“A STUDY ON INDICATIONS, COMPLICATIONS AND ITS...

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“A STUDY ON INDICATIONS, COMPLICATIONS AND

ITS MANAGEMENT OF INTESTINAL STOMA”

A DISSERTATION SUBMITTED TO

THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY

In partial fulfillment of the regulations for the award of the degree of

MASTER OF SURGERY (GENERAL SURGERY)

BRANCH I: M.S (General Surgery)

DEPARTMENT OF GENERAL SURGERY

GOVERNMENT STANLEY MEDICAL COLLEGE AND HOSPITAL

THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY

CHENNAI

APRIL 2015

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INTRODUCTION

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INTRODUCTION:

Stoma is a surgically created opening in the anterior abdominal wall. The

purpose of stomas are divert the feces away from the distal bowel loops in order

to relieve obstruction or product anastomosis (1).

Stomas are classified temporary stoma or permanent stoma based on the

need (2). After construction of stoma, it produces multiple complications (3).

Most of the stoma complications are minor, can be managed with proper care,

but major complications requires intervention by means of surgery which

produce high morbidity and mortality (4).

The basic types of stomas derive their name from the gastrointestinal

segment in which they are sited. For example, gastrostomy in stomach,

jejunostomy in jejunum, ileostomy in ileum, caecostomy in caecum and

colostomy in colon.

Indications for ileostomy are intestinal obstruction due to benign or

malignant disease, perforation with peritonitis, ulcerative colitis or Crohn’s

disease and mesenteric ischemia (5). Indications for colostomy are colonic

growth, colorectal malignancies, and peritonitis due to perforation, anorectal

malformations, and high anal fistula.

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Multiple factors play a role in construction of stoma rather than primary

resection anastomosis. They are blood loss, peritonitis, co morbidity of the

patient, contamination, and other injuries associated with bowel injuries.

Multiple Factors are responsible for different type of complications (6). They

are patient’s presentation, timing of surgery, preoperative education, location of

stoma(7), ileostomy Vs colostomy(8), co morbidity (9), and quality of life

(10)(11)(12).

Complications of Ileostomy:

Prolapse, retraction, paraileostomy hernia, stomal bleeding, stenosis of

ileostomy orifice, skin reaction around the stoma. (Excoriation, erosion,

sloughing),distal end gangrene, fluid and electrolyte imbalance (ileostomy flux)

and ileostomy diarrhoea(13)

Complications of Colostomy:

Prolapse, retraction, paracolostomy hernia, bleeding, and stenosis of

colostomy orifice, pericolostomy abscess, colostomy diarrhoea and distal end

gangrene.

Our purpose in this study is to identify varies indications, complications

and management of intestinal stoma.

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AIM AND OBJECTIVE OF STUDY

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AIM AND OBJECTIVE OF STUDY

1. To study the various types of intestinal stomas and their indications.

2. To identify the various complications encountered that occur after the

construction of intestinal stomas.

3. To assess the ways in which these complications can be minimized and

managed in a better way.

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REVIEW OF LITERATURE

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HISTORY OF STOMA

The Bible described about stoma. When Eglon was stabbed by Ethud:

“He (Eglon) could not draw the dagger out of his belly and dirt came out”. In

350 BC Praxagoras of Kos has a kind of stoma created by intestinal injuries.

Hippocrates (460-377BC), Cornelius (53BC-AD7), Galen (131-201AD) knew

injuries to the colon and small intestine were often fatal, but did not know what

to do.

Stoma surgery prior to 19th

century:

55BC-7AD Celsus Observations of damage to intestine

1707 Heister First recorded stoma surgery

1756 Cheselden Transverse colostomy

1795 Daguesceau Fashioned colostomy

1799 Larrey Intestine stitched to abdominal wound

Earliest references said damage to the large intestine could offer a very

faint hope of recovery. Celsus (55BC-7AD) wrote: sometimes the abdomen is

penetrated by a stab of some sort, and it follows that intestines roll out. If the

small intestine has been penetrated, no good can be done.

14th

Century: Artillery began to be used in wars, and patients with

Gunshot wound to abdomen mostly dead. Prior to World War I trench did

pioneering work on stoma surgery, which later spread to the rest of Europe.

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Between the Two world wars and after World War II, Americans took the

lead in the field of stoma. Soldier George Deppe injured his back at the Battle of

Ramillies in May 23rd

1706. He sustained a wound to the lower back followed

by he developed what today is known as a fistula. He lived with it for 14 years

with a prolapsed colostomy.

William Cheselden described treatment for this patient, Margaret White.

She had an umbilical hernia from the age of 50, and when she was 73, she had

hernia rupture and prolapsed become gangrenous. Cheselden had to remove

about 26 inches of bowel and formed a transverse colostomy.

In 1757 Lorenz Heister (1683-1758) first described stomas for the

trauma. Heister wrote: "As the lips of the intestines, so wounded, would

sometimes quite unexpectedly adhere to the wound of the abdomen; and

therefore it seemed no reason why we should not take hints from nature". "It is

surely far better to part with one of the conveniences of life than to part with life

itself“(Lorenz Heister).

Dominique Larrey developed his surgical skills on the Napoleonic

battlefields and organized a system for dealing with causalities, offering both on

the spot treatment and evacuation procedures. He described the treatment and

subsequent recovery of a soldier who had a gunshot wound to the abdomen and

intestine. He stitched the damaged intestine to the edge of the abdominal wound

which was kept open until the injured intestine healed.

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Stoma surgery during the 19th

century

1815 Freer First elective stoma surgery

1887 Allingham Loop colostomy

1895 Paul/Miculicz Temporary stoma

Duret was the first person who performed colostomy for anorectal

malformations. The patient survived till age 45. Daguesceau was the first person

described device for collection of feces. He constructed stoma for a farmer who

had an injury due to wheat cart. He collected his feces in a device and died at

age 81. “… He conveniently collected his feces in a small leather pouch”.

The first elective surgery in the United Kingdom was a colostomy created

on a neonate by George Freer in 1815, but the baby died due to complications

three weeks later. Williams Allinghan described his creation of a double lumen

loop colostomy held in place with glass rod in 1887 (14).

Mikulicz-Radecki noted high leak rates due to primary anastomosis in

contaminated wound lead to Morbidity and Mortality(15) . Mikulicz advised to

do two stage procedures for intestinal anastomosis rather than single stage

procedure. Resection with double barreled stoma followed by anastomosis two

weeks later. Mortality decreased from 50% to 12.5% in his first 100 patients.

