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Stoma management
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- 2. Definition • Intestinal stomasare 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 • Flatarea 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 ofstoma 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’sstomies • 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 ofostomies • 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 ofsimethicone 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 ofcomplications – 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 causativefactors •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 • Ifnecrosis 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 • Majorbleeding – 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 • Definedas 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 • Separationof 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 • Typeof 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 • Narrowingof 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 • Telescopingof 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 (onIV 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 wellmanaged stoma after procto-colectomy for UC.