Stoma management

1. Stoma management
Shankar Zanwar

2. Definition
• Intestinal stomas are surgically created openings of small or large
intestine onto the anterior abdominal wall
• Types
Intestinal
stoma
colostomy
ileostomy
Intestinal
stoma
End stoma (single
limb)
Loop
stoma(afferent
and efferent limb)

3. Types
• Colostomies
• End – Left iliac fossa
• Loop
• Ileostomy
• End – right iliac fossa
• Loop
• Continent – Kock’s pouch

4. Indications of ostomies
• Large bowel obstruction
• Colonic stricture
• Rectovaginal fistula
• Fecal incontinence
• Penetrating colonic injuries
• Complex perianal fistulas
• Necrotising enterocolitis
• High risk of anastomotic leaks
• Total procto-colectomy in in UC/FAP

5. Stoma site
• Flat area of skin – adequate of adhesion of appliance
• Pt. should be able to see
• To avoid – skin creases, previous scars, umbilicus, bony prominences,
at the belt line.
• Site should be identified with patient lying, sitting and standing
• Usual sites
• Ileostomies – right iliac fossa
• Sigmoid colostomies – Left iliac fossa
• Transverse colostomies – right/left upper quadrant

6. Basic principles of stoma surgeries
• Midline vertical incision
• Adequate blood supply on either side(skin and bowel)
• Without tension on mesentry or skin
• Avoiding pre-existing infection site
• Avoiding too small hole at fascial level
• No twist

7. Conventional vs Brooke’s stomies
• Before Brooke, ileostomies were
made by exteriorizing the intestine
through the abdominal wall and
suturing the serosa to skin
• Exposure of ileal serosa to alkaline
stomal effluent resulted in serositis
and ileostomy dysfunction
• Brooke introduced technique of
eversion of the full thickness of the
mucosa and suturing it to the
adjacent dermis.

8. Pathophysiologic consequences after
ileostomy
• Colonic diversion – absorptive function of colon is lost
• Normal colon absorbs – 1-1.5L of water and 100 mEq/L of sodium
and if need be it can increase to 5 liter.
• Patients with ileostomy obligatory sodium loss is 30-40mEq/L
• A well functioning ileostomies discharges – 500ml to 1.2L of fluid
daily
• Consequently patients are in state of chronic oliguria
• Also they have lower urinary Na/K+
• Changes in urinary composition – increase chances of urolithiasis –
calcium and urate crystals
• Decreased vitamin B-12 absorption and bile acid reabsorption.

9. Routine care of ostomies
• Pouch placement – types
• Closed end pouches – needs to be removed and replaced
with new pouch every time
• Open end pouches – have reuseable end that can be
opened to drain the content of pouch
• Pouch emptying and care – odor and gas common
concerns of patient
• Assure ostomy bags are odor proof
• Empty the pouch when 1/3rd full prevent pouch seal
from excess weight
• Changing the pouch 1-2/wk and sos
• For foul odor if at all
• Chlorine tabs in bag 1-2 tabs
• Bismuth sub gallate 200 – 400mg
• Cholorophylline complex can be taken orally
Closed end pouch
Open end pouch
Protective skin barrier

10. • Diet – minimal modification needed, avoid unchewed nuts,
fruits with skin, popcorns that can obstruct stoma
• If gas is bothering patient needs to be given list of gas
producing diet, in short to avoid beans, cabbage, cauliflower,
brussels, broccoli, asparagus.
• Low carb diet with less of potatoes, corn, noodles and wheat
products.

11. •SOS use of simethicone can be done
•Adequate fluid intake – increase by 500ml -750ml
even more during high output states like sweating
•Should be taught signs of dehydration and fluid
electrolyte imbalance –dry mouth, decreased urine,
marked fatigue, abdominal cramps.

