types and management of intestinal stomas

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

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