Types of enterostomy and its indications and complications.pptx

Ii

1. INTRODUCTION A stoma is an artificial opening made in the bowel to divert f aeces and flatus outside the abdomen, where they can be collected in an external appliance . Permanent or temporary fecal diversion is necessary for the surgical management of a wide variety of colorectal conditions. Intestinal stomas carry significant social implications, and the prospect of having one commonly engenders very strong reactions from patients and their families. for many patients, having an intestinal stoma can dramatically improve quality of life and allow them to regain control over their lives.

2. The main technical principles for optimal stoma construction include proper stoma siting on the abdominal wall, adequate mobilization of the bowel, preservation of blood supply, and eversion of the bowel wall during stoma maturation. The important nontechnical considerations include providing education and support for patients with stomas, and knowing how to manage stoma-related complications.

3. Enterostomal Therapists The surgeon’s greatest ally in the work of taking care of patients a nurse specializing in the care of stomas. Patients should undergo preoperative counseling by both their surgeon and an ET. better quality of life for patients with new stomas, measured by less self-consciousness and fearfulness, improved facility with stoma care, less pain, and better sleep. In addition to support and education, ETS are also trained to mark appropriate stoma sites.

4. Stoma Site Marking Patients who undergo preoperative marking for stomas are more likely to be able to independently care for their stomas, have more predictable pouching with regard to length of time and leaks, and resume normal life after surgery. The optimal site for an intestinal stoma is within the rectus abdominis muscle, free of creases, and visible to the patient. The most commonly chosen stoma site is in the outer third of the rectus muscle, at the summit of the infraumbilical fat pad. Ileostomy sites are usually in the right lower quadrant, and colostomy sites are usually in the left lower quadrant.

5. . FIGURE- Placement of ileostomy . FIGURE -Placement of colostomy

6. Figure -Four commonly used stoma sites.

7. However, obesity, prior scars, or other patient-related factors will often necessitate stoma placement in other locations. Except in cases involving the sickest of patients, surgeons should be able to mark at least one optimal site before emergent operations. If the patient is able to sit up, then the surgeon can ensure the absence of creases through the planned site and that the patient will be able to see and manage the stoma. FIGURE -Creases, scars, and obesity affect the optimal placement of stomas.

8. KEY CONSIDERATIONS FOR CHOOSING AN OPTIMAL STOMA SITE 1. The stoma should be located in the outer third of the rectus abdominus muscle. 2. Physical characteristics of the torso: a protuberant abdomen or large pannus, abdominal folds, scars, location of the costal margin and iliac crest, pendulous breasts, and hernias. 3. Patient characteristics: mobility (wheelchair-bound), posture (kyphosis), dexterity, vision. 4. Patient preference for location, based on belt line and other individual factors. 5. Surgical considerations: type of stoma (loop vs end), segment of intestine to be used for the stoma, continent vs incontinent, need for both fecal and urinary stomas.

9. Bowel Preparation Mechanical bowel preparation and nonabsorbable oral antibiotics are recommended prior to elective colorectal operations, as they are associated with lower rates of surgical site infections, anastomotic leak, ileus, and readmission. The original Nichols and Condon oral antibiotic regimen from the 1970s of neomycin and erythromycin base can still be used, or metronidazole can be used in place of erythromycin base. Mechanical bowel prep in the absence of oral antibiotics is not recommended. Mechanical bowel prep and oral antibiotics may not be necessary in all types of colorectal operations; this regimen was not shown to decrease complications in patients undergoing total colectomy, and should not be used in patients with ileostomies.

10. Ostomy Appliances The ideal pouching system will provide a receptacle to catch the effluent, protect the surrounding skin, and allow for easy emptying and replacement and predictable timing of the need for replacement. Multiple products are available. The appliance will generally consist of a skin barrier (sometimes called a wafer), a pouch, and a closure device. The appliance can come with the pouch and skin barrier connected as a one-piece appliance or separately as a two-piece system.

