Intestinal Stomas Dr Enja Amarnath Reddy Apollo BGS Hospitals, Mysore
Stoma Stoma (Greek) = Mouth stoma is a surgical bypass of a natural conduit Intestinal Stoma An opening of the intestinal or urinary tract onto the abdominal wall, connected surgically or appearing inadvertently Maingots
Colostomy End – left iliac fossa Loop Ileostomy End – right iliac fossa Loop Loop-End Split Continent (Kock’spouch)
United Ostomy Association Voluntary group of 40,000 people with various stomas In USA, Canada 15,000 ostomies review Ileostomy – UC - Peak incidene – 20yr – 40 yr Crohns – lower peak – same age group Colosomy – Colo-rectal cancers – pear – 60 yr – 80 yr
UOA Survey After ostomy Resumed home – 90% Vocational activities – 73% Social activities – 92% Sexual activities – 70% 73% of registered UOA conventional Ileostomy, Sigmoid colostomy After procto-colectomy sexual dysfunction is due to autonomic denervation, not because of stoma
Quality of Life Development & availability of stoma equipment Good surgical technique Specialized nursing techniques, Counseling Pre-operative Post-operative
Incidence Overall incidence of stomas decreasing New surgical techniques Stapling devises Local treatment for selected rectal tumours Sphincter saving procedures for UC, Familial polyposis
Selection of stoma site A flat area of skin - for adequate adhesion of appliance. The patient should be able to see the stoma. Skin creases, folds, previous scars, Umbilicus, and bony prominences should be avoided. The stoma site should not be located at the beltline. The site should be identified with the patient lying, sitting, and standing. Preexisting disabilities should be taken into account.
Ileostomies – right iliac fossa Sigmoid colostomy – left iliac fossa Transverse colostomy – right/left upper quadrant
Loop Ileostomy vs colostomy Randomized controlled trails Ileostomy superior – low incidence of complications in stoma formation/ closure (high incidence of intestinal obstruction)
Principles of Stoma Surgery Midline vertical incision Adequate blood supply on either side (skin & bowel) Without tension Avoid pre-existing infection Avoid too small hole at fascial level No twist Stoma hole at the end of the surgery.
Circular skin – excise adequate ( 2.5 cm diameter) Subcutaneous fat should not excised – supports stoma Cruciate incision in rectus sheath Muscle split in fiber direction
Colostomy End colostomy Loop colostomy Types By Function Decompressing colostomy Diversion colostomy By Anatomy End-sigmoid colostomy End-descending colostomy Transverse colostomy Caecostomy
Colostomy Decompressing colostomy distal obsructive lesions causing massive proximal colon dilatation Severe sigmoid diverticulitis with phlegmon Toxic megacolon Types Blow-hole stoma constructed in the caecum/ transeverse colon Tube type cecostomy Loop - transverse
Blow - hole
Blow - hole
Blow - hole Rarely performed Reserved for severely acutely ill – with massive distension and impending perforation of colon Elderly Immunocompromised patients Disadvantage can not evaluate other parts of the colon for potential ischemic necrosis due to massive dilatation
Tube caecostomy Malecot/ Mushroom catheter placed in the caecum Advantage Less chance of prolapse Disadvantage Tubes usually blocked with feces Drain poorly leak stool adjacent to the drain
Diverting colostomy Diversion of intestinal content Distal segment of bowel completely resected – APR Known/suspected perforation of distal bowel obstructing carcinoma diverticulitis leaking anastomosis trauma Crohn’s disease Failed/ reconstruction of anal sphincter
End colostomy Right iliac fossa Simoid/ descenting colon Should not protrude > 1.5 cm to 2cm To avoid herniation & prolapse fixation of colon to the abdominal wall extra-peritoneal tunneling of colon – difficult for reversal & revision.
