Stoma complications & its management

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1. Stoma: Complications & Management Dr Harsh S hah MS, FMAS, DNB, MCh (GI) Kaizen Hospital , Ahmedabad

2. Definition & Incidence Not uniformly defined Incidence 10-70% various series Lower in surgical series

3. Complications Early (< 1 Month) Skin irritation Stoma Necrosis Bowel Obstruction Ileostomy diarrhea Muco -cutaneous Separation Stoma Retraction Late (> 1 month) Stoma stenosis Prolapse Parastomal Hernia Fistula Stomal Varices

4. Early Complications

5. Skin I rritation/Rash Most common complication More with ileostomies High risk Poorly sited stoma Non- nippled ileostomies Poorly fitting appliance High output stoma

6. Skin irritation/rash Peristomal rash with satellite lesions – Fungal infection Antifungal powder Peristomal rash conforms precisely to outline of appliance - Allergic reaction Reactivation of inflammatory bowel disease

7. Stoma necrosis 1 to 5 % of patients undergoing ileostomy Gooszen AW et al. Dis Colon Rectum. 2000;43:650-655 Higher incidence with colostomy More commonly seen after emergency surgery and in obese patient Most often noticed within 24 hours postoperatively Leenan LP et al. Dis Colon Rectum. 1989;32;500-504

8. Stoma necrosis Causes Excess tension over mesentery Short mesentery Obesity Stripping of mesentery Avoid dividing sigmoidal arteries Progression of mesenteric ischemia

9. Stoma necrosis - examination Use transparent stoma bag Test tube test - to diagnose the level of necrosis Lubricated small test tube inserted into the stoma ↓ Flashlight shone along the sides of the test tube

10. Stoma necrosis - Management Necrosis above the level of fascia conservative management - often left alone Complications of limited necrosis Flushed / retracted / stenotic stoma Mucocutaneous separation Necrosis below the fascia immediate laparotomy and stomal reconstruction

11. Bowel obstruction Relatively common : incidence - 23% Causes Adhesions internal hernia Recurrent Crohn’s Stomal stenosis Intraluminal - impacted food bolus, just below fascial level

12. Bowel obstruction Clinical features- Cessation of stoma output ( may ↑ in partial obstruction) Crampy pain Vomiting Dehydration Management Resuscitation Fluid and electrolyte restoration Nasogastric suction Close observation

13. Bowel obstruction

14. Bowel obstruction Observed for a period of 24 to 48 hours Patient comfortable with the nasogastric tube decompression Abdomen- soft and free of signs Early operation Pain persists despite nasogastric tube decompression and lavage Increasing pain / distension, leukocytosis ,fever

15. Bowel obstruction small bowel obstruction in patients with stoma requiring re-operation inflammatory bowel disease colorectal neoplasms 2/3 of obstructions related to adhesions 1/3 related to the stoma Hughes ESR et al. Dis Colon Rectum 1979; 22:469–471

16. Mucocutaneous separation Causes Tension- skin opening too large for exteriorized bowel Malnutrition High dose steroids Good ET nursing important Packing of subcutaneous tissue with paste material / absorptive powder until a new junction forms secondarily Late consequence- stenosis at the skin level

17. Ileostomy Diarrhea Etiology Adaptation phase following resection Short bowel syndrome Malabsorption Antibiotics related Infectious Radiation enteritis

18. Ileostomy Diarrhea Management Electrolytes Hydration Apply drainage bag Antidiarrheal agents Loperamide Codeine Isapghul

19. Stoma Retraction Stoma may appear flush or below skin level May result in leakage Sore skin/skin excoriation Causes: Obesity/weight gain Early removal of stoma rod Stoma placement in skin fold Short mesentery for constructing the stoma

20. Stoma retraction Intermittent: Positional Upright position Stoma length and protrusion satisfactory Supine position , abdominal muscles relaxed stoma becomes flush with the skin or may recede below the skin level ↓ soiling and leakage ↓ difficulty maintaining satisfactory appliance seal

21. Stoma R etraction - Management Skilled ET nursing Convex faceplate placed firmly against the skin sometimes maintain a satisfactory seal Weight reduction Persistent leakage and soiling Revision ileostomy

22. Stoma retraction Ileostomy revision. (A) Circumferential incision around stoma. (B and C) Stoma is mobilized to fascia and peritoneum, and tip is resected . (D) Ileum is fixed to fascia. (E) New Brooke maturation is done .

