Stoma managementShankar Zanwar

Definition

• Intestinal stomas are surgically created openings of small or large intestine onto the anterior abdominal wall

• TypesIntestinal

stoma

colostomy

ileostomy

Intestinal stoma

End stoma (single limb)

Loop stoma(afferent

and efferent limb)

Types

• Colostomies• End – Left iliac fossa• Loop

• Ileostomy• End – right iliac fossa• Loop• Continent – Kock’s pouch

Indications of ostomies

• Large bowel obstruction• Colonic stricture• Rectovaginal fistula• Fecal incontinence• Penetrating colonic injuries• Complex perianal fistulas• Necrotising enterocolitis• High risk of anastomotic leaks• Total procto-colectomy in in UC/FAP

Stoma site

• Flat area of skin – adequate of adhesion of appliance• Pt. should be able to see• To avoid – skin creases, previous scars, umbilicus, bony prominences,

at the belt line.• Site should be identified with patient lying, sitting and standing

• Usual sites • Ileostomies – right iliac fossa• Sigmoid colostomies – Left iliac fossa• Transverse colostomies – right/left upper quadrant

Basic principles of stoma surgeries

• Midline vertical incision• Adequate blood supply on either side(skin and bowel)• Without tension on mesentry or skin• Avoiding pre-existing infection site• Avoiding too small hole at fascial level• No twist

Conventional vs Brooke’s stomies

• Before Brooke, ileostomies were made by exteriorizing the intestine through the abdominal wall and suturing the serosa to skin

• Exposure of ileal serosa to alkaline stomal effluent resulted in serositis and ileostomy dysfunction

• Brooke introduced technique of eversion of the full thickness of the mucosa and suturing it to the adjacent dermis.

Pathophysiologic consequences after ileostomy• Colonic diversion – absorptive function of colon is lost• Normal colon absorbs – 1-1.5L of water and 100 mEq/L of sodium

and if need be it can increase to 5 liter.• Patients with ileostomy obligatory sodium loss is 30-40mEq/L• A well functioning ileostomies discharges – 500ml to 1.2L of fluid

daily• Consequently patients are in state of chronic oliguria• Also they have lower urinary Na/K+ • Changes in urinary composition – increase chances of urolithiasis –

calcium and urate crystals• Decreased vitamin B-12 absorption and bile acid reabsorption.

Routine care of ostomies

• Pouch placement – types• Closed end pouches – needs to be removed and replaced

with new pouch every time• Open end pouches – have reuseable end that can be opened

to drain the content of pouch

• Pouch emptying and care – odor and gas common concerns of patient

• Assure ostomy bags are odor proof• Empty the pouch when 1/3rd full prevent pouch seal

from excess weight• Changing the pouch 1-2/wk and sos• For foul odor if at all

• Chlorine tabs in bag 1-2 tabs• Bismuth sub gallate 200 – 400mg • Cholorophylline complex can be taken orally

Closed end pouch

Open end pouch

Protective skin barrier

• Diet – minimal modification needed, avoid unchewed nuts, fruits with skin, popcorns that can obstruct stoma

• If gas is bothering patient needs to be given list of gas producing diet, in short to avoid beans, cabbage, cauliflower, brussels, broccoli, asparagus.

• Low carb diet with less of potatoes, corn, noodles and wheat products.

• SOS use of simethicone can be done

• Adequate fluid intake – increase by 500ml -750ml even more during high output states like sweating

• Should be taught signs of dehydration and fluid electrolyte imbalance –dry mouth, decreased urine, marked fatigue, abdominal cramps.

• Physical activity – all usual activites can be performed without any restriction, bathing can be done with pouch on or off the stoma,.

• Most sports can be performed even with stoma in place except for extreme contact sports.

• Sexual activity – does not affect organic function, dysfunction if at all occurs is due to autonomic denervation after proctocolectomy

Complications of ostomies

• Over all complications rate of 14 to 79%

• Risk in life time• Colostomy – 25%• End –ileostomy – 57%• Loop ileostomy -75%

Arumugam PJ Colorectal Dis 2003

Complications

• Skin – excoriation, dermatitis, ulcerations• Ischemia• Obstruction • Retraction• Para- stomal hernia• Prolapse• Fistula• Stenosis• Bleeding• Perforation

• Timing of complications – early - are related to technical issues, defined to be occurring within 3 months

• Usually these are due suboptimal stoma site selection - necrosis, bleeds, retraction.

• Late – May be related to delayed healing – parastomal hernia, prolapse, stomal stenosis.

• Risk factors• Height of stoma <10mm• Co-morbid medical illness –

• obesity, Crohn’s, diabetes• Tobacco use• Obesity• Emergency surgery• Malnutrition• Advanced age• Malignancy• Use of steroids• InexperienceOrkin B: J of Reoperative Pelvic Surgery 2009

Dermatological complications

• Dermatitis : • More common with ileostomies – enzymatic nature of effluent, less with colostomies• Severely denuded skin along the inferior surface of the stoma• Protuberant spout ~2-3cm high is best method to minimize the contact of effluent to skin• Skin irritation may be also due to

• Allergic reaction to pouching products –pruritus, erythema and blisters • Mechanical trauma• Fungal infections - more during warm and humid climates• Antibiotic therapy related

Allergic contact dermatitis

Peristomal fungal infection

•Treatment • Correction of causative factors• Elimination of allergens• Denuded areas – use skin barriers• Antifungals – Nystatin/ miconazole• Topical steroids in case of severe allergic reaction

