Using a Bedside Video-assisted Test Tube Test to Assess Stoma Viability: A Report of 4 Cases
Mucosal discoloration of an intestinal stoma may indicate self-limited venous congestion or necrosis necessitating operative revision. A common bedside technique to assess stoma viability is the “test tube test”.
A clear tube is inserted into the stoma and a hand-held light is used to assess the color of the stoma. A technique (video-assisted test tube test [VATTT]) developed by the authors utilizes a standard video bronchoscope inserted into a clear plastic blood collection tube to visually inspect and assess the mucosa. This technique was evaluated in 4 patients (age range 49–72 years, all critically ill) with a discolored stoma after emergency surgery. In each case, physical exam revealed ischemic mucosa at the surface either immediately after surgery or after worsening hypotension weeks later. Serial test tube test assessments were ambiguous when trying to assess deeper mucosa. The VATTT assessment showed viable pink mucosa beneath the surface and until the fascia was revealed in 3 patients. One (1) patient had mucosal ischemia down to the fascia, which prompted operative revision of the stoma. The new stoma was assessed with a VATTT and was viable for the entire length of the stoma. VATTT provided an enhanced, magnified, and clearer way to visually assess stoma viability in the postoperative period that can be performed at the bedside with no adverse events. It may prevent unnecessary relaparotomy or enable earlier diagnosis of deep ostomy necrosis. Validity and reliability studies are warranted.
Stoma creation is a common gastrointestinal operation, but it is not without complications. The incidence of peristomal (eg, skin problems) and stomal complications (ie, excoriation and leakage and stomal complications as well as necrosis, stenosis, retraction, hernia, prolapse, granuloma, peristomal abscess, and high stoma output) ranges from approximately 10% to 86% in the literature. This wide range encompasses various follow-up times and all ostomy types studied, not only in large retrospective1-4 and prospective5,6 studies, but also in a recent systematic review6 of 21 prospective studies.
In a systematic review by Salvadalena,7 the incidence of stomal necrosis ranged from 2% to 22%. Although the aforementioned studies identify stomal necrosis as an early postoperative concern,1-6,8 literature focusing on its diagnosis and management is scant. Stomal necrosis first manifests as a dark discoloration of the stoma 3 to 5 days after surgery. Although it is usually limited to the superficial mucosa and sloughs off with time, deeper or transmural necrosis, if left undiagnosed or untreated, increases the risk of perforation, peritonitis, stoma retraction, and/or stricture formation. Incidence of stomal stricture or stenosis in the long term (occurring after 30 days2) is estimated to be between 2% and 10%.2,7 In a prospective study of 408 consecutive patients with a colostomy or ileostomy, Robertson et al9 reported outcomes at progressive points in time (up to 2 years) and noted the incidence of stomal stenosis was low (1% to 2%) but did not improve with time, suggesting a source of long-term morbidity.9 Stomal necrosis also may lead to retraction and/or prolapse over time.10 To prevent these complications, the ostomy should be revised in the operating room if observed necrosis extends below the level of the fascia, as described by Shellito10 in a review of complications after stoma surgery.
The traditional teaching is to assess whether the ischemia is limited to the mucosa by performing a “test tube test” at the bedside. This technique is recommended in reviews and letters1,10-13 discussing complications after stoma surgery; however, no case series or observational studies have been published assessing whether this technique actually affects operative decision-making, clinical course, or patient outcome. Anecdotally, it involves gentle insertion of a clear, lubricated test tube (or blood collection tube) into the stoma, followed by shining a hand-held light into the tube to assess for color changes (see Figure 1a); no adverse events have been reported when using this procedure. If the flash of color is pale or pink below the stomal surface, the test is considered negative for proximal or deeper necrosis.
The authors developed a simple innovation to the traditional test tube test to assess stoma viability, the video-assisted test tube test (VATTT). This test consists of a test tube inserted and held within the stoma with 1 hand, while a standard video bronchoscope is inserted into the tube with the other hand (see Figure 1b). The bronchoscope can be advanced for the length of the test tube. The image is projected onto a monitor, creating an enlarged and illuminated internal assessment of the stoma. The test has been performed by surgeons or surgical trainees, but it can be safely performed by any provider trained to use a standard bronchoscope. The VATTT was developed during the work-up and management of the first patient in this series and then applied to 3 subsequent patients who also developed persistent stomal discoloration after emergency laparotomy.
The purpose of this case series is to describe an enhancement to traditional internal assessment of stomal viability.
Written informed consent for participation in this case series and any accompanying images was obtained from patient’s next of kin (due to death of patient) for patients 1, 2, and 3 and directly from patient 4.
