Complications of stoma

1. Photo
Dr. Name
Present Designation : Professor of Surgery
Present Affiliation : Banaras Hindu University
Major Achievements :
Ex Governing Council Member ASI,
Past President of UP Chapter ASI
Past Vice President ACRSI
More than 350 publications
More than 100 Guest lectures
Awarded with >15 orations
Editor of 5 books
More than 70 chapters in various books.
Prof. Ajay K. Khanna

2. Complications of Stoma
and its management
Prof. Ajay Khanna
Department of Surgery
Banaras Hindu University

3. • A properly created stoma dramatically
improve a patient’s quality of life.
• Conversely, when a patient develops
complications related to their stoma, the
impact on physical and mental health can be
profound.

4. Incidence
• Rate of stoma-related complications range
from 20 to 70%.
– Stoma Formation
• Temporary
• Permanent
– Stoma Formation
• Elective
• Emergency

5. Factors associated with Complications
• Colostomy (Loop colostomy had highest
complication)
• Short stoma length,
• Body mass index > 30,
• Emergency surgery,
• Lack of preoperative marking

6. Complications
Early complications
(<30 days)
• Ischemia/ Necrosis
• Retraction/ Stenosis
• Mucocutaneous separation,
• Parastomal Irritation/Rash
abscess /Pyoderma
• Fluid and electrolyte
imbalance/ Ileostomy
diarrhea
• Bowel Obstruction
• Wrongly matured stoma
Late complications
• Prolapse,
• Retraction/Stenosis
• Parastomal hernia,
• Varices
• Fistula
• Granuloma

7. Stoma Necrosis
• Resulting from inadequate stomal blood
supply that can occur in up to 13% of stomas .
• Types :
– Venous
– Arterial
– Above Fascia
– Below Fascia Treatment :

8. Ischemia
Full thickness
necrosis
Above the
fascia : needs
early revision
Below the
fascia : urgent
reoperation
Superficial
Needs close
observation
To create a new stoma at a new site and/or resect the remaining bowel conduit

9. Stoma Retraction and Stenosis
• Stoma retraction from 1 to 30%, most
commonly associated with colostomies and
emergent operations.
• Rate of stenosis is from 1 to 9%

10. Reason for Stoma Retraction and
Stenosis
• Inadequate bowel mobilization, leading to
muco cutaneous tension and ischemia,
• Heavy bulky mesentery
• Obesity,
• malnourishment,
• Immuno suppression.

11. Prevention for Stoma Retraction and
Stenosis
• Ensuring adequate mobilization
• Adequate blood supply to the stoma conduit
• Creating an adequately sized fascial aperture
to facilitate delivery of the stoma to the skin

12. Mildly
symptomatic
case
• convex faceplate and a tight belt may be
used to control leakage around the
appliance
Significant
retraction
• operative revision
Complete
retraction
• Repair through laparotomy

13. Causes
Improper approximation of the
mucosa to the dermal layer
Steroid or
malnutrision
Infection
Exicceve bowel
tension

14. Muco Cutaneous seperation
• Minor : Observe
• Complete seperation : Local Revision

15. Skin Irritation/Rash
▶ Most common complication
▶ More with ileostomies
▶ High risk
▶ Poorly sited stoma
▶ Non-nippled ileostomies
▶ Poorly fitting appliance
▶ High output stoma

16. PERISTOMAL SKIN IRRITATION
• Chemical dermatitis due toexposure to
the stoma effluentdue to leakage
• Desquamation of peristomal skin resulting
from frequentappliance changes
• Reactivation of inflammatory bowel
Disease.

17. Skin irritation/rash
▶ Peristomal rash with satellite lesions – Fungal
infection
▶ Antifungal powder
▶ Peristomal rash conforms precisely to outline
of appliance - Allergic reaction
▶ Barrier dressings

18. Ileostomy Diarrhea
▶ Etiology
▶ Malabsorption
▶ Antibiotics related
▶ Infectious
▶ Short bowel syndrome
▶ Radiation enteritis

19. Ileostomy Diarrhea
▶ Management
▶ Electrolytes
▶ Hydration
▶ Apply good drainage bag
▶ Antidiarrheal agents
▶Loperamide
▶Codeine
▶Isapghul

20. Bowel obstruction
▶ Relatively common : incidence - 23%
▶ Causes
▶ Adhesions
▶ internal hernia
▶ ▶ Stomal stenosis
▶Intraluminal - impacted food bolus, just
below fascial level
Recurrent Crohn’s

21. Bowel obstruction
▶ Clinical features-
▶ Cessation of stoma output
▶ Crampy pain
▶ Vomiting
▶ Dehydration
▶ Management
▶ Resuscitation
▶ Fluid and electrolyte restoration
▶ Nasogastric suction
▶ Close observation

