Early complications Stoma not working Ileus Small bowel obstruction Obstruction at abdominal wall Maturation of the wrongstoma (sigmoid and ileum) Retraction Stomal necrosis due to vascularcompromise Muco-cutaneous separation Retraction Later stomal stenosis andstricture Acute parastomal hernia withsigns of strangulation Working too much High output Leaking with peristomalskin irritation Poor siting Non nippled ileostomy Muco-cutaneousseparation Wound infection Peristomal abscess andfistula Necrotizing fascitis
Intermediate or late complications Stenosis Prolapse Parastomal herniation Peristomal varices in patients with portal hypertension
Overall Morbidity Widely varies 21-70% (most 30-50%) Observer dependent Stoma type plays a huge role Likely underestimated by most studies
Vascular compromise In obese individuals, exteriorizing an ileostomy with anadequate blood supply can be quite challenging. The thickened, foreshortened mesentery often does nothave enough length to reach the surface of thethickened abdominal wall easily, especially whenattempting to create a loop ileostomy. In these instances, an end-loop configuration mayallow the bowel to more easily reach the abdominalsurface
Vascular compromise When assessing the vascular integrity of a congestedstoma postoperatively, transillumination with aflashlight will demonstrate viability. A flashlightplaced in direct contact with a viable stoma will stilltransilluminate bright red, even in the face of venouscongestion. Failure to transilluminate the surface of the stoma ornonviable appearing mucosa beneath the surfacegenerally indicates that the stoma requires revision.
Vascular compromise If there is a question regarding viability below thestomal surface, a well-lubricated blood collection tubecan be carefully passed into the stoma, below thefascia if possible. When a light is shone into the tube,viable mucosa will have a healthy, bright-redappearance. Darker hues or frank infarction require revision if thecompromise extends below the skin level.Compromise below the fascia requires relaparotomy. Questionable stomas can also be evaluated with apediatric proctoscope or flexible endoscope
Retraction Retraction of a stoma in the immediate postsurgicalperiod is usually a result of tension on the bowel or itsmesentery due to inadequate mobilization. Also, in patients who are malnourished, obese, or oncorticosteroid therapy, the stoma may retract due topoor wound healing and gravity.
Retraction Mild distal stomal ischemia or stomal necrosis that ismanaged expectantly may eventually result inretraction with or without stenosis. Complete acute retraction with mucocutaneousseparation can result in subcutaneous or subfascialcontamination, peritonitis, and sepsis. In thiscase, immediate laparotomy and revision is advised.
Retraction More commonly, retraction is seen without completemucocutaneous separation. The most significant problem in this instance isobtaining a secure seal between the stoma applianceand the abdominal wall, leading to fecal leakage andsignificant peristomal skin irritation. The majority of these stomas with significantretraction eventually require revision.
Retraction The approach to a retracted stoma is similar to distalischemia. If the mucosa is viable and there is no undue tension,local revision can often be performed by detaching themucocutaneous junction, advancing the bowel andexcising devitalized tissue, and resecuring viablemucosa to the skin using Brooke-type sutures. If this is not technically feasible, laparotomy andcomplete revision is required.
PERISTOMAL SKIN IRRITATION In most instances, peristomal skin irritation is a directresult of (1) chemical dermatitis due to exposure to the stomaeffluent due to leakage, and (2) desquamation of peristomal skin resulting fromfrequent appliance changes. Often, appliance leakageand local skin irritation result in the need for morefrequent appliance changes, starting a vicious cycle.
PERISTOMAL SKIN IRRITATION Additionally, allergic reactions due to sensitivity toskin barriers, adhesives, and tapes are fairly common. Fungal irritation from Candida albicans colonizationof the peristomal skin also is commonly seen.Antifungal powders may help alleviate this.
PERISTOMAL INFECTION, ABSCESS, AND FISTULAFORMATION In the early postoperative period, parastomalinfections and abscesses are relatively uncommon,with a reported incidence of 2 to 14.8%. Peristomal abscesses in the immediate postoperativeperiod are most commonly seen in the setting of stomarevision or reconstruction of a stoma at the same site,mainly due to preoperative colonization of theperistomal skin and perioperative seeding of thesurgical site.
PERISTOMALINFECTION, ABSCESS, AND FISTULAFORMATION They may also be seen due to an infected hematoma oran infected suture granuloma. In a patient with Crohns disease, a peristomal fistulain conjunction with an ileostomy is almost invariablythe result of recurrent Crohns disease
Parastomal hernia (PSH) Definition Incisional hernia related to an abdominal wall stoma Varies in different studies Palpable defect or bulge adjacent to a stoma Cough impulse at ostomy site Radiologic definition-any intra-abdominal contentprotruding along an ostomy Sometimes confused with prolapse
PHS subtypes Subcutaneous-subcutaneous sac Interstitial-sac within the muscular oraponeuroticlayers of the abdomen Perstomal-the sac is circumferential enclosing thestoma Intrastomal-in ileostomies, sac between theintestinal wall and evertedintestinal layerNB there may be a diffuse type of hernia due to stretchand paralysis of abdominal muscles with the stoma onthe summit of this bulge.
