Surgical Science, 2011, 2, 252-256
doi:10.4236/ss.2011.25056 Published Online July 2011 (http://www.SciRP.org/journal/ss)
Loop Ileostomy and Colostomy—A Comparison between
Supporting Plastic Rods and Epicutaneous or
Subcutaneous Silicon Drains
Mike Ralf Langenbach1, Ste fan Sauerl and 2, Eiyad Issa1, Claudia Nitschke3, Hubert Zirngibl3
1Helios St. Elisabeth Klinik Oberhausen, Department of S urgery II, University of
Witten/Herdecke, Oberhausen, Ger many
2Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
3Helios Klinikum Wuppertal, Department of Surgery II, University of Witten/Herdecke, Wuppertal, Germany
Received March 21, 20 1 1; revised May 23, 2011; accepted J un e 1, 2011
Abstract
Purpose: Beside the conventional plastic rods, different techniques and materials have been proposed in the
last years to prevent the loop from retraction into the abdominal cavity. The aim of this retrospective com-
parative study was to assess three different techniques of loop support. Methods: The study included 65 pa-
tients who had loop ileostomy or colostomy formed. Depending on the decision of the operating surgeon,
one of three techniques was chosen to fixate the stoma loop: an epicutaneous plastic rod (group 1, n = 14), an
epicutaneous suture-fixated silicone drain (group 2, n = 27), or a subcutaneous silicone drain (group 3, n =
24). Results: The majority of patients (85%) received loop ileostomy. Pain intensity was significantly (p =
0.0014) different among the three groups. A total of 19 patients (30%) suffered a complication. There was a
tendency towards less complications if the stoma was secured by a silicone drain with epicutaneous fixation.
Comfort with stoma care was significantly different, with group 3 experiencing the best results. Conclusions:
Using a subcutaneously tunnelled silicon drain as a stoma bridge results in less complications, less pain and
higher satisfaction as compared to the conventional plastic rod. Conventional plastic rods should be avoided.
Keywords: Ileostomy, Colostomy, Drains, Plastic Rods
1. Introduction
Loop ileostomy and colostomy are frequently indicated
in patients with acute or complicated intestinal diseases,
such as acute neoplastic obstruction, inflammatory steno-
sis or perforation. Irregardless of the differences between
ileostomy and colostomy [1-3], stomas usually cause a
number of medical but also psychosocial problems. In
two of the largest studies on this problem [4,5], local
complications of minor severity were noted in one third
of patients. According to Cottam, et al. [4], the most
frequent complication was retraction of the stoma, which
occurred in one quarter of patients. However, this figure
needs to be interpreted with caution, because the defini-
tion of retraction is not straightforward.
Since many years plastic rods have been used to sup-
port a loop stoma and to prevent the loop from falling
back into the abdominal cavity [6-8]. However, the use
of rigid plastic rods is not without complicatio ns, mainly
because the rod lies on the skin surface for one or two
weeks after surgery, which can lead to skin maceration
and local infection. Dissatisfaction with plastic rods is
highly prevalent as evidenced by the large number of
alternative techniques that were proposed in more recent
years [9-16]. In most of these articles, the bridge which
supported the stoma limbs was reinforced with a softer
material, such as a Jackson-Pratt drain, a suction drain
tube, or a Penrose drain. So me surgeons have even ques-
tioned whether the use of supporting br idges is necessar y
at all [17,18].
Based on clinical experience, the technique of secure-
ing loop ileostomies and colostomies at the authors’ in-
stitution has been variable during th e last years. The aim
of this retrospective study therefore was to assess which
technique of loop support provided the lowest rate of
complications and the highest level of satisfaction for

M. R. LANGENBACH ET AL. 253
stoma therapist and patient.
2. Material and Methods
Consecutive patients with a first stoma between June
2008 and December 2009 were studied. Stoma construc-
tion followed either an emergency or an elective surgical
procedure. Depending on the decision of the operating
surgeon, one of three stoma techniques was chosen: a
conventional epicutaneous plastic rod (group 1), an
epicutaneous suture-fixated silicone drain (group 2), or a
silicone drain placed in a subcutaneous tunnel (group 3).
The selection of surgical technique depended more on
the surgeon’s personal expertise than on the patient’s
characteristics.
The steps in performing a loop colo- or ileostomy with
a suprafascial bridge device were similar to those gener-
ally described in international textboo ks. After a suitable
incision in the abdominal wall had been made, the colic
or ileic loop was gently pulled through the opening and a
small incision was made in the mesentery. In group 1, a
conventional plastic rod (ConvaTec®, Coloplast Inc.,
Hamburg, Germany) measuring 7 or 10 cm in length was
placed through the mesenteric window. At both ends of
the rod small wings were opened, so that the rod could
not slip through the mesentery.
