STOMA COMPLICATIONS

Ass. Pr. POP EMIL CEZARUniversity of Medicine and Pharmacy

1st Surgical Department Emergency County HospitalCluj Napoca, Romania

An excellent operation finished with a bad stoma determines us to think to the masterpiece of a sculptor who after having finished his statue brakes its nose.

M. Sparberg

(reproduced by G. Guillemin)

STOMA COMPLICATIONS

Mrs White: ostomate 1740

Early complications of colostomas Hemorrhage

• Is the result of :– bleeding at the level of colic transection– incomplete hemostasis at the mesenteric level– incomplete hemostasis in the trephine

• Treatment: – hemostasis– hematoma drainage

Early complications of colostomas infarcted colostomy

• Ethiology:– arterial compromise– high tension in a barreled colostomy– insufficient diameter of the trephine

• Diagnosis– colour changement of the stoma

(black)– transillumination or small needle

pricks can be useful• Extension: limited or large• Treatment: stoma revision

Early complications of colostomas mucocutaneous separation

• Forms: – partial– total (sometimes stoma

slides in the peritoneal cavity)

• Treatment: – rematuration of the stoma– Stoma revision +

treatment of peritonitis

Stoma complications – StomalEvisceration (bowel, omentum)

• Causes: – insufficient maturation of

the stoma – too large diameter of the

trephine

• Treatment: – curing the evisceration– stoma revision

Early complications of colostomas

Occlusion• Causes:

– stenosis of the trephine (lack of aponeurotic opening)

– twisting of the colon– colon volvulation around

the barrel

• Treatment:– recalibration of the

trephine – avolvulation of the colon

Early complications of colostomas

Occlusion of the small bowel

• Causes : – sliding of the small bowel in an

unstiched coloparietal space

• Treatment: 1.Reoperation

2.Treatment of the small bowel according to its state

3.Closure of the coloparietal space

Early complications of colostomasSuperficial peristomal

fistula. Deep peristomal fistula

1. Superficial peristomal fistula– Causes: mucocutaneous

maturation of the stoma by colon transected stiches

– Treatment: division of the maturation stiches

2. Deep peristomal fistula– Causes: aponeurotic

maturation of the stoma by colic transected stiches

Late complications of colostomas

stomal prolapse (I)

• A well known complication

• Frequency : about 2% (less than ileostomas)

• Occurs both on end stomas and on loop stomas

• Bad siting of stoma can determine the prolapse

Late complications of colostomas

stomal prolapse (II)

• Varieties: mucous or total– Cylindrical (in end stomas)– T-shaped (in loop stomas)

• Causes and risk factors: technical failure, abdominal pressure, nervous tone

• Features: – excessive protrusion and pouching difficulties– Bad functioning of stoma

• Treatment: Stoma revision ± resection of the colon

Late complications of colostomas

peristomal incisional hernia (I)

• It is an incisional hernia at the level of the trephine

• It has a variable frequency• Predisposing factors:

– patient’s health state – The used surgical technique

– Stoma siting – Postoperative outcome

Late complications of colostomas

peristomal incisional hernia (II)

• Types: – True parastomal incisional hernia– Pseudohernia (subcutaneous prolapse of the

bowel)

• Treatment: – Local repair– Mesh repair– Stoma resiting

• Preffered technique: – extrafascial mesh repair– *Laparoscopic approach

Late complications of colostomas

peristomal incisional hernia(III)

Robert R Cima; Parastomal hernia; Literature review 2011

• We suggest that most patients with a parastomal hernia be managed with nonsurgical conservative management, such as using an ostomy hernia belt (Grade 2C).

• We recommend that patients with signs and symptoms of ischemic bowel undergo an urgent or emergent

surgical repair. (Grade 1C).

Robert R Cima; Parastomal hernia ;Literature review 2011

• We suggest using prosthetic mesh for the repair of the PSH (Grade 2B). The mesh can be inserted laparoscopically or via a laparotomy.

• We suggest that the repair be performed laparoscopically in patients with a hernia less than 8 to 12 centimeters and when there is no pre-operative evidence of extensive intra-abdominal adhesions (Grade 2C). In patients not meeting these criteria, we suggest that the repair be performed via laparotomy. (Grade 2C).

