Intestinal Stomas and Their Complications

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Intestinal Stomas and Their Complications

• 26 March 2008
• Thomas Garofalo, MD, FACS
• Cleveland Clinic East Region

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Disclosure

• No affiliations

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Introduction

• Can serve as the end of the gastrointestinal and
  urinary tracts
• Can be used to protect distal anastomoses
• Relieve obstruction

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Ileostomy Colostomy

• Mucosal Ulcerative Colitis
• Crohns Disease
• Familial Adenomatous Polyposis
• Cancer

• Cancer
• Diverticulitis
• Trauma
• Hirschprungs
• Rectal atresia

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Stoma Construction

• Discussion with
• surgeon
• ET Nurse
• patient
• Marking
• Surgery
• Teaching
• Follow-up

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Marking
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Poorly Marked
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Complex Marking
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Surgery
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Loop Ileostomy
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Results
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End Ileostomy
?
?
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Loop End Ileostomy
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Complications

• Wrong placement
• Fistula and abscess
• Too tight
• Large stoma incision
• Dead stoma
• Mucosal implants
• Stoma Prolapse
• Hernia
• Parastomal varices secondary to portal HTN

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Parastomal Abscess Drainage
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Ischemia
Mucosal ischemia
Gangrenous ischemia
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Stoma Prolapse
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Stomal Prolapse
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Indications for Repair

• Pouching problems
• Stoma is constantly injured
• Incarceration
• Unacceptable body image

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Difficult to Reduce?
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Parastomal Hernia Disposition

• Obesity
• Large abdominal wall aperture
• Stoma location outside rectus
• Previous hernia surgery

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Hernias
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Management

• Non-surgical
• -no symptoms
• -abdominal binder
• Surgery
• -abdominal pain
• -incarceration/strangulation/obstruction
• -difficulty maintaining an appliance

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Surgical Repair

• Direct fascial repair
• Mesh repair
• Stoma relocation
• Extra peritoneal stoma

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Parastomal Hernia RepairRadial Approach
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Radial Incision
Hernia Contents
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Stomas and Portal Hypertension
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Treatment of Stomal Varices
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Obstructing Rectal Cancer
What would you do?
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Turnbull Blowhole
Turnbull Weakley Atlas
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Decompression
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Blowhole Formation
Turnbull Weakley Atlas
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Turnbulls Subcutaneous Support Rod
Courtesy Dr. Turnbull ca. 1970s
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Complications Related to Stoma Closure

• Outcome in 1504 patients
• 11.4 complication rate
• SBO 6.4
• Wound infection 1.5
• Abdominal septic complication 1
• ECF 0.6

Wong, Remzi 2005 DCR
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Small Bowel Obstruction

• Most common complication N97
• N83 (86 ) within 30 days
• N72 (74 ) managed conservatively
• N25 (26) patients needed surgery
• No difference between handsewn and stapled
  anastomosis

Wong, Remzi 2005 DCR
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Wound Infection

• Closed ileostomy sites had higher rate of wound
  infection compared to the ones that were either
  partially closed or left open

Wong, Remzi 2005 DCR
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Abdominal Septic Complications

• N-15 (1)
• 5 patients with pelvic abscess managed
  non-operatively
• 10 patients were operated
• 6 anastomotic leaks
• One leak from an enterotomy that was repaired
  during the surgery
• One unrecognized enterotomy
• Two with no apparent source

Wong, Remzi 2005 DCR
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ECF

• N9
• 6 closed with conservative therapy
• 3 needed surgery

Wong, Remzi 2005 DCR
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Final Thoughts

• Careful Pre-op preparation
• When in doubt, pick a safe place
• Use sound surgical principles

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