TYPES AND

MANAGEMENT OF
INTESTINAL STOMAS
INTRODUCTION
 Fecal and urinary diversion
 Intestinal stoma is opening of
intestinal tract on abdominal wall
 Temporary and permanent stomas
 Continent and incontinent stomas
 Enterostomal therapy for improving
quality of life of ostomate
INDICATIONS
 Permanent ileostomy –
Inflammatory bowel disease
Familial Adenomatous Polyposis
Multiple synchronous colorectal
cancers
INDICATIONS
 Temporary ileostomy -
Protecting a complicated anastomosis
Anastomotic leakage
Anastomosis in irradiated field /
peritonitis
Multiple distal anastomosis
Crohn’s Disease
Abdominal Trauma
Congenital Anomalies
INDICATIONS
 Colostomy –
Rectal cancer
Incontinence
Radiation proctopathy
Refractory anorectal infection
Ischemia
Crohn’s disease
Diverticular disease.
ILEOSTOMY
 An opening constructed between the
small intestine and the abdominal
wall, usually by using distal ileum,
but sometimes more proximal SI.

 Daily output is 500 – 800 ml.

DETERMINATION OF ILEOSTOMY
LOCATION
 Ostomy Triangle
 Avoid any deep folds of fat, scars,
and bony prominences
 Site examined in various postures
 Enterostomal Therapist visit for siting
 Stoma visible to patient
 Special care for pts with prostheses
 Left paramedian skin incision with
slanting to midline fascia
End Ileostomy
 Popularized by Brooke and Turnbull
 Usually done after total colectomy
 A protruding, everting stoma is made
 The ileum is brought out about 6 cm.
 Absorbable tripartite sutures are
placed
 Sutures through the skin avoided
Loop Ileostomy
 Constructed for both diversion and
decompression of the distal intestine
 Technique popularized by Turnbull
 Placing the orienting sutures
proximally and distally
 Some surgeons recommend orienting
the proximal functioning loop in the
inferior position
Loop Ileostomy
 In massively obese patients with a
shortened mesentery - conical
configuration of the opening in the
abdominal wall made.
 Loop opened by a four-fifths
circumferential incision at the distal
aspect allowing 1 cm of ileum above
the skin level
 The recessive limb is formed distally
Completely diverting Ileostomy
 Described by Abcarian and Prasad
 Ileum divided with linear stapler
 Proximal ileum constructed as end
ileostomy
 Recessive limb - one corner of the
staple line excised
 Ileum sutured to the dermis at
superior aspect of the stoma
Loop-End Ileostomy
 If there is tension on mesentry when
bowel brought to wall
 Thickened mesentry, very obese or
multiple previous surgeries
 Ileum transected with stapler and
closed end left closed
 Proximal loop ileostomy constructed
Continent Ileostomy
 Kock pouch
 Alternative to conventional ileostomy
after total colectomy
 Avoids permanent appliance application
 Indicated if pt has allergy to appliance
 Requires multiple intubations
 High complication rate in construction
 Contraindicated for Crohn’s disease
Complications
 Related to seal of appliance –
Leakage
Destruction of peristomal skin

