eISSN: 1897-4317
ISSN: 1895-5770
Gastroenterology Review/Przegląd Gastroenterologiczny
Current issue Archive Manuscripts accepted About the journal Editorial board Abstracting and indexing Subscription Contact Instructions for authors Ethical standards and procedures
Editorial System
Submit your Manuscript
SCImago Journal & Country Rank
2/2022
vol. 17
 
Share:
Share:
Review paper

Perineal colostomy: advantages and disadvantages

Francesk Mulita
1
,
Konstantinos Tepetes
2
,
Georgios-Ioannis Verras
1
,
Elias Liolis
3
,
Levan Tchabashvili
1
,
Charalampos Kaplanis
1
,
Ioannis Perdikaris
1
,
Dimitrios Velissaris
3
,
Ioannis Maroulis
1

1.
Department of Surgery, General University Hospital of Patras, Patras, Greece
2.
Department of Surgery, University Hospital of Larissa, Larissa, Greece
3.
Department of Internal Medicine, General University Hospital of Patras, Greece
Gastroenterology Rev 2022; 17 (2): 89–95
Online publish date: 2021/10/04
Article file
- Perineal colostomy.pdf  [0.08 MB]
Get citation
 
PlumX metrics:
 

Introduction

In the past few years, developments in the field of rectal cancer surgery have mostly been aimed towards preservation of sphincter function, with the pinnacle of modern technical approaches being low anterior resection with total mesorectal excision and primary colo-anal anastomosis, for tumours as close as 2 cm to the anal sphincter [1]. Despite every effort being made to preserve sphincter function, in order for the patient to achieve satisfactory quality of life, in many instances tumour localization makes abdominoperineal resection of the colon inevitable – a procedure first popularized by Ernest Miles in 1908 [2]. As opposed to forming an end colostomy placed in the left iliac fossa (or right ileostomy, of total resection), many surgeons have come up with different techniques in order to place the resulting colostomy in the perineal area. The perineal colostomy, following total abdominoperineal excision, is a type of colostomy, achieved by multiple, evolving approaches, which aims to utilize the natural anal orifice as the ostomy’s point of exit, while simultaneously employing several reconstructive and grafting techniques, in order to restore sphincteric function, despite radical bowel excision [35].

Technical considerations

The first described perineal colostomy technique was published by Schmidt in 1982 [6]. In his version, a small segment of about 8–10 cm of bowel is resected and prepared for use as a pseudo-sphincter [5]. This fragment is stripped of its mesocolon and epiploic fat and placed in an antibiotic solution. The graft is turned “inside-out” like a sleeve, so the serosa is on the inside and the mucosal layer is on the outside. Then, the segment is carefully stripped of the mucosal layer, until the muscular layer is encountered. A small mesocolon window is opened, approximately 2 cm from the distal end of the bowel, and the graft is threaded through the window and wrapped around the colon, typically for 1.5 turns, and sutured secure in place. Finally, the colon is lowered to the perineum, taking care to ensure that the length is adequate for a tension-free colostomy. Once in place, the colostomy is matured through the anal aperture [5, 7]. Another utilized technique is that of constructing valve-like stenoses in the colonic segment, by making circumferential incisions through the seromuscular layer, which are then approximated by invaginating sutures, in order for the protruding mucosa, to create a valve-like structure within the lumen [8, 9]. Then, the bowel is placed as described above, tension-free, within the perineum. The distance between the incisions is usually 10 cm, but some authors also suggest more continent results when the incisions are at 5 cm [8, 10]. A much discussed issue is whether the omentum must be used to compensate for the tissue loss after total mesorectal excision – a process called omentoplasty [8, 11]. Omentoplasty is usually necessary when adequate closure of the pelvic peritoneum cannot be achieved [10]. Wang et al. described a novel technique that is useful in laparoscopic abdominoperitoneal excisions. According to their publication, after excision, a small incision is made in the abdominal wall, through which the colon can be pulled. In addition to creating the circumferential incisions as mentioned above, they also described folding the colon at a 90o angle, so that it resembles the sigmoid colon [12]. Then, it is reintroduced in the abdominal cavity, and colostomy construction is finished laparoscopically with perineal assistance. A modified technique for pseudocontinent colostomy is also found in the literature. In this variation, apart from Schmidt’s graft, an additional vertical rectus abdominis mucocutaneus (VRAM) flap is utilized [13]. Once the above-described process is complete, mobilization of a skin pad, along with part of the rectus abdominis muscle, up to the pubic symphysis is started. Once mobilized, the flap, along with the skin pad, is passed below the pelvis and rotated in such a way that the skin pad will cover the perineal opening and the connected VRAM will pass around the neo-rectum, acting as the external sphincter [13]. According to Nassar, this modified technique achieves satisfactory continence rates of up to 93%, while minimizing perineal incision complications [13]. Utilization of gracilis muscle flaps or in some cases, gluteus maximus flaps, as a reconstructed anal sphincter, is a technique that has also gained ground the past few years [1416]. In this technique, following standard abdominoperineal resection, the gracilis muscle is harvested from the interior thigh. Utilizing 2 or 3 small incisions, the muscle and its distal tendon can be easily identified and dissected, with a combination of sharp and blunt dissection. Care must be taken to localize the neurovascular pedicle early on the muscle’s posterolateral side and preserve it. Once the colon transposition on its final ostomy site is complete, the muscle is pulled through the first incision, assessing for viability of the neurovascular pedicle, and it is threaded towards the ostomy site through a subcutaneous tunnel. There, it is wrapped around the colon to simulate an anal sphincter [14]. Alterations of this technique include using both gracilis muscles, to form a reconstructed pelvic floor, and implanting neurostimulators, that can further assist in effective muscle contraction [7, 14, 15].

