Colostomy complications

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Colostomy complications

  1. 1. By:     Abdulelah  Alhawsawi,  MD,  FRCSC,  DABS  
  2. 2. Outline   —  Surgical  Considera0ons:   1.  Timing.   2.  Outcome  Measures.   3.  Colostomy  Vs.  Ileostomy.   4.  Loop  Vs.  End.   —  Stoma  Complica0ons.  
  3. 3. Surgical  Considera2on  (Timing)  
  4. 4. Surgical  Considera2on  (Timing)   — Preopera0ve  :    -­‐  Elec0ve:  e.g.  Pelvic  Exentera0on    -­‐  Emergency:  Trauma.   — Intraopera0ve:    -­‐  Colonic  and  /  or  Rectal  Injury  
  5. 5. Surgical  Considera2on  (Timing)   — Preopera0ve  :    -­‐  Counseling  of  pa0ents.      -­‐  Stoma  Therapist  Evalua0on.   — Intraopera0ve:    -­‐  Should  be  An#cpated  and  Men#oned  in  Consent!    
  6. 6. Surgical  Considera2on  (Si2ng)  
  7. 7. Surgical  Considera2on  (Si2ng)  
  8. 8.   Surgical  Considera2on     (Colostomy  vs.  Ileostomy)    
  9. 9. Surgical  Considera2ons   (Outcome  Measures)     —  Construc0on  Measures:    -­‐  necrosis,  prolapse,  retrac0on,  parastomal  hernia,  stenosis,   sepsis,  hemorrhage   —  Func0on  Measures:   -­‐  skin  irrita0ons,  occlusion.   —  Closure  Measures:           -­‐  occlusion,  wound  infec0on,  anastomo0c  leak  or  fistula,   hernia    
  10. 10. Surgical  Considera2on     (Colostomy  vs.  Ileostomy)  
  11. 11. Surgical  Considera2on   (Colostomy  vs.  Ileostomy)   Colostomy   Ileostomy  
  12. 12. Surgical  Considera2on   (Colostomy  vs.  Ileostomy)       Author   Year   N  (Pts)   Conclusion   Duchesne  et  al   2002     164     No  Significant  Difference     Robertson  et  al   Prospec#ve   2005   408   No  Significant  Difference   Colostomy:  Odor!   Ileostomy:    Leakage!   Leenen  et  al   1989   266   345(Stomas)   No  Significant  Difference.  Subset  Analysis:   Colostomy:  More  Hernia  (19%)   Ileostomy:  High  Output  &  Local  Irrita2on.       Duchesne  et  al   Prospec#ve   2003   97   No  Significant  Difference   Park  et  al   1999   1616   Complica2ons  Rate:   -­‐  Loop  Ileostomy:  75%   -­‐  End  T.  Colostomy:  6%   Makela  et  al   2006   119   Ileostomies  have  a  lower  overall  complica2on  rate,  but  leakage   was  seen  more  frequently  with  ileostomies  than   colostomies.  
  13. 13. Surgical  Considera2on     (Loop  vs.  End)  
  14. 14. Surgical  Considera2on     (Loop  vs.  End)   Loop  Stoma  
  15. 15. Surgical  Considera2on     (Loop  vs.  End)   End  Stoma  
  16. 16. Surgical  Considera2on     (Loop  vs.  End)   —  Loop:  Technically  easier  (Forma0on  &  Closure),   temporary!   —  End:  Permanent!,  easier  to  exteriorize  (more  length!).    
  17. 17. Surgical  Considera2on     (Loop  vs.  End)       Author   Year   N  (Pts)   Conclusion   Harriset  al   2005     345     loop  colostomy  had  the  highest  complica2on  rate  and  end   ileostomy  had  the  lowest     Caricato  et  al   2007   132   The  stoma  with  the  lowest  complica2on  rate  was  end   colostomy.    
  18. 18.   Fecal  Diversion   (Loop  vs.  End)  
  19. 19. Fecal  Diversion   (Loop  vs.  End)   —  Large  meta-­‐analysis  :  12  compara0ve  studies  and  1529   pa0ents.   —  Conclusion:  pa0ents  with  a  loop  ileostomy  had  a  lower   risk  of  prolapse  and  sepsis  but  an  increased  risk  of   occlusion  aXer  stoma  closure  and  dehydra0on.         Rondelli F, et al. Loop ileostomy versus loop colostomy for fecal diversion after colorectal or coloanal anastomosis: a meta-analysis. Int J Colorectal Dis 2009;24 (5):479–88
  20. 20. Fecal  Diversion   (Loop  vs.  End)   —  Prospec0ve  randomized  clinical  trial.   —  Fecal  diversion  aXer  rectal  resec0on.     —  Study:  36  pa0ents  with  loop  transverse  colostomy  Vs.  34   pa0ents  with  loop  ileostomy       Edwards DP, et al. Stoma-related complications are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial. Br J Surg 2001;88(3):360–3.