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The first successful ileostomy performed by Maydl, of Vienna in 1883.

Finney first demonstrated flush loop ileostomy. In 1888, the concept of

supportive rod was introduced. The use of supportive rod will prevent retraction

of stoma into the peritoneal cavity.

Stoma surgery in 20th

century

1913 Brown Temporary ileostomy

1923 Hartmann End colostomy

1943 Miller Proctocolectomy and

ileostomy

1950 Bricker Ileal conduit

1952 Brooke Eversion ileostomy

1969 Kock Internal pouch

1978 Parks Preserved anal sphincter

1980 Mitrofanoof Internal reservoir for

urine

In 1907, Mayo first demonstrated right transverse colostomy can be used

in treatment of diverticulitis with reversal after resolution of inflammation. In

the 1930s, Mayo, Rankin and Braun independently described a three stage

procedure. First stage was transverse colostomy and drainage, second stage was

sigmoid resection and anastomosis and final stage was colostomy closure.

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Brown reported 10 patients with ileostomy at lower part of incision for

laparotomy. After his report ileostomy became used by everyone in 1913. He

described Stoma 2-3 inches away from abdominal wall can be emptied without

complications.

Henry Hartmann, between 1909 and 1923 devised the “Hartmann

procedure” for obstructing sigmoid cancer(16) . Unknown if he ever performed

this for diverticulitis. In 1879, Baum, demonstrated the first diverting ileostomy

for colorectal malignancies. It is a single operation involving the excision of the

upper rectum and sigmoid colon, construction of a terminal colostomy.

In 1943, Miller combined the first two stages of Hartmann’s procedure

and performing a protocolectomy on a young girl with severe ulcerative colitis.

Miller and his team were the first to perform at one stage panprotocolectomy,

excision of colon, rectum and anal canal and formation of a permanent

ileostomy from the terminal ileum.

Crile created the mucosal grafted ileostomy in order to prevent

dysfunction of ileostomy in 1942. Turnbull and Gill coined the term

“Enterostomal therapist” in 1958 (17). Turnbull was the first person who

opened the first school of Enterostomal therapy in 1961. The first reel pouch

was created in 1944 by Henry Koenig.

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First recorded Ileostomy in 1879 by Wilhelm Baum, a German Surgeon

from Danzig created an ileostomy in a patient with malignant tumor and patient

died 9 weeks later. Successful recovery after ileostomy was reported by Maydi

from Vienna in 1883.

Brooke made very important advancement in ileostomy (18). In 1952, in

his article, he described “Management of Ileostomy and its Complications”. He

described most important step “evaginate the ileal end at the time of operation

and suture the mucosa to the skin; no complications have occurred from this” -

Bryan Brooke (1952).

In 1952, Bryan Brooke of Birmingham devised an improved technique

for fashioning an ileostomy which involved everting the end of the withdrawn

small bowel and suturing it into position to form a spour(19). In 1969, Nils

Kock, reported on his technique of creating an internal pouch from the terminal

ileum to act as a reservoir for feces.

In 1978, Sir Alan Parks described his procedure for forming a reservoir

from a length of terminal ileum. The ileum is fashioned into a J or W shape,

opened and formed into a pouch(20).

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Stoma appliances in the 20th

century

1910 Heavier surgical belts with plastic cups

1930 Thick, heavy rubber bags

1944 Koenig-Rutzen bags

1960 Thin odour proof disposable plastic bags

Karaya gum

Hydrocolloid skin barriers

Stoma care nurses

1980 Plug system

Toilet flushable colostomy bags

The technical evolution in the stoma care are responsible for facilitating

self-care, improving quality of life and giving support not only to the physical

rehabilitation but also to the ostomy patient, psychological and social life (21).

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ANATOMY OF INTESTINE

Small Intestine:

The duodenum, jejunum, and ileum make up the small intestine. The

duodenum is anatomically distinct, but the jejunum (proximal two fifths) and

ileum (distal three fifths) have no true anatomic border between them (22).

The Duodenum

The duodenum is divided into four parts: the first portion or the bulb, the

second or descending portion, the third or transverse portion, and the fourth or

ascending portion. The first portion begins at the pylorus and sweeps to the

right; it is anchored by the hepatoduodenal ligament. Blood supply is from the

supraduodenal and gastroduodenal arteries; both arise from the hepatic artery.

The second portion of the duodenum travels posteriorly and caudad to the

level of the first lumbar vertebra. The arterial supply is from the celiac axis

through the gastroduodenal artery to the anterosuperior and posterosuperior

pancreaticoduodenal arteries and from the superior mesenteric artery (SMA)

through the anteroinferior and posteroinferior pancreaticoduodenal arteries.

The third portion begins as the duodenum sweeps to the left at the level

L3 vertebra. It is associated with pancreas and superior mesenteric artery.

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The fourth portion of the duodenum begins at the aorta, extends to the

left, and passes ventral to the left psoas. It emerges into the peritoneum at the

duodenojejunal flexure, which is fixed to the posterior abdominal wall at the

ligament of Treitz, Venous drainage from the duodenum is through the splenic,

superior mesenteric, and portal veins.

Jejunum and Ileum

The jejunum and ileum are the distal two parts of the small intestine (23).

The jejunum begins at the duodenojejunal flexure. There is no clear

demarcation between jejunum and ileum (24).

The blood supply of the jejunum and ileum derives from the SMA, which

has an extensive anastomotic network near the mesenteric border of the bowel

called the marginal artery.

The jejunum tends to have a single marginal artery from which arise long,

relatively straight branches of the vasa recta. This pattern gradually blends into

arcades that travel close to the mesenteric edge of the bowel and give rise to

short branches in the ileum.

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The intestine tends to become thinner and paler distally, along with a

decrease in diameter. Lymphatic tissues to the small intestine, called Peyer's

patches are most numerous in the distal ileum, whereas plicae circulares are

more prominent in the proximal jejunum.

The vascular supply to the small intestine arises from SMA. The arterial

branches derived from SMA pass through the two layers of the mesentery into

the gut at the mesenteric margin of the small bowel.

In the jejunum, the arcades are comprised of long vasa recta (3 to 5 cm),

whereas in the distal ileum the arcades are elongated and the vasa recta are

relatively short. Venous drainage from the intestine parallels the arterial supply,

with the superior mesenteric vein being the major venous collecting system; it

also lies within the mesentery to the right of the SMA.

Innervation to the small intestine is through the autonomic nervous

system and includes sympathetic, parasympathetic, and enteric divisions.

