Types of intestinal stomas and management

a brief guide to intestinal stoma

1. Types of intestinal stomas and management Dr Venugopal Ravi JR Surgery MODERATOR: Dr. Ankita Singh (SR Surgery, AIIMS Delhi)

2. Objectives Definition Indications Classification Principles of stoma formation & challenges Complications Stoma appliances Dietary advice to ostomates

3. Definition of intestinal stoma Greek word “ stoma ”- mouth or opening An artificial opening in the abdominal wall, which connects a segment of the gastrointestinal tract to the exterior environment.

4. Indications 1. When restoration of intestinal continuity is either: Not feasible immediately : Condition of bowel Patient factors OR Contraindicated : Inoperable distal obstruction 2.For diverting enteric content : To protect distal anastamosis Protection of complex perineal reconstruction Treatment of perineal diseases/trauma

5. Classification of intestinal stoma Duration: Temporary or Permanent Anatomical location :

6. Classification of intestinal stoma Reconstruction:  End  Loop & End loop  Double Barrel ( Mickulicz )  Bishop-Koop (distal ileostomy with end to side ileal anastamosis )  Santulli (proximal ileostomy with end-to-side anastomosis ) Incontinent : need to wear appliance pouch Continent : control using ostomy cap

7. Types of intestinal stoma Temporary: Loop: faecal diversion to protect distal anastomosis/ distal obstruction . Proximal- diversion Distal-venting of distal loop End loop: distal loop is placed in subcutaneous space, if concern for distal obstruction Double barrel: proximal and distal ends as separate ostomies Hartman's procedure : distal closed bowel end left in-situ in abdomen and tagged Permanent: End: when entire colon removed with no residual anal continent mechanism Continent: made when patient demanded for continence mechanism

8. Purpose of ostomy creation Permanent ostomy : Created when entire distal bowel removed and anal sphincter mechanism is compromised. Unresectable distal bowel malignancy. Commonly made as end ostomy, in sigmoid/ descending colon post abdomino-perineal resection has less complication rate, or can be made in ileum when entire colon removed. Temporary ostomy : created when anastomosis is unsafe/ to protect distal anastomosis or for faecal diversion in case of distal obstruction/ complex perineal reconstruction. Commonly made as loop/ double barrel ostomy in ileum/ sigmoid/ transverse colon. has higher rate of complication.

9. When diversion ostomy required? Absolute indication: Pelvic anastomosis < 5 to 6 cm from anal verge including colo -anal anastomosis and IPAA, Severe peri -anal CD frequently requires diversion Primary anastomosis with diverting ileostomy in the setting of diverticular perforation Diverting stoma can be used as a bridge to primary resection in the setting of an obstructing malignancy. Relative indications : steroid usage, radiation proctitis, traumatic injury, infectious colitis, chronic wounds, and bowel care for paraplegics and after anastomotic leak

10. Principles: Preop planning Preoperative counseling : ostomy education Explain indication Psychosocial & physical preparation Stoma care Possible complications Role of clinical nurse specialist in stoma care

11. Principles: Preop planning Site selection is influenced by Patient factors (e.g., age, dexterity, diagnosis, occupation, prior radiation, vision) Physical factors (e.g., abdominal creases / folds/scars/ valleys, belt/ waist line, bony structures, large/protruding abdomen, pendulous breasts) Positioning issues (e.g., contracture, mobility, posture) Multiple sites ; faecal and urinary stomas should be located at differing horizontal levels

12. Principles: Preop planning Marking stoma site: Examine clothed as well as exposed Positions of examination Stoma mark should be easily visible & accessible to patient Either side of the abdominal midline, lateral and inferior to the umbilicus, should pass through rectus muscle(marking edges of muscle) At least 5 cm from all folds, creases, proposed incision, previous surgical scars, belt line, umbilicus, and bony prominences OSTOMY TRIANGLE

13. Principles of stoma formation Special considerations: In obese patient it can be above umbilicus where fat is less thick Ventral hernia Multiple stomas Prior stoma Lifestyle

14. Example of marking a stoma site for a female with a protuberant abdomen , creases, and folds. Wound, Ostomy and Continence Nurses Society. (2014). WOCN Society and ASCRS Position Statement on Preoperative Stoma Site Marking for Patients Undergoing Colostomy or Ileostomy Surgery. Mt. Laurel: NJ. Author.