INCIDENCE Believed to be between 30-50% 50% occur within 2 years Incidence with ileostomy (0.8-10%)Several studiesfailed to show any difference between ileostomies andcolostomies
Parastomal hernia Incidence is unknowndue to underreportingand difficult dx. Estimated to be between20-80% More frequent withcolostomy thanileostomy Cingi et al 23 patients Patient examination(PE) detected PSH in52% CT detected total of78%
Parastomal Hernia Early Presents with acutepain, mass, obstruction < 30 days from stoma Technical failure Too large of an aperturein fascia Late Inevitable? Presents with slowgrowing mass,abnormal contour oftissues around stoma Consequence ofincreasingintraabdominal tension “There’s already a holethere, Doctor.”R. Schwartz 2008
TECHNICAL CONSIDERATIONS INSTOMA FORMATION Extraperitoneal vs intrapertioneal(9% vs17%) Transrectal vs lateral to the rectus (3% vs22%) Size of the trephine: 2.5cm usually Todd and Celestine-2cm for ileostomies and 1.5cmfor colostomies with a later retraction of 0.5cm
SYMPTOMS Asymptomatic +++ Parastomal discomfort with intermittent obstructiveepisodes Stoma appliance issues with leak and skin irritation Obstruction/strangulation 10-20% have symptoms severe enough to requiresurgical repair
SURGICAL MANAGEMENT Local aponeurotic repair with or without mesh Relocation of the stoma Open repair with mesh Laparoscopic repair
Primary Repair Just sew the hole aroundthe stoma High recurrence ratehistorically 50-100% Add mesh? Still doesn’t work 50-88% recurrence
SURGICAL MANAGEMENT LOCAL REPAIR Aponeurotic repair-primary closure of the defect-recurrence 50-76% (up to 100%) Onlay mesh repair-involves applying a nonresorbable mesh on top of the primary repair andfixing it to the fascia-recurrence 9-10% (smallstudies without long follow up) Sublay mesh repair-the mesh is placed in theproperitoneal space after plication of the sac
SURGICAL MANAGEMENTDifferent possiblelocations for meshplacement inparastomal herniarepair
SURGICAL MANAGEMENT RELOCATION Risk of recurrence at least as high as the primarysite Recurrence rates as high as 24-86% Higher if relocated on the same side The primary site should be treated as anincisional hernia and repaired with meshplacement-recurrence rate 26-48%
Re-Siting of Stoma Traditional boards answer for symptomatic PSH Has expected high recurrence rate Baig et al. 4/27 recurrences at 56 months 3/16 with laparotomy 1/11 without laparotomy Historically has rates up to 50-68% (essentially thesame as hernia rate for each new stoma)
SURGICAL MANAGEMENT OPEN MESH REPAIR IPOM (Intraperitoneal Onlay Mesh) vs Sublay Keyhole technique vs Sugarbaker technique(bowel entering lateral to the mesh)
Surgical management OPEN MESH REPAIR- IPOM ePTFE-most commonly used 2 layers Inner non reactive layer for bowel contact Prone to infection Keyhole technique-risk of Button hole hernia withshrinkage and contamination Sugarbaker Technique-risk of erosion of the bowelwhere it passes under the mesh Recurrence 0-15%
Surgical management OPEN MESH REPAIR- SUBLAY Proposed as the most advantageoustechnique 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%
Surgical management LAPAROSCOPIC APPROACH Done in a way similar to open IPOM Keyhole technique or Sugarbaker technique Recurrence rates vary between4-44% Higher risk of bowel injury 22% Higher risk of mesh infection (4% in one study)
Surgical management LAPROSCOPIC APPROACH: TECHNICAL TIPS Fashion the mesh before insertion in the abdomenwith a circular defect and a slit If the mesh is cut in a linear fashion the slitwill enlarge with intraabdominal pressure A good way to reduce recurrence may be toplace 2 pieces of mesh one on top of theother
Laparoscopic techniques Lap vs Open McLemore – 49 pt with PSH Laparoscopic vs Open suture repair No significant difference in morbidity or short term outcomes Pastor – 25 pts 4/12 laparoscopic had recurrence 7/13 open had recurrence
Laparoscopic Keyhole vsSugarbakerMuysoms, et. al.Keyhole – recurrence 72.7%Sugarbaker – recurrence 14.2%Mancini, et alRetrospective review of 25 pts with Sugarbakertechnique1 recurrence at 30 months. (4%)
Surgical management BIOPROSTHETICS Studies reporting the use of bioprosthetics for treatment ofparastomal hernias are scant, low powered and have a shortF/U Most advantages are extrapolated from the use of bioprostheticsin incisional hernias Most studies seem to show a low incidence of complications andan equivalent incidence of recurrence as synthetics BIOPROSTHETICS Recurrence rates vary between 9-27%depending on the studies and the type of mesh used(human dermis vs porcine small bowel submucosa)
An ounce ofprevention is worth450 pounds of cure
Prevention of PSH Metaanalysis of 3randomized trials of meshvs no mesh 12.3% vs 54.7% No increased morbidity Serra-Aracil et al 5 year data Mesh - 14.8% hernia rate No mesh – 40.7% herniarate 5 prospective observationalstudies All show reduction inherniation rate, no changein morbidity Long term dataforthcoming Planned endcolostomies/ileostomies