Peristomal pyoderma gangrenosum

• Usually seen with IBD• Selecting uninvolved segment best way to avoid• Seen also in patient with malignancy• Develops within weeks to years after stomaconstruction• Typically present as full thickness ulcer, pain and pathergy• Diagnosis by excluding other common possibilities(r/o infections also)• Bx. may increase the size of lesion• HPE – acute and chronic inflammation +/- granulomas

JAMA 2000

• Frequent misdiagnosis – stitch abscess, contact dermatitis, extension of Crohn’s

• Treatment –• Systemic, intralesional, and or topical anti-inflammatory drugs - Steroids

• When associated with Crohn’s or in other refractory cases, tacrolimus 0.1%topical solution daily till healing

• Severely refractory – Infliximab or other biologicals

• Minimize trauma since pathergy is prominent

Stomal necrosis• Incidence – immediate post op period 14%

AU Harris J of ARCES 2005

• Causative factors – inadequate – mobilization of bowel, preservation of blood supply to stoma

• Risk factors – emergency surgery, obesity, CD

• Early post-op – d/t venous congestion or arterial insufficiency – tight fascial opening, excessive mesentric stripping.

• Assessment - Inserting a lubricated test tube and using a torch to determine extent

• Alternatively using a sigmoidoscope

• Treatment

• If necrosis extends to proximal bowel below the anterior fascia – immediate revision

• If proximal - bowel viable, limited necrosis – superficial to ant. fascia – observation

• If sloughing occurs only gentle debridement

Stomal bleeding

• Major bleeding – uncommon

• Usually due to stomal laceration d/t poor fitting appliance or due to peristomal varices in UC with PSC.

• Initial management – • direct pressure• Local cauterisation – hand held cautery/ silver nitrate• Suturing of bleeding vessel if identified

• Peristomal varices – direct pressure, sclerotherapy or direct suturing

• Beta-blockers may help

• Recurrence are frequent in varices if so – TIPSSEur J Gastro –Hep 2006

Stomal retraction

• Defined as stoma that is 0.5cm or more belowthe skin surface within six months of construction,typically as result of tension on stoma.• Incidence 1-40% of all ostomies

Arumugam Colorectal dis 2005

• It causes – leakages and difficulty with pouch adherence – skin irritation• Proper ostomy height(>1cm) and minimising tension at stoma site

prevent retraction• Management – use of convex pouching system• If fails surgical correction

• If retracted mobile – non cutting linear stapling• If immobile - laparotomy

Mucocutnaeous separation

• Separation of ostomy and peristomal skin• Incidence 12 -24% • Leads to leakage and skin irritation • Prevention – meticulous skin approximation• Partial or circumferential• If circumferential stomal stenosis may occur as tissue heals• Circumferential separation – immediate surgical revision• Partial – fill absorptive material – calcium alginate, skin barrier

powder, hydrofiber• Covering area with appliance wafer protects the wound from effluent

– promotes healing.

Parastomal hernia

• Type of incisional hernia• Incidence from – 0-50%• Unsightly bulge at stoma site• Leakage around the stoma site• Skin rashes, non fitting appliances• Obstruction and strangulation • Surgical repair –

• local repair, - 100% recurrence• stoma relocation – 76% recurrence• Mesh repair – 10% recurrence

Janes, Arch Surg 2004

Stomal stenosis

• Narrowing of the stoma sufficient enough to prevent normal functioning• Incidence 2-15%, more with end colostomies• Early / late• Early – d/t edema at the fascial and more superficial level• Dilatation of this can be done using 36 Fr soft tipped Foley’s catheter

just proximal to fascial level, do not inflate balloon• Late – scarring or tightness of mucocutaneous junction.• May be due to peristomal sepsis, stomal retraction, ill fitting pouch.• Mild – gentle routine dilatation, soft diet• Significant stenosis – causing cramps followed by explosive output –

Surgical correction.

Stomal prolapse

• Telescoping of intestine out from the stoma • Incidence 7-26%• Highest with loop transverse colostomy and descending colostomies• Difficulty in appliance placement, if prolonged intestinal edema if

significant enough – incarceration or strangulation• Uncomplicated prolapse – conservative – cool compresses and

osmotic agents to reduce edema – honey followed by manual reduction and application of binder.

• Complicated prolapse producing ischemic changes or severe mucosal irritation and bleeding – surgical intervention

• Relocation may be ultimate measure needed.

High output stoma

• Definition - >1500ml/day• Causes

• Adaptation phase• Gastric acid hypersecretion• SIBO• Prestomal ileitis• Revealed latent disease (celiac/pancreatic insufficiency/thyrotoxicosis)• Infections including Cl.difficle• Partial obstruction – parastomal hernias• Short bowel syndrome• Uncontrolled inflammation, sepsis, malnutrition.

Assessment

• Complications• Dehydration• Dyselectrolytemia• Renal oxalate stones• Psychological morbidity• Death

• Assessment• Examination of stoma• Review op notes amount of bowel length remaining• Small bowel radiology• Ileostogram

Treatment• NBM 48hours (on IV fluids) to assess baseline output

• Hyper caloric nutritional supplement

• Reduce oral hypotonic fluids to <500ml use ORS instead

• Reduce oral fluids and increase IV fluids

• Monitor electrolytes frequently including Mg supplement Mg and vit. D

• Omeprazole – 80mg/d PO, if <50cm of jejunum left - IV

• Antibiotics trial for SIBO

• Megadose loperamide 16-40-100mg/d

• Additional codeine can be used up to 60mg 4X a day

• Octreotide may be used in cases of refractory high outputs upto 100mcg TID

• If baseline output >1500ml/d then consider long term IV fluids/TPN who are nutritionally deprived with a central line

Guidelines for management of patients with a short bowel, GUT 2006

Thank you

A well managed stoma after procto-colectomy for UC.