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

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

Apr 13, 2023 305 likes •1.08k views

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

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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)

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COPING WITH DIFFICULT STOMAS- BRIDGING THE GAP

  • DR. NAGHAM AL-MOZANY

CONSULTANT GENERAL & COLORECTAL SURGEON AUCKLAND CITY HOSPITAL & MACMURRAY CENTRE

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BRIDGING THE GAP

Knowledge Doctor-patient relationship Patients with stoma & Family/Society

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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?
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DEFINITION

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INTESTINAL STOMA

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CLASSIFICATION OF STOMAS

Stoma Temporary vs. Permanent Source Type Technical type

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ILEOSTOMY

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Ileostomy consistency: TOOTH-PASTE!

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Loop/Defunctionning Ileostomy

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HOW CAN I TELL THE DIFFERENCE?

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WHO CARES?

  • Effect on reversibility of the stoma in future?
  • Volume of output?
  • Effect on complications?
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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
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Table 1.

COMPARISON BETWEEN STOMAS

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  • Form of Urostomy
  • Diverts urine if

bladder has been removed

  • Common problem

is urine infection

  • Issues: Refer to

Urology

ILEAL CONDUITS URINARY DIVERSION

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A SURGEON’S PERSPECTIVE

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Indications for surgery/stoma formation

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TECHNICAL ASPECTS OF STOMA FORMATION

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POST-OPERATIVE COMPLICATIONS

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INDICATIONS FOR STOMA TYPE

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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
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INDICATIONS FOR ILEOSTOMY FORMATION

Elective:

  • Surgery for rectal cancer or inflammatory

bowel disease

  • Technically easier to reverse
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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
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  • Counselling
  • Stoma nurse specialists
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  • Stoma

management training

  • ↓Time to ostomy

proficiency

  • ↓ Length of

hospital stay

  • ↓ Unplanned

interventions

  • Highly cost

effective

STOMA EDUCATION

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STOMA SITING

Lying Standing Sitting

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STOMA COMPLICATIONS

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High Stoma output ?

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HIGH STOMA OUTPUT Risk factors:

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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

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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
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PARASTOMAL HERNIA

Risk factors:

  • Oversized apertures
  • Obesity
  • Advanced age
  • Poor tissues / weak

musculature

  • Wound infections
  • Smoking
  • Increased abdominal

pressure after surgery

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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
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MANAGEMENT OF PARASTOMAL HERNIA

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  • Operative repair /

re-siting strategies

  • +/- Mesh use
  • Laparoscopic or

Open surgery

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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
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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

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NECROSIS

  • Occur within 1-5 days
  • f surgery
  • Particularly the first 24

hours

  • Risk factors:
  • 1. Oedema
  • 2. Abdominal distension
  • 3. Critical illness
  • 4. Obesity
  • 5. Tension
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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
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STOMAL PROLAPSE

Risk factors:

  • 1. Large abdominal wall
  • pening
  • 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

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STOMAL PROLAPSE

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

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Refer to stoma nurse specialist

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Refer to Surgeon

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STOMAL RETRACTION

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

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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

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A PATIENT’S PERSPECTIVE

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

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FAMILY AND SOCIETY

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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
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“THE STOMA EFFECT”

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