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INTESTINAL STOMAS

Techniques and Complications

Arif Kurnia Timur


October 10th, 2014

Classification of Stomas
GI (bowel diversion)

Incontinent
Permanent
Colostomy
End
Functional

urostomy (urinary
diversion)
continent
temporary
ileostomy
loop
mucus fistula

Types of Ostomy

Stoma types

Pre-operative management

Surgical technique
Consider stoma formation to be like an
anastomosis between bowel and skin
Healing depends on:
Good blood supply
No tension

End ileostomy

End colostomy

Surgical technique

Surgical technique

Surgical technique

Bowel Diversions
Incontinent types of diversions:
Colostomy-opening between the colon and the
abdominal wall.
Ascending colostomy:
semi-liquid stool consistency, increased fluid
requirements, needs appliance and skin barriers,
cannot be irrigated.
Indications for surgery: perforating diverticulitis in
lower colon, trauma, inoperable tumors of colon,
rectum or pelvis, rectovaginal fistula.

Colostomies
Transverse colostomy:
Semi-formed stool consistency, possibly increased
fluid requirement, uncommon bowel regulation,
requires appliance and skin barrier, cannot
irrigate.
Indications for surgery: Same as for ascending
colostomy. May also be performed in children
who are born with imperforate anus

Colostomies
Sigmoid colostomy-Formed stool consistency,
no change in fluid requirements, bowel
regulation possible with irrigations and/or diet;
need for appliances and barriers dependent on
regulation.
Indications for surgery: cancer of the rectum or
rectosigmoid area, perforating diverticulum,
trauma.

Ileostomy
Opening from the ileum or small intestine
through the abdominal wall. Bypasses the entire
large intestine. Stool is liquid to semiliquid
consistency and contains proteolytic enzymes,
Increased fluid requirement. No bowel regulation
or irrigation. Requires wearing an appliance and
skin barrier.
Indications for surgery:
ulcerative colitis,
Crohns disease, trauma, cancer, birth defect,
familial polyposis.

Surgical interventions
1. Loop colostomy
Bringing a loop of bowel to the surface where it is held in place by a
plastic or glass rod passed through the mesentery. Firm adhesion of
the colostomy takes place after 7 days then the bridge can be removed.

Loop stoma

2- Double Barrelled colostomy:


The colon is divided so that both ends can be brought separately to
the surface with a skin bridge intervening.
Advantage: ensures that the distal segment (colon, rectum) is
completely defunctioned (Absolute Rest).

3- Hartmanns Procedure:
This includes a Proximal End Colostomy with a distal closed colonic
segment. This procedure can be used when resecting a tumour of
the Lt. site of the colon or in Complicated diverticular disease.

Double-barrel stoma

End stoma with Hartmanns


pouch

End ostomy types

(A) End stoma (inset shows everting maturation); (B) double-barrel stoma:
End stoma and mucous hop-Koop stoma; and (F) fistula are divided and
brought through the same incision (inset shows closed mucus fistula sutured
to abdominal wall); (C) loop stoma; (D) decompressing blowhole stoma; (E)
Bis Santulli stoma

Continent fecal diversions


Ileoanal pull-through-The colon is removed
and ileum is anastomosed or connected to an
intact anal sphincter.
Ileoanal reservoir-Internal pouch created from
ileum. End of pouch sewn or anastomosed to
the anus. Surgery is done in several stages and
patient may have a temporary colostomy (6-12
weeks) until ileal pouch is healed.

Ileoanal reservoir

Kock Pouch
Internal pouch created from a segment of the ileum.
Part of the pouch is brought out low onto the abdomen
as the external stoma. A one-way nipple valve allows
fecal contents to drain when a catheter is intermittently
inserted in the stoma. No external collecting device is
required. Immediately after surgery, a drainage catheter
is left in place for 2-4 weeks. This catheter is irrigated
with 20 ml of NS every 3-4 hours. Patients are taught to
catheterize intermittently with 28fr. Catheter.

Laparoscopic options
Laparoscopic
colostomy / Ileostomy
3 ports usually, SILS
Operative time
usually ~ <1 hour

Lap Transverse Colostomy

Complications
20-41% of patients will have complications
Nearly 50% of these will require a revision
Early complications
Ischemia, hemorrhage, stenosis, fistula and retraction.

Late complications
6% -76% incidence
Prolapse, obstruction, hernia and skin irritation
Complication due to poor technique and poor care and
management.

Stoma Ischemia/Necrosis

2.3-17% incidence

Ranges from harmless mucosal


sloughing to frank Necrosis

Causes
Aggressive stripping of mesentery
Stenotic fascia defect
Extensive tension

Assess depth of necrosis

Necrosis beyond fascial defect


warrants immediate reconstruction

Consider End loop

Hemorrhage
Mild hemorrhage common and self limiting.
Usually mucosal.
Apply pressure

Active bleeding
Implies failure to ligate a mesenteric vessel

Stomal Stenosis/Stricture
2-14% incidence
Could manifest early or late
Ischemia is usual underlying
factor
Other causes: -Infection and
retraction
Crohns or recurrent
malignancy
Treat initially with dilation
Definitive Stoma revision

Mucocutaneous Separation
Separation along
mucocutaneous border
Occurs to some extent in many
patient

Caused by underlying tension


and or separation of sutures
Supportive care usually
resolve problem
Could lead to eventual
stricture, serositis or infection

Infection/Fistula
Incidence of 2-14.8%
Fistula may form from Abscess
Beyond immediate post op,
fistula formation or infection
could be signs of recurrent
Crohns disease

Stoma Retraction

1-6% for colostomy and 3-17% for


ileostomy

Most common reason for re-operation

Tension:

Tension
Obesity
Steroids use. Poor wound healing

Can lead to leakage and severe skin


problem, more in ileostomy

Convex stoma plate or use of


protective barrier helps

Most eventually need revision

Prolapse
2-26% incidence
Seen mostly in transverse loop
colostomy (30%)
May occur with parastomal
hernia
Managed by reduction and
supportive care until definitive
surgery
Convert to end colostomy if
need be

Ileostomy Prolapse

Parastomal Hernia

Predisposing factors

Stoma placement lateral to rectus


Large stoma aperture
Obesity
Prior abdominal incisions
Malnutrition
Wound infection

Symptomatic Repair with mesh,


Relocation

Acute Parastomal hernia/Bowel


obstruction
Incidence 4.6-13% in early post op
Causes
Technical
Too large fascial defect

Rarely seen in mature stomas

Signs of bowel obstruction


Repair hernia with mesh

Skin Complication

3-42% Incidence

Range from mild skin dermatitis to fullthicknes skin necrosis and ulceration

More common with illeostomy

Skin Erosion from constant exposure to


stoma effluent

Contact dermatitis

Fungal infection

Intervention

Contact Dermatitis

Better fitting appliance


Improve cleaning of peristomal skin
Application of desents and skin barriers
Anti fungals and antibiotics
Stoma paste

Effluent Irritation

Edema

Skin Complications

Candida albicans infection

Foliculitis

Skin Complication
(Pyoderma Gangrenosum)
First described
associated with Crohns
in 1970
Diagnosis mainly by
physical exam (80%)
Treatment conflicting
Wound debridement
Steroids injection
Systemic therapy

Skin Complications
(Pyoderma Gangrenosum)

Skin Complications
(Granulomas)
Granulomas are lumpy
lesions due to
inflammation in the
dermis.

Stomal granulomas may


be due to:
Granulation tissue (poor
wound healing and
infection)
Crohn's disease

Stoma warts

Stoma Appliances

Thank You