Perineal colostomy advantages

The absolute priority, when discussing any reconstructive technique, is to always ensure that it does not compromise the oncological results of the original surgery. Several studies have shown that perineal colostomy not only does not compromise, but also facilitates more radical excisions, to ensure R0 results, by providing a reconstruction alternative [3, 13, 17]. Patient satisfaction rates are significantly better when compared to ostomy procedures, and they also tend to score higher on everyday functionality scores and quality of sexual life scores [5, 7, 10, 11, 18]. Some authors have reported overall satisfaction scores of up to 85% in patient series [7]. When compared to abdominal colostomy, perineal colostomy was able to demonstrate a better postoperative course for the patients involved, significantly less healing time, and a decreased frequency in ostomy-related complications [10]. One of the most discussed aspects of perineal colostomy formation is whether the reconstructive technique and the neo-sphincter manage to substitute the natural pelvic sphincteric mechanism. In many case series, satisfactory continence (usually reported as Kirwan class up to C) can be seen in up to 93% of the patients, with or without the use of anti-diarrhoeal medicine [7, 12, 13, 19, 20]. Known reports indicate that regardless of the technique employed, perineal colostomy with reconstruction seems to achieve satisfactory continence results, as well as anticipatory bowel habits, through scheduled irrigation [4, 5, 21]. In many studies, sphincter functionality was also confirmed via rectal manometry and defecographic studies, which demonstrated achievable increase in tone after voluntary contraction [7, 9, 19, 22]. Additionally, constructing a continent perineal colostomy through a natural orifice also allows for easier distal “neo-rectal” examination, colonoscopy, or endoscopic US, for the detection and screening of local recurrence [5, 7, 13, 21].

Perineal colostomy disadvantages

Being such an invasive procedure, formation of pseudo-continent perineal colostomy is expected also to have certain drawbacks. When compared to traditional abdominal colostomy, some patients felt it was harder to manage, due to the need for frequent irrigation, and while physical and sexual functionality was better, the social functionality of the patients seemed to be worse [18]. Among the reported complications, was mucosal prolapse from the colostomy, suppurative complications of the perineum, wound dehiscence, herniation, absence of perineal sensation, and in approximately 25% of the male patients, erectile dysfunction [3, 5, 7, 9, 1114, 18, 21, 2325]. Among these, suppurative complications are the most frequently reported in higher percentages when compared to abdominal end colostomy [5, 7, 9, 12, 13, 22].

Table I summarizes the advantages and disadvantages of perineal colostomy based on 20 selected PubMed-indexed articles.