Sympathetic fibers arising from thoracic segments of the spinal cord synapse in

the celiac ganglion. Parasympathetic fibers arise from the vagus nerve and

synapse in the submucosal (Meissner's) and myenteric (Auerbach's) plexus.

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The Large Intestine

The large intestine originates from both the midgut and the hindgut. The

colon is approximately 150 cm long, and its greatest caliber is 7.5 cm at the

cecum, from where it gradually diminishes to 2.5 cm at the rectosigmoid.

The longitudinal muscle layer is concentrated to form three linear bands

that are equidistant from each other and make up the taeniae coli. These shorter

taeniae cause the circular muscle coat to be puckered and thrown into haustral

sacculations because the length of the taeniae is less than that of the bowel wall.

The taeniae extend from the tip of the cecum to the rectosigmoid and are

approximately 6 mm wide. Most of the colon, other than the appendix and

cecum, is peppered with peritoneum-covered adipose pieces known as

appendices epiploicae.

CECUM

The cecum is the commencement of the large intestine and just above the

ileocecal valve. Its average axial diameter is approximately 6 cm, with a breadth

of about 7.5 cm. Anteriorly, cecum is in contact with the anterior abdominal

wall but may have greater omentum or coils of small intestine overlying it. The

cecum is mobile and has a complete covering of peritoneum, although this may

be absent at the superior part.

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ASCENDING COLON

The ascending colon is narrower than the cecum at its origin and is about

15 cm long. It then turns down, forward, and to the left, forming the hepatic

flexure. The ascending colon is covered on all sides except its posterior surface.

It is not uncommon for it to be completely covered with peritoneum and to

contain a narrow mesocolon. The hepatic flexure has a vertical mobility of 2.5

to 7.5 cm with respiration.

TRANSVERSE COLON

The transverse colon begins at the hepatic flexure and passes across the

abdomen into the left upper quadrant, where it curves acutely onto itself, down

and backward, to form the splenic flexure. It is about 50 cm long, and in its

course across the abdomen, it forms an arch with its concavity facing backward

and up. The transverse colon is almost completely covered with peritoneum

between the head of the pancreas and the splenic flexure.

The transverse colon joins the descending colon at the splenic flexure.

This may be so acute that the distal transverse colon lies anterior to the

descending colon. The splenic flexure is connected to the diaphragm by the

phrenicocolic ligament, at the level of the 10th and 11th ribs.

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DESCENDING COLON

Descending colon is 25 cm, long and extends from the splenic flexure

down to the pelvic brim. It is covered by peritoneum over its anterior surface

and side. On its anterior aspect, it is related to the coils of the small intestine,

and in its lower portion, it is related to the anterior abdominal wall.

SIGMOID COLON

Sigmoid colon begins at the pelvic brim and forms a loop of about 40 cm

that lies within the pelvis. It becomes continuous with the rectum at the level of

S3 vertebra and is marked by lower end of the sigmoid mesocolon.

ARTERIAL SUPPLY

SMA supplies the colon to a level just short of the splenic flexure. IMA

supplies the large intestine as far as the mucous membrane of the upper third of

the anal canal. The following branches are responsible for supplying the colon:

1. The ileocolic artery branches early from the superior mesenteric trunk. The

artery then divides into anterior and posterior cecal arteries to supply the cecum.

2. The right colic artery has its origin at the right side of the root of the SMA. At

left side of colon, it divides into a descending branch, which anastomoses with

the colic branch of the ileocolic artery, and an ascending branch, where it

anastomoses with a branch of middle colic artery.

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Figure 1- vascular anatomy of small bowel

Figure 2- vascular anatomy of large intestine

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3. The middle colic artery is the most proximal branch of the SMA. It divides

into right and left branch at the transverse colon. The right branch anastomoses

with the ascending branch of the right colic artery, whereas the left branch

anastomoses with a branch of the left colic artery.

The inferior mesenteric artery arises opposite the L3 vertebra from the front of

the aorta. The following branches supply the left side of the colon:

1. The first branch is the left colic artery. It then divides into the upper branch,

and the lower branch. Both branches further divide into branches that

anastomose with the left branch of middle colic artery.

2. Sigmoid arteries are three or four branches that arise from a common origin

at the inferior mesenteric artery below the left colic artery. They pass forward in

the sigmoid mesocolon and supply the sigmoid colon.

The marginal artery is the name given to a single arterial trunk made up

of anastomoses around the concave border of the large intestine from the

ileocecal junction to the rectosigmoid junction. The marginal artery is therefore

made up of branches of both the superior and inferior mesenteric arteries.

VENOUS DRAINAGE

Veins from the right side of the colon flow into the superior mesenteric

vein (SMV), which drains the midgut. Veins from the left side of the colon flow

into the inferior mesenteric vein (IMV), which drains the hindgut.

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PATHOPHYSIOLOGIC CHANGES FOLLOWING OSTOMY

Sodium and water balance:

Colon absorbs at least 1000 ml of water and 100 mEq of sodium chloride

each day. After an ileostomy, because of the absence of the colon prevents

sodium and water reabsorption.

In high-output stoma may suffer from dehydration, hypomagnesaemia

and malnutrition(25). When there is low salt intake, sodium losses in normal

stool can be reduced to 1 or 2 mEq/day, but patients with ileostomies have

sodium losses of 30 to 40 mEq/day.

When oral intakes of sodium, chloride, and fluid are adequate, patients

with ileostomies does not become depleted in volume or electrolytes. Negative

sodium balance occurs when there is diminished intake or excessive loss.

Renal compensation:

Chronic oliguria can occur in ileostomies, because normal stools contain

100 ml of water, whereas ileostomies patients lose 500 to 600 ml of water per

day(26). They have lower urinary Na

+/K

+ ratios because of compensatory renal

conservation (27).

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Malabsorption:

Stoma patients may have malabsorption due to loss of absorptive

surface(28). When an ileostomy is accompanied by resection of the terminal

ileum, abnormalities of bile acid reabsorption, malabsorption of vitamin B12, fat

malabsorption can occur (29).

After ileostomy, ileostomy adaptation does occur in order to conserve

body salt (30). Jejunostomies have high output up to several liters per day in

this early phase, with losses of Na, K, and magnesium (31).

Carbohydrate and fat malabsorption:

Absorption of CHO, amino acids, and bile acids was markedly decreased

and of short chain fatty acid mildly reduced in ileal reservoir mucosa compared

with normal ileum, largely owing to a decrease in reservoir absorptive surface

area from flattened villi (32).

