Complications of stoma

Lecture on the various complications of stoma creation for medical student. Encompasses classification, pathophysiology and principles of management.

1. Complications of stoma Chea Chan Hooi General Surgeon Sibu Hospital

2. Up to 35% of patients with stoma suffer some form of stoma-associated complications Classified by timing Early (within a month) Late ( after a period of physiologic adjustment, arbitrarily taken as after 6 weeks)

3. Early Improper stoma site Ischaemia Retraction Peristomal skin irritation Peristomal infection/abscess Acute parastomal herniation with bowel obstruction High output

4. Improper stoma site More frequent change of bag and dressings Spillage, soiling Leads to difficulties in self-care and securing a stoma bag Increased cost and emotional stress Translocation with appropriate pre-operative marking – resection of stoma and creation of new stoma in fresh location with native virgin tissue

5. Ischaemia The most serious early complication Due to: Interrupted segmental arterial supply to exteriorised bowel Mesentery removed from bowel wall >5cm Tension on exteriorised bowel limb Too tight trephination How to assess clinically ? Flash light in direct contact with stoma will trans illuminate if viable Blood specimen tube inserted into lumen below fascia and light shone within shows healthy mucosa if viable Laparotomy for reassessment R evision (if short segment) Segmental bowel resection with reconstruction

6. Retraction Etiology Technical failure from tension on bowel limb Poor patient general condition – malnourished, obese, steroid therapy May lead to peristomal abscess, peritonitis Treatment options Local revision – detach the mucocutaneous junction, advance the bowel limb, excised all necrotic tissue and reanchor stoma Laparotomy & complete revision if unsuitable for local revision

7. Peristomal skin irritation Etiology Chemical dermatitis from contact with stoma effluent, esp. ileostomy Desquamated skin from frequent change of stoma bag Prevention Proper stoma siting and ensuring ileostomy well spouted Proper appliance of stoma bags to prevent leaks Treatment Excoriated skin dressed with semi-permeable dressings to protect from effluent Revision as the last resort

8. Peristomal infection/abscess Risk factors: Stoma revision or reconstruction at the previous stoma site Peristomal haematoma, granuloma Iatrogenic perforation of bowel limb Treatment options Incision and drainage, if possible outside the border of stoma bag wafer Translocation if persistent peristomal fistula

9. Acute parastomal herniation with bowel obstruction Technical failure due to too large fascial defect Keep in mind as bowel edema subsides, the dead space around bowel limb increases Treatment options Reoperation with reduction of hernia, resect non-viable bowel if present and tightening of fascial opening Mesh repair can be considered if no significant contamination with bowel content

10. High output Systemic derangements – dehydration, electrolyte & acid-base imbalance Treatment options Symptomatic correction Closure of stoma

11. Late Parastomal hernia Subcutaneous prolapse Prolapse Stricture Obstruction Peristomal varices Parastomal skin conditions Diversion colitis Psychological distress

12. Parastomal hernia The most common late complication Treatment options Local reduction/resection of hernia sac with repair of the muscular wall defect, with or without mesh Translocation

13. Subcutaneous prolapse AKA pseudoherniation Convoluted, capacious bowel encountered before fascial layer upon digital stomal examination Bowel moves directly outward and coil into extrafascial soft tissue (similar to a sliding hiatal hernia) without protrusion of a hernia sac

14. Prolapse Transverse loop stomas carry the highest risk Treatment options If stoma is for temporary purpose, expectant management until date for closure of stoma Resection of prolapsed segment, similar to Altemeier perineal proctectomy Linear stapler amputation of prolapsed segment

15. Stricture Predisposed by ischaemia , infection or retraction Treatment options Expectant management with dietary modification or/and cone catheter irrigation Endoscopic dilatation if at subcutaneous level Translocation

16. Obstruction Etiology : Adhesional obstruction Stricture/Stenosis Parastomal hernia Recurrent malignancy or Chron’s disease Internal herniation Food bolus obstruction Definitive management depends on identifying the likely cause of obstruction

17. Peristomal varices Patients with underlying portal hypertension   Typically a patient with IBD & primary sclerosing cholangitis with liver cirrhosis

18. Local modalities Pressure with adrenaline-soaked gauze Suture ligation Sclerotherapy Surgical procedures Mucocutaneous disconnection – incising mucoctaneous junction & continuing dissection along bowel wall down till fascia level Translocation Systemic therapy TIPS procedure Liver transplant

19. Parastomal skin conditions Peristomal dermatitis Irritation, inflammation & break down of skin around an ileostomy Allergic dermatitis Solvents , adhesives and dressings used in conjunction with stoma bag Candidal infection The most common infection S imilar appearance to contact dermatitis but with satellite papules & pustules Individualised treatment

20. Diversion colitis Occurs in retained colon distal to a diversion stoma Short-chain fatty acids (from bacterial breakdown of dietary carbohydrate) is diverted away and therefore causes inflammatory changes to diverted distal bowel Treatment options No treatment for asymptomatic patients If symptomatic: Short chain-fatty acid enema or suppository Closure/Reversal of stoma

21. Psychological distress

22. Thank you Q&A?