Conservative management of necrotic colostomy in a fragile patient under palliative chemotherapy

Complications with surgically placed ostomies are common. Up to 81.1% of patients with an ostomy will develop a related complication, most of them occurring during the first three postoperative weeks and their causes are multifactorial. Most frequent early complications include oedema (10%), retraction (5%), prolapse (between 2% and 10%) and haemorrhage (2%). Long-term complications including parastomal hernia and colostomy prolapse have an incidence of about 50% according to recent guidelines. Other complications such as poor stoma location, ischaemic necrosis, retraction, stenosis, peristomal fistula, small bowel obstruction, cancer at the stoma site and peristomal abscess are less likely to appear. Stomal necrosis and dehiscence are a particularly difficult management problem due to early presentation and failure of conservative measures including wound care. Their incidence is not insignificant, with 7–25% dehiscence and 1–34% ostomy necrosis, and almost 7% of patients require surgical reintervention. Obesity, malnutrition and concomitant chemotherapy administration are well-known risk factors, affecting cell regeneration and tissue healing. Furthermore, it is known that an ostomy created during emergency surgery considerably increases the risk of presenting related complications. Goals of conservative treatment of stoma complications include avoiding reoperation, decreasing length of hospital stay, promoting self-care and finding the best device to help skin healing, keeping parastomal skin intact. This report presents the authors’ experience treating necrosis and dehiscence of a colostomy by conservative measures, avoiding reoperation in a fragile patient. A 64-year-old female with a medical history of smoking who was diagnosed with stage IV rectal cancer 2 months previously and was currently undergoing palliative chemotherapy treatment is presented. She was admitted to the emergency room after receiving the last chemotherapy cycle a few hours previously, presenting with abdominal pain, hypotension and tachycardia. A computed tomography scan demonstrated rectal perforation around the tumour location and the patient was taken to the operating room. The findings were faecal peritonitis caused by rectal perforation. The tumour was involved in an unapproachable pelvic mass, and the surgeons decided to perform an end colostomy in the left iliac fossa. During the intervention, the patient was haemodynamically unstable, requiring vasoactive amines, intensive fluid therapy and blood transfusion. After 24 h in the intensive care unit with satisfactory postoperative evolution, she continued care in the hospital ward. On the second post-operative day, necrosis appeared in the medial area of the stoma, progressing to reach the entire mucosa (Fig. 1). On the sixth post-operative day, aggressive debridement and lavage of the wound bed was performed, appreciating mucocutaneous dehiscence in the lower third of the stoma without detachment, with no faecal content reaching into the subcutaneous tissue (Fig. 2). This allowed continuing a conservative approach, knowing the high risk of reoperation attending the patient’s fragility. The patient was discharged on the 16th post-operative day and then ambulatory follow-up was crucial to obtain excellent results (Fig. 3). Written permission was obtained from the case subject to publish the case details and associated images. Specialized nursing action was based on isolating the stoma and adjusting the device to prevent leaks (using paste and moulding resins and many device changes) and infection, protecting the peristomal skin using barrier films and stoma dusts and seeking second-intention healing with hydrocolloid hydrofibre dressings.