MEDC 6421 - General Surgery

Gastrointestinal
Stoma

Dr. Mahmoud W. Qandeel

Dr. Alaa H. Rostom
 Definition of Stoma
• Stoma is an artificial opening or ‘mouth like 'to the exterior, the
abdominal wall so as to drain the content from the tubular
structures inside, like bowel or ureter.

• It is done for diversion of urine or faecal matter in case of

malignancy, trauma, and sepsis or after surgery
 Types of Stoma
• According to permanence :
 Temporary
 Permanent

• According to Site:
 Ileostomy:
 Colostomy
 Cutaneous ureterostomy
 Ileal urinary conduit:
 Vesicostomy

• According to Teqnique :
 End Stoma
 Loop Stoma
 Double Barrel stoma
 Intestinal Stoma
Types of stomas includes a:

• Colostomy

• Ileostomy

• Caecostomy

• Jejunostomy

• Gastrostomy
 Indications for Stoma Formation
Think Distally !

1. Anal sphincter failure

2. To “protect” distal anastomosis or when anastomosis not

appropriate

3. To reduce disease activity distally

 Indications for Stoma Formation
Anal Sphincter Failure

o Congenital anorectal atresia

o Surgical removal
• APER
• Proctocolectomy

o Destruction by disease
• Tumour
• Crohn’s
• Severe incontinence
 Indications for Stoma Formation
 To “protect” distal anastomosis
o Post anterior resection
o Post ileal pouch anal anastomosis

 Anastomosis not appropriate:

o Perforated sigmoid diverticulitis
o Acute fulminant colitis

 To reduce disease activity distally

o Severe Crohn’s colitis
o Severe perianal Crohn’s disease
 Criteria taken into consideration when
positioning a stoma:
1- Away from any bony prominence.
(Anterior superior iliac spine , Symphysis pubis)

2- Away from the umbilicus.

3- Away from any previous surgical incision.

4- Visible when the patient stands.

5- Comfortable for the patient.

Sites to avoid
• Scars/Wrinkles , Skin Folds/Creases , Bony Prominence
• Suture Lines , Umbilicus , Belt/Waistline
• Hernia , Mobile Abdominal Tissue ,Radiation Sites
Stoma Site Selection
 Types of Bowel Stomas
• End (terminal).

• Loop.

• Double Barrel. (Two ends brought to the surface seperately with a

skin bridge intervening)

• Paul-Miculikz. (Two ends brought to the surface together where the

adjacent serosal surfaces are hitched by sutures, and adjacent
mucosal surfaces are sutured)

• Seperation proximal faecal fistula from a distal mucous fistula.

 Colostomy

It is an artificial opening made

between the large bowel and
skin, to divert faeces and flatus
to the exterior, where it can be
collected in an external
appliance.

Effluent is usually solid.

 Temporary Colostomy:

Indications:
• Distal Obstruction.

• Defunction a low rectal anastomosis after anterior resection of

the rectum.

• Following traumatic injury to the rectum or colon.

• During operative treatment of a high fistula in ano.

• Fulminant Colitis (IBD).

• Complicated Diverticular disease.

Site of the colon used:

• Transverse colon :(Disease involve Lt. side of the colon)

• Sigmoid colon : (Disease involve the rectum or rectosigmoid

junction)
Types of temporary colostomies:
1- Loop colostomy:
• Bringing a loop of bowel to the surface where it is held in place by a
plastic or glass rod passed through the mesentery.

• Firm adhesion of the colostomy takes place after 7 days then the bridge
can be removed.

• Closure: follows the surgical cure or healing of the distal lesion for which
the temporary stoma was constructed .
(a distal loopogram) is best performed to check there is no distal
obstruction or any problem at the site of previous surgery).

• Also the stoma should be mature

(at least 2-3 months)
• Compared with takedown of an end colostomy, local
takedown of a loop colostomy is associated with a shorter
average hospital stay, less intraoperative blood loss, and a
lower complication rate.
2- Double Barrelled colostomy:
Advantage: ensures that the distal segment (colon, rectum) is
completely defunctioned (Absolute Rest).