23. Late Complications

24. Stomal s tenosis Narrowing at skin or fascial level ‘Ribbon stools’ – end colostomy Causes Ischemia Small opening in the skin or fascia Radiotherapy Crohn’s disease Reaction to suture material

25. Stomal stenosis Initial management Gentle dilatation Low- fiber diet Stool softners for colostomy Recurrent obstructive episodes or pain Revision

26. Stomal stenosis Skin-level stenosis detaching the skin from the mucosa excising a small amount of skin to increase the trephine size Malt et al- technique for relieving stricture at fascial level Malt RA et al. Surg Gynecol Obstet 1984; 159:175–76

27. Stomal stenosis Incisions are made outside ostomy appliance Fascia is split with scissors to relieve stenosis

28. Prolapse Incidence : 11% at 13 years Stoma increased in size & length Higher incidence with loop stomas esp. transverse loop colostomies Bleeds & easily traumatized

29. Prolapse Risk factors Obesity Poor muscle tone Larger trephine Raised intra-abdominal pressure Presentation Enlarged stoma Dislodgement of appliance Bowel obstruction Pain due to engorgement & constriction of prolapsed segment

30. Prolapse < 10% complicated by incarceration, strangulation Reduction of acute prolapse Supine position Apply sugar to reduce edema Reduce with gentle rocking motion Repair Resection muco -cutaneous disconnection, eversion of prolapsed segment, resection of exteriorized bowel, recreation of stoma

31. Parastomal Hernia Incisional hernia related to abdominal wall stoma ‘There is already a hole there!’ Incidence 2-28 % - end ileostomy 4-48% - end colostomy

32. Parastomal Hernia “It doesn’t matter if God Himself made your ostomy . If you have it long enough you have a 100% risk of a parastomal hernia .” J Byron Gathright

33. Parastomal hernia- types True parastomal hernia Subcutaneuous prolapse ( pseudohernia ) with intact fascial ring Intrastomal hernia Pseudohernia due to weakness of abdominal wall without fascial defect

34. PSH risk factors Patient Waist circumference over 100cm Smoking Age Malnutrition Technical aspects Rectus/oblique? Preop Siting Aperture size > 2-3 fingers (cm?) Emergent? Disease processes Obesity Diabetes IBD COPD Intraabdominal hypertension Postop Sepsis Perioperative steroid use Malignancy Ascites

35. SYMPTOMS Asymptomatic +++ Parastomal discomfort with intermittent obstructive episodes Stoma appliance issues with leak and skin irritation Obstruction/strangulation

36. Parastomal hernia Physical examination with a finger in stoma- often all that is necessary to diagnose and characterize Abdominal CT scan helpful in c/o difficulty ~ 30% require repair – pain, obstruction, difficulty in maintaining appliance Steele SR et al. Am J surg.2003;185:436-440

37. SURGICAL MANAGEMENT Local aponeurotic repair Open repair with mesh Laparoscopic repair Relocation of the stoma

38. SURGICAL MANAGEMENT LOCAL REPAIR Aponeurotic repair-primary closure of the defect-recurrence 50-76% (up to 100%)

39. Different possible locations for mesh placement in parastomal hernia repair

40. Surgical management Open mesh repair SUBLAY proposed as the most advantageous technique for mesh repair of PSH Low weight polypropelene meshes are used Have better resistance to infection than PTFE Placed away from bowel Recurrence rates from pooled studies 7-40%

41. Surgical management Laparoscopic surgery IPOM - Intraperitoneal Onlay Mesh ePTFE - most commonly used mesh 2 layers Inner non reactive layer for bowel contact Prone to infection

42. Surgical management Laparoscopic approach Technical tips Fashion the mesh before insertion in the abdomen with a circular defect and a slit A good way to reduce recurrence may be to place 2 pieces of mesh one on top of the other

