The sigmoidostomy as a determining factor in the change of cutaneous bacterial colonization

The infection of the surgical area after the suture of the colostomy is attributed to the intestinal manipulation, exposing its content, added by the predominantly gramnegative bacterial colonization, present on the skin of these patients, developed from the colostomy procedure [1,2]. The incidence of stoma related complications ranged from 2.9% to 81.1%. Peristomal skin complications and parastomal hernia were the most common complications. End colostomy had the highest incidence of morbidity, followed by loop colostomy and loop ileostomy [3].


Methods
This study has included 19 patients with temporary sigmoidostomy, who had undergone reconstruction of the intestinal transit. The study has been approved by the Medical Ethics Commission and all patients have been informed on the procedure and agreed to participate, signing the Informed Agreement Term. The material analyzed has only been collected after written and clear agreement of patients.
Patients within the clinical stages I or II, adopted by the American Society of Anesthesiology were included, within the oncologic staging of TNM until stage II and who had been colostomized for more than six weeks. We did not admit patients with cutaneous changes, either located in the pericolostomic region or any other systemic ones, who would be undergoing chemotherapy and/or radiotherapy, or had undergone one less than thirty days before. Neither did we admit the immunedepressive, diabetic, cachectic, and the ones being treated or having been treated with antibiotics and anti-infl ammatories in the last thirty days and with infectious or infl ammatory processes in other tissues.
Eleven individuals (58%), among the studied patients, were male and eight (42%) were female. As far as the age group is concerned, we observed that the average age was 52 years, with the minimum age of 16 and the maximum age of 84 years.
The colostomies were carried out in the sigmoid in the type terminal or loop. The illnesses whose surgical procedure involved a colostomy were: rectum trauma, rectum tumor, left colon tumor, sigmoid volvolus, acute diverticulitis of sigmoid, trauma of left colon and dehiscence of colorectal anastomosis. The interval of permanence time of the colostomy was the average time of 16.9 weeks. In the present study, ten patients underwent sigmoidostomy due to malignant neoplasia and nine patients had benign sigmoiderectal disease.
The anti-sepsis was carried out in the pericolostomic region with saline solution at 0.9% and polyvinylpyrrolidone-iodine and sodium lauryl ether sulfate at 10%, for fi ve minutes at least. By means of a punch of 0.3 cm of diameter, two biopsies of the cutaneous tissue were performed, next to the lower edge of the colostomy, at around 0.5 cm from the enterocutaneous anastomosis and around 1.0 cm equidistant from it.
The dermis samples were studied in two ways, regarding the presence of microorganisms: by means of aerobic and anaerobic culture (qualitative study), colonies counting and quantifi cation of bacteria per gram of tissue (quantitative study).

Results
In the culture exam in the derm of sigmoidostomy, the Escherichia coli (100%) has predominated among the aerobic bacteria in 100% of cases, followed by Klebsiella spp (31.6%), and among the anaerobic bacteria, the Bacteroides spp (31.6%) and the Bacteroides fragilis (31.6%), as it can be seen in Table 1.
When it comes to the bacterial species identifi ed as being more frequently present in the pericolostomic region, we found that in patients with benign condition, the Escherichia coli (100.0%) and the Klebsiella spp (38.9%) were the aerobic bacteria more often found, whereas the Bacteroides spp (44.5%) and Peptococcus spp (33.3%) were the anaerobic ones; in the malign condition though, the aerobic bacteria Escherichia coli (81.2%) and Enterobacter spp (31.2%) and the anaerobic bacteria Peptococcus spp (43.7%) and the Bacteroides fragilis (37.5%) were more frequently present, according to the description seen on Table 2.
The quantitative analysis has been performed from the determination of the quantity of microorganisms present per gram of tissue. When analyzing the number of microorganisms per gram of tissue according to the benign colorectal condition, the main aerobic bacterium present was the Escherichia coli, with the average of 1.6×1010, followed by Klebsiella spp with the average of 7.7×109. The anaerobic bacterium, Bacteroides fragilis, presented the average of 1.2×1010, followed by the Bacteroides spp with 9.9×109 and the Peptococcus spp with 6.9×109. As for the analysis of the number of microorganisms per gram of tissue, according to the malign colorectal neoplasic condition, the main aerobic bacterium was the Escherichia  should be considered to reduce the risk of stoma-related complications [9].
The modern devices of stool collection are placed as to remain adjusted to the enterocutaneous transition, with the intention of minimizing the complications developed in the pericolostomic skin. Microbial organisms present in liquids in contact with the skin result in exposure both by preferential adsorption to the skin surface as well as through remaining in liquid retained in the skin. As a result, the quantity of pathogens retained on the skin after liquid contact is a function of both the volume of liquid on the skin and the concentration of the agent in the liquid. Exogenous factors such as temperature, humidity or the use of topical products have an impact on the hydration of the skin, and skin hydration could potentially infl uence water retention [10], fact that can be transposed to the fecal content that is in frequent contact with the cutaneous surface.
In this study, we chose an area next to the lower edge of the colostomy, in a stripe of cutaneous tissue around 0.5 cm away from the enterocutaneous transition, admitting that permanent contact of the enteric content with the cutaneous tissue would occur.
Loss of skin integrity may be related to chemical injury, mechanical destruction, infectious conditions, immunological reactions, disease-related conditions. Peristomal irritant dermatitis caused by skin contact with ostomy effl uent is by far the most ordinary condition seen. Mechanical trauma, infection and aggravation of pre-existing skin diseases are also seen. Allergic contact dermatitis, which is often cited as the cause of peristomal skin problems, appears to be a rare condition with an estimated prevalence of only 0.6% [11].
The material would be collected before the administration of antibiotics and after the anti-sepsis of the skin, since the use of antibiotics can alter the bacteriologic exam, by inhibition or destruction of the infecting bacteria, the same way occurring when the topic anti-septic is used, since it works only in the bacterial fl ora of the cutaneous surface [12].
Among the bacteria, only 5% to 10% are coliform bacteria and the other are facultative bacteria, and the restricted anaerobic bacteria are present in 90% to 95% of times [13]. The more frequently aerobic bacteria found are: the Escherichia coli, the Klebsiella, the Proteus, the Enterobacter and the Enterococcus. Among the anaerobic ones, the Bacteroides fragilis, the Peptostreptococcus and the Clostridium [14]. The enteric bacteria Escherichia coli, Bacteroides spp, Peptococcus spp and Klebsiella spp were considered to be the most frequent found ones, due to the fact that they have been identifi ed many times, throughout the proposed analysis. This does not mean that other bacteria have not developed in the samples of the collected material, as they occurred with a signifi cantly less frequency than the fi rst ones.
In the pericolostomic dermal area of the sigmoidostomy, the Escherichia coli and the Bacteroides fragilis, were the enteric bacteria quantitatively identifi ed with the highest number of microorganisms per gram of tissue.

Discussion
Several factors can be involved in the genesis of pericolostomic bacterial colonization, which is made easier by the permanent contact of the local cutaneous area with the enteric content. Among the main factors, we highlight the colocutaneous fi xing suture, including the mucosa, the intestinal segment with some kind of infl ammatory disease, the dehiscence of the colocutaneous anastomosis, the presence of a foreign body, the contamination of a paracolic hematoma and the insuffi cient preparation of the colon [7,8]. The rate of stoma complications is not signifi cantly different between patients who underwent nonemergent surgery and patients who underwent emergency surgery. Early stoma complication rates are higher in patients with malignant diseases. The site of the stoma is an independent risk factor for the development of