 Odor and gas control –

Meticulous personal hygiene
Limit swallowed air
Deodorants
Allergic reaction to appliance
Skin problems
Dehydration
 Greatest risk in early post-operative
period
 More in hot weather and after
physical activity
 Adequate fluid and electrolyte intake
 Mild diarrhea – fiber supplements,
cholestyramine, H2 receptor blockers,
loperamide, opiates.
 Refractory cases – somatostatin,
parenteral hydration
Bowel obstruction
 Adhesive / volvulus / internal hernia
 Food Bolus Obstruction –
Intravenous fluid administration
Catheter irrigation of stoma – if food
particles return, continue irrigation
If clear return, water soluble contrast
study done
Stomal Prolapse
Stomal Prolapse
 Prolapse may be caused by increased
abdominal pressure
 Conservative management initially
 Persistent or recurrent prolapse
requires surgery
 Surgical emergency if associated with
ischemia
Stomal Retraction
Stomal Retraction
 To skin level or below
 Early (Thick wall, tension) or late (wt
gain, ascites, tumor growth)
 Difficult pouching situations – convex
pouches required
 May require surgical correction
Stomal necrosis
Ischemia
 Postoperative edema and venous
congestion – self limiting
 May occur due to tension on
mesentry or excessive division
 If ischemia extending below fascial
level – immediate laparotomy and
revision of stoma
Parastomal hernia
Parastomal hernia
 Herniation through the muscle defect
created by the stoma
 Typically reducible spontaneously
 Managed conservatively – hernia belt,
abdominal binders, adjusting pouch
 Pts with pain, obstruction or difficulty
maintaining appliance – surgery
 Direct repair/stoma relocation/mesh
repair
Peristomal Varices
 At mucocutaneous border of ostomy
 Anastomoses between portal system
and subcutaneous veins of abdomen
 Pts with liver disease (liver
mets/PSC)
 Typical purplish hue or caput
medusae in peristomal skin
 May cause life threatening h’ge
 Rx: Mucocutaneous
disconnection/definitive Mx of CLD
Stomal stenosis
Miscellaneous
 Stomal stenosis (ischemia, excessive
tension, retraction or IBD)
 Injury to stoma – painless
 Paraileostomy fistula – Crohn’s
 Urinary stones – reduced urinary pH
and volume (60% are uric acid stones)
Closure of loop ileostomy
 Distal integrity confirmed with
contrast study
 Anal sphincter function adequate
 Circumferential incision with minimal
rim of skin
 Hand sutured or stapled transverse
closure
Colostomy
 Most commonly done for rectal cancer
 Location:
sigmoid or descending – left lower
distal transverse – left upper
rest factors as in ileostomy
 Types by anatomy:
End Sigmoid
End Descending (if IMA transected)
Transverse colostomy
Cecostomy
 Left colonic stomas – solid, few motions
Decompressing Colostomy
 Constructed for distal obstructing
lesions without ischemic necrosis
 Act as bridge to definitive surgery
 Does not necessarily provide
complete fecal diversion – risk of
sepsis if distal perforation
 Blow Hole stoma / tube cecostomy /
loop transverse colostomy
Cecostomy and Blow Hole Stoma
 Obsolete procedure
 Severly acutely ill pts with massive
distension and impending perforation
 Small incision over most dilated part
 Other parts of colon can’t be evaluated
 Tube cecostomy – Malecot catheter
placed after taking purse string
 Tube gets blocked / drain poorly /
peridrain leak
Loop Transverse Colostomy
 Provides decompression and usually
diverts flow as well.
 Can serve as a long term stoma
 Can be constructed for pts with low
colorectal anastomosis
 Colon should be mobile enough &
brought to abdominal wall
 Dissected free of omentum
Loop Transverse Colostomy
 Fascia closed on either side of loop to
allow passage of one fingertip
 Loop incised transversely or
longitudinally
 Full thickness absorbable sutures
between skin and colon
Diverting Colostomy
 If distal segment completely resected
or suspected distal obs / perf or
destruction or anal sphincter dysfn.
 If proximal to obstructing lesion,
mucus fistula created
 Mucus fistula can be a separate
stoma or through same stoma
 End colostomy with closure of distal
bowel (Hartmann resection)
End Colostomy
 Left colon mobilized with or without splenic
flexure
 End of colon brought out; mesentry sutured to
lateral abdominal wall
 Full thickness absorbable sutures taken
between skin and colon
 Spigot configuration for IBD or radiated bowel
 If midline, mesentry fixation not required,
fascia to be closed around stoma
Closure of colostomy
 Distal integrity
 Sphincter function – manometry /
electromyography / ability to hold
enema
 Closure done with sutured or stapled
anastomosis
Colostomy irrigation
 Colostomy can be irrigated once a
day or alternate day
 600-1000 cc of lukewarm tap water
delivered by soft rubber cone
 Advantages: minimal appliance use,
reduced uncontrolled gas, comfort.
 Disadvantages: time consuming,
minimal risk of perforation.
Criteria for choosing Colostomy
irrigation
 Descending or Sigmoid colostomy