Patient 1. Ms. H, 60 years old, presented with 1 to 2 days of worsening abdominal pain. She had a history of stage IV lung adenocarcinoma diagnosed 1 year prior and treated recently with 6 rounds of chemotherapy (carboplatin and pemetrexed). She was hemodynamically stable but in acute distress, with an abdominal exam concerning for peritonitis. Serum complete blood count was significant for chemo-induced neutropenia and thrombocytopenia. A computed tomography scan of the abdomen revealed gas and fluid collection adjacent to the sigmoid colon with fat stranding and free intraperitoneal air, suggesting perforated diverticulitis. She underwent an emergency exploratory laparotomy, resection of the affected sigmoid colon, and creation of a descending end colostomy and Hartmann’s pouch. Postoperatively, she recovered in the surgical intensive care unit. The ostomy was immediately productive of formed stool but began to appear dusky on postoperative day (POD) 4. Serial test tube examination using a hand-held flashlight showed a pale color flash, but these results were equivocal and her clinical condition remained critical along with persistent stoma discoloration. On POD 7, a VATTT was done, which showed ischemic discoloration, mucosal hemorrhage, and necrosis down to the level of the fascia (see Figure 2a,b). She underwent operative revision of the stoma. Intraoperative assessment and pathology reports confirmed transmural necrosis of the resected segment. A postrevision VATTT was done in the operating suite, which demonstrated pink viable mucosa (see Figure 2c,d). Due to her metastatic lung cancer and severe immunosuppression, Ms. H’s prognosis was poor. She died several weeks later upon withdrawal of care by family due to overwhelming sepsis refractory to medical therapy.
Patient 2. Mr. M, 49 years old with a history of Tetralogy of Fallot status postrepair in 1969, presented with pulmonary valve regurgitation and underwent a pulmonary valve replacement by cardiac surgery. The postoperative course was complicated by severe bleeding, right heart failure, and respiratory failure, requiring venoarterial extracorporeal membrane oxygenation. He developed melena and underwent a nuclear scan that localized radioactively tagged red blood cells to the small bowel, identifying it as the source of the gastrointestinal bleeding. After multiple failed attempts by Interventional Radiology to embolize the source, an emergency exploratory laparotomy was performed. A carcinoid mass was found, leading to a small bowel resection, creation of an end ileostomy, and mucus fistula with temporary abdominal closure due to hemodynamic lability. Despite further resuscitation, serial washouts, and eventual abdominal closure, Mr. M clinically deteriorated and developed septic shock of unclear etiology. The congested but productive ostomy was assessed with a VATTT after a test tube test did not show clearly whether ischemia extended deeper than the surface. The mucosa was pink and viable throughout the ostomy, suggesting it was not the source of his instability, thus preventing further relaparotomy. The patient ultimately developed severe acute respiratory distress syndrome and expired after withdrawal of care.
Patient 3. Mr. P, a 66-year-old man with severe left heart failure, developed septic shock and hyperlactinemia after placement of a left ventricular assist device. After an emergency exploratory laparotomy and resection of gangrenous ileocecal segment, an end ileostomy and mucus fistula were created. Mr. P had intermittent hemodynamic instability and increasing vasoactive pressor requirements over the next 2 weeks. On POD 15, ostomy congestion and duskiness had not resolved, and after a test tube test did not clearly show distinct depth of ischemia, a VATTT was done, which showed viable pink mucosa of the proximal bowel. Four (4) days later, Mr. P developed abdominal distension and elevated peak airway pressures. A decompressive laparotomy was done at the bedside, yielding several liters of simple ascites. The ileostomy was assessed at this time, and it appeared healthy. An ileoscopy also was performed to diagnose and control a new onset gastrointestinal bleed, and the mucosa was noted to again be viable for 15 cm, although no bleeding source was identified. The patient eventually developed severe coagulopathy, intractable gastrointestinal hemorrhage, and due to futility of further intervention, he expired after the family withdrew care.
Patient 4. A 72-year-old man with distal pancreatic cancer, Mr. Q underwent a distal pancreatectomy and splenectomy. On POD 4, he developed peritonitis with fecal drainage noted in the Jackson-Pratt drain. He underwent an emergency exploratory laparotomy, which revealed a perforated transverse colon. The diseased area was resected and an end transverse colostomy was created. By POD 3, the colostomy remained congested and discolored. The standard test tube test was equivocal with respect to the color of the mucosa deeper in the stoma. A VATTT showed pink viable mucosa. The ostomy was observed with no further surgical intervention. The patient recovered and was discharged home within 1 week. Pertinent patient information is summarized in Table 1.
