Intestinal stomas

• Definition

• Classification

• Principles of stoma formation

• Attachment of the stoma appliance

• Complications of intestinal stomas

• Dietary advice to ostomates

Definition

Intestinal stomas are,

surgically created openings of small or

large intestines onto the anterior

abdominal wall.

COLOSTOMY

INTESTINAL STOMA

ILEOSTOMY

Classification

COLOSTOMY

INTESTINAL STOMA

ILEOSTOMYEND STOMAConsists of

a single intestinal lumen

LOOP STOMAGives access to

both afferent & efferent limbs

Classification

INTESTINAL STOMA

Classification

PERMANENT TEMPORARY

Principles of stoma formation

1. Discussion –

Discuss the possibility of a stoma with patients

undergoing elective or emergency colorectal

surgery.


2. Assessment – by stoma therapist

Assess the patient preoperatively – lying down

sitting

standing

Mark the best site for a stoma.

• Area should be easy to see and access.

• Avoid bony prominences (e.g. iliac crest, rib cage),

scars, skin creases, anticipated surgical wounds &

belt line.



3. Stoma creationCreate an opening (about the width of 2 fingertips) in

anterior abdominal wall.

Deliver well-vascularized, tension-free segment of

bowel through the rectus abdominis.

Close any other wounds

Open bowel & secure to skin with evenly spaced

absorbable sutures.


3. Stoma creation – Ileostomy

Ileostomy effluent –

• Liquid.

• Frequently at alkaline pH.

• Contains activated digestive enzymes.

• Discharged almost continuously.

• Excoriates & digests skin.


3. Stoma creation – Ileostomy

• Elevate the ileostomy opening 2-3 cm from skin

to ensure the effluent passes directly into a

stoma bag with minimal contact with skin.

• Ileum is everted on itself to form a spout.



3. Stoma creation – Colostomy

Colostomy effluent-

• Formed faeces.

• Discharged intermittently.

• Not directly corrosive to skin.

• Usually falls directly into stoma bag.


3. Stoma creation – Colostomy

• Colostomies are sutured flush with skin.

• Allowed to pout slightly to prevent retraction after

weight gain.


• In right iliac fossa

• Usually a permanent stoma

Electively - Proctocolectomy for:

► inflammatory bowel disease or

► familial adenomatous polyposis coli

END STOMAS - End ileostomy

• Usually temporary in the emergency setting

►Subtotal colectomy with end ileostomy-in fulminant or perforated ulcerative colitis.

in distal obstruction of large bowel where caecum is non viable or perforated.

►After a segmental resection of small bowel where primary anastomosis is unsafe.

e.g. perforated Crohn’s disease,

thromboembolic bowel ischamia



• In temporary end ileostomy:

Distal bowel

closed &

left in abdomen

exteriorized

as a mucous fistula





Relaparotomy to restore intestinal continuity when the patient has recovered (after 3-4 months).

END STOMAS - End colostomy

• Usually in left iliac fossa.

• Frequently sigmoid colostomies.


Abdominoperineal excision for anorectal tumours

• a permanent end colostomy

• an elective surgery



Hartmann’s procedure

• In emergency setting.

• For ischaemia, perforation or obstruction of

distal colon or rectum.

• Potentially reversible 3-4 months later.

• Patients are often elderly & frail. 40% never

undergo reversal.


Hartmann’s procedure

• Most common in terminal ileum, transverse

colon & sigmoid colon.

• A loop of bowel is brought to the anterior

abdominal wall & held in place by a plastic

bridge passed through the mesentery.

• Bowel wall is incised & edges are sutured to

skin.

• Plastic bridge is removed when mucocutaneous

anastomosis has matured (after 5-7 days).

LOOP STOMAS

LOOP STOMAS

• In general, temporary stomas.

• Can be reversed via the stoma site 2-3 months

after formation.

• Used to divert faecal stream to protect -

►a distal anastomosis after low anterior

resection.

►Difficult anal sphincter repairs.

►Complex perianal fistula procedures.

LOOP STOMAS

A loop transverse colostomy

can be done to

defunction an anastomosis

after an anterior resection.

LOOP STOMAS

Stoma appliance

Pouch (Bag)Protective skin barrier

Closed-end Drainable

Remains on the skin

between bag changes &

needs to be changed

every few days.

• Cut the central hole of the

skin barrier to match the

diameter of the stoma.

Attachment of the stoma appliance

• Gently clean the stoma & peristomal skin.

• Dry the peristomal skin & apply filling paste

on it.

• Remove the sticker of the

skin barrier.

• Fix the skin barrier to the

peristomal skin.


• Clip the other end of the pouch.

• Finally apply plaster around the skin barrier.


• Fix the pouch to the skin

barrier.


Complications of intestinal stomas

Early

1. Ischaemia

2. Retraction

Late

1. Stenosis

2. Prolapse

3. Parastomalherniation

4. Obstruction of small bowel

5. Haemorrhage

6. Diversion colitis

7. Dermatitis

8. Psychological

• Ischaemia

Stoma should be pink & moist.

When ischaemic grey / black & dry



Complete retraction into

peritoneal cavity

Peritonitis

Partial retraction

Subcutaneous tissue is

exposed to faecal

contents

Peristomal cellulitis,

abscesses & fistulae

• Retraction


Predisposing causes:

►Aponeurotic opening

too small

►Stomal ischaemia

►Recurrence – Crohn’s

disease

Severe stenosis

Intestinal obstruction

• Stenosis


• Stomal prolapse

Predisposing factors:

►Aponeurotic opening too large

►Excessive mobilization of redundant bowel

►Raised intra-abdominal pressure

Common in loop colostomies.


• Parastomal herniation

The most common late complication of end

colostomies.

Occurs in up to 30% of stomas.

Incidence increases with time.

Predisposing factors – similar to those for

prolapse.


• Obstruction of the small bowel

Occur particularly in loop stomas. (10-15%)

Attributed to intra-abdominal adhesions.


• Haemorrhage

Can be due to:

►A trvial bleed from a fragile granuloma

►Recurrent / novel gastrointestinal disease

►Parastomal varices between the veins of

mesenteric & anterior abdominal wall –in patients with portal hypertension


• Diversion colitis

Chronic inflammation of the distal bowel left in

situ when faecal stream is diverted away.

May develop bloody discharge from rectum.


• Skin manifestations

Faecal irritant dermatitis



Contact dermatitis from occlusive appliances

Allergic responses to adhesives

Fungal & bacterial infections



Peristomal psoriasis in a patient with Crohn's

disease.


Peristomal cutaneous Crohn's disease



Peristomal pyoderma gangrenosum in a patient

with ulcerative colitis.


Dietary advice to ostomates

• Take low fibre food to reduce bulk in stool & help prevent intestinal obstruction.

• Avoid vegetables known to result in offensive odour.

×Raddish

×Cabbage

×Garlic

×Cucumber

• To reduce flatus, avoid:

× carbonated beverages

× chewing gum

× smoking

• Chew food well.

• Drink adequate amounts of water.

Dietary advice to ostomates

Intestinal stomas

Health & Medicine

anterior abdominal

temporary

stoma formation

end ileostomy

end stomas

stoma formation

loop stomas

peristomal