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Intestinal stomas
- Intestinal stomas are surgically created openings of the small or large intestine onto the abdominal wall. There are three main types: colostomy, ileostomy, and loop stoma. - Complications include prolapse, herniation, stenosis, dermatitis from effluent, and obstruction. Dietary advice focuses on reducing gas, bulk and odorous foods. Management involves properly attaching collection bags and monitoring for complications.
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Introduction to intestinal stomas, definitions, classifications (Colostomy, Ileostomy), and types.
Guidelines on creating stomas, including discussions with patients, assessments, and technical steps.
Details on end ileostomy and end colostomy, including indications for surgery and surgical processes.
Explanation of loop stomas, their temporary nature, and their purpose in diverting fecal streams.
Steps for attaching stoma appliances, including pouch types and proper cleaning techniques.
Overview of early and late complications associated with stomas, including ischaemia, retraction, and skin issues.
Nutritional advice for ostomates, including fiber management and foods to avoid for odor control.
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Intestinal stomas
- 1. • Definition • Classification •Principles of stoma formation • Attachment of the stoma appliance • Complications of intestinal stomas • Dietary advice to ostomates
- 2. Definition Intestinal stomas are, surgicallycreated openings of small or large intestines onto the anterior abdominal wall.
- 3.
- 4. COLOSTOMY INTESTINAL STOMA ILEOSTOMYEND STOMA Consistsof a single intestinal lumen LOOP STOMA Gives access to both afferent & efferent limbs Classification
- 5.
- 6. Principles of stomaformation 1. Discussion – Discuss the possibility of a stoma with patients undergoing elective or emergency colorectal surgery. Principles of stoma formation
- 7. 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. Principles of stoma formation
- 8. Principles of stomaformation 3. Stoma creation Create 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.
- 9. Principles of stomaformation 3. Stoma creation – Ileostomy Ileostomy effluent – • Liquid. • Frequently at alkaline pH. • Contains activated digestive enzymes. • Discharged almost continuously. • Excoriates & digests skin.
- 10. Principles of stomaformation 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.
- 11. Principles of stomaformation
- 12. Principles of stomaformation 3. Stoma creation – Colostomy Colostomy effluent- • Formed faeces. • Discharged intermittently. • Not directly corrosive to skin. • Usually falls directly into stoma bag.
- 13. Principles of stomaformation 3. Stoma creation – Colostomy • Colostomies are sutured flush with skin. • Allowed to pout slightly to prevent retraction after weight gain.
- 14. Principles of stomaformation
- 15. • In rightiliac fossa • Usually a permanent stoma Electively - Proctocolectomy for: ► inflammatory bowel disease or ► familial adenomatous polyposis coli END STOMAS - End ileostomy
- 16. • Usually temporaryin 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 END STOMAS - End ileostomy
- 17. END STOMAS -End ileostomy • In temporary end ileostomy: Distal bowel closed & left in abdomen exteriorized as a mucous fistula
- 18. END STOMAS -End ileostomy • In temporary end ileostomy:
- 19. END STOMAS -End ileostomy • In temporary end ileostomy: Relaparotomy to restore intestinal continuity when the patient has recovered (after 3-4 months).
- 20. END STOMAS -End colostomy • Usually in left iliac fossa. • Frequently sigmoid colostomies.
- 21. END STOMAS -End colostomy Abdominoperineal excision for anorectal tumours • a permanent end colostomy • an elective surgery
- 22. END STOMAS -End colostomy
- 23. END STOMAS -End colostomy 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.
- 24. END STOMAS -End colostomy Hartmann’s procedure
- 25. • Most commonin 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
- 26.
- 27. • 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
- 28. A loop transversecolostomy can be done to defunction an anastomosis after an anterior resection. LOOP STOMAS
- 29. Stoma appliance Pouch (Bag)Protectiveskin barrier Closed-end Drainable Remains on the skin between bag changes & needs to be changed every few days.
- 30. • Cut thecentral 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.
- 31. • Remove thesticker of the skin barrier. • Fix the skin barrier to the peristomal skin. Attachment of the stoma appliance
- 32. • Clip theother end of the pouch. • Finally apply plaster around the skin barrier. Attachment of the stoma appliance • Fix the pouch to the skin barrier.
- 33. Attachment of thestoma appliance
- 34. Complications of intestinalstomas Early 1. Ischaemia 2. Retraction Late 1. Stenosis 2. Prolapse 3. Parastomal herniation 4. Obstruction of small bowel 5. Haemorrhage 6. Diversion colitis 7. Dermatitis 8. Psychological
- 35. • Ischaemia Stoma shouldbe pink & moist. When ischaemic grey / black & dry Complications of intestinal stomas
- 36. Complications of intestinalstomas Complete retraction into peritoneal cavity Peritonitis Partial retraction Subcutaneous tissue is exposed to faecal contents Peristomal cellulitis, abscesses & fistulae • Retraction
- 37. Complications of intestinalstomas Predisposing causes: ►Aponeurotic opening too small ►Stomal ischaemia ►Recurrence – Crohn’s disease Severe stenosis Intestinal obstruction • Stenosis
- 38. Complications of intestinalstomas • Stomal prolapse Predisposing factors: ►Aponeurotic opening too large ►Excessive mobilization of redundant bowel ►Raised intra-abdominal pressure Common in loop colostomies.
- 39. Complications of intestinalstomas • 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.
- 40. Complications of intestinalstomas • Obstruction of the small bowel Occur particularly in loop stomas. (10-15%) Attributed to intra-abdominal adhesions.
- 41. Complications of intestinalstomas • 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
- 42. Complications of intestinalstomas • Diversion colitis Chronic inflammation of the distal bowel left in situ when faecal stream is diverted away. May develop bloody discharge from rectum.
- 43. Complications of intestinalstomas • Skin manifestations Faecal irritant dermatitis
- 44. Complications of intestinalstomas • Skin manifestations Contact dermatitis from occlusive appliances Allergic responses to adhesives Fungal & bacterial infections
- 45. Complications of intestinalstomas • Skin manifestations Peristomal psoriasis in a patient with Crohn's disease.
- 46. • Skin manifestations Peristomalcutaneous Crohn's disease Complications of intestinal stomas
- 47. • Skin manifestations Peristomalpyoderma gangrenosum in a patient with ulcerative colitis. Complications of intestinal stomas
- 48. Dietary advice toostomates • 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
- 49. • To reduceflatus, avoid: × carbonated beverages × chewing gum × smoking • Chew food well. • Drink adequate amounts of water. Dietary advice to ostomates