STOMA
Prepared By: Wasihun Endalek
Cont….
Ileostomy
• 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.
• It can be loop or end made temporarily or permanently.
• It should be 5cm lateral to the umbilicus and brought out through the
lateral edges of the rectus abdomens muscle.
• It is usually made in the Rt. Iliac fossa.
Temporary ileostomy
• used to protect an anastomosis that is at risk for leakage.
• It included patients
Immunocompromised
Malnourished
Previous radiation to the pelvis
Emergency condition
On steroids and immunosuppressive therapy
• The stoma often is constructed as a loop ileostomy.
• Closure often can be accomplished without a formal laparotomy.
• Endoscopy exam & contrast enema are recommended before closure to ensure that the
anastomosis has not leaked & is patent.
Permanent ileostomy
• After total proctocolectomy for patients with IBD or familial
adenomatous polyposis
• End ileostomy is preferred configuration for a permanent ileostomy
Loop ileostomy
indications
used as an alternative of a loop colostomy for Dysfunctioning (for
protection)
1- Low rectal anastomosis following a anterior rectal resection
procedure.
2- Ileoanal pouch procedure following Total proctocolectomy.
End ileostomy
The end of the ileum is eveted to create a spout under the skin to
anchor the ileum in place
indications
Used In cases where total proctocolectomy is done.
1- Ulcerative colitis.
2- Crohn’s disease.
3- Familial polyposis Coli.
COLOSTOMY Vs ILEOSTOMY
Preoperative preparation
• Education – counseling help the patient to coup up psychological
stress associated with Stoma
• includes stoma site selection,
• preoperative and postoperative technical advice,
• emotional support, discharge planning, outpatient follow-up, and
ongoing rehabilitation care for the patient and family
Cont’d …site selection
• The ostomy placement must be;
• at least 5 cm from all folds,
• creases, previous incision,
• belt line, umbilicus, and bony prominences because these can
interfere with the appliance adherence
-This is particularly important in patients who are morbidly obese or
who have had prior abdominal surgery
Complication
• The incidence of ostomy complications ranges from 14 to 79 percent
• Complications vary with type of ostomy, with the least complications
occurring in patients with end colostomies and ileostomies .
• Loop ileostomies are associated with the highest complication rates
• Risk factors for developing complication
• Absence of peri-operative siting
• Height of stoma <10 mm
• Emergent stoma formation
• Comorbid medical illnesses, such as obesity, Crohn’s disease, inflammatory bowel disease, diabetes
• Tobacco usage
• Ideally ileostomy out put should be maintained < 1500ml/d to avoid complications
Cont’d
• Complications are typically categorized into early or late occurrences.
Early complications
• include inappropriate stoma site, stomal necrosis, stomal retraction,
mucocutaneous separation, peristomal skin dermatitis, surgical
wound infection, and sepsis.
• Many complications occur within days after ostomy construction and
are primarily related to technical failures.
• Early complications are defined as those occurring within three
months of stoma construction
Early complication
• Inappropriate stoma site — A poorly sited stoma increases the risk of complications (eg,
leakage, skin irritation, skin breakdown) and adversely affects the patient’s quality of life
• Stomal necrosis — Ischemia or necrosis of the stoma typically results from either venous
congestion from excessive tension, arterial insufficiency from aggressive mesenteric
dissection, or a tight fascial aperture.
• The incidence is as high as percent in the immediate post-operative period .
• Emergency surgery, obesity, and inflammatory bowel disease, in particular Crohn’s
Disease, have been identified as independent risk factors for stomal necrosis
• Adequate mobilization of the bowel, preservation of the blood supply to the stoma, and
an adequate trephine are critical factors for avoiding this complication.
Early complication cont’d..
• Stomal retraction — Stomal retraction is defined as a stoma that is
0.5 cm or more below the skin surface within six weeks of
construction .
• Less problematic with colostomy than ileostomy, why?
• The best method to prevent stomal retraction is to construct a stoma
at least 10 mm high for colostomies and 2 to 3 cm high for
ileostomies.
Early complication…
• Peristomal skin dermatitis — Peristomal skin irritation is more common for
patients with an ileostomy . Why?
• Treat allergy using steroid & fungal infection with nystatin or miconazole
• Creating a protuberant spout for the ileostomy approximately 2 to 3 cm high is the
best method to avoid direct contact of effluent with the skin
• Mucocutaneous separation — may be partial or completely circumferential.
• Results in leakage and skin irritation.
• Complete dehiscence of the suture line.
Reference
Schwartz principles of surgery 9ED
Sabiston text book of surgery 19ED
Uptodate 20.3