43. IPOM Technique

44. Sugarbaker technique

45. Sugarbaker technique

46. 5 cm

47. Surgical management Laparoscopic approach Recurrence rates vary between : 4-44% Higher risk of bowel injury - 22% Higher risk of mesh infection (4%)

48. Laparoscopic IPOM vs Sugarbaker Muysoms , et. al. IPOM – recurrence 72.7% Sugarbaker – recurrence 14.2% Mancini, et al Retrospective review of 25 pts with Sugarbaker technique 1 recurrence at 30 months. (4%)

49. Surgical management Bioprosthetics Studies are scant, low powered and have a short F/U Most advantages are extrapolated from the use of bioprosthetics in incisional hernias Most studies seem to show a low incidence of complications and an equivalent incidence of recurrence as synthetics R ecurrence rates vary between 9-27% depending on the studies and the type of mesh used (human dermis vs porcine small bowel submucosa)

50. SURGICAL MANAGEMENT RELOCATION Risk of recurrence at least as high as the primary site Recurrence rates as high as 24-86% Higher if relocated on the same side The primary site should be treated as an incisional hernia and repaired with mesh placement-recurrence rate 26-48%

51. Prevention of PSH

52. Stomal Reinforcement

53. Sublay

54. Intra peritoneal

55. Prevention

56. Fistula Serious problem Superficial fistula Stitch abscess, trauma, crohn’s disease (indicate recurrent disease) Heal spontaneously Major fistulas B elow the skin level R econstruction or resiting Todd IP et al. Clin Gastroenterol . 1982; 11:268–273 Fistula tract debrided with a pipe cleaner soaked in 6% aqueous phenol Greatorex RA. Br J Surg 1988; 75:543

57. Peristomal Varices Causes Primary Sclerosing cholangitis A lcoholic cirrhosis Incidence Upto 27% in those with hepatic dysfunction Strong SA. Semin Colorectal Surg.1994; 5:50–58.

58. Peristomal Varices Control of bleeding D irect pressure Suture ligation Mucocutaneous disconnection Cauterization of stoma Transposition of the stoma Portosystemic shunts/TIPS Liver transplantation Mortality high; depends on severity of the underlying liver disease Roberts PL et al. Dis Colon Rectum 1990; 33:547–549

59. Stomal & Peristomal Granuloma Causes: Reaction to retained suture Cohn’s disease Sign of poor healing Management Silver nitrate application

60. Difficult stoma !!

61. How are we going to get this through that ?

62. Skin Fascia 9 cm 9cm + 2cm = 11cm of Sigmoid Colon 9cm + 6cm = 15cm of Terminal ileum BMI 48.7

63. Tips for success Avoid a Stoma if at all possible Excise all inflamed Sigmoid colon Segment used for stoma must be free of inflammation

64. Difficult End Colostomy Take down Left lateral peritoneal reflection

65. Mobilize Splenic Flexure

66. Divide IMA/IMV if necessary Must have good pulse in marginal artery! Stay proximal to Left colic!

67. Windows Create windows through the peritoneum of the left mesocolon Useful for providing extra length Be careful not to devascularize colostomy!

68. “Bigger Hole!” Expand fascial aperture or skin edges Remove subcutaneous tissues “Smaller Colon!” Remove excess fatty tissues – epiploic appendages Trim mesentery – leave 1 cm of mesentery on distal bowel to preserve marginal artery Decompress distended bowel

69. PseudoLoop Herbert, et al - maturation of antimesenteric border of colon No Brooking, often ends up skin level, or retracted Emergencies only, only when no other stoma will reach

70. Go North In obese patients Supraumbilical placement of stomas is desirable Thinner abdominal wall above umbilicus Patients can see it !

71. Remember Preoperative planning, operative technique, postoperative education are of vital importance “An Ounce of prevention is worth a pound of cure” ‘Make every stoma as though it were going to be permanent’

72. Summary High incidence of complications Early recognition & management is desirable Patient education & involvement of ET is essential

73. Summary PSH Very common condition Only a small proportion will require surgical therapy The high recurrence rates underline the fact that there is no perfect operation for this condition Promising results with laparoscopy and bioprosthetics Prophylactic mesh placement seems to be the way to go

74. Life beyond stoma Thank You