  21. 21. Fecal  Diversion   (Loop  vs.  End)   —  Conclusion:     -­‐  No  difference  in  difficulty  of  forma0on  or  closure     -­‐  No  difference  in  postopera0ve  recovery.   -­‐    10  complica0ons  in  the  loop  colostomy  group  (1  fecal   fistula,  2  prolapse,  2  parastomal  hernia,  5  incisional   hernias)  and  no  complica0on  in  the  loop  ileostomy  group.   —  Authors  supported  loop  ileostomy  for  defunc0oning  a   low  anastomosis.      Edwards DP, et al. Stoma-related complications are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial. Br J Surg 2001;88(3):360–3.
  22. 22.     Stoma  Complica2ons  
  23. 23. Normal  Stoma!  
  24. 24. What  is  this?  
  25. 25. Parastomal  Hernia   —  Incidence:   -­‐  Incidence  up  to  48  %  in  some  series.   -­‐  More  with  End  Stomas  Vs.  Loop  Stomas     -­‐  More  with  Colostomies  Vs.  Ileostomies.   —   Risk  Factors:   -­‐  Matura0on  Not  Through  Rectus  Muscle.!   -­‐  Size  of  Fascial  opening.   -­‐  General:  Obesity,  COPD,  DM,  Age  
  26. 26. Parastomal  Hernia   —  Treatment:   1.  Non-­‐opera0ve.     2.  Primary  Repair.   3.  Stoma  Reloca0on.   4.  Mesh  Repair.   —  Suture  repair  has  been  shown  to  be  inferior  to  mesh   repair  or  stoma  reloca0on  in  terms  of  recurrence.    
  27. 27. Parastomal  Hernia   —  Treatment  (Cont):   —  Laparoscopic  parastomal  hernia  repair  is  safe  and  feasible   (No  Long  Term  Data  Yet!)   —  Biologic  graXs  (less  infec0on,  Expense!)   —  prophylac0c  mesh  placement  seems  to  decrease   subsequent  parastomal  hernia0on  without  increasing   periopera0ve  morbidity.    
  28. 28. What  is  this?  
  29. 29. Prolapse   —  *Incidence:   -­‐  Ileostomies:  3%   -­‐  Colostomies:  2%   -­‐  Urostomies:  1%   —  More  with  Loop  Stomas  Vs.  End  Stomas     —  More  with  Distal  End  Vs.  Proximal  End.       *Based  on  the  United  Ostomy  Associa#on  Registry  in  1991.    
  30. 30. Prolapse   Risk  Factors:   -­‐  Size  of  Fascial  opening.   -­‐  General:  Obesity,  COPD,  DM,  Age   -­‐  Failure  to  fix  the  mesentery.        
  31. 31. Prolapse   —  Treatment:   1.  Conserva0ve:  Sugar   2.  Resec0on.   3.  Revision.   4.  Reloca0on  
  32. 32. Prolapse   —  Conclusions   —  Stoma  prolapse  is  not  uncommon  after  colostomy  or   ileostomy  creation,  with  rates  up   —  to  42%  reported  for  loop  colostomies.  Although   typically  asymptomatic,  obstruction,   —  difficulty  with  appliance  fitting,  and  ischemia  can   occur.  Multiple  surgical  options  for   —  repair  are  available,  most  of  which  can  be   accomplished  locally.  Stoma  closure  should   —  always  be  considered.  
  33. 33. High  Ostomy  Output   Normal  Physiology  
  34. 34. High  Ostomy  Output   —  Defini#on:   -­‐  A  daily  stoma  output  greater  than  2  L  (or  the  amount  that   leads  to  dehydra0on).   —  High  output  is  commonly  encountered  aXer  jejunostomy   or  ileostomy  crea0on     —  can  be  either  transient,  such  as  in  the  early  postopera0ve   period,  or  chronic.     —  Excessive  stoma  losses  can  lead  to  dehydra0on,   electrolyte  abnormali0es,  vitamin  deficiencies.  
