Stoma PDF - A Medical Guide

Stoma Mohammad Jundy Ostomy: 8. Fecal incontinence 9. Inflammatory bowel disease -...

Stoma Mohammad Jundy Ostomy: 8. Fecal incontinence 9. Inflammatory bowel disease - Os: mouth, opening, tomy: intervention 10. Abdominoperineal resection (End Stoma) - Artificial (surgical) opening between a hollow organ 11. Infections (necrotizing fasciitis, Fournier's gangrene & body surface (skin) or between 2 hollow organs. 12. Congenital disorders: imperforate anus, Hirschsprung's disease, NEC, Atreasia Stoma: Base Preoperative planning: Parts: - Counselling: explaining and understanding - Base: adhered to the by Adhesive material. Bag - Stoma Marking: - Bag: Connects to base & collects discharge. ➔ While standing, avoid skin folds Instructions: ➔ Avoid bony prominences and umbilicus - Opening of stoma must fit the size & shape of the stoma - exteriorized bowel must be: ➔ Prevent direct contact of intestinal discharge with skin. ➔ must brought through the rectus sheath. - Different types of bags according to nature of stoma ➔ non-stretched mesentery (↓ strangulation) ➔ Reach skin without tension (↓ retraction) Classification (based on): ➔ Opening: about 2 fingers (↓ parastomal hernia) *not wide* - Duration: Temproary or Permanent. ➔ Excise disc of skin not slit (↓ stenosis & obstruction) *not narrow* - Anatomical site: ➔ Colon – skin: Colostomy Based on duration: ➔ Ilium – skin: Iliostomy - Temporary stoma Indications: ➔ Stomach – Skin: Gastrostomy ➔ Temporary = Reversible, at least after 6 weeks (many uses) ➔ Urinary bladder – Skin: Cystostomy. ➔ Diffuse peritonitis patients (perforation) ➔ Ileum – Colon (2 hollow organs): Iliocolostomy ➔ Protect distal anastomosis - Construction type: - Permanent stoma indications: ➔ Loop stoma ➔ Sphincter or anal problems ➔ End stoma ➔ Fecal incontinence ➔ Loop – End stoma. ➔ Anus removal like abdominoperineal resection (APR) ➔ All can be used for both small & large bowel. APR: Indications for stoma: :‫بشكل عام االسباب‬ - Remove anus, rectum, & part of sigmoid colon 1. Protection of distal anastomosis ‫) حماية‬1 ‫) طريق مسدود‬2 - used in rectal cancer patients. 2. Large bowel obstruction 3. Bowel perforation ‫) نسيج متدمر‬3 4. Abdominal or perineal trauma 5. Rectal injury 6. Complicated diverticular disease (perforation) 7. radiation Complications  Stoma Mohammad Jundy Based on anatomy: Based on construction: Colostomy: Loop stoma: - Colon is brought through fascia & skin. - Stoma contains both limbs of bowel (proximal + distal) = whole loop - Stoma opening is flat (flush with skin) - Brought together through same fascial defect. - Appearance: Iliostomy: ➔ 2 openings near each other separated by thin septum. - liquid Discharge: ➔ Appear as one stoma (in a connected way) ➔ Alkaline Juice (digestive enzymes) >> ↑ skin irritation - Function: - Need protective mechanicms: ➔ Proximal opening: functional (stool passage) Nipple, volcano shaped A) Maturation process: ➔ Distal opening: non-functional (mucos drainage) ➔ Evert stoma edges: Spouted, proturded. ➔ So it decompress both sides in the same stoma ➔ Drain to bag directly without skin contact - Most are temporary. B) Evert ilial mucosa: - MC sites: Ileum & sigmoid colon ➔ Two stiches - Pros: easy to reverse ➔ Three stiches. - Cons: large stomal defect >> hernia, prolapse, peristomal sepsis. ‫ر‬ Comparasion (‫بالمحاضة‬ ‫اش‬ ‫(اهم ي‬ Iliostomy Colostomy Site Right iliac fossa Left iliac fossa Discharge Liquid Effluent (watery) Formed Stool (succus entericus) Solid material Intestinal juice/digestive enzymes Frequancy Continuous Intermittent Output (500-1300 ml/day) Output (200-700 ml/day) End stoma: Stoma Opening Spouted (Protruded) Flat (flush with skin) - proximal end: skin irritation More less ➔ Bowel pulled out to the skin (End stoma) electrolyte More less ➔ Functioning stoma (passage of stool) imbalance Parastomal Hernia less More - Distal end: (two scenarios) A) Double barrel stoma: ➔ 2 opening separated from each other ➔ Proximal (end stoma): Stool. ➔ Distal: mucus fistula. ➔ Used when distal part of bowel is too long (↑↑ mucos) ➔ Usually permanent  Stoma B) Hartmann’s Procedure: Notes: ➔ Surgery that removes sigmoid colon + part of rectum - Anastomosis leakage: ➔ proximal end (above sigmoid): ➔ Apper 5 – 7 days Post-op (As hypotension) ▪ Temporary end colostomy ➔ Not within 24 hours. ➔ Distal end: - Brooke ileostomy = End ileostomy ▪ Rectum & anus are stapled - Stoma don’t cause cancer. & left out as blind pouch. - Stomas may cause Gallstones. ▪ Small distal part = little mucus ➔ Esp. if ass. with ileal resection. (loss of bile salts) (decompressed through anus) - MC cause for Intestinal obstruction in stoma: Food bolus (Not sure) ➔ Usually temporary (reconnect & anastomosis) - Uretrostomy: ➔ Bypass bladder (use part of ileum) - End stoma Pros : Smaller (↓ hernia/prolapse) ➔ Complications: ureteric obstruction (colicky abd. pain) + the rest - Cons: hard reversal (extensive surgery) Loop-End stoma: - Brings bowel up to skin as a loop with the distal end being closed. - Improve vascularity of stoma ➔ Less mesentry strech as simple end stoma - Done in obese Pt. (difficult to bring an end stoma) Complications of stoma: - Skin Irritation (dermatitis): ➔ MC complication in iliostomy Done by Mohammad jundy. - Intestinal Obstruction (Colicky abd. pain) Dermatitis - Infection ‫ه قضية الشفاء‬# ‫ي‬ - Ischemia - Bleeding - Parastomal Hernia. Parastomal Hernia - Prolapse (more in loop stoma) - Retraction - Stenosis - Electrolyte disturbance More with Prolapse - Dehydration ileostomy - Urinary Stone Formation: ➔ Dehydration ➔ Alkaline secretion (loss of Hco3 > acidic urine >uric acid stone)