11. One-piece appliances tend be lower profile. Two-piece appliances allow for the pouch to be changed without changing the skin barrier. Most appliances are disposable and are made to last 3 to 7 days. Reusable appliances also have to be changed every 3 to 7 days and require the extra maintenance to wash and reuse them.

12. COLOSTOMY

13. It can be, Diversion Colostomy- It is done when there is breach in bowel wall, trauma, Crohn’s, carcinoma rectosigmoid. 2. Decompression Colostomy- It is done for obstructive lesions in rectosigmoid, toxic megacolon. Types- Blow Hole, Tube caecostomy , loop transverese colostomy 3. Irrigation colostomy- It avoids need for appiliance wear, reduces the passage of uncontrolled gas with less leak of stools. But it is time consuming with chance of water intoxication due to excess water absorption during irrigation.

14. End Colostomy INDICATIONS- abdominoperineal resection of the rectum and Hartmann’s procedure, in which proctectomy and/or sigmoidectomy is performed without colorectal anastomosis. reoperation for takedown of a leaking colorectal anastomosis also require creation of an end colostomy. for complete temporary or permanent fecal diversion for nonobstructive pathology such as a rectourethral or rectovaginal fistula, necrotizing soft tissue infection of the perineum, or severe trauma to the rectum, anus, or perineum.

15. If takedown of an end colostomy is planned, consider covering the distal staple line and wrapping the colostomy in an adhesion barrier such as Seprafilm ® to decrease adhesions to both structures. An end colostomy is not an acceptable solution for a distal obstruction, as stapling off the distal side of the colon will create a closed loop between the staple line and the obstruction, which may eventually result in perforation at the staple line.

16. OPEN TECHNIQUE Place Kocher clamps on the dermis and on the fascia of the abdominal wall to stabilize the layers of the abdominal wall in relation to each other. A folded laparotomy sponge held firmly up against the anterior abdominal wall at the planned stoma site, to ensure that no inadvertent bowel injury. Excise a disk of skin at the previously marked

17. Once the fascia is exposed, make a vertical or cruciate incision to expose the underlying rectus muscle. spread the muscle fibers medially and laterally, exposing the posterior rectus sheath. Make a vertical or cruciate incision in the posterior sheath, exposing the laparotomy sponge

18. Pass the Mayo clamp, through the defect and bring the end of the clamp through the midline incision. Dilate the defect to two to three fingerbreadths . Ensure that the colon is oriented correctly and that there is adequate mobilization of the colon to bring it through the abdominal wall without tension. If proctectomy with ligation of the inferior mesenteric artery is being performed, then the left colon will need to be mobilized adequately and used for the stoma, as the sigmoid colon blood supply may be compromised in this case.

19. Insert a Babcock clamp through the stoma defect to grasp the end of the colon and bring the colon through the defect. Ensure that at least a few centimeters of colon sit without tension above the skin, and that it is well-perfused. Insert a finger alongside the colon through the stoma defect to ensure that the defect is not too tight.

20. After abdominal closure, remove the staple line from the end of the colon and place absorbable sutures in all four quadrants through the full thickness of the colon wall and to the dermis or epidermis. Then place additional sutures between those four stay sutures. Some surgeons will create a colostomy that is slightly budded so that it protrudes slightly from the level of the skin, while others prefer a skin-level colostomy.

21. FIGURE- Suturing the free edge of the colon mesentery to the lateral abdominal wall may close the lateral space, but it has not been shown to reduce the risk of bowel obstruction, hernia, or prolapse.

22. LAPAROSCOPIC TECHNIQUE The stoma defect can be made during pneumoperitoneum by excising a disk of skin and subcutaneous tissue at the previously marked site, dividing the fascia, spreading the muscle, and incising the peritoneum. Use two fingers to dilate the stoma defect and maintain pneumoperitoneum. After making the stoma defect, bring the end of the colon through the defect while ensuring proper orientation with laparoscopic vision. Slide a Babcock clamp through the stoma defect alongside the fingers to grasp the colon under laparoscopic vision, and then bring the end of the colon through the defect It is important to remember that pneumoperitoneum stretches the abdominal wall, and may thus make the stoma defect larger under insufflation than it will be after desufflation . Prophylactic mesh reinforcement of the stoma defect using the modified Sugarbaker or keyhole technique and Creation of an extraperitoneal tunnel are amenable to a laparoscopic or robotic approach.

