Ostomy Complications

Dheeraj Reddy

Nomenclature

  • + [ Bowel segment ] (i.e. sigmoid, colon, ileum).
  • + [ Surgical Construction ] (i.e. loop, end, reservoir).
  • + [ Duration ] (i.e. temporary/permanent).
  • Highest complication rates: loop ileostomies 
  • Lowest complication rates: end ileostomies/colostomies 
  • Early complications typically arise from issues related to surgical technique or site selection 
  • Late complications are more associated with high-risk patient factors (i.e. nutrition, age, tobacco) 
  • Early (< 3 months postop):
Presentation/SymptomEtiologyManagement
Peristomal skin irritation (25-34% of patients in immediate postop)
  • Leakage of effluent onto skin
  • Mucocutaneous separation
  • Mechanical injury
  • Stomal necrosis, bleeding, or retraction

Begin with conservative management:

  • Skin barrier rings, pectin-based powder.
  • If fungal, antifungal powder with sealant + 2wk reevaluation
  • If allergic: skin sealant +/- steroid spray for persistent cases

If conservative management fails, EGS/colorectal and ostomy team consult

Dehydration from high ileostomy output (1.5L/day)Leading readmission cause
  • Glucose-electrolyte oral rehydration
  • 1st line: Loperamide QID
  • 2nd line: Tincture of opium
  • Late (> 3 months postop):
SymptomPresentation/Management
Gas

- High starch / high soluble fiber diet
Consider also gas ingestion (drinking straws, chewing gum, smoking)

-Dietary modifications, OTC meds.
If unresponsive, can consider flatus filters

Parastomal hernia

-No management necessary unless incarceration/strangulation/bowel obstruction

Stomal prolapse

-Telescoping of the intestine out from the stoma
Risk of intestinal edema, incarceration

-Uncomplicated: Cool compresses +/- application of osmotic agent, with manual reduction and abdominal binder
-Complicated (ischemia +/- bleeding): urgent EGS consult

Stomal stenosis

-Most common with loop ileostomies; stomal necrosis, retraction, thick abdominal wall increase risk

-Mild: Avoidance of insoluble fibers +/- routine dilation
-Severe (cramping, explosive output): Surgical correction

Mechanical trauma

-Microtrauma associated with shaving, skin stripping due to poor adhesive removal technique, pressure injury from complex stomal appliance

-Give stoma management education

Dermatitis

-Most commonly with ileostomy

-Barrier powder + removal of allergen, nystatin/miconazole powder (if fungal), topical steroids (refractory cases)

Granulomas

-Red, moist, elevated lesions (+/- bleeding) at the mucocutaneous border usually from retained extraneous material

-Removal of extraneous material + Silver nitrate

Peristomal Pyoderma Gangrenosum (PPG)

-Idiopathic, inflammatory neutrophilic dermatosis

-Mild: topical steroids vs tacrolimus, wound care
-Severe: systemic steroids +/- anti TNF, surgery

Neutrophilic Dermatosis

-Pathergy, seen in IBD

-Avoid biopsy

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