In groups 2 and 3, a 21 Charrière silicone drain was
used. Both ends were pointed to ease tissue penetration.
In group 2, after placement through the mesentery, the
ends of the silicon drain were fixed with nonresorbable
polyamid sutures (Ethilone, 3.0; Ethicon, Inc.) to the skin
at the incisional site. The stitches were inside the range
of the stoma appliance. When the surgeon decided to
secure the stoma with a subcutaneous silicone drain
(group 3), the silicone drain was cut to a length of about
20 cm. After being placed through the mesentery, both
ends of the drain were subcutaneously tunnelled, were
brought out and fixed with a stitch. Entry and exit point
of the drain were just beyond the circumference of the
stoma flange. Finally, both end of the drain were short-
ened to the level of the skin.
Whilst in the hospital the patients were regularly re-
viewed and stomata were assessed by a surgeon and
stoma therapist. Using standardized forms, we recorded
demographic characteristics, surgical indication, and type
of surgery. At the first, third, fifth and tenth postopera-
tive day, the severity of local pain (u sing a 0 to 10 visual
analogue scale [VAS]), the occurrence of local compli-
cations, and the level of satisfaction of stoma therapist
and patient were recorded. The definition of complica-
tions was adapted from other studies and required the
presence of patient-reported symptoms, or the necessity
of specific therapy (local or systemic). Follow up was
continued until stoma support was removed, which took
place between the seventh and tenth postoperative day.
All data collected in the patients’ charts were retrospect-
tively reviewed and analysed.
Statistical Analysis
Differences in baseline and outcome parameters between
the three groups were statistically assessed using analysis
of variance (ANOVA) or chi square testing. In order to
account for the fact that pain scores represented repeated
measures of the same individual, these were analyzed
with a general linear model followed by post hoc Tukey
tests. Significance was defined as a p-value smaller than
0.05.
3. Results
Among the 65 patients, there were 55 (85%) loop ileo-
stomies and 10 (15%) loop colostomies. In colostomy
patients, a plastic rod was used more frequently. With
regard to other baseline variables, the groups were more
or less comparable (Table 1).
As shown in Figure 1, pain was clearly different
among the three groups (p = 0.014). Group-wise com-
parisons indicated that pain was significantly lower in
the group with subcutaneous silicone drains than in each
of the other two groups: p = 0.008 vs. plastic rod and p <
0.001 vs. silicone drain on skin. No patient required an-
algesics because of local pain.
A total of 19 patients (29%) suffered a complication.
There were slightly less complications in patients who
had their stoma secured by a superficially placed silicone
drain (Table 2), but this difference was not significant.
However, the severest complications (arrosion of the in-
testine) were all seen exclusively in the group with con-
ventional plastic rods. All wound infections in the group
with subcutaneously tunnelled silicon drains were super-
ficial and mild.
From the viewpoint of the stoma therapist, comfort
and ease of stoma care was significantly different among
the groups, as the group with subcutaneously placed sili-
con drains showed the best results. Since entry and exit
site of the silicon drain in this group were outside the
diameter of the stomal flange, changing the stoma bag
did not interfere with any type of rod or drain.
4. Discussion
The creation of a loop ileo- or colostomy strongly influ-
ences the patients’ quality of life after an operation. Fur-
thermore, patient cooperation is necessary for correct
stoma care. Therefore, it is essential that no complication
decreases the patients' trust in the normal functioning of

M. R. LANGENBACH ET AL. 254
Table 1. Demographic baseline characteristics.
Conventional plastic rod Silicon drain on skin surfaceSilicon drain with
subcutaneous tunnel P-value
Number of patient s 14 27 24
Age (in years) with ra n ge 63 (16) 31 - 81 66 (12) 27 - 86 73 (11) 40 - 87 0.028a)
Gender (proport i o n males) 9 (64%) 15 (56%) 15 (63%) 0.82b)
Underlying disease
Rectal cancer
Colon cancer
Intestinal ischemia
Inflammatory bowel disease
Sacral pressure ulcer
Diverticulitis
Other c)
6 (43%)
1 (7%)
2 (14%)
0
0
1 (7%)
4 (27%)
16 (59%)
3 (11%)
3 (11%)
2 (7%)
1 (4%)
1 (4%)
1 (4%)
16 (67%)
4 (17%)
1 (4%)
1 (4%)
2 (8%)
0
0
0.15b)
Type of stoma
Loop ileostomy
Loop colostomy
11 (79%)
3 (21%)
24 (89%)
3 (11%)
20 (83%)
4 (17%)
0.05b)
Data are means ± standard deviations (with ranges) or counts (with percentages); a) by ANOVA, b) by Chi square test, c) This category in cluded rectal i mpale-
ment injury, advanced prostatic cancer, rectocele, complicated ileus, and multiple sclerosis.
