Stomas and Fistulas

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?

  1. 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?

  1. 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
  1. 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

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