Correction of a Leaking Stoma: Using Silicone Block Insertion

Peristomal skin problems are common. In a retrospective study by Anja et al,¹ 235 of 325 patients (73%) with an ostomy had a history of peristomal skin complications. The leakage of stomal contents is also a common complication. In a study by Nugent et al,² 27 of 43 patients (62%) with a stoma experienced stomal leakage at time of the study, which can be related to social, psychological, and physical problems.³ Leakage can occur due to anatomical problems, such as stomal retraction, skin folds, or scar contraction. According to a retrospective study of 137 patients, obesity also is a risk factor of urostomy complications.⁴ Obesity can cause problems preoperatively when deciding on the proper site for stoma creation, intraoperatively when trying to create a tension-free stoma, and postoperatively when weight gain alters the abdominal contour.⁵

When leakage occurs, it can be managed with conservative methods including adjustment of the stomal appliance by a stoma nurse.¹ If conservative management fails, minimally invasive techniques, such as collagen injection or suction-assisted lipectomy, can be used to modify the abdominal contour.^6-8 However, these techniques can correct only small amounts of leakage, and repeated injections or lipectomy procedures are often required. A periodic review of stomal appliances, dressing methods, and injection of filler can be used to compensate for alterations in abdominal contours, but in some cases these methods are ineffective.¹ If symptoms and functional impairment are persistent despite conservative management and/or minimally invasive procedures, more invasive treatments such as surgical revision (including modified abdominoplasty and flap surgery) can be considered.

This article presents the case of a patient with urine leakage at the stoma site 1 year after total cystectomy and ureterocutaneostomy. The patient then underwent treatment with a fasciocutaneous V-Y advancement flap. Seven (7) months after that surgery, the patient underwent silicone block insertion in the peristomal indentation to further alleviate symptoms and correct the soft tissue irregularity around the stoma; the outcome was satisfactory. The authors introduce the management of stomal leakage using silicone block insertion for consideration as an alternative to currently used techniques.

The patient was a 39-year-old woman with a history of chronic interstitial cystitis and dysfunction of the bladder due to a neurogenic problem. Her body mass index was 27 kg/m². She first presented to the Urology Department when she was 32 years old because of dysuria and lower abdominal pain after the removal of a Foley catheter, which had been inserted for conservative care after a seizure, the cause of which is still unclear. Due to acute pyelonephritis after the seizure and Foley catheter insertion, the patient had been treated with antibiotics for 5 years and was repeatedly admitted to the hospital. However, symptoms did not improve dramatically with conservative management, and the patient underwent total cystectomy and ureterocutaneostomy under general anesthesia performed by a urologist.

At one (1) year after surgery, the patient presented to the Department of Plastic and Reconstructive Surgery with consistent urine leakage at the site of the stoma. Leakage occurred at the medial aspect of the urostomy and was caused by an abdominal soft tissue irregularity (Figure 1). The patient underwent conservative treatment by a skilled stoma nurse, including the placement of the peristomal appliance using a urinary pouch, but the urostomy appliance needed to be changed every hour. Because of the cost and the effects on her quality of life, the patient wanted a lasting solution and decided to undergo surgical treatment. Because the leakage was occurring due to skin depression with scarring at the site of the previous surgery, a fasciocutaneous V-Y advancement flap procedure was performed to increase the volume of the depressed skin (Figure 2). After surgery, urine leakage was diminished and the change interval of the urostomy appliance was extended to once a day. The patient was discharged on postoperative day 5. Although symptom improvement was seen, the patient requested another consultation 7 months later regarding options for further improvement and to address leaking urine at the medial side of the stoma (Figure 3).

A surgical silicone block was inserted at the authors’ clinic. Under local anesthesia, a 3-cm-long vertical incision was made along the previous scar, and dissection was performed to the level just above the superficial fascia. Then, a presculpted silicone block was inserted (Figure 4). The silicone block was immovable because it was stuck in a tight space. The dermis was repaired with Vicryl no. 4-0 suture (Johnson & Johnson) and the skin with Ethicon no. 6-0 (Ethicon, Inc).

Dramatic improvement was seen after surgery. The patient needed to change the urostomy appliance only every other day and was satisfied with the result. On the day after surgery, the patient was discharged and subsequently followed at the outpatient clinic. No other complications were noted during the 1-year follow-up period (Figure 5).

The number of patients with a stoma in the United States is estimated as being up to 450,000 people, with 120,000 new stomas created each year.⁹ Turnbull¹⁰ predicted that the number of patients in the United States with an ostomy will rise by 3% per year, with colostomy accounting for 36.1% of these patients, ileostomy accounting for 32.2%, and urostomy accounting for 31.7%.

Complications after stoma creation, especially leakage of stomal contents, have a direct impact on quality of life. Conservative management, including stomal appliance methods such as 2-piece ostomy pouching system and drainable pouch provided by or under the instruction of stoma nurses, can often be effective in treating this symptom.¹¹ However, conservative management can incur long-term and high costs. The average cost for managing an episode of peristomal skin complications (assumed to last 7 weeks) ranged from $133 to $776 in the United States between 2008 and 2012.¹² Additionally, conservative management does not treat the cause of stomal leakage, and more invasive treatment must be considered when the symptom is refractory or when treatment is required by the patient.