Table 2. Clinical results.
Conventional plastic rod Silicon drain on
skin surface Silicon drain with subcutaneous tunnel P-value
Number of patient s 14 27 24
Any complication 7 (50%) 8 (30%) 4 (17%) 0.41
Local complications
Arrosion of intestine
Partial necrosis of intestine
Intestinal malperfusion
Fixation suture torn out
Infection at drain entry site
Small stoma prolapse
Small parastomal hernia
Local swelling
5c)
1
1
2
1
1
1
3
2
1
1
NA
Comfort of stoma care
Good
Average
Bad
2 (14%)
5 (36%)
7 (50%)
12 (44%)
9 (33%)
6 (22%)
24 (100%)
0
0
0.001
Data are means ± standard d eviations (with ranges); a) by ANOVA, b) by Chi square t est, c) On day 1, 3 (three cases) and 5 after stoma creation.
the stoma. In this study, complications were more fre-
quent and more severe in patients with a conventionally
secured stoma. In order to avoid arrosion of the intestinal
loop, the use of softer material for the stoma bridge ap-
pears necessary. Nevertheless, complications were still
quite common in the two groups, where a silicon drain
was used instead of a plastic rod. This shows the need for
further improvements in surgical techniques.
The complication rate of this study (29%) is well in
line with previous research [4,19-26]. In a large registry
study, Cottam, et al. identified 34% of 3970 stomas as
problematic [4]. In that study, type of stoma and gender
of the patient were described as significant risk factors,
but also the height of the stoma was predictive for com-
plications. In our experience, securing the stoma loop
with a silicon drain effectively prevented any retraction
of the loop into the wound. Although stoma height is
Figure 1. Local pain on day 1, 3, 5, and 7 after different type s
of stoma creation Data are means with error bars indicat-
ing one standard error.

M. R. LANGENBACH ET AL. 255
difficult to measure quantitatively, the subcutaneous po-
sition of a silicon drain is fully sufficient to support the
loop, which then guarantees for correct emptying of in-
testinal contents into the stoma appliance.
Using a subcutaneously tunnelled suction drain as a
stoma bridge was first described in 2008 by Harish [13].
As the two main advantages of this technique, he con-
sidered the quick availability of suction drains in operat-
ing theatre and the ease of stoma care device application.
In the present study, surg ical techniques were exactly the
same as described by Harish, except for the fact that he
used tubes of 16 or 18 French, whereas a calibre of 21
Frenc h was pref err ed b y us . Th is difference can probably
be best explained by the larger body size of Europeans as
compared to Indians, in whom Harish developed the
technique.
Already in 1984, Jenkinson, et al. proposed to use the
subcutaneous layer for placement of the stoma bridge
[27]. In a more recent study, Branco, et al. [12] im-
planted a conventional plastic bridge device in the sub-
cutaneous tissue. In this technique, there is no need for
additional skin incisions, which clearly reduces the risk
of wound infection. Among the 19 cases reported by
Branco, et al., there was not a single infection, but ap-
parently pain was a problem, as two patients requested
analgesics. Of note, pain during bridge removal was not
reported in the study by Branco, et al., because the plas-
tic rod remained in place until stoma reversal. However,
a permanent plastic rod in the abdominal wall may cause
discomfort to the patient. Since silicone is a softer mate-
rial than plastic, pain was clearly reduced in the present
study. It is quite interesting that a silicon drain causes
less pain when subcutaneously tunnelled than being
placed on the skin. Apparently, the stitches for securing
the drain must also be considered a potential source of
pain, because the intestinal loop may pull on these
stitches.
An important strength of the present study is that it
represents a comparative design including three com-
parison groups and assessment of patient-reported out-
comes. Although the assignment of patients into the three
groups was not randomised, the potential for selection
bias was very small, because during the study period
most surgeons performed only one of the three tech-
niques. Usually, evidence derived from prospectively
controlled trials allows for more valid conclusions than
do case series without a control group. To some extent
the lack of comparative studies is certainly responsible
for the large variety in surgical techniques in this field
and the lack of a consensus on the best technique [28].
5. Conclusions
In summary, our data implicate that a subcutaneously
tunnelled silicon drain provides the lowest rate of com-
plications and pain and the highest level of satisfaction
for patient and stoma therapist. Plastic rods should be
avoided.
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