23. Loop Colostomy INDICATIONS- distal obstruction requiring temporary or palliative fecal diversion. Patients with symptomatic fistulas between the rectum and urethra, bladder, or vagina may also find relief with a l oop colostomy. A downside of using the colon rather than the ileum for diversion in the case of fistula is the potential compromise of a segment of colon that may be needed to reach a low pelvic anastomosis for the purposes of reconstruction. trauma to the extraperitoneal rectum or perineum, and complicated soft tissue infection of the perineum requiring significant debridement. The ideal segment of colon to use for a loop colostomy is the sigmoid, as it is the most mobile part of the distal colon. In cases of unresectable obstructing lesions at the splenic flexure or left colon, or when the sigmoid is not available for use, the use of the transverse colon may be necessary.

24. OPEN TECHNIQUE Make the stoma defect in the fashion described for end colostomy. Mobilize the loop of sigmoid or transverse colon so that it will reach through the abdominal wall. Make a defect at the junction between the colon and the mesentery, and pass a ½-inch umbilical tape or Penrose drain through this defect. Use an umbilical tape or Penrose drain to guide the loop of colon through the stoma defect while pushing it out from the inside of the abdomen. After closing the abdominal incision, mature the loop colostomy. Some surgeons prefer the use of stoma rods that can be placed through the mesentery defect to replace the umbilical tape. Transversely incise the antimesenteric border of the distal side of the loop. This division should be more than half the bowel circumference so that the functioning proximal limb and nonfunctioning distal limb are separated. Suture the free edge of the bowel to the dermis or epidermis.

25. LAPAROSCOPIC TECHNIQUE If a laparoscopic approach is safe and feasible, mobilize the loop of colon adequately to reach the anterior abdominal wall while the abdomen is insufflated. Make the stoma defect and dilate it to two to three fingerbreadths under pneumoperitoneum, and slide a Babcock clamp alongside the fingers to grasp the mobilized loop of colon. Bring the loop gently through the stoma defect. Check laparoscopically to determine the orientation of the colon, and mature the proximal side. A single-port or reduced-port laparoscopic technique using the planned stoma site as the port site results in fewer or no additional incisions aside from the stoma defect itself.

26. Blowhole Colostomy Combined with loop ileostomy, blowhole colostomy is a minimally invasive way to decompress the colon and allow these very sick patients to recover until they are stable enough to undergo colectomy. First, localize the transverse colon by taping a coin on the patient’s epigastrium and taking an abdominal film. Determine the location of the transverse colon by using the location of the coin in relation to the most dilated part of transverse colon as a guide. With local anesthetic, make an incision in the mid-epigastrium right over the transverse colon. Incise the fascia and peritoneum to expose the serosa of the transverse colon.

27. Place interrupted sutures to secure the colon to the abdominal wall and to isolate this window of bowel from the rest of the abdominal cavity. Then, decompress the gas in the dilated colon using a large-bore needle. Incise the colon and suction out the gas and stool that is under pressure. Place interrupted sutures between the full thickness of the bowel wall edge to the skin .

28. FIGURE -The blowhole colostomy is located usually in the midline epigastric position.

29. Divided Loop Colostomy INDICATIONS- The indications for a divided loop colostomy are similar to those for a loop colostomy, which include a distal obstruction, a symptomatic fistula between the rectum and urethra, bladder, or vagina, trauma to the extraperitoneal rectum or perineum, and complicated soft tissue infection of the perineum with a large perineal wound. A divided loop colostomy has two advantages over an end colostomy: reversal of a divided loop colostomy can be performed through the stoma site, and it can be used in the case of distal obstruction since the distal limb remains open.