15. Example of marking a stoma site for a male with a protuberant abdomen .

16. Principles of making stoma.. Basic principles to be followed in making of stoma are similar to anastomosis: free of tension should have adequate blood supply

17. Creation of stoma Circular skin excised full thickness with diameter to adequate bowel, no subcutaneous tissue is incised till the anterior rectal sheath

18. Creation of stoma Anterior sheath is incised cruciately , rectus muscle fibres separated, posterior sheath incised carefully adequate to pass two fingers easily

19. Creation of stoma Loop / cut end of bowel is brought out through aperture without tension/twisting Lumen opened & matured (absorbable sutures) * Stomal fixation to fascia is optional End ileostomy Loop ileostomy Double barrel colostomy

20. Ileostomy vs colostomy

21. End loop ileostomy End loop colo -ileostomy

22. Difficult stoma Challenging issues: Obesity: consider supra umbilical stoma, end loop stoma and need for abdominal wall management Shortened mesentery: seen in patients with central obesity as well as patients with a history of desmoid tumors , inflammatory bowel disease, previous laparotomies, or prior external beam radiotherapy

23. Challenges during Colostomy End descending colostomy creation is difficult as mobilisation of left colon, splenic flexure and distal transverse colon is needed Division of IMA at origin, IMV at lower border of pancreas preserving the bifurcation of ascending & descending arteries A nd excision avascular window in between

24. Challenges during Colostomy Bulk of mesentery reduced by amputation of appendices epiploicae Mesenteric fat reduced by touching with cautery without damaging vasculature In case of severe mesenteric shortening loop ileostomy can be done In case of previously scarified IMA, loop colostomy preferred to end colostomy as it preserves the marginal artery

25. Caution during Ileostomy Usually easy to reconstruct because it has less bulky & long mesentery Ileum can be mobilised from retro-peritoneum by dividing midgut mesentery Ileo-colic artery divided with out risk of ischemia, a window of avascular mesentery bordered by these vessels and an inner arcade of vessels that runs parallel to the mesenteric margin of the bowel wall can be excised to improve length End loop ileostomy can be performed in staged manner, ischemia is concern for prohibitively short mesentery

26. Loop stoma To protect distal anastomosis, require larger aperture, greater risk for parastomal hernia Prior to delivering of loop through aperture needs marking of proximal and distal limbs (to avoid rotation of loop to prevent maturation of wrong limb of stoma) Can be supported by stoma rods placed alongside one another to distribute the tension over a greater surface area Mesentery can be braced at the fascia level rather than the skin level with malleable tube left in place for several days to weeks (source?)

27. Caution during bowel Passage In case bowel is bulky or the abdominal wall is thick, an extra-small wound protector can be placed in the stoma aperture, to assist the passage by feeding the bowel and mesentery into the wound protector as opposed to pulling the tissue and causing injury. Ring of the protector on the peritoneal cavity side is divided and amputated from the protector sheath, sheath then removed Transected intestine is initially passed through the rectus muscle and fascia, and then through the subcutaneous tissue and skin in a staged manner

28. Abdominal Wall Modification Rarely used initially for creating stoma. Abdominoplasty : for obese patients, intended for thinning of the subcutaneous fat around the intended stoma site to provide a flat, smooth surface for adherence of the stoma appliance. Procedure: a low curvilinear transverse incision 2 to 3 cm above the pubis and anterior superior iliac spines, skin and subcutaneous tissue are elevated off the underlying fascia to a point above the redundant skin or the existing stoma site, and the excess tissue of the flap is excised. Remaining subcutaneous tissue can be removed to thin the flap, with caution to avoid flap ischemia or necrosis umbilicus is repositioned, a new stoma opening is created, the bowel is passed through the aperture, closed suction drains are placed under the flap, and the flap is sutured to the lower wound edge

