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Part 1: Assessment and Management of Stomal Complications: A Framework for Clinical Decision Making
Stoma complications can be classified into five major categories based on either the etiology or location: Poor Siting, Stoma Proper, Peri-Intestinal Area, Mucocutaneous Junction, and Iatrogenic. The categories are a modification of the framework presented by Celestine.1 Stoma Proper complications are further subdivided into four types of complications: necrosis, retraction, prolapse, and bleeding. An example of a peri-intestinal area complication is herniation. Mucocutaneous junction complications are divided into subcategories of: bleeding, detachment or separation, and stenosis. The iatrogenic stoma complication most often noted in the literature is stomal laceration or trauma.
Poor Siting
A common and usually avoidable complication often seen in clinical practice relates to poor siting of the stoma during surgery. A "poor site" is one in which the stoma is sited in a location or position that makes it difficult if not impossible for a person to perform the necessary cleansing and pouching system management, conceal the stoma under clothing, and enjoy the normal freedom of movement without fear of leakage. Poor stoma siting clinically presents as a stoma sited close to prominent bones, in the vicinity of old scars or the umbilicus (see Figure 1), on the main incision (see Figure 2), or in deep peristomal creases. Leakage and the resultant peristomal irritant contact dermatitis are the clinical manifestations the patient most often experiences because of poor stoma siting.2
Prevention is the best management. Persons who are to have stoma surgery must have their stoma site selected preoperatively by a certified ostomy nurse or their surgeon. Stoma site selection is done while assessing the patient in various positions (eg, standing, sitting, and supine). Abdominal contours may change with position change and abdominal folds and creases become more pronounced in the sitting position. The basic rules for stoma site selection are to place the stoma through the rectus muscle, at the apex of the infra-umbilical fat mound, at least 4 inches from the planned incision, and far enough from umbilicus, bony prominences, scars, incision site, or skin creases to allow proper application and adherence of the pouching system. Waist- and beltline should be avoided for cosmetic reasons. It is also necessary to avoid selecting a stoma site on skin previously damaged from radiation, burns, or skin grafting. Once selected, the stoma site is either marked by an indelible marking pen or tattooed with indelible ink at the center of the selected site.3,4 Certain situations such as obesity, cachectic patients, pendulous breasts, and physically challenged persons (such as those confined to wheelchairs or wearing braces) may require special considerations when selecting stoma sites.
Poor stoma siting often results in leakage beneath the pouching system. If a patient presents with leakage related to improper pouching system fit over deep peristomal creases, the clinician must correct the defect by matching the pouching system to the patient's contours - eg, using a flexible pouching system that folds with the patient's abdominal movements. When the patient has a soft abdomen, using a firm faceplate, convexity, and a belt supports the peristomal tissues and eliminates the crease. When the creasing is only on one side of the stoma, barrier strips or wedges can create an even pouching surface. If scars, gullies, or defects prevent a good pouching seal, filling these with barrier paste (small defects) or moldable barrier wedges or strips (large defects) will help prevent leakage beneath the pouching system. Measures to increase pouching system adherence also may help.
Stoma Proper
Necrosis. Stoma necrosis occurs when the blood flow to or from the stoma is impaired or interrupted, resulting in a change in the stoma viability or tissue death. Ischemia is most often noticed within 24 hours postoperatively.5 The occurrence rate of necrosis varies depending on stoma type and general health status of the patient. the incidence of fecal stomas ranges from 12% to 22%.6 A high rate of necrosis has been reported in obese and acutely ill patients.7
Stoma necrosis may result because of surgical problems that occur during stoma construction - eg, extensive tension on the mesentery, excessive stripping of the mesentery, sutures too narrowly spaced, or constricting sutures. It also can result from interruption of blood flow secondary to embolization or because of abdominal structure anomalies such as thick abdominal wall secondary to edema, distention, or obesity.7-9
Stoma necrosis presents as a stoma that appears either ischemic (dark red, purplish tint or cyanotic hue discoloration), or necrotic brown or black. The stoma may be flaccid or hard and dry. Necrosis may be circumferential or scattered on the mucosa and may be superficial or deep. In the later stages, sloughing of the necrotic mucosa and odor are evident.