Most patients with ileostomy and jejunostomy are in a negative calcium

balance; therefore, an oral supplement of calcium at a daily dose of 800 to 1500

mg is recommended. High output fistula is associated with hyper secretion of

Hcl. Use of H2 blockers or proton pump inhibitors may be benefit for these

patient. To control fluid loss we can use antimotility drugs; these drugs to

reduce stoma output by up to 50% (33).

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Vitamin malabsorption:

Fat soluble vitamin (A, D, E, and K) deficiency may occur as a result of

fat malabsorption. Most of vitamin K is synthesized by colonic flora, so patients

who underwent colonic resection prone to develop vitamin K deficiency. Zinc

and selenium are lost in the faeces.

INDICATION FOR OSTOMY

A colostomy is required after APR of a low rectal or anal canal tumor. An

ileostomy is employed after excision of the whole colon and rectum (pan

proctocolectomy) unless a pouch reconstruction is performed. Ileostomy is

created either as a temporary means of fecal diversion when an anastomosis is

unsafe or unwise or as permanent orifices for the passage of excrement.

Permanent colostomies are nearly always created from the sigmoid or

descending colon, usually in association with distal bowel resection.

Colostomies proximal to the splenic flexure typically function poorly, are often

placed in locations difficult for ostomy to manage, and are at high risk for

complications.

A colostomy can be looped, double barrel and end colostomy. Colostomy

again divided into diverting colostomy or defunctioning colostomy (34),

decompression colostomy, irrigation colostomy

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Diversion colostomy done when there is a breach in the bowel wall,

destruction, trauma (35), sphincter injuries, Cohn’s disease, rectosigmid growth.

Most of the time it is done as an end colostomy with mucus fistula or with a

Hartmann’s procedure. Site selection can be transverse colon, descending colon,

sigmoid colon. It also indicated in colorectal endometriosis (36)

Decompression colostomy done when there is an obstructive lesion in the

rectosigmoid junction. Types of decompression colostomy are blow hole

colostomy, tube caecostomy and loop transverse colostomy. Blow hole

procedure done as a single or multiple small stomas onto the skin to decompress

colon in severely ill patient with obstructive lesion.

Common Indications for Permanent Colostomy are colorectal cancer(37),

carcinoma anal canal, after Hartmann’s operation(38) , Radiation proctopathy,

Incontinence, Refractory anorectal infection, Ischemia, Crohn's disease,

Diverticular disease, Sacral decubitus(39) .

Indications for temporary colostomy was congenital mega colon,

anorectal malformations (13) , colonic atresia (40)sigmoid volvulus (41),

perforation of left sided colon, left sided colonic growth , high anal fistula and

trauma to left sided colon (42), perianal burns (43)

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Permanent ileostomies are far less common like for inflammatory bowel

disease, familial adenomatous polyposis, multiple synchronous colorectal

cancers, and a variety of other miscellaneous disorders.

Most common indications for loop ileostomy was a rectal tumor (cancer

or large villous tumor), inflammatory bowel disease(44) (ulcerative colitis and

Crohn's disease ) Familial adenomatous polyposis and other diseases (45). In

pancreatitis with perforations also loop ileostomy indicated to prevent bacterial

translocation(46). Loop-ileostomy is also indicated protect distal anastomosis

in colorectal resections (20)(17) (47).

OPERATIVE TECHNIQUE

PREOPERATIVE COUNSELING

Adequate preoperative counseling prevents lot of post operative

complications. Stoma education before the procedure will prevent

complications due to stoma(48). Providing patients with literature on their

disease and the proposed surgery is often helpful. Patient education (stoma

education)and counseling regarding stoma construction is very important to

prevent stoma complications (49)(50). A preoperative visit with the

enterostomal therapist is essential.

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SELECTION OF STOMA SITE

Improper stoma causes morbidity and affect quality of life(51)(52). In

many instances, it may not be possible to decide the type of stoma(53). High

incidence of wound infection and incisional hernia occur if main incision is

used for stoma site (54). Stoma education leads to shorter hospital stay and less

stoma related complications(55). Location of the stoma was determined by site

of bowel selection (56)(57).

Criteria for stoma site selection:

A flat skin surface is preferred.

Stoma should be seen by patient when bend, sit, stand.

Previous scars, bony prominences, waist, beltline, inguinal crease, should

be avoided if possible.

Stoma site is marked with a permanent marking pen or by intradermal

methylene blue dye.

The opening of the faceplate corresponds to the outer half of the rectus

muscle

Pre-existing disabilities should be considered.

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Figure 3- Stoma should be seen by patient when bend, sit, stand.

Figure 4- Preoperative stoma site marking

Ostomy should come out of through the rectus abdominis; it will prevent

the incidence of parastomal hernia. Preoperative marking of the stoma area is

considered important for the prevention of postoperative complications

(58)(59).

PRINCIPLE OF STOMA

A laparotomy incision is preferable for construction of stoma, because it

allow place for stoma construction on the either side of abdomen. Minimally

invasive surgery like single-port laparoscopic surgery for stoma, creation is

possible. It can be used for construction of ileostomies as well as colostomies,

end, or loop stomas(60).

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Patients should be marked prior to surgery. Abdominal landmark used for

stoma construction are called ostomy triangle. They are anterosuperior iliac

spine, pubic tubercle, and umbilicus. Stoma site should be marked 5 cm away

from bony prominences.

TYPES OF STOMA

END ILEOSTOMY

Stoma site was marker before surgery

Midline laparotomy incision made with adequate bowel resection

2.5cm of skin disk is marked site with sparing of subcutaneous fat

Fat is dissected with scissors to expose the anterior rectus sheath

While doing dissection fat shouldn’t be removed

Cruciate incision is made over the anterior rectus , 2cm on each side

Medial extension of incision should be avoid

The rectus abdominis muscle is split in the direction of its fibers to

expose the posterior sheath.

After preparation of stoma site, ileum should be prepared.

Any residual retroperitoneal attachments are divided to facilitate passage

of the bowel through the abdominal wall without tension.

The mesentery should be cleared from the terminal 5 to 6 cm of the

ileum.

Terminal ileum divided with a stapler or knife (73).

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Figure 5- A, Ileostomy site marked preoperatively in the right lower

quadrant. B, Two-centimeter disk of skin excised with a scalpel. C,

Anterior fascia divided via a cruciate incision. D, Posterior rectus sheath

divided longitudinally after spreading the rectus muscle

The circular staple line provides a watertight seal that prevents

contamination of the subcutaneous tissues (74).