29. C omplications Stoma to function normally: good blood supply & devoid of undue tension Early complications (<3 months): Necrosis Bleeding Retraction Mucocutaneous separation Late complications (>3 months): Parastomal hernia Prolapse Stenosis * Peristomal skin problems (any time) Mechanical trauma Dermatitis Parastomal ulceration Granuloma  Peristomal pyoderma gangrenosum Nipple valve slippage

30. Complications Necrosis : Venous congestion or arterial insufficiency ( eg, tight fascial opening, excessive mesenteric stripping), managed according to the length and depth of involvement Venous outflow obstruction > venous congestion> necrosis of stoma Suprafascial ischemia Subfascial ischemia

31. Complications Peristomal bleeding : M ay due to trauma varicial bleeding due to portal hypertension Coagulopathy First is managed with local pressure or ??with cautery , suture ligation of bleeder, correction of coagulopathy, later managed with sclerotherapy , transjugular intrahepatic porto -systemic shunting

32. Complications Stomal retraction: Definition-stoma that is 0.5 cm or more below the skin surface within 6 weeks of construction Typically results from tension, but may also result due to poor wound healing (malnutrition, steroids) Immediate operative revision required, if retracts below fascia However retraction above the fascia can be managed with local wound care, a convex pouching system, and the use of a belt or binder, wt loss can be advised if obese

33. Complications Mucocutaneous separation : partial or circumferential if circumferential: stomal stenosis can occur as the tissues heal by secondary intention, prevented by meticulous suturing technique, covering the area with the skin protective barrier with a barrier ring will help protect the wound from effluent and facilitate healing Gastrointestinal Nursing(2018) Clinica . VOL . 16, NO. 10   https://doi.org/10.12968/gasn.2018.16.10.26

34. Complications Stomal prolapse : occurs in 10% of patients with end stoma, also loop colostomy Predisposed by: large aponeurotic opening, excessive mobilised redundant bowel, raised IOP If acute with gangrenous prolapse, prompt resection without an attempt at reduction is indicated If the non-ischemic prolapse & uncomfortable, can generally be reduced with gentle pressure sometimes aided by application of hypertonic substance coating the mucosal surface of the exteriorized bowel to reduces the edema Temporary stoma usually managed expectantly, distal loop prolapse managed with stapled closure.

35. Complications Parastomal hernia: more commonly associated with colostomies (18–40%) compared with ileostomies (9–22%) Open repair of these hernias include stoma relocation and fascia repair with or without reinforcing onlay , sublay , or underlay mesh. Re-siting is usually restricted to stomas that are poorly sited Recurrence rate is high (50%) if mesh not used Mention latest article on parastomal hernia n managemnt ?????

36. Complications Some centres use prophylaxis against a peristomal hernia with mesh decreases hernia from 50% to 13 % Postoperative complications included surgical site infection (3.8%), infected mesh (1.7%), and obstruction requiring reoperation (1.7%)

37. Complications Stomal stenosis : 2-15 % incidence more common with an end colostomy. may be attributable to peristomal sepsis, retraction, an ill-fitting pouching system, or suboptimal surgical technique and Crohn's disease Mild stenosis managed by dietary modifications, gentle routine dilatation of the stoma with 32f Foley's catheter Severe stenosis usually causes cramping pain followed by explosive output and usually requires surgical correction, local repair involves excision of scar tissue with adequate mobilization and creation of a new tension-free stoma at a new or relocated site.

