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Stoma complications & its management
This document discusses complications that can occur with stomas. It defines stomas and provides the incidence of early and late complications. Early complications include skin irritation, stoma necrosis, bowel obstruction, ileostomy diarrhea, and mucocutaneous separation. Late complications include stoma stenosis, prolapse, parastomal hernia, and fistula. For each complication, the document discusses causes, clinical features, and management approaches. It provides details on evaluating and treating various early and late stoma complications.
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Stoma complications & its management
- 1. Stoma: Complications & Management DrHarsh Shah MS, FMAS, DNB, MCh (GI) Kaizen Hospital, Ahmedabad
- 2. Definition & Incidence Not uniformly defined Incidence 10-70% various series Lower in surgical series
- 3. Complications Early (<1 Month) Skin irritation Stoma Necrosis Bowel Obstruction Ileostomy diarrhea Muco-cutaneous Separation Stoma Retraction Late (> 1 month) Stoma stenosis Prolapse Parastomal Hernia Fistula Stomal Varices
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- 5. Skin Irritation/Rash Mostcommon complication More with ileostomies High risk Poorly sited stoma Non-nippled ileostomies Poorly fitting appliance High output stoma
- 6. Skin irritation/rash Peristomalrash with satellite lesions – Fungal infection Antifungal powder Peristomal rash conforms precisely to outline of appliance - Allergic reaction Reactivation of inflammatory bowel disease
- 7. Stoma necrosis 1to 5 % of patients undergoing ileostomy Gooszen AW et al. Dis Colon Rectum. 2000;43:650-655 Higher incidence with colostomy More commonly seen after emergency surgery and in obese patient Most often noticed within 24 hours postoperatively Leenan LP et al. Dis Colon Rectum. 1989;32;500-504
- 8. Stoma necrosis Causes Excesstension over mesentery Short mesentery Obesity Stripping of mesentery Avoid dividing sigmoidal arteries Progression of mesenteric ischemia
- 9. Stoma necrosis -examination Use transparent stoma bag Test tube test - to diagnose the level of necrosis Lubricated small test tube inserted into the stoma ↓ Flashlight shone along the sides of the test tube
- 10. Stoma necrosis -Management Necrosis above the level of fascia conservative management - often left alone Complications of limited necrosis Flushed / retracted / stenotic stoma Mucocutaneous separation Necrosis below the fascia immediate laparotomy and stomal reconstruction
- 11. Bowel obstruction Relativelycommon : incidence - 23% Causes Adhesions internal hernia Recurrent Crohn’s Stomal stenosis Intraluminal - impacted food bolus, just below fascial level
- 12. Bowel obstruction Clinicalfeatures- Cessation of stoma output ( may ↑ in partial obstruction) Crampy pain Vomiting Dehydration Management Resuscitation Fluid and electrolyte restoration Nasogastric suction Close observation
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- 14. Bowel obstruction Observedfor a period of 24 to 48 hours Patient comfortable with the nasogastric tube decompression Abdomen- soft and free of signs Early operation Pain persists despite nasogastric tube decompression and lavage Increasing pain / distension, leukocytosis ,fever
- 15. Bowel obstruction smallbowel obstruction in patients with stoma requiring re-operation inflammatory bowel disease colorectal neoplasms 2/3 of obstructions related to adhesions 1/3 related to the stoma Hughes ESR et al. Dis Colon Rectum 1979; 22:469–471
- 16. Mucocutaneous separation Causes Tension- skin opening too large for exteriorized bowel Malnutrition High dose steroids Good ET nursing important Packing of subcutaneous tissue with paste material / absorptive powder until a new junction forms secondarily Late consequence- stenosis at the skin level
- 17. Ileostomy Diarrhea Etiology Adaptation phase following resection Short bowel syndrome Malabsorption Antibiotics related Infectious Radiation enteritis
- 18. Ileostomy Diarrhea Management Electrolytes Hydration Apply drainage bag Antidiarrheal agents Loperamide Codeine Isapghul
- 19. Stoma Retraction Stomamay appear flush or below skin level May result in leakage Sore skin/skin excoriation Causes: Obesity/weight gain Early removal of stoma rod Stoma placement in skin fold Short mesentery for constructing the stoma
- 20. Stoma retraction Intermittent:Positional Upright position Stoma length and protrusion satisfactory Supine position , abdominal muscles relaxed stoma becomes flush with the skin or may recede below the skin level ↓ soiling and leakage ↓ difficulty maintaining satisfactory appliance seal
- 21. Stoma Retraction -Management Skilled ET nursing Convex faceplate placed firmly against the skin sometimes maintain a satisfactory seal Weight reduction Persistent leakage and soiling Revision ileostomy
- 22. Stoma retraction Ileostomy revision.(A) Circumferential incision around stoma. (B and C) Stoma is mobilized to fascia and peritoneum, and tip is resected. (D) Ileum is fixed to fascia. (E) New Brooke maturation is done.
