acute stoma problems - acpgbi · –hernia. acute stoma problems early complications of a new stoma...
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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