Table I

The main characteristics and results of identified studies are summarized

Study 1st author, publication yearCountryStudy designNumber of participants, female %Age [years]Advantages of perineal colostomyDisadvantages of perineal colostomy
Souadka, 2015 [4]MoroccoRetrospective cohort146, 51.4%Mean (SD): 47 (10)Simple, safe, and reliable pelvic reconstruction technique
Provides a high degree of patient satisfaction without compromising oncological results
Good option in selected patients, especially in Muslim and low-income country populations
da Silva, 2014 [8]BrazilRetrospective analysis55, 60%Mean (range): 58 (38–80)Irrigation timing varies and can be adjusted per patient
Fills the pelvis
Prevents dermatitis and vaginosis
The valve method is graft-ndependent
10.9% mucosal prolapse
Valve slows but does not prevent motility altogether
Kirzin, 2010 [10]FranceRetrospective analysis110, 41.8%Mean (SD): 62 (12)Vs. abdominal colostomy
Less postoperative intra-perineal complications (infectious, wound dehiscence, time to heal) (p = 0.008)
Significantly less average healing time (p = 0.048) and fewer cased requiring more than 1 month (p = 0.018)
Those with radiotherapy, showed fewer complications in the perineal colostomy group (p = 0.001)
Farroni, 2007 [18]BelgiumQualitative QoL analysis13, 53.8%Mean (range): 61 (53–62.5)Vs. abdominal colostomy
Higher scores in physical functioning and sexual functioning
Fewer instances of fecal loss
Fewer stoma-related problems
Vs. abdominal colostomy
Lower scores in social functioning
Bowel control was more difficult to manage
Lasser, 2001 [5]CanadaProspective analysis40, 32.5%Mean: 50Satisfactory functional results in 86% of the patients
Screening for local recurrence, using rectal examination, or endoscopy, was easier
Little to no extension of surgical time
Used same incision
Schmidt’s observations for hypertrophy and plexus preservation were confirmed upon excision of failed perineal colostomy
55% of the patients reported any kind of morbidity
25% reported suppurative complications
60.5% report gas incontinence
23.5% report minimal soiling
In case of functional failure, a second operation was needed to convert to iliac colostomy
Hirche, 2010 [11]GermanyRetrospective analysis27, 58.8%Mean (range) 55 (37–65)Sphincter manometry, showed 5 to 81 cmH2O for resting and 49 to 364 cm H2O for compression pressures, after primary reconstruction
Median continence score, revealed sufficient continency
74% of the patients were sexually active
Acceptable results in global health and disease specific questionnaires
Minor complications related to continence in 23% of the patients
Erectile dysfunction in 25% of the patients
Landen, 2018 [20]UKCase report1, 100%51The patient reported good continence after 1 year, despite short bowel length, and absence of neosphincterSerious perineal herniation and colostomy prolapse
Gamagami, 1998 [7]U.S.Prospective analysis63, 50.8%Mean (range): 60 (31–79)85% of the patients were satisfied with the functionality
59% gained satisfactory continence
Avoided additional incisions for sphincter construction
Earlier detection of local recurrence, with digital examination or ultrasound guidance
Wound dehiscence, strictures and muscular prolapse
33% of the patients required medication to control stool frequency
1/3 felt uncomfortable
1/3 had gas incontinence
1/3 had difficulty with colonic irrigations, especially obese and mentally challenged patients
El Marouni, 2018 [25]MoroccoCase report175Bowel prolapse from perineal colostomy
Souadka, 2014 [21]MoroccoLetter to the EditorPreservation of body image
Use of natural orifice, and avoidance of pouching systems
Good functional results and high ostomy satisfaction rates
Counteracts the “phantom bowel” syndrome
Allows accessibility for distal rectal examination
Regular colonic irrigation
Lirici, 2004 [14]ItalyRetrospective analysis6, 33.33%Mean (range): 62 (42–76)Adequate continence achieved in the artificial sphincter group
Satisfactory continence and social QoL scores, in patients with gracilloplasty
No postoperative infections
Skin ulceration from device pouch, in the artificial sphincter patents
Gracilis muscle, is a fast-twitch muscle, and that leads to premature fatigue
Velitchkov, 1997 [9]BulgariaProspective analysis9, 77.7%Mean: 55.6Adequate continence without the use of enema in 55% of the patients
Soiling was adequately managed with anti-diarrheal medicine
Parastomal suppuration
Minimum to moderate fecal soiling in 44% of the patients
Absence of neo-anal sensation
Technique unavailable if left colectomy is employed
Dumont, 2013 [3]FranceRetrospective analysis22, 72.3%Mean (range): 60.3 (39–89)Vs. Intersphincteric Resection
Less evacuation-related difficulties
Physical functioning scores, better in the PPC group
Lower risk of recurrence
Vs. intersphincteric resection
Peri-perineal infection and disunion
Higher defecation problem score
Need for irrigation
Wang, 2014 [12]ChinaRetrospective analysis21, 38%Mean (range): 57 (36–72)55.6% of the patients had satisfactory continenceMucosal oedema in 33% of the patients
Mucosal prolapse in 9.5% of the patients
Wound infection in 4.8% of the patients
Mucosal necrosis in 4.8% of the patients
Nogueira, 2013 [23]BrazilRetrospective analysis27 (44.44%)Mean (range): 56.3 (37–87)Decreasing the distance between valves, results in better continence
Low recurrence rate (3.7%)
Perineal prolapse in 14.8%
Dehiscence in 7.4% of the patients
Stenosis in 7.4% of the patients
Nassar, 2011 [13]EgyptProspective cohort study14, (21.42%)Mean (range): 41 (22–63)A technique that can be implemented in R0 excision
57% of the patients were fully continent
After 12 months, 93% of the patients reported no more than minor soiling
Easily identifiable by endoscopic US
Complete remission of enemas in some patients
VRAM has well documented less perineal complications (dehiscence, sepsis)
Lack of sensation for bowel movement or gas passage
Perineal sepsis in 14%
Stricture in 29%
Mucosal prolapse in 21%
Santoro, 1994 [19]ItalyRetrospective analysis14 (50%)Mean (range): 61 (32–73)72% of the patients were satisfied with continence and sensation
Defecographic studies were satisfactory in all patients
Increased tone in voluntary squeeze
Serious bleeding complications in 21% of the patients
Perineal infection
Neo-anal stenosis
Souadka, 2016 [17]MoroccoRetrospective study15 (60%)Mean (SD): 50 (9)80% of the patients had no postoperative soiling
Muscular graft shoed response, and could act as a sphincter
Colonic irrigation necessary in 75% of the patients
Hypotonic pseudosphincter
Hosdurg, 2018 [24]IndiaCase report130Prompt return to social functionality
Acceptable continence
Azizi, 2013 [22]FranceRetrospective study17 (41.1%)Mean (range): 46 (34–71)Both muscle fibre types, result in better continence
Low rate of strictures
Overall quality of life scales > 70%
Early complications in 40%