End colstomy Interrupted Absorbable Sutures Full thickness bite at the end Sero-muscular bite at skin level
Loop Colostomy Quick & temporary method. Acute colonic obstruction/ for diversion RUQ – proximal transverse colon LIF – left colon Disadvantages Large hole – where colon is greatly dilated Para-stomalheria, prolapse Appliance leakage Risk of damage to marginal artery
Double barrel colostomy This vogue has passed Still has place In colo-rectal trauma After resection of damaged colon Proximal & distal ends colon tracked together along anti-mesenteric surfaces with interrupted absorbable sutures Easier to close
End Ileostmy After total procto-colectomy Distal end of the ileum is prefered (save length, future ileal pouch) Right iliac fossa Aim – 2.5 cm spout Mesenteric surface oriented superiorly Ease until 5cm of ileum protrude above the skin Superior 2 sutures – 5cm serosal bite from end Inferior 1 suture – 4cm serosal bite from end Series of interrupted absorbable sutures Everted spout directed downwards
Loop Ileostomy To rest the distal bowel/ to protect an anastomosis Distal ileal loop preferred Similar to loop colostomy Proximal limb – lower position Marking suture to identify proximal limb Supporting rod may be used Ante-mesenteric 80% circumferential incision – distal limb Proximal limb everted Muco-cutaneous sutures
Loop-end ileostomy ileum and its supporting mesentery are grossly thickened and the surgeon is encountering difficulty in preparing a sufficient length of well-vascularized ileum for a conventional end ileostomy. ileum is prepared as in a conventional end ileostomy, but the vascular arcades are left undisturbed. stapled closed end of the ileum lies just within the abdominal cavity. Ileostomy constructed same as conventional loop ileostomy.
Split ileostomy Bringing out two cut ends at different sites Proximal end – ileum Distal end – ileum/ colon – mucous fistula can be included in the abdominal wound Advantage Completely defunctions the bowel without the risk of intra-abdominal leakage from a closed distal stump. Disadvantage difficult to close - necessitates reopening of the main incision.
Continent ileostomy(Kock’s Pouch) Ileal pouch reservoir Non-return nipple valve Emptied regularly via a catheter
Continent ileostomy(Kock’s Pouch) Intestinal reservoir for feces was first described by Nil Kock – 1967 Originally described – U shaped pouch will interrupt co-ordinatedperisstalisis and would enhance the capacity Since then J, S shaped pouches have been used with similar results.
Continent ileostomy(Kock’s Pouch) Has been used as an alternative to conventional ileostomy Selected patients ( ileo-anal anastomosis – alternative) Ulcerative colitis Familial polyposis Malfunctioning ileostomy Poorly located ileostomy Severe injury to the peri-stomal skin – allergic reaction to ostomy appliance Contraindication Crohn’s disease (recurrence)
Continent ileostomy(Kock’s Pouch)
Continent ileostomy(Kock’s Pouch)
Continent ileostomy(Kock’s Pouch)
Kock-pouch continent ileostomy showing a Marlex mesh collar reinforcing the nipple valve
Urinary Conduit Constructed intestinal segment with well-maintained vascularity, connected to urinary tract to allow egress of urine through stoma Indications After removal of urinary bladder - invasive cancer Severe obstructive uropathy Severe neurogenic bladder (spinal cord injury) Congenital abnormalities spina bifida bladder exstrophy
Complications of urinary conduit Leaking appliance – common improper construction – flush stoma spigot configuration is best Radiation skin breakdown – relocation Stone formation in the conduit Crystal formation around the stoma good hygiene acidification – with venigar Recent advances Kock’s continent urinary diversion
Stoma closure Loop Ileostomy At least 12 weeks to settle edema inflammatory adhesions Peri-stomal skin incision 2 mm from the muco-cutaneous junction Sharp dissection – divide adhesions Excise rim of skin end-to –end anastomosis Loop colostomy Same as loop ileostomy closure
Loop ileostomy closure
Complications Complication rate in life time Colostomy – 25% End-ileostomy – 57% Loop-ileostomy – 75% Cumulative complication at 20 yrs for ileostomy Ulcerative colitis – 76% Crohn’s disease – 56% Many complications can be successfully managed with proper entero-stomal care Surgical correction is often unsatisfactory
Complications Skin – Excoriation, Ulceration Ischemia Obstruction Retraction Para-stomal Hernia Prolapse Fistula Stenosis Other - Bleeding, perforation, Cancer
Ischemia Mild ischemia – common – resolve in few days Satisfactory healing depends on blood supply Loop ostomies has better healing rate than end ostomies Recommended Prepare relevant bowel segment for the stoma before end of the operation – asses blood supply at the end Patchy necrosis confined to the mucosa – heal by secondary intension Complete necrosis of ileostomy – urgent revision Short segment colostomy with necrosis – no necessity to revise, heal with stenosis, fistula will form.
