Acute Stoma Problems

John Hartley

ACPGBI Course

Walsall, April 2016

Acute stoma problems

Introduction

• Stoma associated morbidity 30-50%

• Ileostomy > colostomy

• Emergency > elective

• Approx. 1/3 of those with complications require

eventual revision

Acute stoma problems

Definition

• Early complications of a new stoma

– Dysfunction/Obstruction

– Ischaemia

– Retraction

• Acute complications of an established stoma

– Retraction/Stenosis

– Prolapse

– Hernia

Acute stoma problems

Early complications of a new stoma• Anticipate and prevent

– Ensure appropriate marking

– Make an adequate trephine

– Avoid the inferior epigastric vessels

– Ensure correct orientation of stoma

– If a loop stoma ensure matured correctly

– ENSURE TENSION FREE

– IF SPLITTING A STOMA ENSURE THE BUSINESS

END IS MATURED

Stoma formation

Left iliac fossa end

colostomy

• Point of division with linear cutter– Where mobilised sigmoid

reaches pubis

• Mobilisation of splenic flexure usually not needed

• Draw colon through trephine until 1cm proud of skin

• Open and mature after wound closed

Stoma formation

Right iliac fossa end

ileostomy

• Preserve the marginal vessels in thin strip of mesentery

• Pull through trephine 5cm of ileum proud of skin

• Mesentery cephalad

• Suture divided mesenteric edge to peritoneum of abdominal wall

Difficulty raising a stoma

Use the upper abdomen

Difficulty raising a stoma

• Consider an end loop

stoma

or

• The Alexis wound

retractor

Difficulty raising a stoma

The last resort….

• Stoma through the wound

• Proximal loop stoma leaving blind end distal

• Mature the stoma before closing the

laparotomy

• Don’t leave theatre unless you’re sure

the stoma is viable

Acute complications – new stoma

Ileostomy dysfunction

• High output/variable output

– Extremely common

– Rule out intra-abominal sepsis, paradoxical

obstruction

• Supportive treatment with anti-diarrhoeals,

fluid and electrolyte replacement

Acute complications – new stoma

Ileostomy obstruction

• Prolonged ileus vs mechanical obstruction

– Watery high output

• Stomal injection or CT scan

• Intubation of stoma

• Supportive management if patient well

Acute complications – new stoma

Ileostomy obstruction

• Establish diagnosis before 7 to 10 day post op

• Following proctocolectomy beware potential

loss of small gut length

• Loop stoma – consider supportive treatment

until closure appropriate

Acute complications – new stoma

Ileostomy retraction

• Unusual

• Likely to be problematic

– Pouching

– Excoriation

• Consider early revision

• Timing important

• ASSESSMENT WITH

STOMA NURSE

Acute complications – new stoma

Ileostomy ischaemia

• True ischaemia unusual

• Usually requires revision

– Will result in sloughed, flush,

or retracted ileostomy

• Venous congestion – will

usually resolve

Acute complications – new stoma

Colostomy ischaemia

• Ischaemia at the

mucocutaneous junction

very common

• Particularly after emergency

surgery

• Dehiscence and retraction

follows

• Stenosis may result

Acute complications – new stoma

Colostomy

Ischaemia

• Assess the extent of

ischaemia

– If above sheath –

supportive

management

• Avoid local revision

Acute complications – established

stomaRetraction/stenosis

• Usually the end result

of early ischaemia (in

the absence of Crohn’s

etc)

• Consider dilatation

• Local revision usually

possible (beyond 8-10

weeks post op)

Acute complications – established

stomaStoma prolapse

• Particularly loop

colostomy (distal limb)

• Reassure or revise

• Amputate through local

approach

• If loop then split stoma

(mature correct end)

• Recurrence the norm

Acute complications – established

stomaParastomal hernia

• Acute presentation with

incarceration/obstructio

n/strangulation is

uncommon

• Laparotomy and stomal

transposition

• Be aggressive if post

proctocolectomy

Acute stoma problems

Conclusions

• Morbidity common

• Meticulous technique important

• Joint assessment with stoma therapy

• Early revision rarely necessary