Types And Management Of Intestinal Stomas

TYPES AND MANAGEMENT OF INTESTINAL STOMAS

INTRODUCTION  

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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.

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Daily output is 500 – 800 ml.

DETERMINATION OF ILEOSTOMY LOCATION  

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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     

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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 

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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 

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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   

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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 

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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  

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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

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Odor and gas control – Meticulous personal hygiene Limit swallowed air Deodorants

Allergic reaction to appliance

Skin problems

Dehydration 

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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 

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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  

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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 

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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 

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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  

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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 

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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 

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Distal integrity confirmed with contrast study Anal sphincter function adequate Circumferential incision with minimal rim of skin Hand sutured or stapled transverse closure

Colostomy  

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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 

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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  

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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 

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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 

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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 

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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 

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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  

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Distal integrity Sphincter function – manometry / electromyography / ability to hold enema Closure done with sutured or stapled anastomosis

Colostomy irrigation 

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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

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History of regular bowel movements

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Ability to learn & perform procedure

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Willingness for time commitment

Contraindications for Colostomy irrigation 

Peristomal hernia or stomal prolapse

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Diseased proximal colon

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Multiple colon resections

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Chemotherapy or pelvic/abdominal radiotherapy

Colostomy complications 

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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  

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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

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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 

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Irregularity of function: IBS / radiotherapy Odor and gas problems Improper appliance seal Minimal peristomal bleeding from mucosa

Laparoscopic stoma creation  

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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 

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United ostomy association (UOA) formed in USA and Canada Ostomy association of India formed in 1975 in Mumbai International Ostomy Association: coordinates different associations First stoma clinic in India: TMH, Mumbai in 1978

Enterostomal Therapist 

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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 

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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.) 

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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.) 

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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 

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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.)  

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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 

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Adopted by UOA annual conference 1977 Contains the rights of any patient with ostomy

Gastrostomy 

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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 

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Thought to decrease the risk of aspiration Witzel Jejunostomy Stamm jejunostomy Needle catheter jejunostomy Laparoscopic jejunostomy Percutaneous endoscopic jejunostomy

Complications     

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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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