Lessons 26-27: Stomal Complications

Question 1

Stomal Necrosis

Answer 1

Due to impaired blood flow
- Tension on mesentary
- Excessive stripping of mesentery
- Surgical trauma

Risk factor = obesity
- Presentation
- Change in colour from pink/red to dark purple/gray/black
- Change in hydration status
- Loss of no real turgor
- Can involve all parts of the stoma
- Can limit to stoma or extend to proximal bowel

Management
- Regular assessment of stoma throughout early post-op period
— Test tube endoscopy PRN
- If necrosis limited to stoma
— Ongoing monitoring
— Necrotic tissue with slough
— Debridement PRN
- If necrosis extends to proximal bowel
— Urgent surgical revision

Question 2

Mucocutaneous Separation

Answer 2

• breakdown of suture line attaching stoma to skin

Risk factors
- tension on suture line
- compromised healing d/t steroids/malnutrition

Management
- Small/superficial defects
— Ostomy powder covered with barrier ring + pouch
- Large defects extending to subcutaneous/fascia level
— Absorptive dressing to fill defect covered with barrier ring + pouch
— Alginate or hydrofiber dressing
- Extends beyond fascia
— Surgical repair to prevent intra-abdominal contamination

Question 3

Stomal Retraction

Answer 3

• Loss of stomal protrusion
• Os empties at or below skin level

Risk factors
- Stoma site not marked preop
- Obesity
— Tension on stoma and mucocutaneous suture line
— Mesentery is short, thick, and abdo wall is thick
- Adhesions limited bowel mobility
- Stomal necrosis
- Mucocutaneous separation

Management
- Assess stoma + os location in various positions
- Modify pouching system to obtain secure seal
— Use of convexity and belt

Question 4

Stomal Stenosis

Answer 4

Narrowing of stomal lumen
- interferes with stomal functioning + elimination of urine/stool
- at skin level and/or fascia level

Risk factors
- mucocutaneous separation
- stomal necrosis
- chronic inflammation
- repeated stomal dilations

Presentation
- fecal diversion
— pain with eleimination
— small, ribbon-like stools
— episodes of no output, followed by explosive elimination
- urinary diversion
— projectile urine stream
— flank pain
— recurrent UTIs

Management
- Fecal
— Hydration
— Low fiber diet
— Stool softeners
— Colostomy irrigation
- Urinary
— Hydration
— Monitor for UTIs + renal damage

Question 5

Stomal Malignancy

Answer 5

• Biopsy any unexplained stomal or peristomal lesions
• consult appropriate service

Question 6

Stomal Trauma

Answer 6

• Damage to stoma d/t pouching system
• Can occur d/t seat belt trauma
• Presents as linear lesions or dusky/friable

Question 7

Stomal Prolapse

Answer 7

Intestine telescopes through stoma

Risk factors
- Large opening in fascia/muscle for stoma creation
- Location of stoma outside rectus muscle
- Increased abdominal pressure
- Crying in infants
- Coughing
- Straining
- Obesity

Assessment
- Length + severity of prolapse
- Stoma viability and function
- Ischemia
- Stoma color
- Evidence of congestion
- Stoma output
- Abdo distension
- Cramping pain
- Stomal trauma

Management
- modify pouching system
- attempt to reduce prolapse + wear binder

Question 8

Parastomal Hernia

Answer 8

Defect in fascia/muscle layer allowing loops of bowel through
- Creates bulge in soft tissue

Risk Factors
- obesity
- large fascia opening
- increased abdo pressure
- compromised healing

Prevention
- surgical technique
- appropriate post-op restrictions
- isometric core exercises (1 week post-op)
- active abdo exercises (6-8 weeks post-op)

Presentation
- Abdo pain/discomfort
- Bulge around stoma with coughing/sitting/standing
- Pouching problems
- Skin irritation
- Difficulty with colostomy irrigation

Management
- reduce hernia
- use of abdo supports
- surgical repair PRN