 History of regular bowel movements

 Ability to learn & perform procedure

 Willingness for time commitment

Contraindications for Colostomy
irrigation
 Peristomal hernia or stomal prolapse

 Diseased proximal colon

 Multiple colon resections

 Chemotherapy or pelvic/abdominal
radiotherapy
Colostomy complications
 Stomal Stricture:
usually due to ischemia
repaired by local (if at skin level) or
transabdominal approach (if deep)
 Colostomy necrosis:
Colostomy sensitive to changes in
perfusion
managed locally / laparotomy
Paracolostomy hernia
 Frequent complication of colostomy
 Asymptomatic hernias managed
conservatively
 Symptomatic repaired: high rates of
recurrence
 Mesh repair has relatively low
recurrence rate
 Laparoscopic repair with mesh
 Colostomy Prolapse:
Most often with transverse loop
colostomy
Best Rx: restore intestinal continuity
Convert loop to end colostomy with
mucus fistula
 Colostomy perforation:
Cause - irrigation / contrast study
Most require laparotomy &
reconstruction
Miscellaneous complications
 Irregularity of function: IBS /
radiotherapy
 Odor and gas problems
 Improper appliance seal
 Minimal peristomal bleeding from
mucosa
Laparoscopic stoma creation
 Reported first in early 1990s
 Both ileostomy and colostomy
creation done
 Allows evaluation of liver and
peritoneum in rectal cancer
 Laparoscopic approach also used for
stoma closure
Post operative stoma care
 United ostomy association (UOA)
formed in USA and Canada
 Ostomy association of India formed in
1975 in Mumbai
 International Ostomy Association: co-
ordinates different associations
 First stoma clinic in India: TMH,
Mumbai in 1978
Enterostomal Therapist
 Care to pts with stomas, fistulas,
draining wounds, incontinence
 Pre operative counseling & stoma site
selection
 Emotional support & discharge
planning
 Outpatient follow up
 Ongoing rehabilitation care
Stoma care
 Effective pouch management absolutely
necessary
 Protection of surrounding skin
 Rehabilitation of patient to be able to
perform all kind of activities
 Advice on nutrition, personal hygeine,
clothing, exercise, social gatherings,
possible complications & ostomy
associations.
Pouching Principles

One piece drainable pouches

Two piece drainable pouches
Closed pouches
Pre sized vs cut-to-fit
Pouching principles (contd.)
 Match pouching system to abdominal
contours and stoma
 Stomas in concave valleys or
retracted stomas require convexity
 Stomas in deep creases: all-flexible
pouching system
 Size the pouch opening: 0.25” larger
than stoma; 0.5” for skin level or
retracted stoma
Pouching principles (contd.)
 Use pectin based paste routinely in
presence of enzymatic drainage
 Apply pouch to clean, dry skin
 Teach to empty the pouch when one
third or half full to avoid tension
 Teach the patient to change the
appliance
Stoma Clinic
 To provide rehabilitation to patients
with ostomy, wound & incontinence
 Services provided:
 Preoperative counseling
 Stoma siting
 Post operative counseling
 Teaching pouching technique
 Irrigation procedure for colostomate
Services by Stoma clinic (contd.)
 Nutritional guidance
 Discussion of pregnancy, sex and
vocational needs of ostomates
 Mx of draining wounds, fistulas
 Mx of urinary/fecal incontinence
 Follow up care
 Inservice education
 Training programme in enterostomal
therapy
Ostomate Bill of Rights
 Adopted by UOA annual conference
1977
 Contains the rights of any patient
with ostomy
Gastrostomy
 Most desirable and commonly used
route for enteral nutrition
 Stomach provides a reservoir: cyclic
bolus feeding, acidification of
nutrients.
 Open Gastrostomy (Stamm method)
 Percutaneous Endoscopic
Gastrostomy (PEG)
 Laparoscopic Gastostomy
Jejunostomy
 Thought to decrease the risk of
aspiration
 Witzel Jejunostomy
 Stamm jejunostomy
 Needle catheter jejunostomy
 Laparoscopic jejunostomy
 Percutaneous endoscopic jejunostomy
Complications
 Mechanical: occlusion, tube displacement
 Aspiration pneumonia
 Dislodgement of tube
 Bowel obstruction
 Volvulus or internal herniation around tube
insertion site
 Hematoma, contained leak or abscess
 Wound infection
 THANK YOU