Minimally invasive treatment for correcting a soft tissue irregularity, such as collagen injection and suction-assisted lipectomy, can be an effective way to treat stomal leakage caused by relatively localized, small irregularities.^6,7 These procedures also have merit in that symptoms can be handled at a relatively lower cost than invasive surgical procedures, and patients require no anesthesia or only local anesthesia in most cases. Nevertheless, minimally invasive techniques cannot be used to effectively manage deep, large defects or irregularities. In addition, measurement of the true cost-effectiveness is difficult because patients treated with these techniques often need repeated procedures. For example, in a study in which collagen injection was used to manage the stomal skin contour defect in 8 patients, 37.5% of patients who underwent collagen injection experienced no improvement in the symptom, and 12.5% of patients needed to undergo collagen injection twice yearly.¹

More invasive procedures, such as abdominoplasty or localized flap surgery, should be considered when symptoms cannot be managed with conservative treatment or minimally invasive techniques, especially when leakage is high in quantity and the alteration of soft tissue of abdominal wall occurs.¹³ Although the cost of the procedure and burden on the patient are relatively high, revisional surgery can be a more long-lasting treatment. It is the opinion of the authors that when symptoms are refractory to conservative treatment and minimally invasive procedures, revisional surgery is a valid choice to manage leakage. Modified abdominoplasty and flap surgeries are used to modify the contour of the abdominal wall. However, the main drawback of these surgical techniques is that the patient requires general anesthesia.

In the case study presented, the patient initially decided to manage the stomal leakage that occurred after total cystectomy and ureterocutaneostomy conservatively. Although she was well-educated and assisted by the stoma nurse, after 1 year the patient found the need to change the urostomy appliance every hour to be too demanding. In addition, this treatment approach was expensive. Eventually, the patient decided to undergo surgical management and consulted with the authors’ department. Despite the requirement of general anesthesia and the cost of the surgery, it was believed that invasive surgery would be cost-effective in the long run. The patient underwent a fasciocutaneous V-Y advancement flap and was initially satisfied with the result because the stomal appliance needed to be changed only once a day. However, the change interval of urostomy appliance shortened as the scar remodeled and the abdominal contour altered. The patient consulted with the department again, and it was decided not to use minimally invasive techniques, such as collagen injection, because repeated injections were expected as the effect diminished. Thus, silicone block insertion was used in anticipation of its several advantages. The patient was satisfied with the outcome and did not need additional procedures during the 1-year follow-up period.

The authors believe that abdominal contour modification by silicone block insertion has several merits compared with other minimally invasive techniques or more invasive surgical procedures. First, silicone block insertion does not require general anesthesia, which is essential to perform more invasive surgical procedures such as abdominoplasty. Second, repeated procedures, which are potentially necessary with minimally invasive procedures, such as collagen injection, are not needed because the silicone block does not dissolve or absorb and can be immovable when placed in a tight subcutaneous pocket.¹ Third, silicone block insertion as a corrective procedure can be used with other types of stomas that leak and when the alteration of the soft tissue of the abdominal wall occurs. Fourth, silicone blocks have been found to be safe in terms of both biocompatibility and biodurability in a review article about silicone breast implant materials.¹⁴ Because of these factors, silicone block insertion could be considered as a useful and minimally invasive option to treat stomal leakage that is not corrected by other procedures. More research is needed to evaluate short- and long-term outcomes.

There are several limitations to this study. The result is not generalizable because the authors presented only 1 case with silicone block insertion and, to the best of the authors’ knowledge, there are no other studies describing the use of this technique. Furthermore,  it is unknown if this technique is effective for other types of stomas, nor is anything known about its long-term effectiveness. The patient in the current study has undergone follow-up for only 1 year. Additional studies are needed with larger and more diverse patient populations.

A 39-year-old patient with a urostomy presented with a history of ongoing urinary leakage that could not be resolved with conservative management strategies and was caused by a peristomal indentation. Initial improvement following fasciocutaneous V-Y advancement flap surgery was seen, but subsequent scar remodeling resulted in a return of the peristomal abdominal indentation and subsequent leakage. A silicone block was inserted under local anesthesia and, 1 year later, the patient needed to change the appliance once every other day compared with several times a day prior to the silicone block insertion. This case study illustrates a satisfactory result of managing stomal leakage using silicone block insertion. This technique may be useful for other patients compared with treatments, such as collagen fillers, that must be repeated regularly. However, more studies are needed to evaluate the short- and long-term outcomes of this treatment option.

Dr. Sung is a resident and Dr. Lee is a professor, Department of Plastic and Reconstructive Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang-si, Republic of Korea. Address all correspondence to: Soo Hyang Lee, MD, PhD, Department of Plastic and Reconstructive Surgery, Inje University Ilsan Paik Hospital, Inje  University College of Medicine, Goyang-si, Republic of Korea; tel: +82-31-910-7320; fax: +82-31-910-7814; email: shyanglee@naver.com.