30. TECHNIQUE Mobilize the loop of colon, create the stoma defect, and bring the loop of colon through the defect in the same fashion as a loop colostomy. Make a defect in the mesentery adjacent to the bowel wall, avoiding the mesenteric vasculature. Divide the colon with a linear cutting stapler. Excise the corner of the distal staple line and suture the bowel wall to one side of the stoma defect, creating a mucus fistula. Remove the entire staple line of the proximal limb, and mature the colostomy with interrupted full-thickness 3-0 Chromic sutures to the skin. Part of the colostomy will be adjacent to the mucusfistula . Suture the bowel wall edges together.

31. Loop-End Colostomy INDICATIONS A patient with a short colonic mesentery and/or thick abdominal wall that precludes the end of the colon to reach through the abdominal wall may require a loop-end colostomy. TECHNIQUE Mobilize the colon and create a stoma defect. Make a defect at the bowelmesentery border and pass a ½-inch umbilical tape or Penrose drain through the defect. Use this to guide the loop of colon through the defect while pushing the colon and mesentery from the inside. Exchange the umbilical tape for a stoma rod and suture it in place. Divide the colon transversely at the distal side of the loop. Mature the stoma as a loop colostomy.

32. Colostomy Function Colostomy function varies greatly among patients and depends on several factors, including diet and fluid intake, and preexisting bowel habits. While most patients wear stoma appliances at all times, a smaller proportion of patients choose to irrigate their colostomies to reduce the need to wear an appliance.

33. CECOSTOMY A cecostomy may occasionally be useful for colon decompression in cases of obstruction or refractory pseudo-obstruction, or as a point of fixation and drainage for the cecum after volvulus or a repaired perforation. A tube cecostomy is constructed by first placing two concentric purse-string sutures at the planned tube site. An opening in the cecum is then created and the tube is inserted. The pursestrings and the opening should be appropriately sized for a 30-French or larger Malecot or Foley catheter. The catheter is inserted through the colotomy and the pursestring sutures are tied around the shaft of the tube in layers. Postoperatively, tube patency is maintained with irrigation. Once the need for the cecostomy has passed, removal of the tube typically allows the fistula to close by secondary intention.

34. Cecostomy construction.

35. ILEOSTOMY The consistency of ileostomy output is more watery, and the composition is more caustic to the skin. These two differences increase the risk for pouch leaks and subsequent skin breakdown in patients with ileostomies compared to those with colostomies. It is very important that ileostomies be budded to allow the os to be above the surface of the skin and within the pouch, decreasing the risk of pouch leakage.

36. End Ileostomy INDICATIONS Patients undergoing total colectomy or total proctocolectomy without restoration of intestinal continuity require end ileostomy. Disease processes include ulcerative colitis, Crohn’s colitis, familial adenomatous polyposis, ileocolic anastomotic leak requiring reoperation and takedown of the anastomosis, and colonic inertia without ileorectal anastomosis.

37. TECHNIQUE Mobilize the ileal mesentery off the retroperitoneum up to the duodenum. Ensure that there is adequate blood supply to the ileum. Make the stoma defect as described for a colostomy, but only dilate to two fingerbreadths. If the end ileostomy is temporary, wrap the stoma in Seprafilm to facilitate subsequent takedown, and then gently guide the ileum through the defect. After closing the abdominal wall, mature the ileostomy by removing the staple line and placing four sutures of 3-0 Chromic full-thickness through the free edge of the ileum, through the seromuscular layer at the base of the stoma, and the dermis.

38. FIGURE- The Kocher clamps will keep the fascial layers in line. The anterior rectus sheath is incised, the muscle is spread, and the peritoneum is incised to make the stoma defect.

39. Loop Ileostomy INDICATIONS The indications for a loop ileostomy include a distal colonic obstruction in the setting of an incompetent ileocecal valve, a distal colorectal anastomosis with a high risk for an anastomotic leak, severe perianal Crohn’s disease, perineal or perianal trauma, perineal wounds that require fecal diversion, and fistulas between the bowel and genitourinary tract which are not ready for definitive repair.

