INTESTINAL STOMASTechniques and Complications

Arif Kurnia TimurOctober 10th, 2014

Classification of Stomas

• GI (bowel diversion) urostomy (urinary diversion)

• Incontinent continent• Permanent temporary• Colostomy ileostomy• End loop• Functional mucus fistula

Types of Ostomy

Stoma types

Pre-operative management

Surgical technique

• Consider stoma formation to be like an anastomosis between bowel and skin

• Healing depends on:– Good blood supply– No tension

End ileostomy End colostomy

Surgical technique

Surgical technique

Surgical technique

Bowel Diversions

• Incontinent types of diversions:Colostomy-opening between the colon and the abdominal wall.

» Ascending colostomy:semi-liquid stool consistency, increased fluid requirements, needs appliance and skin barriers, cannot be irrigated. Indications for surgery: perforating diverticulitis in lower colon, trauma, inoperable tumors of colon, rectum or pelvis, rectovaginal fistula.

Colostomies

Transverse colostomy:Semi-formed stool consistency, possibly increased

fluid requirement, uncommon bowel regulation, requires appliance and skin barrier, cannot irrigate.

Indications for surgery: Same as for ascending colostomy. May also be performed in children who are born with imperforate anus

Colostomies

• Sigmoid colostomy-Formed stool consistency, no change in fluid requirements, bowel regulation possible with irrigations and/or diet; need for appliances and barriers dependent on regulation.

• Indications for surgery: cancer of the rectum or rectosigmoid area, perforating diverticulum, trauma.

Ileostomy• Opening from the ileum or small intestine

through the abdominal wall. Bypasses the entire large intestine. Stool is liquid to semiliquid consistency and contains proteolytic enzymes, Increased fluid requirement. No bowel regulation or irrigation. Requires wearing an appliance and skin barrier.

• Indications for surgery: ulcerative colitis, Crohn’s disease, trauma, cancer, birth defect, familial polyposis.

Surgical interventions1. Loop colostomyBringing a loop of bowel to the surface where it is held in place by a plastic or glass rod passed through the mesentery. Firm adhesion of the colostomy takes place after 7 days then the bridge can be removed.

Loop stoma

• 2- Double Barrelled colostomy: • The colon is divided so that both ends can be brought separately to

the surface with a skin bridge intervening. • Advantage: ensures that the distal segment (colon, rectum) is

completely defunctioned (Absolute Rest).

• 3- Hartmann’s Procedure: • This includes a Proximal End Colostomy with a distal closed colonic

segment. This procedure can be used when resecting a tumour of the Lt. site of the colon or in Complicated diverticular disease.

Double-barrel stoma

End stoma with Hartmann’s pouch

End ostomy types

 (A) End stoma (inset shows everting maturation); (B) double-barrel stoma: End stoma and mucous hop-Koop stoma; and (F) fistula are divided and brought through the same incision (inset shows closed mucus fistula sutured to abdominal wall); (C) loop stoma; (D) decompressing blowhole stoma; (E) Bis Santulli stoma

Continent fecal diversions

• Ileoanal pull-through-The colon is removed and ileum is anastomosed or connected to an intact anal sphincter.

• Ileoanal reservoir-Internal pouch created from ileum. End of pouch sewn or anastomosed to the anus. Surgery is done in several stages and patient may have a temporary colostomy (6-12 weeks) until ileal pouch is healed.

Ileoanal reservoir

Kock Pouch• Internal pouch created from a segment of the ileum.

Part of the pouch is brought out low onto the abdomen as the external stoma. A one-way nipple valve allows fecal contents to drain when a catheter is intermittently inserted in the stoma. No external collecting device is required. Immediately after surgery, a drainage catheter is left in place for 2-4 weeks. This catheter is irrigated with 20 ml of NS every 3-4 hours. Patients are taught to catheterize intermittently with 28fr. Catheter.

Laparoscopic options

• Laparoscopic colostomy / Ileostomy

• 3 ports usually, SILS • Operative time

usually ~ <1 hour

Lap Transverse Colostomy

Complications• 20-41% of patients will have complications• Nearly 50% of these will require a revision

• Early complications– Ischemia, hemorrhage, stenosis, fistula and retraction.

• Late complications– 6% -76% incidence– Prolapse, obstruction, hernia and skin irritation– Complication due to poor technique and poor care and

management.

Stoma Ischemia/Necrosis• 2.3-17% incidence

• Ranges from harmless mucosal sloughing to frank Necrosis

• Causes– Aggressive stripping of mesentery– Stenotic fascia defect– Extensive tension

• Assess depth of necrosis

• Necrosis beyond fascial defect warrants immediate reconstruction

• Consider End loop

Hemorrhage• Mild hemorrhage common and self limiting.

– Usually mucosal.– Apply pressure

• Active bleeding– Implies failure to ligate a mesenteric vessel

Stomal Stenosis/Stricture• 2-14% incidence

• Could manifest early or late

• Ischemia is usual underlying factor

• Other causes: -Infection and retraction

• Crohn’s or recurrent malignancy

• Treat initially with dilation

• Definitive Stoma revision

Mucocutaneous Separation• Separation along

mucocutaneous border

• Occurs to some extent in many patient

• Caused by underlying tension and or separation of sutures

• Supportive care usually resolve problem

• Could lead to eventual stricture, serositis or infection

Infection/Fistula• Incidence of 2-14.8%

• Fistula may form from Abscess

• Beyond immediate post op, fistula formation or infection could be signs of recurrent Crohn’s disease

Stoma Retraction

• 1-6% for colostomy and 3-17% for ileostomy

• Most common reason for re-operation

• Tension:– Tension– Obesity– Steroids use. Poor wound healing

• Can lead to leakage and severe skin problem, more in ileostomy

• Convex stoma plate or use of protective barrier helps

• Most eventually need revision

Prolapse• 2-26% incidence

• Seen mostly in transverse loop colostomy (30%)

• May occur with parastomal hernia

• Managed by reduction and supportive care until definitive surgery

• Convert to end colostomy if need be

Ileostomy Prolapse

Parastomal Hernia

• Predisposing factors– Stoma placement lateral to rectus– Large stoma aperture– Obesity– Prior abdominal incisions– Malnutrition– Wound infection

• Symptomatic – Repair with mesh, Relocation

Acute Parastomal hernia/Bowel obstruction

• Incidence 4.6-13% in early post op

• Causes– Technical– Too large fascial defect

• Rarely seen in mature stomas

• Signs of bowel obstruction

• Repair hernia with mesh

Skin Complication• 3-42% Incidence

• Range from mild skin dermatitis to full- thicknes skin necrosis and ulceration

• More common with illeostomy

• Skin Erosion from constant exposure to stoma effluent

• Contact dermatitis

• Fungal infection

• Intervention– Better fitting appliance– Improve cleaning of peristomal skin– Application of desents and skin barriers– Anti fungals and antibiotics– Stoma paste

Effluent Irritation

Contact Dermatitis

Edema

Skin Complications

Foliculitis

Candida albicans infection

Skin Complication(Pyoderma Gangrenosum)

• First described associated with Crohn’s in 1970

• Diagnosis mainly by physical exam (80%)

• Treatment conflicting– Wound debridement– Steroids injection– Systemic therapy

Skin Complications(Pyoderma Gangrenosum)

Skin Complications(Granulomas)

• Granulomas are lumpy lesions due to inflammation in the dermis.

• Stomal granulomas may be due to:

– Granulation tissue (poor wound healing and infection)

– Crohn's disease

Stoma warts

Stoma Appliances

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