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- 24. Stomal stenosis Narrowingat skin or fascial level ‘Ribbon stools’ – end colostomy Causes Ischemia Small opening in the skin or fascia Radiotherapy Crohn’s disease Reaction to suture material
- 25. Stomal stenosis Initialmanagement Gentle dilatation Low-fiber diet Stool softners for colostomy Recurrent obstructive episodes or pain Revision
- 26. Stomal stenosis Skin-levelstenosis detaching the skin from the mucosa excising a small amount of skin to increase the trephine size Malt et al- technique for relieving stricture at fascial level Malt RA et al. Surg Gynecol Obstet 1984; 159:175–76
- 27. Stomal stenosis Incisions aremade outside ostomy appliance Fascia is split with scissors to relieve stenosis
- 28. Prolapse Incidence :11% at 13 years Stoma increased in size & length Higher incidence with loop stomas esp. transverse loop colostomies Bleeds & easily traumatized
- 29. Prolapse Risk factors Obesity Poor muscle tone Larger trephine Raised intra-abdominal pressure Presentation Enlarged stoma Dislodgement of appliance Bowel obstruction Pain due to engorgement & constriction of prolapsed segment
- 30. Prolapse < 10%complicated by incarceration, strangulation Reduction of acute prolapse Supine position Apply sugar to reduce edema Reduce with gentle rocking motion Repair Resection muco-cutaneous disconnection, eversion of prolapsed segment, resection of exteriorized bowel, recreation of stoma
- 31. Parastomal Hernia Incisionalhernia related to abdominal wall stoma ‘There is already a hole there!’ Incidence 2-28 % - end ileostomy 4-48% - end colostomy
- 32. Parastomal Hernia “It doesn’tmatter if God Himself made your ostomy. If you have it long enough you have a 100% risk of a parastomal hernia.” J Byron Gathright
- 34. Parastomal hernia- types Trueparastomal hernia Subcutaneuous prolapse (pseudohernia) with intact fascial ring Intrastomal hernia Pseudohernia due to weakness of abdominal wall without fascial defect
- 35. PSH risk factors Patient Waist circumference over 100cm Smoking Age Malnutrition Technical aspects Rectus/oblique? Preop Siting Aperture size > 2-3 fingers (cm?) Emergent? Disease processes Obesity Diabetes IBD COPD Intraabdominal hypertension Postop Sepsis Perioperative steroid use Malignancy Ascites
- 36. SYMPTOMS Asymptomatic +++ Parastomal discomfort with intermittent obstructive episodes Stoma appliance issues with leak and skin irritation Obstruction/strangulation
- 37. Parastomal hernia Physicalexamination with a finger in stoma- often all that is necessary to diagnose and characterize Abdominal CT scan helpful in c/o difficulty ~ 30% require repair – pain, obstruction, difficulty in maintaining appliance Steele SR et al. Am J surg.2003;185:436-440
- 38. SURGICAL MANAGEMENT Localaponeurotic repair Open repair with mesh Laparoscopic repair Relocation of the stoma
- 39. SURGICAL MANAGEMENT LOCALREPAIR Aponeurotic repair-primary closure of the defect- recurrence 50-76% (up to 100%)
- 40. Different possible locations formesh placement in parastomal hernia repair
- 41. Surgical management Open meshrepair SUBLAY proposed as the most advantageous technique for mesh repair of PSH Low weight polypropelene meshes are used Have better resistance to infection than PTFE Placed away from bowel Recurrence rates from pooled studies 7-40%
- 42. Surgical management Laparoscopic surgery IPOM- Intraperitoneal Onlay Mesh ePTFE - most commonly used mesh 2 layers Inner non reactive layer for bowel contact Prone to infection
- 43. Surgical management Laparoscopic approach Technicaltips Fashion the mesh before insertion in the abdomen with a circular defect and a slit A good way to reduce recurrence may be to place 2 pieces of mesh one on top of the other
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- 48. Surgical management Laparoscopic approach Recurrence rates vary between : 4-44% Higher risk of bowel injury - 22% Higher risk of mesh infection (4%)