Prevention Janeset al. randomized 54 patients to stomacreation with sublay mesh vs no mesh with amean F/U of 24 months 1 hernia occurred in the mesh group vs13 in thenon mesh group There was no complications Retrospective studies were also in favor of prophylacticmesh placement
Prevention CONCLUSION Placement of mesh at the primary operation issafe Reduces the occurrence of parastomal hernia Prophylactic meshes were also placed in contaminatedcases without infection More randomized studies needed
Conclusions Very common condition Only a small proportion will require surgicaltherapy The high recurrence rates underline the fact thatthere is no perfect operation for this condition Promising results with laparoscopy andbioprosthetics Prophylactic mesh placement seems to be theway to go
Obesity and Stoma Creation Increased depth of skin creases causes pouchingdifficulties, even in properly constructed, well locatedostomies Difficult to identify the rectus muscles preoperatively Obese patients cannot see their lower abdomen Thicker abdominal wall adipose tissue requiresincreased amount of length of mobilization
SkinFascia9 cm9cm + 2cm = 11cm of Sigmoid Colon9cm + 6cm = 15cm of Terminal ileumBMI48.7
Tips for success Avoid a Stoma if at allpossible Excise all inflamedSigmoid colon Segment used for stomamust be free ofinflammation
Difficult End Colostomy Take down Left lateralperitoneal reflectionfully Transect medialperitoneal attachmentsto left mesocolon.
Divide IMA/IMV if necessaryMust havegood pulsein marginalartery!Stayproximal toLeft colic!
Windows Create windows throughthe peritoneum of theleft mesocolon Useful for providingextra length Careful not todevascularize colostomy!
“Bigger Hole!” Expand fascial aperture or skin edges Remove subcutaneous tissues“Smaller Colon!”• Remove excess fatty tissues – epiploic appendages• Trim mesentery – leave 1 cm of mesentery on distalbowel to preserve marginal artery• Decompress distended bowel
PseudoLoop Herbert, et al -maturation ofantimesenteric border ofcolon No Brooking, often endsup skin level, orretracted Emergencies only, onlywhen no other stomawill reach
“Better to create an ugly stomain a good location than a prettystoma in an ugly location.”--Peter Cataldo
Thinner wall? Abdominal wall modification Lipectomy Meguid (1997) described technique of excision ofsubcutaneous fat to reduce abdominal wall thickness Leave convex contour to abdominal wall – can lead topouching issues Liposuction Margulies elucidated technique of peristomal suctionlipectomy for removal of excess fat during stomal revision
Thinner Wall? Flaps Good for Retraction and pyoderma/skin ulcerations inObese people. Functionally Better than Lipectomy because ofrestoration of flat abdominal wall, but have risk ofpotential flap necrosis Not described for initial placement of ostomy
Decrease the friction Stuff bowel into 1 inch Penrose drain and slidethrough trephine Sleeve of Sterile Glove (size 5 ½) Alexis wound retractor
Penrose Pass Mavroidis (1996) Passage of bowel intolarge penrose drain(1 inch) Passage of drain throughstoma aperture eased bybowel compression anddecreased “catchin’.” Difficult to pass bowelinto drain
Alexis Wound retractor method Described by Meagher, et al 2009 Stomal aperture created in usual fashion Small (2.5-6cm) Alexis inserted and wound retracted Colon passed through wound retractor Inner (green) ring divided and plastic sheath cut off Plastic slides out, Colon left in perfect position
(Anecdotal) Benefits “Noticeably” Smaller size of aperture Less tissue damage/bruising F/U < 14 months, but no retractions nor parastomalhernia Abdominal wall 7-8 cm
Go North In obese patients Supraumbilical placement of stomasis desirable Improved Pouching Decreased skin irritation Thinner abdominal wallabove umbilicus Patients can see it
Stoma Formation Is life altering forpatients Is not a benignprocedure Is associated with a highrate of early and latetechnical complications May require Operativeimagination
RememberPreoperative planning, operativetechnique, postoperative education are of vitalimportanceMake every stoma as though it were going to bepermanent
Park, et al. Cook County Retrospective analysis of 1616 pts (20 years) Data compiled by EST 553/1616 complications (448 early/105 late) Early complications (28%) Skin irritation 12% Pain/poor location 7% Partial necrosis 5%
Park, et al. Cook County Late complications (6%) Skin irritation 6% Prolapse 2% Stenosis 2% Parastomal hernia not mentioned Trauma/colorectal had lowest complication rate No difference in emergent vs elective
Park, et al. Cook County Highest complication rate loop ileostomy (74%) Lowest complication rate transverse end colostomy(5.8%)
Duchesne, et al -- LSU Case control study 204 patients in 3 years had ostomies created Records available for 164 Complications in 41/164 (25%)