoma complications. For instance, in a study by Jonkers et al. (9), 82% of patients experienced one or more stoma-related complications; skin irritation, fixation problems, and leakage were the most prevalent, whereas superficial necrosis, bleeding, and retraction occurred in 20%, 14%, and 9% of patients, respectively.Another study involved 85 patients, with a gender distribution of 83.52% male and 16.47% female, representing a ratio of approximately 5:1. The most frequent age group for stoma formation across both genders was 21–30 years (23.52%), although male patients were more prevalent in the 51–60 age range. Regarding procedure type, 46 patients underwent end ileostomy, and 27 underwent loop ileostomy. Edema was most commonly noted in 19 patients who received a loop ileostomy. Reported complication rates included superficial necrosis or excoriations in 52.9% of patients, wound infection in 55.2%, and stoma retraction in 5.8% (19).Duchesne et al. observed complication rates of 26%, 25%, and 25% within their respective cohorts (20).Reported incidence rates of peristomal skin irritation range from 3% to 42%, encompassing conditions from mild peristomal dermatitis to full-thickness skin necrosis and ulceration. The most frequent complications identified in these studies were peristomal skin irritation and erythema, followed by laparotomy wound infection, peristomal skin infection, abscess formation, and fistula development. A separate study conducted in Karachi involving 84 intestinal stoma patients—predominantly male, with 22 females—identified underlying pathologies including tuberculous intestine, typhoid ileal perforation, trauma, and gangrenous appendicular perforation. Among this cohort, 61 patients developed complications, most notably skin excoriation, followed by wound infection, nonfunctioning stoma, prolapse, stenosis, retraction, high-output fistula, parastomal hernia, necrosis, and hemorrhage (21). These observations are consistent with the current findings.

IIntestinal stomas are associated with a diverse range of complications. The most frequently observed issues include superficial necrosis, stoma retraction, hemorrhage, skin irritation, fixation challenges, and leakage. Investigating the incidence, severity, and etiology of these abdominal stoma complications is essential, as it establishes a scientific foundation for future research. Such insights are critical for developing evidence-based interventions designed to enhance clinical care and improve the quality of life for patients managing stomas.

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