Stomas: Technical Considerations By: John N. Afthinos, M.D.

Patient Preparation Patient education Patient education –Disspell myths –Confront patient’s fears Enterostomal therapist Enterostomal therapist –Involvement from the pre-op period improves outcomes

Patient Preparation Stomal marking Stomal marking –Center of triangle bounded by umbilicus, ASIS, and pubis Through rectus abdominus Through rectus abdominus Have pt lie down, sit and bend forward Have pt lie down, sit and bend forward Avoid creases, scars, bony prominences, belt line Avoid creases, scars, bony prominences, belt line

Types of Stomas End End –Often in more permanent situations, but not necessarily APR APR Loop Loop –For temporary diversions of fecal stream –Theoretically technically easier to restore continuity Technique Technique –Brooke 1952: suture mucosa directly to the skin

Basic Function and Care Ileostomy Ileostomy –Begins to 48 – 72 hrs –Initially green, viscous secretions Not a sign of true peristalsis Not a sign of true peristalsis –Adaptation phase 1.5 – 1.8 L/d 1.5 – 1.8 L/d Compensating for loss of colon and ileocecal valve Compensating for loss of colon and ileocecal valve

Basic Function and Care Ileostomy Ileostomy –Stool thickens to toothpaste consistency –Final outputs range from 0.5 and 0.8 L/d Sigmoid/Descending Colostomy Sigmoid/Descending Colostomy –Function returns on ~POD 5 –Soft formed stool with a pre-op elimination pattern

Basic Function and Care Ostomy Management Ostomy Management –Application of pouch system in OR Collects secretions and protects skin Collects secretions and protects skin –Cut aperture to 1/8” from stoma to protect skin and prevent mucosal trauma Frequent resizing for 4 – 6 weeks post-op Frequent resizing for 4 – 6 weeks post-op –Skin protectants limit irritation from frequent appliance changes NOT for use with ileostomies NOT for use with ileostomies

Basic Function and Care Skin Barrier Skin Barrier –Adherent porous material that protects skin from stoma output—especially ileostomies –Must preserve skin integrity so appliance adheres and prevent leakage –Examples: karaya, Stomahesive Pouch Pouch

Basic Function and Care Frequency of Changes Frequency of Changes –Enough to prevent leakage and skin irritation Average of about 5 – 7 days Average of about 5 – 7 days

Complications Stomal Necrosis Stomal Necrosis –Ischemia from venous congestion, inadequate supply, small fascial opening –Dusky, blue mucosa—eventually black and necrotic –If not corrected, the stoma may retract into the abdomen

Complications Retraction ~18.5% incidence Retraction ~18.5% incidence –Usually from stomal ischemia but also from weight gain –Can cause peritonitis, enterocutaneous fistula, or stricture of stomal opening –Repair by: circumcising ostomy at skin and recreation circumcising ostomy at skin and recreation formal laparotomy and recreation formal laparotomy and recreation Panniculectomy with abdominoplasty Panniculectomy with abdominoplasty

Complications Prolapse Prolapse –Overall rare but seen more often after loop colostomy –Oversized fascial opening, sudden Valsalva, redundant loop of bowel leading to stoma –If acute, reduce immediately either with gentle pressure, or sugar if manually irreducible

Complications If occurs late If occurs late –Circumcise the mucosa and excise redundant colon –Re-anastomose the distal mucosa to the proximal If occurs early If occurs early –Circumcise at mucocutaneous junction

Complications Peristomal Hernia Peristomal Hernia –Reportedly, 2.8% rate if through rectus –Causes include placement lateral to rectus, too large a fascial opening, age, chronically increased abdominal pressure –If defect small, circumcise colostomy, repair defect and remature stoma Can repair defect with mesh Can repair defect with mesh

Complications Peristomal Hernia Peristomal Hernia –If defect larger and no room in the rectus sheath, then recreate at umbilicus or contralateral rectus