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Colostomy Complications

Colostomy Complications

  The colostomy is a technique that causes around 40% of complications secondary to this technique.

 

Edema:

 

  All stomata are edematized immediately after the intervention due to bowel manipulation, but this edema will gradually diminish during the following weeks and the size will be established after 6 weeks. It is very important to observe it. The size should be measured regularly, so the edge opening is cut correctly. If it is cut too large, any leakage of the efflux fluid into the skin around the stoma can cause irritation, and if it is cut too small, it can cause ischemia (1)

 

Necrosis and Ischemia:

 

  It usually manifests within the first 24 hours of the postoperative period, and may even appear in the operating room before the end of the intervention. A color change of the mucosa of the stoma occurs, from reddish to grayish blackish. Ischemia can be superficial of the mucosa or extend into the peritoneal cavity, which will undoubtedly determine the action to be followed: conservative treatment, depending on the extent of injury and the general conditions of the patient or reoperation. It is necessary to identify up to what level the ischemia arrives: if it is total, the treatment is the resection and reconstruction of the stoma. It is convenient to place a transparent device to easily observe the evolution of necrosis. (2)

 

Mucocutaneous Separation:

 

  Occurs when there is a dehiscence of the suture line, it fixes the stoma on the abdominal surface, and leaves a cavity in the wound. It is treated using stoma pastes and an adhesive washer (3).

 

Stenosis:

 

  It occurs when the stoma opening narrows. It may be due to the formation of non-elastic tissue after retraction, mucocutaneous separation and necrosis. It is characterized by abdominal pain and difficulty in expelling stool. The treatment of stenosis consists of instructing patients to maintain soft stools through diet and faecal softening drugs (such as lactulose) and also by introducing a dilator into the stoma lumen to keep it permeable. Long-term treatment may be that the patient needs surgical reshaping of the stoma (4).

 

Infection:

 

  It is one of the most frequent complications. Presents a clinical of pain of the stomal area with inflammatory signs. It occurs more frequently in interventions performed urgently due to lack of colon preparation (1, 2).

 

Retraction:

 

  It is called retraction to the sinking of the stoma below the level of the skin. It is usually due to excessive bowel tension, usually due to little mobilization, although in many occasions also the weight gain of the patient can favor it in the same way as a hyperpressure abdominal pain, postoperative ileus and peristomal septic complications.

  If the degree of retraction is important, it may be accompanied by stenosis of the ostomotic mouth, it is giving rise to difficulty passing stools that justifies a surgical reconstruction of it. It will also require a reoperation if It makes the placement of collector devices difficult. The stability of device to the skin is often hindered when the stoma has retracted for this reason, in the nurse performance it will be advisable to use devices as flexible as possible, so they adapt to the unevenness and folds of the skin with the least difficulty and thus avoid leaks, preventing skin irritations by contact (4).

 

Evisceration:

 

  It is a complication with a low incidence. When the hole in the wall abdominal is too large in relation to the diameter of the stoma, either by an intra-abdominal hyperpressure or because the abdominal wall is hypoplastic, one of the bowel loops comes out around the hole (5).

 

Prolapse:

 

  It is the excessive exteriorization of the colon due to puffiness caused by the increase in intra-abdominal pressure or by incorrect fixation of the colon. Its size varies and can reach 15-20 millimeters (mm). It is noted an excessive protrusion of the estomal loop on the cutaneous plane of the abdomen, it can occur unexpectedly, although in most cases appear progressively.

  Prolapse is the most important organic complication of the stoma after the hernia, it is more common in the lateral or loop ostomy than in the terminals, especially in the transverse colostomy. Some factors that increase the chance of presenting a prolapse are: age, is more frequent in children than in adults; the existence of a disease prior to the ostomy; bowel movements and all the conditions that they raise the intra-abdominal pressure (cough, effort). The use of excessively tight devices that exert a suction effect they can also be triggers of prolapses. It is necessary that nurse control both the growth and the color and appearance of the prolapsed to follow the evolution of it, in case it causes ulcerations with signs of ischemia in the mucosa or in case of discomfort. The local application of compresses with cold saline on the mucosa itself may be favorable (6).

  You can also adapt devices do not cause friction in the mucosa and it should be advised to avoid physical efforts. There is a manual technique reduction of the prolapse: The patient is placed in the supine position very relaxed and with gloved hands soft massage is given to the stoma in the direction of the abdominal wall. If it is not possible to reduce the prolapse, it is necessary to excision of the prolapsed colon and, in extreme cases, internal fixation and resettlement (6).

 

References:

(1) Hierro, J.; Abed, G.; Galindo, F. (2009). Complicaciones de las colostomías. Cirugía Digestiva. III-311, pág. 1-12.

(2) Kann, B. (2008). Early stomal complications.Clinics in colon and rectal surgery, 21(1), 23-30.

(3) Steinhagen, E.; Colwell, J.; Cannon, L. (2017). Intestinal Stomas-Postoperative Stoma Care and Peristomal Skin Complications.Clinics in colon and rectal surgery, 30(3), 184-192.

(4) Suwanabol, P.; Hardiman, K. (2018). Prevention and Management of Colostomy Complications: Retraction and Stenosis. Colon Rectum.61(12):1344-1347.

(5) Salles, J.; Saba, E.; Pissinin, E.; Rodrigues, A.; Rubens, F.; Machado, H. (2011). Complication related to colostomy orifice: intestinal evisceration.Journal of Coloproctology (Rio de Janeiro), 31(4), 397-400.

(6) Krishnamurty, D.; Blatnik, J.; Mutch, M. (2017). Stoma Complications. Clinics in colon and rectal surgery.30(3), 193-200.

Leonardo Tortolero
3 April, 2019

Written by

Dr. Tortolero is a surgeon specializing in Clinical Angiology (ASCARDIO). Fellow in comprehensive and interventional ultrasonography (UNEFM) and biomedical researcher. Member of the Venezuelan Association for the Advancement of Science, Venezuelan Society of General Medicine,...read more:

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