12. • Physical activity – all usual activites can be performed
without any restriction, bathing can be done with pouch on
or off the stoma,.
• Most sports can be performed even with stoma in place
except for extreme contact sports.
• Sexual activity – does not affect organic function,
dysfunction if at all occurs is due to autonomic denervation
after proctocolectomy

13. Complications of ostomies
• Over all complications rate of 14 to 79%
• Risk in life time
• Colostomy – 25%
• End –ileostomy – 57%
• Loop ileostomy -75%
Arumugam PJ Colorectal Dis 2003

14. Complications
• Skin – excoriation, dermatitis, ulcerations
• Ischemia
• Obstruction
• Retraction
• Para- stomal hernia
• Prolapse
• Fistula
• Stenosis
• Bleeding
• Perforation

15. • Timing of complications – early - are related to technical
issues, defined to be occurring within 3 months
• Usually these are due suboptimal stoma site selection -
necrosis, bleeds, retraction.
• Late – May be related to delayed healing – parastomal
hernia, prolapse, stomal stenosis.

16. • Risk factors
• Height of stoma <10mm
• Co-morbid medical illness –
• obesity, Crohn’s, diabetes
• Tobacco use
• Obesity
• Emergency surgery
• Malnutrition
• Advanced age
• Malignancy
• Use of steroids
• Inexperience
Orkin B: J of Reoperative Pelvic Surgery 2009

17. Dermatological complications
• Dermatitis :
• More common with ileostomies – enzymatic nature
of effluent, less with colostomies
• Severely denuded skin along the inferior surface of
the stoma
• Protuberant spout ~2-3cm high is best method
to minimize the contact of effluent to skin
• Skin irritation may be also due to
• Allergic reaction to pouching products –
pruritus, erythema and blisters
• Mechanical trauma
• Fungal infections - more during warm and humid climates
• Antibiotic therapy related
Allergic contact dermatitis
Peristomal fungal infection

18. •Treatment
•Correction of causative factors
•Elimination of allergens
•Denuded areas – use skin barriers
•Antifungals – Nystatin/ miconazole
•Topical steroids in case of severe allergic reaction

19. Peristomal pyoderma gangrenosum
• Usually seen with IBD
• Selecting uninvolved segment best way to
avoid
• Seen also in patient with malignancy
• Develops within weeks to years after stoma
construction
• Typically present as full thickness ulcer, pain and pathergy
• Diagnosis by excluding other common possibilities(r/o infections also)
• Bx. may increase the size of lesion
• HPE – acute and chronic inflammation +/- granulomas
JAMA 2000

20. • Frequent misdiagnosis – stitch abscess, contact
dermatitis, extension of Crohn’s
• Treatment –
• Systemic, intralesional, and or topical anti-inflammatory drugs
- Steroids
• When associated with Crohn’s or in other refractory cases,
tacrolimus 0.1%topical solution daily till healing
• Severely refractory – Infliximab or other biologicals
• Minimize trauma since pathergy is prominent

21. Stomal necrosis
• Incidence – immediate post op period 14%
AU Harris J of ARCES 2005
• Causative factors – inadequate –
mobilization of bowel, preservation of blood supply to stoma
• Risk factors – emergency surgery, obesity, CD
• Early post-op – d/t venous congestion or arterial insufficiency –
tight fascial opening, excessive mesentric stripping.
• Assessment - Inserting a lubricated test tube and using a torch
to determine extent
• Alternatively using a sigmoidoscope

22. • Treatment
• If necrosis extends to proximal bowel below the anterior
fascia – immediate revision
• If proximal - bowel viable, limited necrosis – superficial to
ant. fascia – observation
• If sloughing occurs only gentle debridement

23. Stomal bleeding
• Major bleeding – uncommon
• Usually due to stomal laceration d/t poor fitting appliance or due to peristomal
varices in UC with PSC.
• Initial management –
• direct pressure
• Local cauterisation – hand held cautery/ silver nitrate
• Suturing of bleeding vessel if identified
• Peristomal varices – direct pressure, sclerotherapy or direct suturing
• Beta-blockers may help
• Recurrence are frequent in varices if so – TIPSS
Eur J Gastro –Hep 2006

