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Dr Nagham Al-Mozany Colorectal Surgeon Auckland City Hospital - PowerPoint PPT Presentation

Dr Nagham Al-Mozany Colorectal Surgeon Auckland City Hospital Clinical Senior Lecturer University of Auckland 11:00 - 11:55 WS #121: Coping with Difficult Stomas 12:05 - 13:00 WS #134: Coping with Difficult Stomas (Repeated) COPING WITH


  1. Dr Nagham Al-Mozany Colorectal Surgeon Auckland City Hospital Clinical Senior Lecturer University of Auckland 11:00 - 11:55 WS #121: Coping with Difficult Stomas 12:05 - 13:00 WS #134: Coping with Difficult Stomas (Repeated)

  2. COPING WITH DIFFICULT STOMAS- BRIDGING THE GAP DR. NAGHAM AL-MOZANY CONSULTANT GENERAL & COLORECTAL SURGEON AUCKLAND CITY HOSPITAL & MACMURRAY CENTRE

  3. BRIDGING THE GAP Knowledge Doctor-patient relationship Patients with stoma & Family/Society

  4. OBJECTIVES • Definition and types of stomas • Indications for stoma formation • How to recognize the type of stoma? • Recognizing the complications? • How to manage simple complications ? • When to refer ? • Support services available?

  5. DEFINITION

  6. INTESTINAL STOMA

  7. CLASSIFICATION OF STOMAS Stoma Temporary vs. Permanent Source Type Technical type

  8. ILEOSTOMY

  9. Ileostomy consistency: TOOTH-PASTE!

  10. Loop/Defunctionning Ileostomy

  11. HOW CAN I TELL THE DIFFERENCE?

  12. WHO CARES? • Effect on reversibility of the stoma in future? • Volume of output? • Effect on complications?

  13. WHO CARES? Effect on reversibility of the stoma in future? Potentially Yes if End ……and YES if Loop Volume of output? 1 L Effect on complications? -High output >1L -Dehydration/Electrolyte imbalance -Skin issues -Leaking bag

  14. COMPARISON BETWEEN STOMAS Table 1.

  15. ILEAL CONDUITS URINARY DIVERSION • Form of Urostomy • Diverts urine if bladder has been removed • Common problem is urine infection • Issues: Refer to Urology

  16. A SURGEON’S PERSPECTIVE

  17. Indications for surgery/stoma formation

  18. TECHNICAL ASPECTS OF STOMA FORMATION

  19. POST-OPERATIVE COMPLICATIONS

  20. INDICATIONS FOR STOMA TYPE

  21. INDICATIONS FOR ILEOSTOMY FORMATION Emergencies: • Conditions that require small bowel or colon resection and a primary anastomosis (“join”) which may be compromised • Friable unhealthy bowel tissue unable to hold a suture: • Long-standing peritonitis or obstruction • Radiation • Crohn’s disease • Perforation • Trauma • Severe infection

  22. INDICATIONS FOR ILEOSTOMY FORMATION Elective: • Surgery for rectal cancer or inflammatory bowel disease • Technically easier to reverse

  23. INDICATIONS FOR COLOSTOMY FORMATION Emergencies: • Colonic obstruction from a cancer • Complicated diverticular disease • Trauma Elective: • Very low rectal cancers • Fistula • Severe incontinence • Radiotherapy • Severe perianal sepsis

  24. • Counselling • Stoma nurse specialists

  25. • Stoma management STOMA training EDUCATION • ↓Time to ostomy proficiency • ↓ Length of hospital stay • ↓ Unplanned interventions • Highly cost effective

  26. STOMA SITING Lying Standing Sitting

  27. STOMA COMPLICATIONS

  28. High Stoma output ?

  29. HIGH STOMA OUTPUT Risk factors:

  30. HIGH STOMA OUTPUT Dehydration • 30% of patients with new ileostomies • Fluid and electrolyte replacement strategies • Vitamin deficiencies and malnutrition • Avoid kidney failure • Dehydration and kidney failure are also the most common cause of unplanned readmission in stoma patients

  31. SO WHAT CAN YOU DO? • Enquire about stoma losses • Number of bag changes and volume in bag • Aim for 1L stoma loss for ileostomies • Regular Creatinine, UE checks, Albumin, Vitamins • Enquire about skin around stoma bag

  32. PARASTOMAL HERNIA • Risk factors: Poor tissues / weak musculature • Oversized apertures • Wound infections • Obesity • Smoking • Advanced age • Increased abdominal pressure after surgery

  33. SO WHAT CAN YOU DO? • Refer to stoma specialist for pouch/belt support • Refer to colorectal surgeon if symptomatic, for consideration of revision, re-siting, repair of hernia • Check integrity of stoma- not ischaemic or necrotic • Analgesia

  34. MANAGEMENT OF PARASTOMAL HERNIA

  35. • Operative repair / re-siting strategies • +/- Mesh use • Laparoscopic or Open surgery

  36. STOMAL BLEEDING • Poor pouching technique • Stoma rubs against an appliance resulting in trauma • More prevalent in patients with parastomal hernias and prolapse • Management includes patient education and pouch resizing to eliminate the causative factors • Refer to stoma nurse specialist

  37. MUCOCUTANEOUS SEPARATION Risk factors include: 1. Surgical wound infections 2. Oversized skin holes 3. Excessive suture tension 4. Stomal necrosis • Superficial separations can be managed by stomal therapists, who will fill the separation with an absorbant product to facilitate healing • Deep separations below the level of the abdominal fascia may warrant surgical revision

  38. NECROSIS • Occur within 1-5 days of surgery • Particularly the first 24 hours • Risk factors: 1. Oedema 2. Abdominal distension 3. Critical illness 4. Obesity 5. Tension

  39. SO WHAT CAN YOU DO? • Clinical assessment is important • Check tightness of the stoma appliance • Inserting a test tube into the stoma may aid in depth assessment • Refer acutely to Colorectal surgeon

  40. STOMAL PROLAPSE Risk factors: 1. Large abdominal wall opening 2. ↑ Abdominal pressure 3. Lack of fascial support 4. Obesity 5. Weak muscle tone and certain anatomical locations • Painless • ↑ risk of stomal trauma • ↑ risk of incarceration and ischaemia

  41. STOMAL PROLAPSE

  42. Patient is lying down and stoma is on the patient’s right

  43. Refer to stoma nurse specialist

  44. Refer to Surgeon

  45. STOMAL RETRACTION Risk factors: 1.Necrosis 2.Mucocutaneous separation 3. Crohn’s disease 4.Excessive tension Expert stomal therapist input is required/Refer

  46. STOMAL STENOSIS Result from: 1.Mucocutaneous separation 2.Ischaemia or necrosis 3.Following chronic skin irritation 4.Excessive scarring 5.Irradiation Management: Refer! 1.Dilation with gloved fingers +/- graded surgical dilating instruments 2.Stool softeners may assist in avoiding impaction

  47. A PATIENT’S PERSPECTIVE

  48. How do we bridge the gap between patients with stomas & family/society

  49. FAMILY AND SOCIETY

  50. A PATIENT’S AND SOCIETY’S PERSPECTIVE • Malodorous • Noisy • Unable to eat normal food • Unable to exercise • Unable to wear normal clothes • Unable to bath, shower, or swim • Unable to work • Unable to travel • Unable to have sex • Loss of partner and friends

  51. “THE STOMA EFFECT”

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