40. TECHNIQUE Choose as distal a segment of ileum as possible that will reach without tension through the abdominal wall. Place orienting sutures of loosely tied knots to prevent inadvertent maturation of the distal side. Make a small defect in the mesentery just adjacent to the bowel wall, taking care not to damage the mesenteric vasculature. Bring a ½-inch umbilical tape or Penrose drain through this defect. FIGURE- Select the most distal segment of ileum that will reach without tension through the abdominal wall, and place orienting proximal and distal sutures on the bowel wall.

41. The ileostomy defect is created in the same manner as for an end ileostomy. After fascial closure and before stoma maturation, some surgeons prefer to place a stoma rod through the mesenteric defect to prevent ileostomy retraction. Remove the stoma rod 3 to 5 days after the operation. Mature the loop ileostomy by transversely incising the distal side of the loop. This transverse enterotomy should encompass at least half the circumference of the bowel wall. Place three-point sutures of 3-0 Chromic full-thickness through the free edge of the bowel, seromuscular through the bowel at the base of the stoma, and through the dermis.

42. Loop-End Ileostomy INDICATIONS A loop-end ileostomy is a good alternative to end ileostomy in the case of a thick abdominal wall or a foreshortened small bowel mesentery that prevents the end of the small bowel from reaching through the stoma defect. It is far better to create a loop-end ileostomy that is adequately everted than to create a suboptimal end ileostomy that is retracted or ischemic, resulting in pouching difficulties.

43. TECHNIQUE A loop-end ileostomy is created by first determining the most distal loop of small bowel that will reach through the abdominal wall. Place an umbilical tape through a defect in the mesentery at its junction with the bowel wall. Place orienting sutures marking the proximal and distal bowel. Oversew the distal end of the bowel. Create the stoma defect and bring the loop through the defect using the guidance of an umbilical tape or Penrose drain after wrapping the bowel with an adhesion barrier if the stoma is temporary. Place a stoma rod through the defect in the mesentery where the umbilical tape was. Transversely incise the distal side of the loop. Evert the proximal side by placing three-point sutures full-thickness through the bowel wall edge, seromuscular through the bowel wall at the level of the skin, and through the dermis. To mature the distal side, place two-point sutures full-thickness through the bowel wall edge, and through the dermis. FIGURE -Find the most distal loop of small bowel that will reach through the abdominal wall and place orienting sutures to mark the proximal and distal bowel.

44. FIGURE -Oversew the distal staple line. FIGURE -Bring the loop of ileum through the stoma defect. FIGURE -Place a stoma rod FIGURE -Mature the loop-end ileostomy by incising the distal side of the loop transversely and everting the proximal side (inferior in this figure) using three-point sutures of 3-0 Chromic.

45. Separated Ileostomy (Divided End-Loop) INDICATIONS A separated ileostomy is useful in situations where complete fecal diversion is necessary, or if there is difficulty in bringing enough bowel through the abdominal wall.

46. TECHNIQUE Divide the ileum with a linear cutting stapler, taking care to preserve all mesenteric vessels. Create the stoma defect. Bring the proximal limb and the antimesenteric corner of the distal limb through the stoma defect. Excise the antimesenteric corner of the distal limb and remove the end of the proximal limb. Mature the proximal side using three-point sutures and the distal corner using two-point sutures. FIGURE- Preserve the mesenteric blood supply when dividing the bowel.

47. FIGURE-Bring the proximal limb through the stoma defect, as well as the antimesenteric corner of the distal limb. In this figure, the proximal limb is inferior and the distal limb is superior but this configuration is not mandatory. FIGURE-Remove the staple line of the proximal limb (inferior in this figure) and the antimesenteric corner of the distal limb (superior in this figure). FIGURE-Mature the proximal limb (inferior in this figure) of the bowel by everting it with three-point sutures.

48. Ileostomy Care and Skin Complications A well-placed and well-constructed ileostomy should offer the patient a good quality of life, minimal restrictions on activity, and ability to enjoy a range of foods. Most patients use a two-piece ileostomy appliance system comprised of a faceplate with a skin barrier and a pouch. The stoma opening of the skin barrier must match the exact size of the ileostomy, so that all the peristomal skin remains protected from the ileostomy effluent. The faceplate typically lasts 3 to 5 days, but if the patient experiences leakage under the appliance, then it requires more frequent changes. A retracted ileostomy with an os at skin level, or a tilted ileostomy with an os pointing down, is likely to result in leaks and pouching problems. Loop ileostomies are more likely to be associated with pouching problems because the distal opening is flush with the skin, allowing mucus to seep under the faceplate and disrupt the seal.