Stomal complications are most commonly attributed to the technical aspects of stoma construction.11,14 The risk of developing necrosis can be reduced by not bringing up an ostomy that is under too much tension, avoiding mesentery trimming >2 cm to 5 cm, creating a large enough aperture in the abdominal wall, and not placing sutures at the skin too close to one another.11,15,16 In addition, the surgeon should aim to create 2 cm to 3 cm of bowel protrusion to ensure good appliance adhesion and to prevent peristomal skin complications.17
In a retrospective study1 of 345 stomas on the small and large bowels with an overall stomal complication rate of 36%, risk factors for stomal necrosis included obesity and ischemic disease. Obesity (body mass index [BMI] >25) was associated with a higher risk of necrosis due to short fatty mesentery and increased depth of abdominal wall.1 The average BMI in the current cases was 32.4 kg/mg2. Cook County’s retrospective study2 of 1616 stoma patients identified older age, enteric stoma type and configuration, and lack of preoperative stoma siting as variables that influenced stoma complications. Age >40 years was found to be a risk factor in a retrospective study3 of 330 colostomy patients, although psychosocial and skin problems were cited as the most common complications observed. Emergency surgery influenced stomal complications in multiple studies, including a prospective trial17 of 100 patients of which 41 stomas were constructed emergently; this study reported a high complication rate of 82%, attributed to a very thorough follow-up design that included patients meeting with an enterostomal nurse 8 times over a period of 1 year. Complications were attributed mostly to inappropriate stoma location, such as inadequate fixation, leakage, retraction, and herniation.4
In a retrospective study18 of all complications after the creation of 345 stomas, stomal necrosis was the only stomal complication significantly associated with emergency surgery, and it varied depending on indication for surgery. For example, stomal necrosis was more common after emergency cancer surgery than elective surgery, but not for diverticular surgery. Stomal necrosis was the most significant predictor of mortality. Whether type of stoma (ileostomy versus colostomy, loop versus end) influences incidence of stomal necrosis after emergency surgery is unclear. A prospective trial by Lindholm et al19 that followed emergently created stomas for 2 years reported stomal necrosis was most common in end colostomies. However, in a large retrospective study of 1758 patients over 19 years, Del Pino et al20 found only emergently created ileostomies (not colostomies) carried a higher risk of postoperative complications including necrosis.
Relaparotomy after major gastrointestinal surgery is associated with high mortality.21,22 In a review22 of more than 4000 patients who underwent urgent relaparotomy, stomal complications accounted for approximately 6% of indications for relaparotomy. Preoperative stoma planning and reduction of early complications can reduce costs associated with creation of a left colostomy,23 as well as improve patient quality of life and independence.
In this case series, all patients were critically ill and a physical exam alone was not sufficiently reliable to assess the stoma status. Three (3) patients were on vasopressors, which compromised mucosal blood flow. The traditional test tube test, a common but not evidence-based assessment method, only provides an indication of color change. In contrast, the VATTT offers an enhanced and magnified assessment of the mucosal architecture. The VATTT is not more invasive than a traditional test tube test. It is safe and simple to perform at the bedside once the clinician is familiar with setting up a bronchoscope. No adverse events were observed in the 4 patients described. Use of a video bronchoscope allows the examining surgeon to record the exam and share the results with the surgical team, permitting collaborative clinical decision-making and peace of mind when choosing a wait-and-see approach to a dusky ostomy versus return to the operating room for revision.
It is important to note this method is not an actual test that provides objective findings or standard values; rather, it is an assessment that requires clinical judgment. Other limitations include the higher cost of having a bronchoscope available and the extra training to use it appropriately, when compared to employing a simple hand-held flashlight. As such, it is best used in the hospital setting by trained physicians and physician extenders.
An alternative technique to assess stomal viability using fluorescein dye was described in 2001 by Snyder and Kaufman.14 It consists of an intravenous injection of 5 mL of fluorescein dye over 10 minutes, followed by inspection of the stoma with a test tube and long-wave ultraviolet lamp as a light source. A strong fluorescence of the proximal intestinal mucosa suggests viability. The VATTT is probably as safe as the test tube method but more helpful because it appears to provide a more detailed assessment of the proximal mucosa because the scope can easily be advanced past the fascia.
In this case series, the VATTT was safe, practical, and provided enhanced stoma visualization at the bedside compared to the test tube method. Three (3) out of 4 patients did not have deep necrosis by VATTT assessment, which may have avoided the risks and costs of an additional laparotomy. This innovation has the potential to prevent unnecessary relaparotomy and complications of undiagnosed deeper stomal necrosis. Further studies should be performed in larger, case-controlled cohorts in order to directly compare the validity and reliability of VATTT and other bedside techniques in assessing stomal necrosis.
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Potential Conflicts of Interest: none disclosed
Dr. Ahmad and Dr. Turner are general surgery residents, Department of Surgery, University of Maryland Medical Center, Baltimore, MD. Dr. Shah is an Assistant Professor of Surgery, Department of Surgery, University of Maryland Medical Center, University of Maryland School of Medicine; and R. Adams Cowley Shock Trauma Center, Baltimore, MD. Dr. Diaz is an Associate Professor of Surgery, Chief of the Division of Acute Care Surgery, Department of Surgery, University of Maryland Medical Center; and R. Adams Cowley Shock Trauma Center. Please address correspondence to: Sarwat Ahmad, MD, Department of Surgery, University of Maryland Medical Center, 22 S. Greene Street, S4D09, Baltimore, MD 21201; email: SarwatBAhmad@gmail.com.