Figure 6- E. Ileum delivered with a Babcock. F. Ileum protruding 2 to 3

cm above the anterior abdominal wall without tension. G. Intraperitoneal

fixation of the ileum and its mesentery.

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The ileum now oriented with the cut mesenteric edge and passed through

the previously created defect in the abdominal wall.

The ileum should protrude 5 to 6 cm beyond skin level and appear pink

and well perfused.

The ileal gutter may be closed to prevent small bowel obstruction

secondary to small bowel rotating around the ileostomy.

The abdominal incision is then closed in routine fashion, including the

skin.

Ileostomies must be everted and matured.

This is accomplished by tripartite sutures containing dermis, the

seromuscular layer of the bowel at the fascial level, and full-thickness

bites of the cut edge of the ileum.

Three or four of these sutures are placed and they are tied while general

traction is placed within the lumen of the ileum.

After the stoma has been everted, the enterocutaneous anastomosis is

completed with sutures between the cut edge of the ileum and dermis.

End ileostomy with subcutaneous buried efferent limb has advantages

over loop ileostomy with regard to the risk of peristomal skin and leakage

problems (70). Quality of life is better in ileostomy compared to

colostomy(71)(72)

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Figure 7- H and I, Placement of three-point sutures in each of the four

quadrants helps evert the ileal mucosa. J, Matured ileostomy

END COLOSTOMY

The lateral attachments of the colon are transected until sufficient colon is

mobilized.

After mobilization of colon, the stoma site is prepared

Abdominal wall defect created similar to end ileostomy.

Colon is oriented without twisting and passed through the abdominal wall

Once the abdominal incision has been closed and protected, the

colostomy can be matured.

Colostomies may be sutured without eversion.

The overall stoma-related morbidity and risk of reoperation were

significantly lower after loop ileostomy than after loop colostomy (61).

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To prevent infection, the colostomy should fully closed and dressed

(62).

The distal end should sit 1 to 2 cm above skin level. Four absorbable

sutures are placed, one in each quadrant of the abdomen.

Each suture takes a seromuscular bite of the emerging colon at skin level,

and a subcutaneous bite of the edge of the skin opening.

This completed by filling in the gaps between the four quadrant sutures

with the skin edge. There should have a small (0.5 to 1 cm) lip, which

facilitates accurate positioning of the colostomy bag.

Figure 8- End colostomy

LOOP ILEOSTOMY

A diverting ileostomy is used to reduce the consequences of a distal

anastomotic leakage (75). Temporary ileostomy preferred over temporary

colostomy in low anterior resection for rectal cancer (77).

The most distal segment of the terminal ileum without tension is selected

(76).

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20 to 30 cm proximal to the ileocaecal valve was selected for loop

ileostomy.

An abdominal wall defect is created as previously described.

The defect should be larger than end ileostomy to accommodate both

loops of bowel.

Distal end is marked with a suture to prevent maturation of the incorrect

segment.

The ileal loop is passed 4 to 5 cm beyond the abdominal skin.

Figure 9- creation of loop ileostomy

Ileum is transected along approximately 80% of its circumference with

preservation of mesentery

soft catheter or nylon tape passes through a small window made in the

mesentery of the ileum

Semi lunar incision is made in the mesenteric border of the distal limb at

skin level, extending around most of the circumference of the ileum.

proximal limb is grasped with Babcock forceps

36

The distal end is matured with simple sutures between terminal bowel

and dermis.

On the proximal side, several sutures take bites of the serosa of the

emerging ileum at skin level. The loop of ileum can also be secured to

the stoma site with a novel 'suture bridge' technique (78).

The loop stoma should protrude adequately, with its functional end

occupying approximately 80% of the trephine circumference.

LOOP-END ILEOSTOMY

A small defect is created in the mesentery at the ileal stomal site.

The bowel is divided with blade or stapling device.

The proximal end of the ileostomy is brought through the abdominal wall

as for a standard end ileostomy.

The antimesenteric corner of the distal, nonfunctional segment is brought

through the same stoma site.

The antimesenteric corner of the distal staple line is transected and the

small opening in the distal bowel is matured to the abdominal wall

without eversion.

The proximal bowel is then everted and matured in a similar fashion to

any end ileostomy.

37

Figure 10- A to E, Creation of an end-loop ileostomy.

A single suture between the proximal end ileostomy and the distally

matured segment connects the two and completes the maturation.

LOOP COLOSTOMY

A loop colostomy created in cases of incontinence and severe anorectal

infection or for proximal protection after complex anal reconstruction. (63). But

loop colostomy associated with higher complication rate due to following

reasons (64). Because of the higher complication rate sometimes loop ileostomy

is preferred(65). During stoma reversal, wound infection more in the loop

transverse colostomy group than in the loop ileostomy (31).

Causes of complication in loop colostomy

Loop colostomy need large stomal wall for accommodation of two loops.

Parastomal hernia will occur due to large stomal wall defect.

Prolapse more common in loop colostomy(66).

Chance of anastomotic leak following loop colostomy due to injury to

marginal vessels (67).

38

OPERATIVE PROCEDURE

Site of loop colostomy should be selected. Left iliac fossa for left colon,

whereas right upper quadrant for transverse colon.

Length of colon should be sufficient to reach stoma site. In case of

disparity mobilization should be done.

Peritoneal reflection should be removed to provide sufficient length.

While dissection care should be taken to take care marginal vessels

Hole in the anterior abdominal wall made, usually bigger than end

colostomy

Bowel loops brought out of hole.

Figure 11- creation of loop colostomy

A window made in the mesentery and s supporting colostomy rod (68) or

catheter is passed.

Care should be taken to maintain the orientation of the colon.

Transverse incision is made across the loop.

39

Edges of the colon are everted and sutured to the skin edge of the hole

with interrupted absorbable sutures.

DOUBLE-BARREL

The procedure requires the construction of a diverting loop colostomy

with division of the colon, approximately 15 cm distal to the stoma.

The procedure has been used in patients without a prior stoma as well as

those with existing loop and end colostomies (69).

Proximal and distal colon tacked together along the antimesentric border

with sutures.

END-LOOP COLOSTOMY

End-loop colostomy created with a preselected segment of the sigmoid

colon.

It is mobilized appropriately and passed through the previously created

abdominal wall defect similar to that of an end-loop ileostomy.

The end colostomy is matured in a similar fashion to that of the end-loop

ileostomy.

As loop colostomies, the proximal end may be everted but a flush

colostomy created.