49. Management of High-Output Ileostomies Many postoperative patients with new ileostomies experience a large volume of liquid output in the first few weeks after the operation. The daily volume of ileostomy output may be over a liter shortly after ileostomy creation, but should slow down to 500 to 800 mL after the small bowel has had a chance to adapt and increase its absorptive capacity. However, some patients may persistently have high output for various reasons including partial obstruction, short gut syndrome, or intrinsic bowel abnormalities. The two main problems with high-output ileostomies are dehydration often accompanied by electrolyte abnormalities and pouching difficulties due to the liquidity and volume of the effluent. The first step in the diagnostic workup is to rule out an underlying obstruction. Assess for an obstruction at the level of the fascia by inserting a finger into the stoma. A contrast study or ileoscopy through the ileostomy will demonstrate a more proximal obstruction. Other possible etiologies include enteritis, short bowel syndrome, or inflammatory bowel disease.

50. General principles for managing high ileostomy output are avoidance of concentrated sugars , hydrating with a combination of water and electrolyte beverages, and eating foods with a balance of protein, healthy fats, and soluble fiber . Patients should avoid drinking large amounts of water. Fiber supplementation in the form of the soluble fiber pectin, powders dissolved in drinks, and fiber wafers are more effective than fiber pills. Medications such as loperamide, diphenoxylate-atropine, and tincture of opium can also be helpful in reducing the stoma output.

51. Management of Ileostomy Obstruction If a patient with an ileostomy develops obstructive symptoms, the first step is to rule out an obstruction due to a food bolus by irrigating the stoma with saline. Food particles in the irrigant raise suspicion of a food bolus as the culprit, and continued irrigation with warm saline should resolve the problem. If there are no food particles in the irrigant , then the obstruction may be due to other causes such as adhesions, volvulus of small bowel around the ileostomy, or parastomal hernia. Cross-sectional imaging or a water-soluble contrast study via the stoma is helpful in making the diagnosis.

52. STOMA COMPLICATIONS

53. Parastomal Hernia Parastomal hernia occurs in up to 50% of patients. Risk factors of parastomal hernia – increased intra-abdominal pressure including obesity, chronic cough, chronic obstructive pulmonary disease, ascites, and straining behaviors. older age, malnutrition, systemic steroids, and creation of the stoma during emergency operation. FIGURE-Patient with a large parastomal hernia, with pouching difficulties.

54. Management- usuallly nonoperative,but complications associated with parastomal hernia such as pouching difficulty, bowel obstruction, or incarceration are indications for surgical repair. The best treatment for parastomal hernia repair is restoration of bowel continuity, as the recurrence rate of parastomal hernia repair with mesh is as high. FIGURE- This parastomal hernia was causing recurrent bowel obstructions due to the incarcerated loops of bowel in the hernia sac.

55. Primary suture repair has recurrence rates ranging from 46% to 100%, and there are few indications for this procedure. The use of biologic or prosthetic mesh is associated with a low incidence of mesh infection. Several options for mesh placement and surgical approach exist. An onlay mesh with a central defect for the stoma sits on top of the fascia. A sublay mesh with a keyhole opening for the stoma sits between the rectus muscle and the posterior rectus sheath. An underlay mesh sits posterior to the peritoneum.

56. It may have a keyhole defect for the stoma opening, or it can be placed as a patch over the most distal intraperitoneal part of the colon. This Sugarbaker technique creates a short tunnel for the distal colon and has been found to have a lower recurrence rate. The final option is stoma relocation with mesh repair of the other stoma defect. FIGURE -Recurrent bowel obstructions and pouching difficulties are indications for parastomal hernia repair.

