STOMA COMPLICATIONS

Ass. Pr. POP EMIL CEZAR

University of Medicine and Pharmacy 1st Surgical Department Emergency County Hospital Cluj 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 Stomal Evisceration (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 colostomas

Superficial 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: patients health state The used surgical technique Stoma siting Postoperative outcome

Late complications of colostomas

Types:

peristomal incisional hernia (II)

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)

 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).
Robert R Cima; Parastomal hernia ;Literature review 2011

Late complications of colostomas

stenosis
There 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 peritoneumperitonitis

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 hernia b. intrastomal hernia c. 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. 2. 3. 4. 5. 6. Suture leakage Anastomotic leak Infection of the wound Local abscess Bowel obstruction Stoma site herniation

loop ileostomy closure is safer than loop colostomy take down and loop ostomy closure is less risky than end 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. 2. 3. 4. 5. 6. Stoma placed through the rectus abdomini Stoma placed away from the bony prominences Stoma placed away from the ombilicus Stoma placed away from postoperative scars Stoma placed outside the cutaneous folds 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.
3.

Development of surgical skills

Instructional courses (continnous medical education) Education of patients in order to recognize stoma complications
*N. Hyman, -Marcel Dekker Inc. 2004

4.