  35. 35. High  Ostomy  Output   —  Causes:   1.  extensive  small  bowel  resec0on.   2.  intrinsic  bowel  diseases  such  as  Crohn  disease.   3.  par0al  small  bowel  obstruc0on.   4.  bacterial  overgrowth.   5.  Others:  radia0on  enteri0s,  infec0ous  enteri0s,   abrupt  withdrawal  of  medica0ons,  such  as  steroids  and     opioids.  
  36. 36. High  Ostomy  Output   —  Metabolic  Effects:   1.  Electrolyte  Disturbance.   2.  Dehydra0on.   3.  Fat  Malabsorp0on.   4.  Vitamin  Deficiency:  B12,  A,  D,  E,  K.   5.  Renal  Stones.    
  37. 37. High  Ostomy  Output   —  Treatment:   1.  Intravenous  Support.   2.  Oral  Intake  Restric0on:   3.  An0darrheal.     4.  An0secretory.    
  38. 38. High  Ostomy  Output   —  and  malnutrition.  The  management  of  patients  with   high  ostomy  output  depends  on   —  a  combination  of  oral  and  intravenous  fluid  and   electrolyte  replacement,  vitamin   —  supplementation,  and  hypotonic  fluid  intake   restriction,  along  with  antidiarrheal  and   —  antisecretory  medications.  
  39. 39. What s  this?  
  40. 40. Skin  Irrita2on   —  *Incidence:   -­‐  Ranges  from  3%  to  42%     —  the  degree  of  irritation  ranges  from  mild  dermatitis  to   full-­‐thickness  skin  necrosis  and  ulceration   —  More  with  Ileostomies  than  Colostomies.     *Kann  BR.  Early  stomal  complica#ons.  Clin  Colon  Rectal  Surg  2008;21(1):23–30.    
  41. 41. Skin  Irrita2on     —  Causes:   1.  an  ill-­‐fiing  appliance  that  results  in  leakage  and   ul0mately  a  chemical  derma00s.     2.  frequent  appliance  changes.   3.  Higher  BMI  (mul0variate  analysis).   4.  DM  (mul0variate  analysis).   5.  Stoma  Contents  (ileostomies!  Liquid  &  Bile  Acids)  
  42. 42. Skin  Irrita2on     —  Preven#on:   1.  Preopera0ve  stoma  site   marking     2.  Enterostomal  Therapist.   3.  Healthy  surrounding   skin.   4.  Good  Stoma  Appliance!  
  43. 43. —  Conclusion   —  Peristomal  skin  irritation  is  a  common  complication   of  stoma  creation,  more  so  with   —  ileostomies  than  colostomies.  Precise  stoma   construction  and  meticulous  stoma   —  and  skin  care  are  key  to  prevention  and  treatment  of   this  troublesome  problem.  Local   —  treatment  is  often  successful.  
  44. 44.   STRICTURE/STENOSIS     —  Stoma  stricture  can  occur  at  the  level  of  the  skin  or  the   fascia.     —  It  is  a  rela0vely  rare  complica0on,  being  found  in  only  1%   to  10%  of  stomas.   —  Causes:   1.  Ischemia.   2.  Mechanical/  Technical.  
  45. 45.   STRICTURE/STENOSIS    —  Treatment:   1.  one  must  rule  out  recurrent  disease  (Crohn  disease,   malignancy)   2.  Dila0on:  Hegar  dilators.   3.  Stoma  Revision.  
  46. 46. Retrac2on   —  Many  series  have  shown  stoma  retrac0on  to   —  occur  in  1%  to  6%  of  all  colostomies  3%  to  17%  of  all   ileostomies.  
  47. 47. Retrac2on   —  Preven#on:   Sufficient  length  of  the  bowel  is  needed  to  prevent  tension   and  retrac0on.   —  Treatment:   -­‐The  use  of  a  convex  stoma  appliance  may  result  in   decreased  leakage.   -­‐Stoma  revision.    
  48. 48. Summary   —  Pre-­‐opera0ve  Planning  is  Key!   —  Parastomal  Hernia  is  common.     —  Use  of  mesh  repair  for  parastomal  hernia  is  superior.   —  Stoma  Prolapse  leads  to  difficul0es  with:  Stoma   appliance,  Obstruc0on,  and  Ischemia.   —  High  Stoma  Output  can  lead  to  dehydra0on,  electrolyte   abnormali0es,  vitamin  deficiencies.   —  Loop  ileostomy  is  a  beker  choice  than  loop  colostomy  for   temporary  fecal  diversion,   —  End  stomas  func0on  beker  than  loop  stomas.  

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