summary of stomal complications from Sabiston text book of surgery

1. Surgical complication
Stomal complication

2. Causes
 Several causative factors are associated with stomal complications.
 Technical factors are most important in minimizing the complication rate
of stoma construction and are largely preventable.
 Stomal complications are numerous and range from a bothersome
problem with fit of the stomal appliance to major skin erosion and
bleeding.
 Complications that occur within 30 days after surgery are considered
early complications.

3. Presentation and Diagnosis
 Ischemic necrosis results from impaired perfusion to the terminal portion
of the bowel as a result of a tight aperture, overzealous trimming of
mesentery, or mesenteric tension.
 Stomal retraction occurs early as a result of tension on the bowel or
ischemic necrosis of the stoma. Late retraction is caused by increased
thickness of the abdominal wall with weight gain.

4. Presentation and Diagnosis
 Stenosis occurs as a result of:
 a small aperture, so-called natural
maturation,
 ischemia,
 recurrence of Crohn’s disease, or
 development of carcinoma.
• Mucocutaneous separation develops
as a result of:
• ischemia,
• inadequate approximation of mucosa
to the dermal layer of skin,
• excessive bowel tension, or
• peristomal infection.

5. Presentation and Diagnosis
 Stomal prolapse is most alarming to the patient and can result in
incomplete diversion of stool, interfere with the stoma appliance, lead to
leakage of stool, or become associated with obstructive symptoms and
incarceration.
 Parastomal hernia formation occurs to some degree in most patients
 A peristomal fistula is often a sign of Crohn’s disease, may result from a
deep suture used to mature the stoma, or may be caused by trauma from
an appliance.

6. Presentation and Diagnosis
 Chemical dermatitis is caused by contact of the stoma effluent with
peristomal skin as a result of a large opening in the faceplate or leakage
from an ill-fitted faceplate. Chemical dermatitis is initially manifested as
erythema, ulceration (ileostomy effluent), encrustation (urostomy
effluent), or pseudoepitheliomatous hyperplasia
 Infectious dermatitis may be caused by fungus, bacteria, tinea corporis, or
C. albicans

7.  Allergic dermatitis may be related to any of the stomal equipment (e.g.,
faceplate, tape, belt), with skin manifestations appearing at the site of
contact.
Presentation and Diagnosis

8. Presentation and Diagnosis
 Patients with a stoma are at risk for diarrhea and dehydration. The risk for
dehydration depends on the type of stoma, the underlying primary
disease process, and any concomitant bowel resection.
 Dehydration commonly occurs in older patients, in hot weather, during
strenuous exercise, and in association with short bowel syndrome.

10. treatment
 Application of the technical points
presented in Box 12-13 ensures
the construction of a healthy and
well-positioned stoma in patients
undergoing surgery.

11. treatment
In emergencies and difficult cases (e.g., obese patients, patients with distended
bowel, and patients with shortened mesentery), to ensure delivery of a viable stoma
free of tension:
 the fascial aperture may be made larger,
 the bowel may have to be extensively mobilized,
 the ileocolic artery and inferior mesenteric artery may have to be divided at their
origin,
 windows may need to be created in the mesentery,
 the stoma may be brought out at a site with less subcutaneous fat (e.g., above the
umbilicus).

12. treatment
 After construction of a stoma, a dusky appearance indicates some degree
of ischemia.
 The ischemia may be mucosal or full thickness, and the extent and depth
of ischemia dictate the need for immediate revision of the stoma.
 Viability of the stoma is checked with a test tube and a flashlight or
endoscopy. Necrosis extending to and beyond the fascia requires
immediate reoperation. Ischemia limited to a few millimeters is observed
and may not result in any long-term sequelae.

13. treatment
 Repair of stomal retraction often requires laparotomy.
 Skin-level stenosis can be repaired locally, and stenoses from other causes
can be repaired via laparotomy
 Complete separation or detachment usually requires revision.

14. treatment
 Local repair of end stomal prolapse can be achieved with a
circumferential incision at the mucocutaneous junction, excision of
redundant bowel, and rematuration.
 Repair of loop stomal prolapse is achieved by local revision to an end
stoma.
 Laparotomy may be required for the treatment of recurrent prolapse and
prolapse associated with a parastomal hernia.

15. treatment
 Large permanent or complicated parastomal hernias are treated by
relocating the stoma or reinforcing the fascia ring with mesh (synthetic or
biomaterial).
 Treatment of a peristomal fistula entails resection of the diseased or
involved segment of bowel and relocation of the stoma.

16. treatment
 Treatment of chemical dermatitis entails cleaning the damaged skin, use
of barriers, and a properly fitting stomal management system.
 Candida dermatitis is best treated with nystatin powder.
 Allergic dermatitis is treated by removal of the offending item;
symptomatic relief is produced by oral antihistamine or topical or oral
steroid therapy