24. Stomal retraction
• Defined as stoma that is 0.5cm or more below
the skin surface within six months of construction,
typically as result of tension on stoma.
• Incidence 1-40% of all ostomies
Arumugam Colorectal dis 2005
• It causes – leakages and difficulty with pouch adherence – skin
irritation
• Proper ostomy height(>1cm) and minimising tension at stoma site
prevent retraction
• Management – use of convex pouching system
• If fails surgical correction
• If retracted mobile – non cutting linear stapling
• If immobile - laparotomy

25. Mucocutnaeous separation
• Separation of ostomy and peristomal skin
• Incidence 12 -24%
• Leads to leakage and skin irritation
• Prevention – meticulous skin approximation
• Partial or circumferential
• If circumferential stomal stenosis may occur as tissue heals
• Circumferential separation – immediate surgical revision
• Partial – fill absorptive material – calcium alginate, skin barrier
powder, hydrofiber
• Covering area with appliance wafer protects the wound from effluent
– promotes healing.

26. Parastomal hernia
• Type of incisional hernia
• Incidence from – 0-50%
• Unsightly bulge at stoma site
• Leakage around the stoma site
• Skin rashes, non fitting appliances
• Obstruction and strangulation
• Surgical repair –
• local repair, - 100% recurrence
• stoma relocation – 76% recurrence
• Mesh repair – 10% recurrence
Janes, Arch Surg 2004

27. Stomal stenosis
• Narrowing of the stoma sufficient enough to prevent
normal functioning
• Incidence 2-15%, more with end colostomies
• Early / late
• Early – d/t edema at the fascial and more superficial level
• Dilatation of this can be done using 36 Fr soft tipped Foley’s catheter
just proximal to fascial level, do not inflate balloon
• Late – scarring or tightness of mucocutaneous junction.
• May be due to peristomal sepsis, stomal retraction, ill fitting pouch.
• Mild – gentle routine dilatation, soft diet
• Significant stenosis – causing cramps followed by explosive output –
Surgical correction.

28. Stomal prolapse
• Telescoping of intestine out from the stoma
• Incidence 7-26%
• Highest with loop transverse colostomy and descending colostomies
• Difficulty in appliance placement, if prolonged intestinal edema if
significant enough – incarceration or strangulation
• Uncomplicated prolapse – conservative – cool compresses and
osmotic agents to reduce edema – honey followed by manual
reduction and application of binder.
• Complicated prolapse producing ischemic changes or severe mucosal
irritation and bleeding – surgical intervention
• Relocation may be ultimate measure needed.

29. High output stoma
• Definition - >1500ml/day
• Causes
• Adaptation phase
• Gastric acid hypersecretion
• SIBO
• Prestomal ileitis
• Revealed latent disease (celiac/pancreatic insufficiency/thyrotoxicosis)
• Infections including Cl.difficle
• Partial obstruction – parastomal hernias
• Short bowel syndrome
• Uncontrolled inflammation, sepsis, malnutrition.

30. Assessment
• Complications
• Dehydration
• Dyselectrolytemia
• Renal oxalate stones
• Psychological morbidity
• Death
• Assessment
• Examination of stoma
• Review op notes amount of bowel length remaining
• Small bowel radiology
• Ileostogram

31. Treatment
•NBM 48hours (on IV fluids) to assess baseline output
•Hyper caloric nutritional supplement
•Reduce oral hypotonic fluids to <500ml use ORS instead
•Reduce oral fluids and increase IV fluids
•Monitor electrolytes frequently including Mg
supplement Mg and vit. D

32. • Omeprazole – 80mg/d PO, if <50cm of jejunum left - IV
• Antibiotics trial for SIBO
• Megadose loperamide 16-40-100mg/d
• Additional codeine can be used up to 60mg 4X a day
• Octreotide may be used in cases of refractory high outputs upto 100mcg TID
• If baseline output >1500ml/d then consider long term IV fluids/TPN who are
nutritionally deprived with a central line
Guidelines for management of patients with a
short bowel, GUT 2006

33. Thank you
A well managed stoma
after procto-colectomy for UC.