Conclusions

This review shows that perineal colostomy is a safe and reliable technique performed after abdominoperineal resection, providing a higher degree of satisfaction and greater quality of life for patients. Although this method could be a good option in selected patients, physicians should always be aware of the disadvantages of perineal colostomy.

Conflict of interest

The authors declare no conflict of interest.

References

1 

Glynne-Jones R, Wyrwicz L, Tiret E, et al. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. ESMO Updat Clin Pract Guidel 2017; 28: iv22-40.

2 

Hawkins AT, Albutt K, Wise PE, et al. Abdominoperineal resection for rectal cancer in the twenty-first century: indications, techniques, and outcomes. J Gastrointest Surg 2018; 22: 1477-87.

3 

Dumont F, Ayadi M, Goéré D, et al. Comparison of fecal continence and quality of life between intersphincteric resection and abdominoperineal resection plus perineal colostomy for ultra-low rectal cancer. J Surg Oncol 2013; 108: 225-9.

4 

Souadka A, Majbar MA, El Harroudi T, et al. Perineal pseudocontinent colostomy is safe and efficient technique for perineal reconstruction after abdominoperineal resection for rectal adenocarcinoma. BMC Surg 2015; 15: 11-6.

5 

Lasser P, Dubé P, Guillot JM, Elias D. Pseudocontinent perineal colostomy following abdominoperineal resection: technique and findings in 49 patients. Eur J Surg Oncol 2001; 27: 49-53.

6 

Schmidt E. The continent colostomy. World J Surg 1982; 6: 805-9.

7 

Gamagami RA, Chiotasso P, Lazorthes F. Continent perineal colostomy after abdominoperineal resection: outcome after 63 cases. Dis Colon Rectum 1999; 42: 626-30.

