The document discusses stomas, which are artificial openings in the colon or small intestine used to divert feces outside the abdomen. It describes two types of stomas - loop ileostomies, which are temporary and used to defunction a low rectal anastomosis, and end ileostomies, which can be permanent. It also discusses short bowel syndrome, defined as less than 200cm of residual small intestine in adults, and its causes and management through medical therapy including TPN, intestinal lengthening surgeries, and intestinal transplantation in severe cases.

1. STOMAS
Dr Rajeev Kumar Pandit
FCPS 1st Yr Surgery Resident
Manmohan Memorial Medical College
Swoyambhu, Nepal

2. • An artificial opening
made in the colon (or
small intestine) to divert
faeces and flatus out-
side the abdomen.
• May be
• Temporary
• Permanent

3. Loop ileostomy
• Used for defunctioning a low rectal anastomosis or an ileal pouch.
• A knuckle of ileum is exteriorised through a skin trephine in the right
iliac fossa.
• The advantages of a loop ileostomy over a loop colostomy
• The ease with which the bowel can be brought to the surface and the relative
absence of odour.
• Care is needed when the ileostomy is closed, so that suture line obstruction
does not occur.
• Closure of a loop ileostomy can be a technically challenging procedure,
particularly if there are dense adhesions resulting from previous surgery.

4. End ileostomy
• Formed after a subtotal colectomy without anastomosis, when it may later be
reversed, or may be permanent after a panproctocolectomy.
• The ileum is normally brought through the rectus abdominis muscle.
• Careful attention to the terminal ileal mesentery should be taken to ensure that it is
not too bulky.
• The use of a spout was originally described by Bryan Brooke; this should project some
2–4 cm from the skin surface
• A disposable appliance is placed over the ileostomy so that it is a snug fit at skin level.
• There may be an ‘ileostomy flux’ while the ileum adapts to the loss of the colon.
• While ileostomy output can amount to 4 or 5 litres per day, losses of 1–2 litres are
more common.
• A consistent ileostomy output in excess of 1.5 litres is usually associated with
dehydration and sodium depletion in the absence of intravenous therapy.
• Complications of an ileostomy include prolapse, retraction, stenosis, bleeding, fistula
and parastomal hernia.

5. Stoma bags and appliances
• Stoma output is collected in disposable adhesive bags.
• Ileostomy appliances tend to be drainable bags, which are left in
place for 48 hours,
• While colostomy appliances are simply changed two or three times
each day.
• A wide range of such bags is currently available.
• Many now incorporate an adhesive backing, which can be left in place
for several days.

7. SHORT BOWEL SYNDROME

8. • Arbitrarily defined as the presence of less than 200 cm of residual small
bowel in adult patients.
• A functional definition, in which insufficient intestinal absorptive capacity
results in the clinical manifestations of diarrhea, dehydration, and
malnutrition, is more broadly applicable
• In adults, the most common etiologies of short bowel syndrome are acute
mesenteric ischemia, malignancy, and Crohn’s disease.
• In pediatric patients, intestinal atresias, volvulus, and necrotizing
enterocolitis
• The ileum, with its tighter intercellular junctions and consequently better
fluid absorptive capacity, can assume the functions of a missing jejunum,
but not vice versa.
• The ileo-caecal valve used to be considered important with regard to
preservation of absorptive function.

9. Pathophysiology
• Resection of less than 50% of the small intestine is generally well tolerated.
• Clinically significant malabsorption occurs when greater than 50% to 80% of
the small intestine has been resected.
• Among adult patients who lack a functional colon, lifelong TPN dependence is
likely to persist if there is less than 100 cm of residual small intestine.
• Among adult patients who have an intact and functional colon, lifelong TPN
dependence is likely to persist if there is less than 60 cm of residual small
intestine.
• Among infants with short bowel syndrome, weaning from TPN dependence has
been achieved with as little as 10 cm of residual small intestine.
• Residual bowel length is not the only factor predictive of achieving
independence from TPN (enteral autonomy), however. Other determinants of
the severity of malabsorption include the presence or absence of an intact
colon, as indicated earlier.

10. Therapy
• Medical Therapy
• Repletion of fluid and electrolytes lost in the severe diarrhea
• TPN
• Enteral nutrition should be gradually introduced, once ileus has resolved
• High-dose histamine-2 receptor antagonists or proton pump inhibitors
should be administered to reduce gastric acid secretion.
• Antimotility agents, such as loperamide hydrochloride or diphenoxylate,
may be administered to delay small-intestinal transit.
• Octreotide can be administered to reduce the volume of GI secretions
• Liver failure is a significant source of morbidity and often leads to liver
transplantation

11. • Intestinal lengthening operation
• Longitudinal intestinal lengthening and tailoring (LILT) procedure
• Serial transverse enteroplasty procedure (STEP).
• Intestinal Transplantation
• Specific complications for which intestinal transplantation is indicated include
• (a) impending or overt liver failure,
• (b) thrombosis of major central veins,
• (c) frequent episodes of catheter-related sepsis, and
• (d) frequent episodes of severe dehydration

12. Serial transverse enteroplasty (STEP)
procedure

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