38. General complications Odour : gas in effluent is from the ingestion and fermentation influenced by type of foods. Patients should be educated about the lag time 2 to 3hrs for ileostomy and 6 to 8 hrs for colostomy, taught to avoid drinking carbonated drinks, garlics, drinking through straws, chewing gum, and smoking If odour is a particular concern for the patient, bismuth subgallate  or chlorophyllin copper complex effectively reduces stool odour when taken routinely

39. General complications Food blockage: occurs in ileostomy as its diameter is less than 2.5 cm, large amounts of insoluble fibre, the undigested fibre may create an obstructing mass (bezoars) prevented by instructing the patient not to consume potential offenders (soft diet)

40. General complications High output stoma : > 1.5L/day, managed with medical treatment with bulk-forming agents, anti-motility agents like loperamide , as bowel adapts out decrease, if oral hydration not adequate then IVF supplemented. Patients with ileostomy are at risk of developing dehydration and electrolyte imbalance. Patients should also be taught the signs and symptoms of fluid-electrolyte imbalance and the importance of prompt treatment should these symptoms occur

41. General complications Clostridium difficile enteritis: increasingly reported cause of ileostomy diarrhoea especially in patients who have had a total colectomy. The typical presentation is ileostomy diarrhoea followed by ileus. associated with a high mortality, although early recognition and treatment appears to be associated with better outcomes

42. General complications Drug malabsorption : Patient education to take medications in dosage forms of quick dissolution, such as liquids, gelatine capsules, and uncoated tablets, and avoid time-released and enteric-coated medications as well as very large tablets since these forms of medication are likely to be incompletely absorbed.

43. General complications Peristomal skin problems: Most common associated complaint Bosio G et al. Ostomy Wound Manage. 2007;53(9):38-43.

44. Prospective study 405 patients Results: Bosio G et al. Ostomy Wound Manage. 2007;53(9):38-43.

45. “It doesn’t matter if a good doctor made your ostomy . If you have it long enough, you have a 100% risk of a parastomal hernia” J Byron Gathright

46. Stoma appliances Pouch systems: broadly 2 types One-piece systems include a protective skin barrier with a tape border fused to an odour-proof pouch, these are flexible, useful for stomas near creases Two-piece systems include a protective skin barrier with a tape border and flange or adhesive landing zone to which the patient attaches a separate odour-proof pouch . Cut to fit or moldable skin barrier Flat and convex barriers/ waffers

47. Stoma appliances

48. Stoma appliances

49. Stoma appliances

50. Stoma care ?? Not required Patients and care givers must be carefully taught and reassured before leaving the hospital and on subsequent follow-up visits. Properly fitted appliances should remain in situ for several days (change every 3 days ). Candidiasis remains a common problem in the parastomal skin, and local antifungal medication should be used at the earliest sign of irritation. With skin excoriation, the area is exposed to air and a synthetic barrier is applied. A hairdryer can be useful. application of silver nitrate may be necessary to control granulation tissue around the mucosa-skin interface in the early stages.

51. Summary Stoma can be colostomy or ileostomy May be temporary or permanent Temporary or defunctioning stomas are usually fashioned as loop stomas An ileostomy is spouted; a colostomy is flush Ileostomy effluent is usually liquid whereas colostomy effluent is usually solid Ileostomy patients are more likely to develop fluid and electrolyte problems

52. Summary An ileostomy is usually sited in the right iliac fossa A temporary colostomy may be transverse and sited in the right upper quadrant End-colostomy is usually sited in the left iliac fossa All patients should be counselled by a stoma care nurse before operation Principles of stoma formation should be followed Complications include skin conditions, prolapse , retraction, necrosis , stenosis, parastomal hernia, bleeding and fistulation

53. Resources Books ????? Shackelford, Mastery of surgery, Maingot Upto date Wound, Ostomy and Continence Nurses Society (2014) www.wocn.org ASCRS www.fascrs.org

54. Any queries?

55. Quiz time!

56. What is the problem here?

57. Is this stoma marking ok? Marking done by resident while lying down, 5 cms away from bony prominences, umbilicus and proposed midline incision. And this site is visible as welll as accesible to care giver.

58. “Better to create an ugly stoma in a good location than a pretty stoma in an ugly location .” Peter Cataldo

59. Lesion??

60. Spot diagnosis

61. Name and indication?

62. Any special diet prescription requiredfor ostomates ?

63. Thank you