22. Bowel obstruction
▶ Observed for a period of 24 to 48 hours
▶ Patient comfortable with the nasogastric tube
decompression
▶ Abdomen- soft and free of signs
Digital evacuation of impacted bolus
▶ Early operation
▶Pain persists despite nasogastric tube decompression and
lavage
▶ Increasing pain / distension, leukocytosis ,fever

23. Stoma Prolapse
• full-thickness protrusion of bowel through a stoma
– 3% of ileostomies,
– 2% of colostomies,
– 1% of urostomies
• Types
– Sliding(if occurs intermittently with increased intra-
abdominal pressure)
– Fixed (if it is present constantly).
• Prolapse occurs more frequently with loop colostomies
than end colostomies and most frequently involves the
efferent (distal) limb

24. Risk factors for stoma prolapse
– advanced age,
– obesity,
– bowel obstruction
– lack of preoperative site marking

25. Prevention of Stomal Prolapse
• extraperitoneal tunneling,
• mesentery-abdominal wall fixation,
• limiting the size of the aperture

26. Symptomatology Stomal Prolapse
• Pain,
• Skin irritation,
• Difficulty with maintaining an appliance,
• Rarely obstruction, incarceration, and
strangulation.

27. Surgical options for stoma prolapse
• Reversal of a temporary stoma (when possible
and feasible)
• Resection,
• Revision
• Relocation.

28. Para stomal hernia

29. Incidence of Parastomal Hernia
• 1.8–28.3% for end ileostomies
• 0–6.2% for loop ileostomies,
• 4–48% for end colostomies and
• 0– 30.8% for loop colostomy
• Paracolostomy hernia develops in more than 50%
of patients followed for longer than 5 years.
• Most parastomal hernias occur in the first 2 years
but can occur up to 10 years after stoma creation.

30. Symptoms related to parastomal
hernias
• Peristomal discomfort,
• Bulge
• Difficulty in maintaining an
adequate appliance skin seal,
• Obstruction, and strangulation.

31. Risk factors for development of
parastomal hernia
• obesity,
• malnutrition,
• advanced age,
• collagen abnormalities,
• corticosteroid use,
• postoperative sepsis,
• abdominal distention,
• constipation,
• obstructive uropathy,
• chronic lung disease.
• Technical factors such as
poor site selection,
oversized fascial trephine
(>3cm),
• Excessive splitting and
stretching of muscle fibers,
• epigastric nerve
denervation,
• placing a stoma in an
incision,
• emergency stoma creation

32. Prevention of Parastomal Hernia
• extraperitoneal tunneling,
• stapled ostomy creation,
• stoma–fascia fixation,
• prophylactic mesh reinforcement
for permanent colostomies,

33. DIAGNOSIS

34. Indications for repair of a parastomal
hernia
Absolute
• Obstruction
• Incarceration with strangulation
Relative
• Prolapse
• Stenosis
• Intractable dermatitis
• Difficulty with appliance management
• Large size
• Cosmesis
• Pain

35. Treatment of parastomal hernia
• The ideal is to eliminate the stoma and restore
intestinal continuity.
• (1) local repair, Associated with high >75% Recurrence
• (2) stomal relocation, exposes the patient to the risk of
three new incisional hernias at the old stoma site, the
laparotomy incision site, and the new stoma site with
reported recurrence rates ranging from 24 to 86%
• (3) prosthetic repair. The risk of parastomal hernia
recurrence is reported to be 16.7% with a mesh
infection rate of 3%).

36. Prosthetic Repair
• Open /Laparoscopioc
• Placement of Mesh
– onlay, inlay, sublay, and
intraperitoneal onlay
mesh (IPOM) location.
– component separation
with retromuscular mesh

37. Stomal & Peristomal
Granuloma
Causes:
▶ Reaction to retained
suture
▶ Crohn’s disease
▶ Sign of poor healing
▶ Management
▶ Silver nitrate
application

38. Peristomal Varices
▶ Causes
▶ Primary Sclerosing
cholangitis
▶ Alcoholic cirrhosis
▶ Incidence
▶ Upto 27% in those with
hepatic dysfunction
;
5:50–58.

39. Control of bleeding in Peristomal
Varices
• ▶ Direct pressure
• ▶ Suture ligation
• ▶ Mucocutaneous disconnection
• ▶ Cauterization of stoma
• ▶ Transposition of the stoma
• ▶ Portosystemic shunts/TIPS
• ▶ Liver transplantation

40. Remember
• Preoperative planning, operative
technique, postoperative education are of
vital importance
• An Ounce of prevention is worth a pound
of cure.
• Make every stoma as though it were going
to be permanent’

41. THANK YOU