Problems with ileostomies

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Problems withileostomies

• Mr Paul S Rooney
• Colorectal surgeon
• Royal Liverpool Hospital

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ileostomy

• End (Brown 1930)
• Everted (Brooke 1952)
• Loop (Turnbull 1961)

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Generic Problems

• Eczema
• Poor seal
• Sweating
• Hygiene
• Psychological (unnecessary changing)
• Physical and metabolic

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Physical problems

• Retraction
• Ischaemia
• Necrosis
• Abscess
• Fistula
• Recurrent disease
• Bleeding
• Hernia
• Pyoderma
• Everting wrong end

• Tension,obesity
• Iatrogenic
• Crohns,Cancer
• Varicies
• negligence

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Varices

• Portal hypertension
• ALD
• Sclerosing cholangitis
• Liver mets

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Treatment

• Injection of sclerosant , phenol,alcohol.
• Needs repeat every 6weeks (Major 86)
• Muco-cutaneous disconnection easy!
• 20 recurrence in 30 months (Beck 88)

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Hernia

• 10-40
• 20 require surgery (pain,obstruction etc)
• Repair by non absorbables 50 recurrence
  rate.(Allen-Mersh (1988)

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Mesh or Move?

• Heamatoma
• Infection
• Erosion
• Low recurrence ratelt1_at_5y (Bokey 2003)

• Laporotomy risk?
• Poorly sited likely to benefit
• Decision depends on patient factors and number of
  previous repairs

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ileostomy Flux

• Normal 3-800ml/day
• gt10cm resection significantly increases flow
• Infection
• Radiation
• Crohns, cancer
• Obstruction 4-5l/day!

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Flux

• Losses of gt1L need replacing as saline
• 1.5l need admitting
• Can fatally induce Addisonian crisis
• 100mg hydrocortisone qds (lifesaving)
• Renal failure
• Somatostatin PPIs

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Metabolic

• Chronic dehydration
• Anaemia ,low ferritin
• Low B12, Na, K
• Urate and calcium stones
• Gall stones (loss of bile salts)

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Closure

• V easy or VV Hard
• Try to avoid early closure wait 6 weeks at least
• 50 complication rate inc death!
• No one way of closure appears to be best
• (Hosie 1991)

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Stoma problems
Retraction
Excoriation
Prolapse
Necrosis