Late complications of colostomas

stenosisThere are two types:

– Folded– Parietal

Causes: – Mucocutaneous junction

fibrosis– Too small trephine

Treatment: – Scared tissue excision

and folded plasty– Stoma resiting

Late complications of colostomas

late bleeding

Causes: – Trauma during pouch changing– Accidents– Caput medusae parastomal variceal bleeding

Treatment: – Surgical hemostasis or

if necessary– Endoscopical hemostasis

Late complications of colostomas

perforation

• Forms:– In the intratrephine segment →

abscess– In the peritoneum→peritonitis

• Causes: – Trauma during irrigation– Perforated diverticulum

• Treatment: – Drainage of the abscess– Stoma revision in intraperitoneal

perforation

Early complications of ileostomas

necrosis

• Causes: – Insufficient irrigation of

the ileon– High tension between

the ileon and the barrel– Too small trephine

• Treatment: ileostoma revision

Early complications of ileostomas

retraction

• Occurs more frequently in loop ileostomies

• Is the result of high tension  due to inadequate mobilization of the mesentery when the stoma is created

• Determines pouching problems

• Induces skin lesions

Early complications of ileostomas

stenosis

• Causes: – small trephine– rotation of the bowel– adhesions– edema of the spout (transient)

• Treatment: – enlargement of the trephine– stoma revision

Late complications of ileostomas

prolapse

Forms:     – Cylindrical (in end stomas)– T-shaped (in loop stomas)

* sliding ileostomy

* incomplete fecal diversion

• Treatment: – Stoma revision– Sugar application in order to

reduce prolapse* *Brandt A.R.M.L.-N. Engl.J.Med. 2011

Late complications of ileostomas

incisional hernia

Types: a. true parastomal herniab. intrastomal herniac. subcutaneous prolapse

• Treatment: • Local repair• Mesh repair• Stoma resiting

Complications of ileostomas

unusual situations

Adenocarcinoma in an ileostomy

Disease reccurence on the stoma

Dysfunctions:– Diarrhea– Bacterial overgrowth– High output of Na, K and nitrogen– Steatorrhea – Cholelitiasis (malabsorbtion or depletion of  bile

acids)– Gastric hypersecretion

Complications of stapled gastrostomy bleeding

• Occurs on the stapling lines

• Is controlled with sutures in open surgery

• Needs application of clips or coagulation in laparoscopic surgery

Complications of stapled gastrostomy:

stenosis of the gastric tube

• Cause: insufficient diameter

of the gastric tube

• Evolution: possible ischemia of the gastric tube

• Treatment: stoma revision

Complications of cecostomy

• Peristomal inflammation (common complication)

• Reflux around the tube• Leakage around the tube• Failure of spontaneous closure

→operative closure of the stoma– the inserted tube must not

exceed 30 F when a good maturation is desired

– replacement of the tube will be done with a smaller one

Complications of stoma take down

1. Suture leakage2. Anastomotic leak3. Infection of the wound4. Local abscess5. Bowel obstruction6. Stoma site herniation

“loop ileostomy closure is safer than loop colostomytake down and loop ostomy closure is less risky thanend stoma take down”*

            *Shellito P.C.-Dis Colon Rectum 1998

Complications related to bad stoma siting

• Parastomal incisional hernia

• Stomal prolapse

• Stoma located in a cutaneous fold

• Stoma not visualized by the patient

Rools to be respected in stoma siting:

1. Stoma placed through the rectus abdomini

2. Stoma placed away from the bony prominences

3. Stoma placed away from the ombilicus

4. Stoma placed away from postoperative scars

5. Stoma placed outside the cutaneous folds

6. Stoma placed in a site where the patient can do its examination

Conditions of peristomal skin*

• Skin irritation (chemical and inflammatory)

• Allergic contact dermatitis

• Trauma

• Folliculitis

*Mahmoud &Bradley –Marcel Dekker 2004

Conditions of peristomal skin (II)*

• Dermatoses:– pyoderma gangrenosum– peristomal bullous pemphigus– epidermal hyperplasia– psoriasis– hidradenitis suppurativa– lichen sclerosis

• Candidiasis• Peristomal cellulitis

            *Mahmoud &Bradley –Marcel Dekker 2004

How to mannage the problem

“Many stomal complications can be prevented by careful technique and

attention to detail”*

1. Improvement of knowledge concerning stoma surgery and stoma care

2. Development of surgical skills

3. Instructional courses (continnous medical education)

4. Education of patients in order to recognize stoma complications

*N. Hyman, -Marcel Dekker Inc. 2004