Stenosis consequence of postoperative ischemia Mild stenosis - simple dilatation – if effluent is liquid Substantial stenosis – sub-acute obstruction – revision
Prolapse Common – loop colostomy Loop colostomies usually assiated with a degree of para-stomal hernia Usual complaint difficulty in fitting the appliance/ leakage Best option – close the stoma Another option – devide loop – convert to end stoma distal segment return in to abdome Proximal – amputate prolapse High recurrence rate
Repair co-existing para-stomal hernia Emerging stoma through rectus abdominis/ fix the mesentary to the abdominal wal
Retraction Commom in ileostomy Causes 1.Leak – poor adhesion between serosal surfaces of everted stoma 2.Para-stomal hernia If retracted stoma is mobile Series of non-cutting linear staplling Avoid mesentary If retracted stoma is immobile - laparotomy
Para-stomal Hernia Formation of an abdominal stoma necessarily involves creating a defect in the abdominal wall to accommodate the emerging bowel. Such defects may become enlarged as a result of tangential force applied to the edge of the opening, and this enlargement may lead to hernia formation Intra abdominal pressure Obesity Emergency procedure – large opening Optimal – incision which admit 2 fingers
Para-stomal Hernia Clinically Unsightly bulge at stoma site Leakage around the stoma appliance Skin rahes Difficulty in irrigation Obstruction/strangulation
Obstruction Stenosis Para-stomal hernia Post-operative adhesions Recurrent disease Crohn’s disease in proximal ileum Recurrent cancer Retrograde contrast study - help in identifying the cause
Fistula Full thickness bite through the bowel while froming stoma Pressure necrosis – tightly fitting appliance Recurrent disease – Crohn’s disease Treatment laparotomy - reformation of stoma at new site
Other complications BLEEDING Trauma, inflammatory polyps PERFORATION Trauma (irrigation) Recurrent disease SKIN ULCERATION Contact dermatitis CANCER FORMATION Recurrence at stoma site/ de-novo cancer
devastating news to a patient sites should be marked preoperatively. They should be on flat skin, away from scars and avoiding bony prominences and the umbilicus. The positioning of the patients clothing should also be taken into account.
MitrofanoffAppendico-vesicostomy Appendix is used to create a conduit between the skin surface and the urinary bladder Indication Urethral cancer Neurogenic bladder Spinal cord injuries Spina bifida
Continent ileostomy (Kock pouch) is an alternative to end ileostomy for patients who have undergone total proctocolectomy. The procedure reached its height of popularity in the late 1960s and early 1970s, but has been supplanted by restorative proctocolectomy, an operation that preserves the natural route of defecation. Continent ileostomy is still appropriate for selected patients with ulcerative colitis and familial polyposis who are not candidates for restorative proctocolectomy, for whom restorative proctocolectomy or end ileostomy have failed, and in a few other selected cases. Complication rates have decreased during the past three decades following technical improvements, but remain significant. In this review, the author summarizes the current indications for continent ileostomy, examines recent technical modifications, and discusses the management of complications.
Malone antegrade continence enema connecting the appendix to the abdominal wall and fashioning a valve mechanism that allows catheterization of the appendix. Indication Fecal incontinence