3- Hartmann’s Procedure : (End Colostomy)

This includes a proximal End Colostomy with a distal closed
colonic segment (rectal stump).
This procedure can be used when resecting a tumour of the Lt.
site of the colon or in Complicated diverticular disease.
 Colostomy closure

• Closure, around 2 wks, but delay of 6–8 wks allows stoma to

mature and for peristomal plane to become better defined

• Contrast study of distal bowel

• Preoperative Preparation;
– low-residue diet, oral antibiotics, irrigations in both
directions through the colostomy .
Permanent Colostomy
Indications:
1- Rectal carcinoma excision( A-P resection) -- End colostomy
colostomy is always end colostomy placed in left iliac fossa—6 cm above
and medial to the anterior superior iliac spine.

2- Inoperable rectal or colonic carcinoma -- Loop colostomy

 Ileostomy
Definition: It is an artificial opening made between the ileum and skin of
the abdominal wall, to divert intestinal contents to the exterior, without a
sphincter to control the timing of its emptying.
Effluent is usually liquid.
• End Ileostomy : (Permanent)
 Indications :where total proctocolectomy is done.
1- Ulcerative colitis.
2- Crohn’s disease.
3- Familial polyposis Coli.
• Loop Ileostomy. (Temporary)
 Indications: as an alternative of a loop colostomy
for Defunctioning (for protection)
1- Low rectal anastomosis following a anterior
rectal resection.
2- Ileoanal pouch procedure following Total proctocolectomy.
Technique of Ileostomy:

• The ileostomy opening should be 5cm lateral to the umbilicus

and brought out through the lateral edges of the rectus abdominus
muscle.

• It is usually made in the Rt. Iliac fossa.

• It should be spouted.
 Cecostomy
Indication:
1- Trauma to the caecum.
2- Closed loop syndrome.(In desperately ill patients with advanced obstruction)
3- Imperforate anus
4- Spina bifida

Site: Rt. Iliac fossa.

 Complications of Stoma

Early vs. Late

20-41% of patients will have complications
Early Complications of Stoma
Psychological effect
 Early Complications of Stoma
Bleeding
• Mild hemorrhage common and self limiting.
– Usually mucosal.
– Apply pressure

• Active bleeding
– Implies failure to ligate
a mesenteric vessel

– Identify and ligate prior

to leaving OR
 Early Complications of Stoma
Ischemia & Necrosis
• 2.3-17% incidence

• Ranges from harmless mucosal

sloughing to frank Necrosis

• Causes
– Aggressive stripping of mesentery
– Stenotic fascia defect
– Extensive tension

• Assess depth of necrosis

Necrosis beyond fascial defect warrants
immediate reconstruction
 Early Complications of Stoma
Retraction
• 1-6% for colostomy and 3-17% for
ileostomy

• Most common reason for re-operation

• Causes :
– Tension
– Obesity
– Steroids use. Poor wound healing

• Can lead to leakage and severe skin

problem, more in ileostomy

Risk of faecal peritonitis – Back to theatre

 Early Complications of Stoma
Stoma not working well ..

• Edema

• Ileus

• Obstruction at abdominal wall

• Retraction

Edema
 Early Complications of Stoma
High output stoma

• Commonly occur with ileostomy

• More than 500c per day

• Lead to electrolyte disturbance , K+

Edema
 Early Complications of Stoma
Leaking
(Poor position & Muco-cutaneous separation)

• Separation along mucocutaneous border

• Occurs to some extent in many patient

• Caused by underlying tension and or

separation of sutures

• Supportive care usually resolve problem

• Could lead to eventual stricture,

Edema
serositis or infection
 Late Complications of Stoma
Skin complication
Contact Dermatitis
• 3-42% Incidence
• Range from mild skin dermatitis to full-
thicknes skin necrosis and ulceration

• More common with illeostomy

• Skin Erosion from constant exposure to stoma
effluent

• Contact dermatitis Effluent Irritation

• Intervention
– Better fitting appliance
– Improve cleaning of peristomal skin
– Application of desents and skin barriers
Edema
– Anti fungals and antibiotics
– Stoma paste
Late Complications of Stoma
Skin complication

Foliculitis Candida albicans infection

 Late Complications of Stoma

Pyoderma Gangrenosum
• First described associated with
Crohn’s in 1970

• Diagnosis mainly by physical

exam (80%)

