The Myth of the Mandatory Colostomy                                                           

The treatment of a stage III or stage IV sacral coccyx pressure injury (ulcer) is complex and has many facets. Wound debridement, moist wound care, specialized dressings, offloading, nutritional support, and negative pressure wound therapy are often initially employed.

A question that often arises is should a diverting colostomy be added to the treatment regimen. This would seem logical as the aim of the procedure is to eliminate the fecal contamination of an open wound. However, the decision to employ this adjunct surgical operation should be based on well-constructed medical trials which demonstrate improved clinical outcomes and not be based on what might seem to be beneficial. Adequate trials to study this problem are few; the evidence-based data supporting its recommendation are extremely limited and the overall benefits remain unclear.

How then does a physician arrive at the decision to perform a colostomy? It may not be so simple. In an already deconditioned patient, often with multiple comorbidities, a careful risk assessment should be obtained along with considering additional contributory factors, which include the patient's age, nutritional status, wound etiology and long-term prognosis.

Ask the following questions. Is the patient permanently disabled, chronically bedridden, or is there a favorable prognosis with the expectation of a meaningful recovery? What is the patient's Braden scale or frailty index? Is the treatment palliative? Has there been any improvement with conservative therapy? Is a surgical rotation flap being considered for treatment? Is the patient incontinent and if so, has there been a reasonable effort to address this? Does the patient understand and comprehend what a colostomy actually is and what care and maintenance will be required? Will the patient require supportive assistance? Are there any psychological or social issues in having a colostomy? Additionally, if closure of the colostomy is desired, a subsequent, future surgery would be required provided that the patient was then a suitable candidate.

What is known is that the operative risks associated with the procedure are real and are well-documented. These include the need for anesthesia, the operation itself, and potential stomal complications such as stenosis, prolapse, necrosis, and retraction, all of which may require additional surgery to correct. Peristomal skin damage and maintaining a proper appliance seal to avoid leakage is not always easy and at times can be bothersome. 

The largest published study dealing with this was by Pussin.¹ The study involved 445 spinal cord injury patients with paraplegia who developed sacral pressure injuries from 2007 to 2017. The study compared wound closure utilizing a proximal diverting colostomy versus no colostomy. The conclusion was that there was no significant effect on the condition of the wound and that the benefits of the procedure remained unclear. The authors recommended against adding fecal diversion as the standard of care in the treatment of stage III and IV pressure injuries.

These findings are supported by the work of Deshmukh and colleagues, who noted that the low rate of pressure injury healing utilizing a diverting colostomy should temper the enthusiasm of those performing this procedure.² Rubio and colleagues stated that a simple diverting colostomy for the treatment of a sacral pressure injury often is not so simple and cautioned when considering its use.³ De la Fuente and colleagues were more optimistic and felt that in selective patients there may be a benefit.⁴

James V. Stillerman, MD, CWSP, FACCWS, is the Medical Director of Samaritan Medical Center for Advanced Wound Care in Watertown, NY. He is board certified in advanced wound care by the American Board of Wound Management and has 35 years of experience including vascular surgery. Dr. Stillerman is a board member for Hospice in Jefferson County, New York. Most recently, he received the SAWC Grand Rounds award for his poster presentation the treatment of enterocutaneuos fistulas. Dr. Stillerman has initiated a wound care lecture series for teaching the medial students and medical residents. He also provides lectures to many of the regional wound care centers. He is currently developing a wound care treatment template to assist the emergency department, local nursing homes and hospital with wound care and prevention. He also consults via telemedicine as an adjunctive evaluation tool.

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References
1. Pussin AM, Lichtenthaler LC, Aach M, Schildhauer TA, Brechmann T. Fecal diversion does not support healing of anus-near pressure ulcers in patients with spinal cord injury—results of a retrospective cohort study. Spinal Cord. 2022; 60(6):477–83.
2. Deshmukh GR, Barkel DC, Sevo D, Hergenroeder P. Use or misuse of colostomy to heal pressure ulcers. Dis Colon Rectum. 1996; 39(7):737–8.
3. Rubio GA, Shogan BD, Umanskiy K, Hurst RD, Hyman N, Olortegui KS. Simple diverting colostomy for sacral pressure ulcers: not so simple after all. J Gastro Surg. 2023; 27(2):382–9.
4. de la Fuente SG, Ludwig KA, Mantyh CR. Preoperative immune status determines anal condyloma recurrence after surgical excision. Dis Colon Rectum. 2003; 46(3):367–73.