Stomas
Definition:
- Opening of hollow viscus to outside
Classifications:
- Temporary or permanent
- Involved organ
- Configuration:
- Loop (post wall is maintained)
- Double barrel (divide the whole circumference, ending up with two openings)
- The reason for it:
- Protective for anastomoses (no stool passing through it to allow healing),
- Decompression of distal obstructive recto-sigmoid tumor
So, the stoma name can include all of these classifications: e.g.:
- Temporary protective loop ileostomy
- Decompressive transverse loop colostomy
Side note: If the proximal opening in a double barrel stoma serves the point of a stoma (where food exists from), why don’t we close the distal opening? To release a distal obstruction, if you leave it closee -> you end up with a closed loop -> pressure increases due to mucus build up and gas fermentation from bacteria -> perforation. The other non-functioning end is called a mucous fistula
Side note: In cases of distal tumor causing obstruction -> do an emergency decompression stoma instead of doing an oncological resection of the tumor, why?
- Risk of leak
- Not giving the pt a chance at neoadjuvant, which can lower the recurrence
- The pt might have synchronous tumor, which if discovered pre-op, would change the resection plan
Where to put the stoma?
- W\in rectus sheath (to give support)
- Away from bony prominence (for the stoma’s appliances to fit nicely)
- Away from main laparotomy scar (so that stool won’t contaminate surgical site)
- Away from active skin lesions and prev scars
- Away from skin creases (in non-emergency -> mark the stoma site pre-op with the pt laying down and standing up so the pt can see it both supine and erect)
Complications:
- Acute
- Necrosis: always due to a technical problem; twisting of the mesentery or it’s under tension -> leads to leaking of the dead stoma
- Hematoma
- Bleeding
- Consequences of the stoma:
- Fluid\electrolyte imbalance
- Skin excoriation and irritation
- Parastomal herniation
- Stoma prolapse of the mucosa
- Retraction
- If ischemia (not severe\acute enough to cause necrosis) -> fibrosis-> stenosis
CASE: Parastomal hernia pt, operated 2 yrs ago. What’s the first question you need to answer?
- Does this pt still need the stoma?
- Parastomal hernia can be a killer and easily missed, esp in obese pts
Enterocutaneous Fistula
Definition:
- Abnormal communication between 2 epithelialized surfaces
Factors affecting spontaneous closure [FRIENDS]:
- Foreign body
- Radiation
- Inflammation (e.g. IBD) or infection (sepsis; local\systemic)
- Epithelialization of fistula tract
- Neoplasm
- Distal intestinal obstruction
- Steroids
QUESTION: 2 fistulas, one is 2 cm, the other is 10 cm. Which fistula will heal faster?
The longer one is more likely to heal faster, why?
- Epithelialization
- The shorter one is more likely to fully epithelialize, while the longer one will have the 2 ends epithelialized and the middle part will collapse
- Pressure
- Short -> high pressure -> stays open
- Long -> low pressure -> more likely to collapse -> fibrosis
Download the PDF version: here
References:
- Dr Alabeidi’s lecture and clinical notes
