1. PERISTOMAL HERNIA: THE CASE FOR EXTRAPERITONEAL COLOSTOMY Garnet Blatchford, M.D.

2.  I have no disclosures to report

3. EXTRAPERITONEAL COLOSTOMY OLD CONCEPT, BUT FORGOTTEN?  Principles and Practice of Surgery for the Colon, Rectum and Anus, Gordon/Nivatvongs – role of extraperitoneal colostomy uncertain  Complications of Colon & Rectal Surgery, Hicks/Beck – no mention  Colon and Rectal Surgery - Corman – no mention for colostomy, only ileostomy  ASCRS textbook-extraperitoneal “extreme” lateral mesenteric closure

4. FACTORS IN PARACOLOSTOMY HERNIA  Poor technique  Lateral to rectus  Trephine size  Fascial fixation  Closure of lateral space  High intra-abdominal pressure  Obesity  Constipation  Chronic cough  Prostate enlargement

6. INTRAPERITONEAL COLOSTOMY

7. EXTRAPERITONEAL COLOSTOMY

8. EXTRAPERITONEAL VS INTRAPERITONEAL COLOSTOMY  Goligher 1958: Br J Surg Vol 46,196:7-8  Goligher 1976 DCR: 19:342-366  251 patients ComplicationsIntraperitoneal n=162 Extraperitoneal n=89 Pericolostomy hernia 288 Prolapse102 Recession10 Stenosis63 Fistula10 Total4613

9. PROBABILITY OF COLOSTOMY COMPLICATION IN INTRAPERITONEAL COLOSTOMIES # of patients Crude Rate (%) Actuarial Rate (%) Years Paracolosto my hernia 4321.236.710 Skin2411.817.411 Prolapse115.411.813 Obstruction115.413.713 Stenosis104.97.310 Retraction31.5NA- Fistula21.0NA Life Table Analysis of Stomal Complications Following Colostomy, Phillips RKS DCR 37:916-920 (1994)

10. META-ANALYSIS OF EXTRA VS INTRA  Seven retrospective studies with a combined total of 1,071 patients (250 extraperitoneal colostomy and 821 intraperitoneal colostomy)  There was a significantly lower rate of parastomal hernia (odds ratio, 0.41; 95% confidence interval, 0.23-0.73, p = 0.002) in the extraperitoneal colostomy group  the occurrences of bowel obstruction and prolapse were not significantly different between the two groups. Int J Colorectal Dis.Int J Colorectal Dis. 2012 Jan;27(1):59-64

11. LAPRASCOPIC EXTRAPERITONEAL COLOSTOMY  12 patients with lap extraperitoneal colostomy  No peristomal hernias  10 patients with lap intraperitoneal colostomy  4 peristomal hernias (33%), occurred at 24, 36, 48 and 72 months  Laparoscopic extraperitoneal colostomy in elective abdomino-perineal resection. Leroy J, Colorectal Dis (2012)

12. OMAHA EXPERIENCE  223 Patients undergoing APR for cancer  Open APR in 209(94%), robotic/lap in 14(6%)  June 2001-July 2013, seven colorectal surgeons  Retrospective chart review  Males 123 (55%), Females 100 (45%)  183 had intraperitoneal colostomy made  40 had extraperitoneal colostomy made

13. OMAHA STOMA STUDY DemographicIP (n=183EP (n=40)P value Age (yr)66.262.8NS Gender (M/F)102/8921/19NS BMI28.024.60.002 ComorbidityIP (%)EP (%)P value Smoker64(34.9)12(30)NS COPD12(6.5)1(2.5)NS DM25(13.7)1(2.5)NS Other hernia15(8.2)1(2.5)NS BPH9(4.9)2(5)NS Hypothyroid19(9.8)2(5)NS

14. OMAHA STOMA STUDY SurgeonAPR nIP n (%)BMIEP n (%)BMI 1.4326 (60)28.117 (40)24 2.4934 (69)25.715 (31)24.9 3.3534 (97)25.7 1 (3)26.5 4.4037 (92)28.8 3 (8)25.6 5.1716 (94)28.2 1 (6)23.1 6.2827 (96)20.4 1 (4)19.7 7.10 7 (70)25.1 2 (10)29.1

15. OMAHA STOMA STUDY VariableIP n=183EP n=40P value Stoma complications 4520.006 -Prolapse20NS -Stoma necrosis20NS -Obstruction01NS -Diverticulitis01NS - Peristomal hernia 410<0.001 time to dx (mos) 25.7 (3-108) op repair17/41 (41%) recurrent hernia4/17 (24%) Bowel Obstruct. 70NS

17. OMAHA STOMA STUDY INTRAPERITONEAL GROUP VariableHernia (n=41)No hernia (n=142) P value Age65.566.4NS BMI29.5 (20-52)27.5 (15-50)NS Smoking/COPD18 (43%)58 (41%)NS DM3 (7.3%)22 (15.5%)NS Gender (M/F)25/1677/65NS BPH1 (2.4%)8 (5.6)NS Hypothyroid2 (4.9%)16 (11.3%)NS

18. OMAHA EXPERIENCE INTRAPERITONEAL COLOSTOMY COMPLICATIONS  Peristomal hernia- 41 patients  Colostomy prolapse – 2 pts at 18, 28 months  Colostomy necrosis requiring revision – 2 patients (2 days postop and at 1 month)  Overall colostomy complication rate of 24.6%(45/183)

19. OMAHA EXPERIENCE EXTRAPERITONEAL COLOSTOMY  Complications in 2 (5%) p<0.001 compared to intraperitoneal group  Bowel obstruction at 2 months related to small bowel entering extraperitoneal space  Diverticulitis of extraperitoneal segment required revision at 64 months  No stomal prolapse/necrosis

21. CONCLUSIONS  Phillips “When surgeons who devote a substantial amount of their time to colorectal surgery and who have extensive personal experience of stomal surgery are also found to have a high rate of stoma related complications (cumulative risk of 58.1% at 13 years) it is time to question some of the tenets that are currently accepted as a sene qua non of good stomal surgery”

23. CONCLUSION OMAHA EXPERIENCE  Extraperitoneal colostomy should be the preferred technique for permanent stoma  We need to be teaching this technique to our residents when making permanent stomas

24. CONCLUSIONS CONT.  FOR DISCUSSION: ? If the colon is not amenable to extraperitoneal approach should we do a sugerbaker technique at the original surgery with biologics?  Should this technique be done for permanent ileostomies?