40

COMPLICATION OF STOMA AND THEIR MANAGEMENT

Complications of stoma are high and affect quality of life(80).Many

stomal complications can be managed with enterostomal care (81).

Complication Treatment

Mucosal sloughing or necrosis of

bowel due to ischemia

Reoperation and refashioning of the

stoma

Obstruction of stoma Exploration and softening enemas

Skin erosion Nursing care

Parastomal hernia Resetting of stoma, placement of mesh

Prolapse of bowel Refashioning of stoma

Parastomal fistula Refashioning of stoma

Retraction of ileostomy Reoperation of stoma

Stenosis of stoma Refashioning of stoma

Perforation after colonic irrigation Requires exploration

ISCHEMIA

Necrosis of a stoma is due to impaired blood supply to the stoma

mucosa. This usually is evident within 24 hours after surgery. Partial necrosis

is more common compared to whole circumference necrosis. The incidence

ranges from 2 to 20%. More serious complete or deep necrosis can occur in 0.37

to 3% of cases (82).

41

It can also occur in people with poor systemic circulation or a thick

abdominal wall. Preparation of proper bowel segment for stoma construction

will prevent necrosis of stoma. Blood supply to the stomal edge should be

confirmed before it fixed to abdominal surface. Because of the ischemia and

necrosis chronic blood loss are common in diversion stoma (83).

The stoma color will change from purple to gray to black and the surface

of the stoma will become dry. Up to 5cm of mesentery will avoid ischemic

necrosis of end ileostomy(84) .

The stoma needs to be viable above fascia level to prevent peritonitis. As

the nonviable tissue sloughs from the stoma, this tissue can be debrided.

Interventions for a necrotic stoma include documenting the mucosa color and

assessing the depth of the necrosis. Urgent intervention is needed when there is

necrosis of ileostomy. But ischemic necrosis of colonic stoma need not be

revised if the necrosis is short.

MUCOCUTANEOUS SEPARATION

Mucocutaneous separation results when the suture line at the junction of

the stoma and skin separates. The incidence ranges from 4.0 to 26 % (85). This

can occur when there is an oversized skin opening of the stoma, excessive

tension on the suture line, insufficient suturing at skin level, or inappropriate

sutures, or with patients who have compromised tissue healing, which may

include those with diabetes, those taking high-dose steroids, those with

malnutrition, or those receiving radiation therapy.

42

Stoma necrosis can also cause a mucocutaneous separation as the necrotic

tissue detaches from the skin. Separation of mucocutaneous junction arises due

to indurations of mucocutaneous junction. The separation may be partial or

circumferential.

There may be drainage present in the separation, usually serous or

purulent in nature. Stool drainage could indicate a possible fistula in the

separation. The separation should be probed gently to determine the depth and

access for tracts that may be present.

The defect can be irrigated gently and then packed with an absorptive

wound dressing if it is more than 1 cm in depth. Absorptive wound dressings,

such as a hydro fiber or calcium alginate, would absorb drainage, prevent

excessive soiling of the wound by stool, and promote healing of the separation.

If the separation is shallow, the base can be filled with a skin barrier powder to

absorb moisture.

Once the separation is packed, the skin barrier of the pouching system is

placed over the stoma and separation to provide protection from the effluent. As

the separation heals, it may be necessary to modify the appliance for improved

fit on the peristomal area. For prevention of mucocutaneous separation

numerous modification proposed (86)(87).

43

SKIN IRRITATION

Skin irritation is most often caused by contact of effluent on the

peristomal skin. This is usually due to an improperly fitting Ostomy appliance,

erosion of the skin barrier if the appliance is left in place too long or skin

sensitivity to products being used. The skin irritation can be treated by applying

a skin barrier powder to protect the skin and absorb moisture from denuded

skin. The most important step is to identify the cause of the skin irritation and

correct it.

STENOSIS

Stoma stenosis is described as a narrowing of the lumen of the ostomy

in the skin or fascia level. The lumen contracts due to scar formation. Stoma

stenosis can occur as a result of insufficient skin excision at the stoma site,

excessive scarring due to stoma necrosis, peristomal abscess, or mucocutaneous

separation (88). Significant stenosis can affect the normal stoma function,

resulting in discomfort when stool passes through the stoma.

Digital examination of the stenosed stoma reveals tightness in the skin or

fascia opening. The patient with a stenosed colostomy may note symptoms of

constipation and increased cramping with stoma function as well as effluent

exiting the stoma under pressure.

Management of stomal stenosis varies from degree of stomal stenosis.

Simple dilatation is sufficient for mild stenosis. Moderate to severe degree of

stomal stenosis need some kind of surgical intervention.

44

Figure 12 – Stomal necrosis

Figure 13 – Mucocutaneous separation

45

LACERATION (STOMA TRAUMA)

Stoma trauma or laceration is an injury or cut on the stoma mucosa. This

can occur when the appliance opening is too small or is improperly placed over

the stoma, with shaving, or direct injury to the stoma. Bleeding may occur at the

site and there may be blood in the pouch.

Management of a stoma laceration is to identify and correct the cause.

The appliance should be altered to fit the stoma appropriately. If the stoma

mucosa is bleeding significantly at the time of appliance change, direct pressure

should be applied to the site until bleeding is controlled.

PROLAPSE

Stoma prolapse is progressive elongation of the stoma through the skin

opening. The incidence ranges from 2 to 22% for stomal prolapse. Loop

ileostomies has less complications compared to loop colostomies ranges from

less than 2% for loop ileostomy, while loop colostomies ranges from 16 to 19%

(89)(90)(91) .

Prolapse can occur with each of the following scenarios:

(a) The stoma has not been placed through the rectus muscle of the abdomen,

(b) Large opening in the abdominal wall at the time of surgery,

(c) Insufficient suturing to the abdominal wall,

(d) Weak abdominal musculature,

(e) Distended bowel or increased intra-abdominal pressure, possibly due to

distention or crying in infants.

46

Figure 14 – Enterocutaneous fistula

Figure 15 – Skin excoriations

47

Prolapse are seen most commonly in a loop stoma (92). Although either

loop can prolapse, it is seen most often in the distal or nonfunctioning loop. A

symptom of prolapse varies from increase in length of stoma to severe bleeding

from the stoma.

In severe stomal prolapse, there will be obstruction due to traction on the

mesentery. There may also be evidence of tiny ulcerations on the stoma mucosa.

Stoma ischemia requires immediate surgical attention.