8 

da Silva AL, Hayck J, Deoti B. Perineal colostomy: an alternative to avoid permanent abdominal colostomy: operative technique, results and reflection. Arq Bras Cir Dig 2014; 27: 243-6.

9 

Velitchkov NG, Kirov GK, Losanoff JE, et al. Abdominoperineal resection and perineal colostomy for low rectal cancer: the Lazaro da Silva technique. Dis Colon Rectum 1997; 40: 530-3.

10 

Kirzin S, Lazorthes F, De Gorce HN, et al. Benefits of perineal colostomy on perineal morbidity after abdominoperineal resection. Dis Colon Rectum 2010; 53: 1265-71.

11 

Hirche C, Mrak K, Kneif S, et al. Perineal colostomy with spiral smooth muscle graft for neosphincter reconstruction following abdominoperineal resection of very low rectal cancer: long-term outcome. Dis Colon Rectum 2010; 53: 1272-9.

12 

Wang M, Kang X, Wang H, Guan W. A technique of continent perineal colostomy after laparoscopic abdominoperineal resection. Tech Coloproctol 2014; 18: 759-60.

13 

Nassar OAH. Modified pseudocontinent perineal colostomy: a special technique. Dis Colon Rectum 2011; 54: 718-28.

14 

Lirici MM, Ishida Y, Di Paola M, et al. Dynamic graciloplasty versus implant of artificial sphincter for continent perineal colostomy after Miles’ procedure: technique and early results. Minim Invasive Ther Allied Technol 2004; 13: 347-61.

15 

Madoff RD, Rosen HR, Baeten CG, et al. Safety and efficacy of dynamic muscle plasty for anal incontinence: lessons from a prospective, multicenter trial. Gastroenterology 1999; 116: 549-56.

16 

Wee JTK, Wong CSK. Functional anal sphincter reconstruction with the gracilis muscle after abdominoperineal resection. Lancet 1983; 322: 1245-6.

17 

Souadka A, Majbar MA, Amrani L, Souadka A. Perineal pseudocontinent colostomy for ultra-low rectal adenocarcinoma: the muscular graft as a pseudosphincter. Acta Chir Belg 2016; 116: 278-81.

18 

Farroni N, Van Den Bosch A, Haustermans K, et al. Perineal colostomy with appendicostomy as an alternative for an abdominal colostomy: symptoms, functional status, quality of life, and perceived health. Dis Colon Rectum 2007; 50: 817-24.

19 

Santoro E, Tirelli C, Scutari F, et al. Continent perineal colostomy by transposition of gracilis muscles–technical remarks and results in 14 cases. Dis Colon Rectum 1994; 37 (2 Suppl): S73-80.

20 

Landen S, Ursaru D, Delugeau V, Landen C. Perineal colostomy prolapse: a novel application of mesh sacral pexy. Ann R Coll Surg Engl 2018; 100: e7-9.

21 

Souadka A, Majbar MA. Perineal colostomy may be the solution of phantom rectum syndrome following abdominoperineal resection for rectal cancer. J Wound Ostomy Cont Nurs 2014; 41: 15-6.

22 

Azizi R, Alvandipour M, Shoar S, Mahjoubi B. Combination of pseudocontinent perineal colostomy and appendicostomy: a new approach in the treatment of low rectal cancer. Surg Innov 2013; 20: 471-7.

23 

Nogueira LP, Mota SD, Flauzino TDA, et al. Perineal colostomy: an option in the treatment of inferior rectal and anal canal cancer. J Coloproctol 2014; 34: 4-8.

24 

Hosdurg V, Sreeharsha M. Perineal colostomy following abdomino-perineal resection for rectal cancer–a case report. Indian J Colorectal Surg 2018; 1: 26-9.

25 

El Marouni A, Zerhouni A, Majdoub KH. Prolapsus d’une colostomie périnéale pseudo continente: une complication exceptionnelle [Pseudocontinent perineal colostomy: an exceptional complication]. Pan Afr Med J 2018; 30: 258.

Copyright: © 2021 Termedia Sp. z o. o. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
 
Quick links
© 2024 Termedia Sp. z o.o.
Developed by Bentus.