Lecture on the various complications of stoma creation for medical student. Encompasses classification, pathophysiology and principles of management.

1. Complications of stoma
Chea Chan Hooi
General Surgeon
Sibu Hospital

2. • Up to 35% of patients with stoma suffer some
form of stoma-associated complications
• Classified by timing
– Early (within a month)
– Late (after a period of physiologic adjustment,
arbitrarily taken as after 6 weeks)

3. Early
• Improper stoma site
• Ischaemia
• Retraction
• Peristomal skin irritation
• Peristomal infection/abscess
• Acute parastomal herniation with bowel
obstruction
• High output

4. Improper stoma site
• More frequent change of bag and dressings
• Spillage, soiling
• Leads to difficulties in self-care and securing a
stoma bag
• Increased cost and emotional stress
• Translocation with appropriate pre-operative
marking – resection of stoma and creation of
new stoma in fresh location with native virgin
tissue

5. Ischaemia
• The most serious early complication
• Due to:
– Interrupted segmental arterial supply to exteriorised bowel
– Mesentery removed from bowel wall >5cm
– Tension on exteriorised bowel limb
– Too tight trephination
• How to assess clinically?
– Flash light in direct contact with stoma will trans illuminate if viable
– Blood specimen tube inserted into lumen below fascia and light shone
within shows healthy mucosa if viable
• Laparotomy for reassessment
– Revision (if short segment)
– Segmental bowel resection with reconstruction

7. Retraction
• Etiology
– Technical failure from tension on bowel limb
– Poor patient general condition – malnourished, obese,
steroid therapy
• May lead to peristomal abscess, peritonitis
• Treatment options
– Local revision – detach the mucocutaneous junction,
advance the bowel limb, excised all necrotic tissue
and reanchor stoma
– Laparotomy & complete revision if unsuitable for local
revision

9. Peristomal skin irritation
• Etiology
– Chemical dermatitis from contact with stoma effluent, esp.
ileostomy
– Desquamated skin from frequent change of stoma bag
• Prevention
– Proper stoma siting and ensuring ileostomy well spouted
– Proper appliance of stoma bags to prevent leaks
• Treatment
– Excoriated skin dressed with semi-permeable dressings to
protect from effluent
– Revision as the last resort

11. Peristomal infection/abscess
• Risk factors:
– Stoma revision or reconstruction at the previous
stoma site
– Peristomal haematoma, granuloma
– Iatrogenic perforation of bowel limb
• Treatment options
– Incision and drainage, if possible outside the
border of stoma bag wafer
– Translocation if persistent peristomal fistula

13. Acute parastomal herniation with
bowel obstruction
• Technical failure due to too large fascial defect
• Keep in mind as bowel edema subsides, the
dead space around bowel limb increases
• Treatment options
– Reoperation with reduction of hernia, resect non-
viable bowel if present and tightening of fascial
opening
– Mesh repair can be considered if no significant
contamination with bowel content

14. High output
• Systemic derangements – dehydration,
electrolyte & acid-base imbalance
• Treatment options
– Symptomatic correction
– Closure of stoma

15. Late
• Parastomal hernia
• Subcutaneous prolapse
• Prolapse
• Stricture
• Obstruction
• Peristomal varices
• Parastomal skin conditions
• Diversion colitis
• Psychological distress

16. Parastomal hernia
• The most common late complication
• Treatment options
– Local reduction/resection of hernia sac with repair
of the muscular wall defect, with or without mesh
– Translocation

18. Subcutaneous prolapse
• AKA pseudoherniation
• Convoluted, capacious bowel encountered
before fascial layer upon digital stomal
examination
• Bowel moves directly outward and coil into
extrafascial soft tissue (similar to a sliding
hiatal hernia) without protrusion of a hernia
sac

20. Prolapse
• Transverse loop stomas carry the highest risk
• Treatment options
– If stoma is for temporary purpose, expectant
management until date for closure of stoma
– Resection of prolapsed segment, similar to
Altemeier perineal proctectomy
– Linear stapler amputation of prolapsed segment

22. Stricture
• Predisposed by ischaemia, infection or
retraction
• Treatment options
– Expectant management with dietary modification
or/and cone catheter irrigation
– Endoscopic dilatation if at subcutaneous level
– Translocation

23. Obstruction
• Etiology:
– Adhesional obstruction
– Stricture/Stenosis
– Parastomal hernia
– Recurrent malignancy or Chron’s disease
– Internal herniation
– Food bolus obstruction
• Definitive management depends on
identifying the likely cause of obstruction

24. Peristomal varices
• Patients with underlying portal hypertension
• Typically a patient with IBD & primary
sclerosing cholangitis with liver cirrhosis

25. • Local modalities
– Pressure with adrenaline-soaked gauze
– Suture ligation
– Sclerotherapy
• Surgical procedures
– Mucocutaneous disconnection – incising mucoctaneous
junction & continuing dissection along bowel wall down till
fascia level
– Translocation
• Systemic therapy
– TIPS procedure
– Liver transplant

26. Parastomal skin conditions
• Peristomal dermatitis
– Irritation, inflammation & break down of skin around
an ileostomy
• Allergic dermatitis
– Solvents, adhesives and dressings used in conjunction
with stoma bag
• Candidal infection
– The most common infection
– Similar appearance to contact dermatitis but with
satellite papules & pustules
• Individualised treatment

28. Diversion colitis
• Occurs in retained colon distal to a diversion
stoma
• Short-chain fatty acids (from bacterial breakdown
of dietary carbohydrate) is diverted away and
therefore causes inflammatory changes to
diverted distal bowel
• Treatment options
– No treatment for asymptomatic patients
– If symptomatic:
• Short chain-fatty acid enema or suppository
• Closure/Reversal of stoma

30. Psychological distress

31. Thank you
Q&A?