Stoma prolapse and peristomal hernias are common in infants. They do

not have well-developed abdominal muscles to support the stoma. Increased

intra-abdominal pressures can also stretch the fascial opening to create a hernia.

As in adults, the distal stoma, in a loop stoma, is more likely to prolapse.

A prolapse can be managed conservatively if the stoma color and

function remain normal. The prolapse may be manually reduced with the patient

lying flat. Continuous pressure is applied to the distal portion of the stoma, or an

ice pack applied directly to the stoma to decrease the edema and aid in reducing

the stoma.

It is common for the prolapse to recur when the person sits, stands, or

coughs, as the intra-abdominal pressure is increased. The pouching system

should be flexible, with sufficient length to accommodate the prolapsed stoma.

The skin opening in the appliance should fit the stoma when it is at its largest

diameter, usually with the person standing. Surgery may be necessary to resect

the prolapse and revise the stoma.

48

Figure 16- Stomal prolapse

Figure 17 – Stomal retraction

49

RETRACTION

Two types of retraction can occur with an ostomy: Stoma retraction or

peristomal skin retraction. Stoma retraction occurs when the stoma does not

protrude above the skin, but has pulled back to skin level or below skin level.

Stoma retraction incidences ranges from 1.4% to 9% (90)(93)(94)(95)(3) .

Retraction is more in ileostomy compared to colostomy (96)(97).

The patient may have a stoma that protrudes 1 to 2 cm or may have a

flush stoma, but the skin retracts around the stoma. The retraction may be

preceded by stoma necrosis or mucocutaneous separation. Retraction is due to

tension on the bowel, obesity, edema, distention, stoma length and short

mesentery.

Skin retraction occurs when the peristomal skin at the mucocutaneous

junction pulls in, especially when the patient is sitting or standing. The stoma

should be evaluated with the patient sitting and standing to determine the degree

of retraction. Patients will present with problems with appliance leakage,

decreased appliance wear time, and skin irritation from stool, contact with skin.

The goal for management of stoma retraction is to maintain an adequate

appliance seal to prevent effluent from causing skin irritation. This may require

the use of a convex appliance, possibly with additional skin barrier rings to

increase convexity, depending on the degree of retraction. Surgical intervention

may be necessary if problems persist.

50

PERISTOMAL HERNIA

A peristomal hernia is due to defect around the opening of stoma. When

stoma becomes larger, it allows the bowel loops through the defect around the

stoma. This results in progressive bulging around the stoma. The bulging is

usually more prominent with sitting and standing.

Although there is no clear identified cause of peristomal hernias, stoma

away from the rectus muscle may be the cause. They can also occur if there is a

large fascial defect; an increase in intra-abdominal pressure, placement of stoma

through an incision; aging; or excessive weight gain.

Peristomal hernias are visible when ever a patient sits or stands. The

bulging variable and may be on one side of the stoma or circumferential. Due to

the changes in the abdominal contour when lying compared to sitting or

standing, it is difficult to seal stoma.

Diagnosis of a hernia can be made by examination, having the patient

cough or bear down to increase abdominal pressure. Digital examination allows

the fascial defect to be felt as well. To confirm the presence of a hernia, a

computed tomography scan with oral contrast or an upper gastrointestinal

radiograph with small bowel or retrograde contrast study can be done.

Nonsurgical intervention is usually recommended if the patient is

asymptomatic. Hernia support belts or binders will provide support around the

stoma, reducing the protrusion of the hernia, and can help with appliance

adherence.

51

It is best to use a flexible appliance to fit the changing contour around the

stoma. The stoma size should be evaluated when the patient is sitting and

standing as it will usually become larger when the hernia protrudes.

Surgical intervention may include primary repair, local repair, mesh

repair, or relocation of the ostomy. Shellito reported the incidence of recurrence

following a local fascial repair without mesh at 76%, a local repair with mesh at

50%, and stoma relocation at 33%.

PARASTOMAL HERNIA

Parastomal hernia is a common complication after colostomy formation

(98).while creating abdominal stoma, we need to create defect in the abdominal

wall. Due to creation of the defect in the abdominal wall leads to formation of

parastomal hernia.

Causes of formation of parastomal hernia:

Obesity, Increased intra abdominal pressure, Dilated bowel loops in pre

operative status, Emergency stoma construction.

Prevention of parastomal hernia:

Make an incision which admits only two finger.

Use of prosthetic mesh prevents parastromal hernia (99).

Prophylactic use of mesh will prevent parastromal hernia in patients who

undergoes permanent colostomy for colorectal malignancy (100)

Stoma construction through rectus abdominis muscle(101).

52

Figure 18- Parastomal hernia

Figure 19- Skin excoriation

53

Clinical presentation

Most of the time asymptomatic

Budging near stoma site

Leakage from stoma

Difficulty in applying stoma bag

Intestinal obstruction

Strangulation of bowel

Parastomal evisceration(102).

Management

Surgical technique included stoma relocation, retromuscular dissection,

posterior component separation, and retromuscular mesh placement (25).

Local repair(103).

Use of prosthetic mesh (104)(105)(106).

Stoma relocation (107) (108) (109).

Complication of management

Highest recurrence rate

Stoma relocation leads to increased morbidity.

Intra abdominal mesh leads to adhesion and obstruction.

Management of parastomal hernia is very difficult. But there is evidence that

use of mesh will prevent complications associated with parastomal hernia (110).

54

OBSTRUCTION

Causes of intestinal obstruction

Stomal stenosis

Parastomal hernia,

Postoperative adhesions, and

Recurrent disease

Management of obstruction depends on the cause of the obstruction

(111).

FISTULA

An enterocutaneous fistula is an abnormal communication between the

stoma and the surrounding skin. It appears as an opening on the peristomal skin

or at the mucocutaneous junction of a matured stoma(112). Stool may be

evident at the fistula site and through the stoma.

Fistulas may occur when a suture was placed through the mucosa of the

stoma at the time of surgery, but most commonly are due to recurrence of Crohn

disease, poor healing, and mechanical trauma from the appliance being used.

Although some superficial enterocutaneous fistulas will heal

spontaneously, surgical intervention may be needed to resolve the fistula(113).

If surgical intervention is delayed or not indicated due to other medical

problems, a pouching system that can accommodate both the stoma and the

fistula should be considered. A convex appliance may provide a better seal for

the skin.

55

PERISTOMAL SKIN COMPLICATIONS

Irritant or Contact Dermatitis

The onset of peristomal skin complications occurred mostly during 3rd

week to 5th

week. The most common skin conditions were irritation (Irritant or

contact dermatitis ) and infection (114).

