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
