of the GI tract utilized to create the ostomy and the method of surgical construction. Depending on the manner of the disease or the site of the obstruction, the surgeon will determine the optimal location to establish the ostomy.
An ileostomy is created when it is necessary to bypass the entire colon and rectum. In general, patients with ileostomies have watery frequent stooling patterns since they do not possess large bowel function. It is usually created within the rectus sheath, in the infraumbilical fat pad, and can be temporary or permanent. In a diverting loop ileostomy, a loop of terminal ileum is brought out through the abdominal wall, opened, and sutured to the dermis. This is the most common type of temporary diversion ostomy and is used in patients who are considered high risk for anastomotic breakdown. A mucous fistula, which will be described in more detail in the next paragraph, can also be created within the construct of a loop ileostomy. An end‐ileostomy is an ostomy in which the ileum is delivered through the interior abdominal wall and sutured in place with everting sutures to create an end stoma.
A colostomy is created when it is necessary to bypass or remove the distal colon, rectum, or anus. As with other ostomies, they can be temporary or permanent and can be created in the loop or end fashion. In general, loop ostomies are easier to reverse and are more frequently used when a temporary ostomy is required. Patients with colostomies usually have semi‐formed stools because the absorptive and storage function of the large bowel is preserved. A mucous fistula is sometimes created during an end‐colostomy. Usually, the distal end of the colon is oversewn or stapled and left in the abdominal cavity as a nonfunctional stump. However, in cases where there is a high likelihood of breakdown of the stump, which can then lead to abdominal sepsis, or if the anus is strictured to a degree that does not allow rectal mucous to drain freely, it can be secured in place adjacent to colostomy as a mucous fistula in the subcutaneous tissue but not matured out to the skin. The mucous fistula does not pass stool but does allow passage of mucous or gas from the nonfunctioning portion of the distal colon or rectum.
The spit fistula is rarely used anymore, but may be created in the setting of an esophagectomy where part of the esophagus is excised, such as in esophageal cancer, swallowing disorders, and trauma. If an anastomotic leak occurs, an ostomy can be created that will allow drainage to be diverted outside the body to the lower neck or clavicle region.
Indications
GI diversions may be necessary for a variety of reasons, both congenital and acquired. Common congenital anomalies requiring ostomy placement include Hirschsprung's disease and imperforate anus. Acquired lesions may include ulcerative colitis, Crohn's disease, necrotizing enterocolitis, obstruction, decompression, trauma, and malignancy. An ostomy may be temporary or permanent depending on the likelihood that a restorative procedure will be possible. Most temporary ostomies are reversed within three to six months of placement.
Management
Stomatherapists are an excellent resource for families and physicians when managing ostomies. However, patients will still present to the ED with ostomy‐related complications, and all ED physicians should be familiar with the types of GI diversions and their complications.
Pouches are used to collect the ostomy effluent, contain odor, and protect the peristomal skin. There are one‐ and two‐piece pouch systems available, and they come in both reusable and disposable varieties. Patients typically empty the pouch when it is one‐third full and change pouches 1–2 times a week.
Diet is also important in the routine management of ostomies. Patients may prefer to modify their diet to avoid gas‐producing foods and must be cognizant of the amount of fluid they must intake to compensate for the volume lost through the effluent, which is determined by location of the stoma relative to the ileocecal valve.
Complications/Emergencies
Overall, complication rates following stoma formation have been reported between 21 and 70%. The incidence is the highest in the first five years postoperatively, but the complication risk is lifelong and can be associated with significant morbidity. Early stomal complications occur within three months of placement and include stomal necrosis, bleeding, and retraction. Late stomal complications usually present in permanent ostomies and can include parastomal hernia, prolapse, and stenosis. Cutaneous complications can occur at any time, and ileostomies can also be associated with metabolic derangements due to their large output.
Early Stomal Complications
Stomal necrosis can be seen in up to 14% of cases, most often in the immediate postoperative period. It is usually due to venous congestion or arterial insufficiency. If the necrosis involves only the superficial few millimeters of the stoma, then observation will usually be successful; however, if it extends deep to the fascial planes, then an urgent revision is warranted. The ED physician can determine the extent of necrosis by inserting a lubricated test tube in the stoma and with a flashlight or using a lighted anoscope.
Major bleeding from the stoma is uncommon. Minor bleeding can be from the initial surgery or over from vigorous stomal cleansing. Pressure, handheld cautery, or silver nitrate is usually sufficient to manage minor bleeding episodes. Topical hemostatic agents are sometimes helpful adjuncts. Finally, a well‐placed figure‐of‐eight stitch of monofilament suture on a noncutting needle can stop bleeding from an isolated bleeding vessel on the surface of the stoma, which is insensate.
Stomal retraction is defined as any stoma that is 0.5 cm or more below the skin surface, is noticed within six weeks of stoma formation, and requires surgical intervention. It can occur from excessive tension on the bowel and occurs more often with ileostomies and in obese patients. Stomal retraction can cause leakage, difficulty with pouch adherence, and skin irritation. Supportive care includes using a convex pouching system and belt and binder; however, many require revision.
Late Stomal Complications
Parastomal hernias are more common with colostomies and have a reported incidence of up to 48%. Other risk factors include obesity, poor abdominal muscle tone, chronic cough, and placement of the stoma outside the rectus muscle. Parasternal hernias are usually asymptomatic, but, as the size increases, it can impede adherence of the ostomy pouch. Strangulation and obstruction are rare but serious complications, and it is important for the ED physician to be comfortable determining if a hernia is incarcerated. Any hernia that cannot be manually reduced, is extremely painful, or appears dusky requires urgent surgical consultation. Symptoms of obstruction, including vomiting, abdominal distention, and decreased ostomy output, require two‐view abdominal x‐rays. Elective surgical revision is performed for definitive management of parastomal hernias; however, there is a high recurrence rate. Nonoperative management includes abdominal support belts and education regarding avoidance of heavy lifting or other maneuvers that may increase intra‐abdominal pressure.
Figure 2.1 Stomal prolapse.
(Source: Photos courtesy Judith Stellar)
Stomal prolapse occurs when a proximal segment of the bowel intussuscepts and protrudes through the stoma (Figure 2.1). The incidence of prolapse is 7–26% and is more common with loop transverse colostomy and end descending colostomies. The majority of prolapses are not of clinical significance but can be distressing to patients and make appliance placement difficult. Small, uncomplicated prolapses can be manually reduced by the ED physician at the bedside. Sedation may be necessary depending on the size of