- 49. Laparoscopic IPOM vs Sugarbaker Muysoms,et. al. IPOM – recurrence 72.7% Sugarbaker – recurrence 14.2% Mancini, et al Retrospective review of 25 pts with Sugarbaker technique 1 recurrence at 30 months. (4%)
- 50. Surgical management Bioprosthetics Studiesare scant, low powered and have a short F/U Most advantages are extrapolated from the use of bioprosthetics in incisional hernias Most studies seem to show a low incidence of complications and an equivalent incidence of recurrence as synthetics Recurrence rates vary between 9-27% depending on the studies and the type of mesh used (human dermis vs porcine small bowel submucosa)
- 51. SURGICAL MANAGEMENT RELOCATION Riskof recurrence at least as high as the primary site Recurrence rates as high as 24-86% Higher if relocated on the same side The primary site should be treated as an incisional hernia and repaired with mesh placement-recurrence rate 26- 48%
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- 57. Fistula Serious problem Superficial fistula Stitch abscess, trauma, crohn’s disease (indicate recurrent disease) Heal spontaneously Major fistulas Below the skin level Reconstruction or resiting Todd IP et al. Clin Gastroenterol. 1982; 11:268–273 Fistula tract debrided with a pipe cleaner soaked in 6% aqueous phenol Greatorex RA. Br J Surg 1988; 75:543
- 58. Peristomal Varices Causes Primary Sclerosing cholangitis Alcoholic cirrhosis Incidence Upto 27% in those with hepatic dysfunction Strong SA. Semin Colorectal Surg.1994; 5:50–58.
- 59. Peristomal Varices Controlof bleeding Direct pressure Suture ligation Mucocutaneous disconnection Cauterization of stoma Transposition of the stoma Portosystemic shunts/TIPS Liver transplantation Mortality high; depends on severity of the underlying liver disease Roberts PL et al. Dis Colon Rectum 1990; 33:547–549
- 60. Stomal & Peristomal Granuloma Causes: Reaction to retained suture Cohn’s disease Sign of poor healing Management Silver nitrate application
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- 62. How are wegoing to get this through that ?
- 63. Skin Fascia 9 cm 9cm +2cm = 11cm of Sigmoid Colon 9cm + 6cm = 15cm of Terminal ileum BMI 48.7
- 64. Tips for success Avoid a Stoma if at all possible Excise all inflamed Sigmoid colon Segment used for stoma must be free of inflammation
- 65. Difficult End Colostomy Take down Left lateral peritoneal reflection
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- 67. Divide IMA/IMV ifnecessary Must have good pulse in marginal artery! Stay proximal to Left colic!
- 68. Windows Create windowsthrough the peritoneum of the left mesocolon Useful for providing extra length Be careful not to devascularize colostomy!
- 69. “Bigger Hole!” Expandfascial aperture or skin edges Remove subcutaneous tissues “Smaller Colon!” Remove excess fatty tissues – epiploic appendages Trim mesentery – leave 1 cm of mesentery on distal bowel to preserve marginal artery Decompress distended bowel
- 70. PseudoLoop Herbert, etal - maturation of antimesenteric border of colon No Brooking, often ends up skin level, or retracted Emergencies only, only when no other stoma will reach
- 71. Go North Inobese patients Supraumbilical placement of stomas is desirable Thinner abdominal wall above umbilicus Patients can see it !
- 76. Remember Preoperative planning, operativetechnique, 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’
- 77. Summary High incidenceof complications Early recognition & management is desirable Patient education & involvement of ET is essential
- 78. Summary PSH Very commoncondition Only a small proportion will require surgical therapy The high recurrence rates underline the fact that there is no perfect operation for this condition Promising results with laparoscopy and bioprosthetics Prophylactic mesh placement seems to be the way to go
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