57. Prophylactic mesh placement at the time of primary stoma creation may prevent parastomal hernia. The two methods for placing prophylactic mesh around a colostomy are the Sugarbaker and keyhole techniques. The modified Sugarbaker technique uses an intraperitoneal onlay mesh covering the stoma defect and the most distal segment of the colon before it exits the abdominal wall via the stoma defect. The keyhole technique uses mesh with a hole or cruciate defect corresponding to the stoma defect, allowing the colon to pass through the mesh.

58. Another technique to reduce the risk of stoma prolapse or parastomal hernia is the creation of an extraperitoneal tunnel from the stoma defect to the lateral abdominal wall. The opening in the peritoneum is lateral to the rectus muscle and the colon runs through a tunnel between the peritoneum and rectus muscle before exiting through the stoma defect. To create the extraperitoneal tunnel, make the stoma defect as usual in the skin and fascia and spread the rectus muscle to expose the posterior rectus sheath. Instead of incising this layer, continue the dissection laterally within this plane, separating the rectus muscle away from the peritoneum. Make a vertical incision in the peritoneum at the lateral end of the extraperitoneal tunnel.

59. Stoma Prolapse Loop colostomies using the sigmoid or transverse colon have the highest risk of stoma prolapse. An accompanying parastomal hernia is common. If the prolapse is incarcerated but the bowel is not ischemic, then manual reduction should be attempted immediately. If the stoma is edematous, pour a generous amount of sugar onto the prolapsed segment and allow it to sit for at least 10 minutes. Place a gauze sponge over the prolapsed bowel and apply gentle constant pressure to the os of the stoma. Giving the patient pain medication or muscle relaxant may aid in this process as well. If manual reduction is successful, then the patient may undergo elective repair.

60. Inability to reduce the stoma or ischemic bowel is an indication for emergent surgical intervention. Operative approach depends on whether the ischemia extends below the fascia. Most cases of incarcerated and ischemic stoma prolapse require resection of the prolapsed segment using the existing stoma site, with creation of a new stoma. A laparotomy is necessary if operating through the stoma site does not allow adequate access for resection of the ischemic bowel segment, or adequate mobilization of proximal bowel for a new stoma.

61. Stomal Retraction Stoma retraction occurs when the bowel wall pulls away from the skin, causing the os of the stoma to sit below skin level. FIGURE-This patient had a retracted ileostomy that was very difficult to pouch, and as a result had caused significant peristomal skin irritation.

62. Risk factors for stomal retraction – inadequate mobilization of the bowel at the time of initial stoma creation, a thick abdominal wall, a short mesentery, and emergency surgery. This complication often occurs in the early postoperative period. If it occurs within a week of the initial operation, then it is worth considering reoperation for stoma revision to avoid the long-term sequelae associated with retraction. If it occurs more than a week from the time of initial operation, then reoperation may be ill-advised due to dense postoperative adhesions that are likely to preclude the additional mobilization that is needed to fix the problem.

63. It is important to determine whether the bowel has retracted below the fascia, as retraction below the fascia may cause intraabdominal stool spillage and is an indication for operative intervention. If stoma retraction occurs too far after the initial operation to safely reoperate, and the distal end of the stoma is above the level of the fascia, then the mainstay of management is pouching strategies that will minimize damage to the peristomal skin and maintain a seal.

64. Prevention of stoma retraction involves mobilizing adequate bowel length at the time of initial stoma creation. a loop-end stoma can often be a good alternative that will reach through the abdominal wall without tension.

65. Stoma Ischemia Risk factors for ischemia of the stoma include a thick abdominal wall, small stoma defect size relative to the bowel caliber, and excessive dissection or tension of the mesentery. The bowel wall may not demonstrate obvious signs of ischemia until several days after the operation. Similar to the case of stoma retraction, it is important to determine whether the ischemia extends below the fascia. If the ischemia only involves the bowel above the fascia, then the ischemic mucosa will slough off with time, and usually does not require reoperation. Ischemia extending below the fascia is an indication for operative intervention. FIGURE -This stoma has mucosal ischemia that did not extend past the fascia, and therefore did not require reoperation.