Postoperative nursing assessment and management also help prevent potential impairment of a good blood supply to the stoma. The nurse assesses for abdominal distention and initiates measures to manage distention when indicated, preventing interruption of the stomal blood supply. It is normal for the stoma to be edematous postoperatively (see Figure 3). Stoma edema begins immediately postoperatively. The stoma looks swollen within 4 to 6 hours, swelling progresses for the first 2 days, and by the fifth day subsides markedly. The stoma continues to decrease in edema (size) for the first 6 to 8 weeks after surgery. While edematous, the stomal mucosa is pale and translucent and the stoma tissue remains soft. During this edematous phase, sizing the opening of the faceplate is important to prevent stomal constriction and ischemia. The stoma measurement selected for the pouching system should allow for an opening 1/8-inch larger than the stoma size to prevent constriction that could impair stoma blood flow.
The nurse also assesses the stoma postoperatively for any clinical manifestations of necrosis. To facilitate this, the postoperative pouching system selected should be transparent or two-piece. The two-piece system allows removal of the pouch to assess the stoma without disturbing the wafer and flange. In the immediate postoperative period, frequent pouch changes place increased pressure on the patient's abdominal surface, causing pain and discomfort.
If necrosis occurs, the level of necrosis must be determined. Stoma necrosis can be limited or extensive. A stoma has limited necrosis when it affects only a quadrant of the stoma, often the distal end of the stoma (see Figure 4). Extensive necrosis extends below the level of the fascia (see Figure 5). A "mini-endoscopy" diagnoses the level of necrosis.9 The nurse lubricates a small test tube, gently inserts it into the stoma while maintaining hold of its upper edge, and shines a flashlight along the sides of the test tube to visualize the mucosa and the level of necrosis. The mini-endoscopy allows the nurse to assess if the proximal bowel above the level of the fascial plane is viable or necrotic.
Limited necrosis management is conservative, often left alone and monitored. Frequent reassessment of the stoma determines any progression of ischemia. The ischemic mucosa sloughs off naturally or can be superficially debrided by a skilled clinician. When necrosis at the mucocutaneous junction sloughs off or is debrided, the stoma separates from the skin at the mucocutaneous junction. This heals by secondary intention; granulation tissue and epithelialization form to produce an acceptable stoma attached to peristomal skin. However, healing may result in partial fibrosis and scarring. When necrosis of most of the mucosa occurs, the mucosa separates and the submucosa and muscle layer survive. Several weeks after mucosal separation, a clear, mucosal covering advances over a well-vascularized submucosa. Complications of limited necrosis include a flushed, retracted, stenotic stoma or the development of a mucocutaneous separation that needs to heal by secondary intention.
Management of extensive necrosis calls for immediate notification of the surgeon, laparotomy, or stomal reconstruction. Risk of perforation and peritonitis are potential sequelae without immediate surgical intervention.
Retraction. Retraction occurs when the stoma is drawn or pulled back below the skin level. It can involve retraction of the entire stoma or may be limited to the stoma at the level of the mucocutaneous junction. Partial retraction involves the skin and subcutaneous tissue. A complete retraction is when the stoma is below the level of the fascia.10 Retraction has been reported to occur in as many as 10% to 24% of all stoma patients.11
The etiology of stomal retraction is varied. It can occur early in the postoperative phase or as a later complication. Postoperative stomal retraction results secondary to poor surgical stoma construction (eg, insufficient stomal length, tension on the mesentery, or inadequate fixation of the bowel to the parietal peritoneum). Similar to necrosis, retraction can be secondary to abdominal structure anomalies such as thick abdominal wall related to edema, distention, or obesity. It also results from premature removal of the loop device, especially when the surgically constructed bowel is looped over the device under tension (see Figure 6). The stoma also draws back below skin level because of scar formation secondary to healing of a mucocutaneous separation or a necrotic stoma. Later stomal retraction may occur secondary to chronic peristomal irritation that healed with scar or adhesion formation at the mucocutaneous junction or from excessive weight gain in the abdominal area.12
Retraction presents clinically with all or part of the stoma located below skin level or with the surrounding skin pulled in due to tension. The stoma appears as a concave defect on the abdomen. Dimpling and creasing of the peristomal skin often occur. The depth of retraction may increase with sitting. The degree or even presence of retraction can vary with peristalsis. Patients with retracted stomas present with effluent undermining the pouching system, persistent leakage, shortened pouch wear time, and resultant peristomal irritant dermatitis.
