Stomas

Question 1

Loop Ileostomy

• Site
• Spout
• Contents
• Skin
• Lumens
• Indications

Answer 1

• Site: RIF usually
• Spout: Yes
• Contents: Small bowel contents usually
• Skin: look for excoriation from alkaline small bowel contents
• Lumens: two- the proximal lumen is the active lumen that has small bowel contents coming
  out of it
• Indications: situations where a primary anastomosis is formed that is deemed to be at risk of a leak, to reduce the risk of a clinically significant leak. For example, in a low anterior resection, especially in patients who have received radiotherapy. The loop ileostomy is brought out to protect the distal anastomosis. Three months postoperatively, the anastomosis is tested by using a dye inserted rectally (a Gastrografin enema) to ensure there is no stricture or leak, and the patient can be brought in for a reversal of ileostomy

Question 2

Risks of more proximal Stomas

Answer 2

The more proximal the stoma, the higher the stoma output and the greater the risk
of electrolyte abnormalities and dehydration.

Question 3

End Ileostomy

• Site
• Spout
• Contents
• Skin
• Lumens
• Indications

Stomas that may Resemble an End Ileostomy

Answer 3

Single lumen of ileum brought to the surface.

• Site: RIF usually
• Spout: Yes
• Contents: Small bowel contents usually
• Skin: look for excoriation from alkaline small bowel contents
• Lumens: One

Indications:

• Permanent: Panproctocolectomy (UC, FAP)
• Temporary: Emergency subtotal colectomy

Question 4

Loop Colostomy

• Site
• Spout
• Contents
• Skin
• Lumens
• Indications

Answer 4

• Site: it may be in the LIF (defunctioning loop sigmoid colostomy) or in the upper abdomen(defunctioning loop transverse colostomy) on the right or left
• Spout: No
• Contents: Faeces
• Skin: usually don’t get excoriation as feces rather than small bowel contents
• Lumens: two- the proximal lumen is the active lumen that has feces coming out of it

Indications: To defunction

• Relieve distal obstruction
• Protect new distal anastomosis

Question 5

End Colostomy

• Site
• Spout
• Contents
• Skin
• Lumens
• Indications

Answer 5

• Site: LIF
• Spout: No
• Contents: Faeces
• Skin: usually don’t get excoriation as feces rather than small bowel contents
• Lumens: One

Indications:

• Permanent: Abdominoperineal resection
  (APR)
• Temporary: Hartmann, Anterior resection

Question 6

Stoma Complications

• Early
• Late

Answer 6

Early

• Dehydration/High Output (>1500m/L 24 Hours)
• Ischemia
• Bowel Obstruction
• Mucocutaneous Separation

Late

• Retraction/Prolapse => Stenosis
• Parastomal Herniation (50% overall. More common in obese patients and those with COPD)
• Peristomal skin ulceration/inflammation
• Bowel Obstruction
• Bleeding
• Psychosexual Issues

Question 7

Indications for surgical intervention on stoma?

Answer 7

Strangulation, obstruction and ischemia

Question 8

Indications for stoma formation?

Answer 8

Resection of diseased portion of bowel:

• Hartmann’s procedure
• abdominoperineal resection (APR)
• panproctocolectomy

Feeding: Gastrostomy/Jejunostomy

Diversion: Protect distant bowel (anastomosis/fistula/abscess)

Decompression: To relieve distal obstruction (loop colostomy)

Lavage: Temporary stoma for on-table lavage prior to bowel resection

Question 9

How to determine if an end colostomy is temporary or permanent?

Answer 9

Ask the patient if they still have a back passage or not

• Yes: Temporary end colostomy; e.g. Hartmann’s procedure or Anterior
  Resection
• No: Permanent end colostomy; APR for low rectal tumor

Question 10

Indication for Right hemicolectomy?

Answer 10

Caecal & ascending colon tumours

Question 11

Indicaiton for Extended right hemicolectomy?

Answer 11

Extended right hemicolectomy

Question 12

Indication for Left hemicolectomy

Answer 12

Descending colon tumours

Question 13

Indications for Sigmoid Colectomy

Answer 13

Sigmoid colon tumour

Diverticular disease

Question 14

Indications for Anterior resection

Answer 14

Low sigmoid or high rectal tumour

Question 15

Indications for Abdominoperineal resection (APR)

Answer 15

Low rectal tumour

Question 16

Indications for Panproctocolectomy

Answer 16

Ulcerative colitis, FAP

Question 17

Define Hartmann’s Procedure

Answer 17

Removal of the sigmoid colon with closure of the rectal stump and formation of a potentially reversible end colostomy

Question 18

Define Panproctocolectomy

Answer 18

Removal of the entire colon, rectum and anus, forming a permanent end colostomy

Question 19

Define Abdominoperineal resection:?

Answer 19

Removal of the lower rectum and anus with
formation of a permanent end colostomy