66. If the cause of ischemia is a tight stoma defect then a local stoma revision to increase the size of the defect and bring up a healthier segment of bowel may be successful. Laparotomy will be necessary if mobilization of additional bowel cannot be performed through the stoma site. Often a loop-end stoma is necessary to preserve adequate mesenteric blood flow in the setting of a thick abdominal wall and a short mesentery.

67. Stoma Stenosis Stoma stenosis often occurs in conjunction with stomal retraction, which allows the skin of the stoma defect to close concentrically over the os . The most effective way to manage stoma stenosis is surgical revision, but patients who cannot undergo operative intervention may undergo stoma dilations. Dilations can be performed in the office setting or under sedation in the operating room, depending on the patient’s comfort level.

68. Mucocutaneous Separation when the edge of the bowel wall separates from the skin edge at the border of the stoma, occurs as a result of poor wound healing. The crevice that is formed by the separation presents a challenge for pouching, and patients may find it difficult to maintain an intact seal around the stoma. MANAGEMENT- keep the peristomal skin in good condition, optimize nutrition, and to employ local wound care techniques to fill in the trough and induce granulation of the wound. FIGURE -This patient had underlying disease that precluded wound healing, and this led to severe mucocutaneous separation of the ileostomy.

69. PERISTOMAL SKIN COMPLICATIONS There is a common misconception that the skin around the stoma is expected to be chronically inflamed or altered. In fact, despite being covered by an adhesive, the skin should be of normal color and texture. Dermatitis presents as confluent or uniform erythema, tenderness, and epithelial erosion with resulting moisture. Hypersensitivity to a particular skin care product and chemical irritation from stoma effluent is the most frequent cause. TREATMENT - removal of the underlying offending agent. Use of routine skin care products, such as lotions, should be avoided unless used for a specific indication. A proper sized and fitting appliance can prevent and treat chemical dermatitis from intestinal effluent.

70. Pseudoverrucous Lesions or Hyperplasia Chronic irritation causes hyperkeratosis and development of overgrowth, warty-like, lesions within the area of chronic irritation. usually gray or red and can bleed easily. TREATMENT -removal of the offending irritant use of a barrier powder can promote wound healing. S ilver nitrate may be applied to speed shrinkage of the excess tissue and allow for easier pouching.

71. Cellulitis due to Staph aureus and Streptococcus species in the setting of ulceration or laceration of the skin. It presents with classic signs of erythema, tenderness, and swelling. Oral and topical antibiotics should be prescribed. Folliculitis traumatic removal of peristomal hair and presents with erythema and pustules of the hair follicles. topical antimicrobial powder, proper techniques regarding clipping of peristomal hair and pouch removal including use of an adhesive removal product. Candidiasis will present in an area of chronic moisture as pustules with a bright red center and advancing border. Treatment includes eradication of moisture and use of topical antifungal powder.

72. Mucosal Transplantation If the suture needle is passed from the mucosa and bowel wall though all the layers of the skin at the time of stoma creation, the needle can seed the epidermis with mucosal cells and create small islands of mucosa within the skin. discharge of mucus and irritation of the skin. treated with a skin barrier powder to absorb the moisture or be cauterized with silver nitrate or electrical cautery.

73. Psoriasis underlying cause is unknown, psoriasis is due to hyperproliferation of the epidermal layer resulting in raised red plaques with a white scaly covering often underneath the skin barrier. family history of psoriasis or personal history of inflammatory bowel disease. treated with topical steroids.

74. Stoma Varices Portal hypertension and venous engorgement can cause a bluish discoloration of the peristomal skin. Bleeding from these varices can be spontaneous and profuse. Bleeding will usually stop with direct pressure, sclerotherapy, or suture ligation but recurrence is common. Pyoderma Gangrenosum A rare complication, exquisitely painful, well-demarcated ulcer often have fibrinous exudate and an underlying necrotizing inflammatory process. It is commonly associated with inflammatory bowel disease, rheumatoid arthritis, and multiple myeloma. TREATMENT - topical high-dose corticosteroids, topical tacrolimus, pain control, and careful attention to local wound care and pouching concerns.

75. THANK YOU