• “Cookie cutter” appearance

• Treatment conflicting
– Wound debridement
– Steroids injection
– Systemic therapy
 Late Complications of Stoma
Stomal Stenosis/Stricture
• Occurs at the mucocutaneous junction, due
to Ischemia, infection and cellulitis which is
followed by scarring

• Treatment should include refashioning of

colostomy site with excision of skin disc

• 2-14% incidence

• Could manifest early or late

• R/o Crohn’s or recurrent

malignancy

• Treat initially with dilation

• Definitive Stoma revision

 Late Complications of Stoma
Infection/Fistula
• Incidence of 2-14.8%

• Peristomal abscess
– infected hematoma
– Stoma revision
– Foliculitis for mature stomas

• I &D

• Fistula may form from Abscess

• Beyond immediate post op,

fistula formation or infection
could be signs of recurrent
Crohn’s disease
 Late Complications of Stoma
Prolapse
• 2-26% incidence

• Seen mostly in transverse loop

colostomy (30%)

• May occur with parastomal

hernia

• Managed by reduction and

supportive care until definitive
surgery

• Convert to end colostomy if need

be
 Late Complications of Stoma
Prolapse

Ileostomy Prolapse Loop colostomy Prolapse

 Al-Shifa’ Hospital
13 Nov. 2015

Ileostomy Prolapse
 Late Complications of Stoma
Parastomal Hernia

• 50% of patients
• Predisposing factors
– Stoma placement lateral to rectus
– Large stoma aperture
– Obesity
– Prior abdominal incisions
– Malnutrition
– Wound infection

• Minor cases- Abdominal binder

• Symptomatic – Repair with mesh,

Relocation

“ 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, 1996
Late Complications of Stoma
Parastomal Hernia
 Complications Summary
Immediate
• Bleeding
• Ischaemia/necrosis: This is generally the result of technical failure and is usually if
the stoma is formed under tension or a poor blood supply
Early
• High output: Ileostomies may put out more fluid than expected (normal 500ml/day)
with massive salt and water loss, which must be corrected
• Obstruction
• Retraction (especially loop colostomy)
Late
• Obstruction
• Prolapse
• Parastomal herniation
• Fistula formation (especially with ileostomies)
• Skin irritation (especially with ileostomies)
• Fluid and electrolyte imbalance. (Ileostomy Flux).
• Psychological
 How to differentiate a colostomy from ileostomy?
Colostomy Ileostomy
Site Rt. upper abdomen (temp.) Rt. iliac fossa
Lt. iliac fossa (permanent)
Effluent(discharge) Formed feces or feculent Fluidy
fluid
Color of discharge Brownish or Blackish Brownish, Greenish,
Yellowis
Odor of discharge Very offensive (excessive Less offensive
gases)
Stoma shape Large Small
Constructed flush or slightly Constructed as a nipple like
elevated from the skin projection above the skin
(spouted)
Reaction of the Usually normal Erythematous, edematous
surrounding skin ;from enzymatic digestion
F&E problems Less common More common problem
 Stoma Appliances
Stoma appliances are devices, which are used to collect and
dispose the effluent materials which come out of the stoma.

Ideal stoma appliance is

• Leak proof

• Should not damage the stoma and

surrounding skin

• Should prevent odour

• Should be available

• Easier to use
Types of stoma appliances:

1- Two piece
• Bag and ring are separate
• Advantage: less trauma to the stoma from frequent
changing.

2- One piece
• Bag and ring are matted
• Disadvantage: higher chance of trauma to the stoma
with granulomas and bleeding, excoriation and
ulcerations around the stoma.
Stoma care
General Care and Advice to Patients with Stoma

• Patient can have normal diet. Diet, which regulates the bowel action, is better.
Plenty of water is advisable.
• Patient can go for normal work, exercise like sports, swimming, tennis. Stoma
appliances suitable for these works are available.
• Antidepressants, anticholinergics might cause constipation. So these drugs
should be taken carefully.
• Using irritant solutions near stoma should be avoided.
• Patient can have normal sexual activity.
• Patient should have additional stoma bags in hand so as to use if required
urgently.
• Patient should be aware of different appliances available and should be well
versed with its use.
• http://www.medicinenet.com/colostomy_a_p
atients_perspective/page5.htm

• http://www.cancerresearchuk.org/about-
cancer/type/bowel-cancer/living/