The goal of managing a retracted stoma is to maintain a secure seal between the pouch and the skin. This often requires modification in pouching techniques such as addition of support and convexity, measures to improve pouch adherence, and use of barrier pastes or wedges to fill small indentations.13 Surgical revision is considered when a good pouching seal cannot be obtained and skin irritation persists. Complete circumferential mucocutaneous separation accompanied with stomal retraction below the fascia may be a surgical emergency as it can lead to peritonitis.
Prolapse. When a stoma prolapses, it lengthens because the bowel telescopes out through the stoma. This occurs most frequently in a loop transverse colostomy. Although either the distal or the proximal segment of the loop ostomy may prolapse, it occurs more frequently in the distal portion of the bowel.14 Prolapse can be partial or complete.10 Seven percent to 25% of loop transverse colostomies prolapse; 2% to 3% of end colostomies prolapse postoperatively but in long-term follow-up, 12% prolapse. Up to 3% of ileostomies are reported to prolapse postoperatively, but the long-term incidence may be as high as 11%.14
Prolapse etiology can involve difficulties with stoma construction or anomalies of the abdominal structure. Stoma construction difficulties include surgically creating an excessively large opening in the abdominal wall, edema of bowel requiring creation of an opening in the abdominal wall larger than will be needed as the edema subsides, or inadequate fixation of the bowel to the abdominal wall. Abdominal structure anomalies include poorly developed (or lack of) fascial support secondary to weak abdominal muscle, increased abdominal pressure secondary to tumors, coughing, excessive crying in neonates and children, or thick abdominal wall secondary to obesity or pregnancy.11,15
The clinical presentation of a prolapse includes a stoma that is increased in size and length, edematous, bleeds, and is easily traumatized. In severe prolapse, stoma obstruction and resultant ischemia may result secondary to excessive tension on the mesentery. The ischemic stoma appears dusky, purple, or cyanotic. The size and bulk of the prolapse complicates pouching techniques and the patient's ability to conceal the stoma beneath clothing. Complications of chronic prolapse may include stomal irritation, bleeding, necrosis, and gangrene of the distal end of the prolapsed stoma (see Figure 7).
The clinician manages prolapse conservatively as long as it is not severe and the stoma remains viable without ischemia or obstruction. Conservative management includes manually reducing the prolapse and then applying a support binder or hernia support belt with a prolapse flap to hold the stoma in place. If a large segment of the bowel prolapses, the belt and prolapse flap may not be able to maintain the reduction. The clinician reduces the prolapse by having the patient lie down to decrease the intra-abdominal pressure and continuously applying a gentle pressure to the distal portion of the stoma (see Figure 8), returning the stoma to its intraperitoneal place. If the bowel is edematous, applying a cold compresses or sugar application (osmotic therapy) for 15 minutes before stoma reduction reduces the edema.16,17
When the stoma is prolapsed, re-evaluating the pouching technique and pouching system is necessary. The goal of care is to provide a leak-proof pouching system applied while the patient is supine and the prolapse reduced. The stomal opening and length of the pouching system have to be adapted to accommodate the wider diameter and increased length of the prolapsed stoma. A flexible, flat faceplate prevents trauma to the stoma. When enlarging the faceplate opening to accommodate the stoma (if peristomal skin is exposed), a skin barrier fitted to the base of stoma should be applied to protect the exposed peristomal skin. The prolapsed stoma should be monitored for color changes and ischemia. Severe and recurrent prolapse with manifestations of ischemia or obstruction requires surgical consult. Surgery involves resection of the prolapse and constructing a new stoma.
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9. Martin R.. Assessment of stomal necrosis: the test tube. J WOCN. 2001;28:233–236.
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12. Wound, Ostomy, and Continence Nurses Society. 2003. Stoma complication: a best practice document for clinicians. Available at www.wocn.org. Accessed July 25, 2004.
13. Hanion M. Surgical and nonsurgical options for a patient with a retracted stoma and peristomal skin crease. J WOCN. 2001;28:219-222.
14. Shellito PC. Complications of abdominal stoma surgery. Dis Colon Rectum. 1998;41:1562–1572.
15. Corman M. Intestinal stomas. In: Colon and Rectal Surgery, Edition 3. Philadelphia, Pa.: Lippincott;1993.
16. d’E Stevens P. Prolapsing loop colostomy in the face of advanced colorectal cancer: the use of osmotic therapy for irreducible stomal prolapse. WCET Journal. 1997;18(1):14–16.
17. Myers J, Rothenberger D.. Sugar in the reduction of incarcerated prolapsed bowel – a report of two cases. Diseases of Colon and Rectum. 1991;34(5):416–418.