Irritant dermatitis of the skin results from contact with a chronic irritant,

such as stool or chemicals (101). Peristomal skin complications ranges from 18

to 55% (115). This may be due to poor stoma construction causing effluent to

be in contact with the skin or from poor technique in appliance care(116).

Effluent may come in contact with the skin if the appliance is not the

appropriate size, has not been applied appropriately, or has been left in place too

long. Also, if the stoma is located in a poor location or is poorly constructed,

this may contribute to leakage and dermatitis(117).

Skin damage correlates with the area that is exposed to the irritant.The

skin shows erythema and swelling. It may progress to denudation, ulceration,

bleeding, and weeping because of the loss of epidermis (118).

Treatment is directed at identifying and eliminating the cause. The goal is

to protect damaged skin and avoid other irritants. The appropriate pouching

system provides a secure, predictable wear time and protects the peristomal skin

from effluent. Topical steroids may be used short term to reduce the

inflammation and pain. The Skin barrier powder can be applied to the skin to

absorb moisture and provide a dry pouching surface.

56

CANDIDIASIS

Candida albicans is the most frequent agent of candidiasis and thrives in

dark, moist areas. A leaking ostomy appliance, body perspiration, and denuded

skin, caused by too large of an appliance opening or prolonged wear time, all

provide optimum environments for candidiasis to develop on the skin.

Predisposing factors

Long term antibiotic therapy

Diabetes mellitus

Immunosuppression

Myelosuppression

Oral contraceptives

Topical corticosteroid therapy

Skin manifestations include papules, pustules, erythema, and pruritus

(119). The lesions are extrafollicular, and satellite lesions, extending beyond the

edge of the appliance, are common. Candidiasis may also be evident in skin

creases, such as the axilla or groin.

Effective treatment of candidiasis begins with identifying the cause and

eliminating it (120). A dry environment may be provided with an appropriately

sized appliance, which fits the abdominal contour. A topical antifungal powder,

such as nystatin or miconazole powder, should be applied sparingly to the

affected area and rubbed into the skin, with the excess brushed off (121).

57

ALLERGIC DERMATITIS

Peristomal allergic contact dermatitis refers to hypersensitivity to

chemical elements resulting in an inflammatory reaction. Damaged or inflamed

peristomal skin is at increased risk for sensitization because the skin's immune

system is over stimulated. The original skin problem may be denudation caused

by an irritant dermatitis(122). The products used to treat the damaged skin may

then create an allergic contact dermatitis. Once the sensitivity develops, it can

last for months to years.

Management of allergic dermatitis consists of determining and

eliminating the causative factors. An allergic dermatitis should be considered

when the skin reaction is located in the area where a specific product is being

used. Treatment may also include the use of topical corticosteroids to reduce the

inflammation, an appropriately fitting ostomy appliance, and the elimination of

any unnecessary products on the skin to prevent further dermatitis.

MECHANICAL INJURY

Damage to the peristomal skin may result from mechanical injury, such

as trauma, shear, or pressure. Common causes include abrasive cleansing

techniques and traumatic tape removal that results in epidermal stripping,

shearing of the skin as the appliance moves on the skin, or continued friction or

pressure from inappropriately fitting equipment (123).

58

The affected skin is painful, and the moist, bleeding areas undermine the

pouch seal, resulting in frequent pouch changes and further exacerbation of the

problem. Lesions are typically shallow and irregularly shaped, and appear as a

full- or partial-thickness skin loss located in the area of the trauma.

Mechanical injury can be prevented by educating the patient in

appropriate appliance removal, which is gently pushing the skin away from the

appliance instead of pulling on the skin. Adhesive removers may be necessary if

the skin is thin or sensitive, but it is important to wash the adhesive remover off

the skin before applying another appliance to prevent contact dermatitis.

The appliance fit should be evaluated to determine if there is excessive

pressure, possibly from a convex appliance or belt, especially with changes in

body contour postoperatively or with a hernia, that may be causing ulceration.

This may necessitate the use of a softer or more flexible appliance or

discontinuing the belt to prevent excessive pressure and promote healing of the

ulceration.

PSEUDOVERRUCOUS LESIONS (HYPERPLASIA)

Pseudoverrucous lesions are raised areas located around the stoma,

usually at the mucocutaneous junction (124). They are thickened epidermal

projections. These lesions are localized to areas of chronic exposure to

moisture, usually stool or mucus, and can be extremely painful and bleed easily.

59

The chronic irritation from moisture causes thickening of the epidermis,

which may be due to the use of an appliance opening that is too large for the

stoma or from chronic appliance leakage. The primary treatment of

pseudoverrucous lesions is to eliminate chronic exposure of effluent on the skin.

The ostomy appliance should be resized to fit within one-eighth inch of the

stoma and should fit the abdominal contour appropriately to prevent leakage or

effluent undermining the skin barrier.

Silver nitrate may be used on large lesions to hasten healing and provide

a flat surface for the pouching system. Appliance change intervals may need to

be more frequent during the initial treatment, every 3 days, but once the lesions

have resolved, a normal appliance change schedule may be resumed.

FOLLICULITIS

Infection of the hair follicles caused by Staphylococcus aureus.

Erythematous and sometimes pustular lesions are present around a hair follicle.

Peristomal folliculitis generally results from traumatic hair removal, which may

be the result of shaving hair from the peristomal skin too frequently(123). Other

causes are indiscriminate shaving or dry shaving techniques and friction from

careless pouch removal.

Management of folliculitis consists of determining the technique for

peristomal hair removal. The patient should reduce the frequency of shaving to

no more than once a week and shave lightly or clip the hair with a scissors to

prevent skin damage.

60

PYODERMA GANGRENOSUM

Most of the time it is associated with ulcerative colitis (125). It may start

pustules, ulcers with irregular, ragged, overhanging margins. A necrotizing

inflammatory process extends peripherally from the primary lesion, resulting in

a necrotic ulcer with undermined edges.

The surrounding skin becomes red and purple, and the entire area is very

painful, which may distinguish it from other types of ulcers (126). Peristomal

pyoderma generally does not extend beyond the adhesive edge of the appliance

system.

Healing typically results in a cribriform scar. Ulcers that result from

pressure are often misdiagnosed as peristomal pyoderma gangrenosum. One

also must consider cutaneous Crohn disease, in which linear ulcers have

undermined violaceous edges.

Pyoderma usually reflects underlying inflammatory processes rather than

being a complication of ostomy construction. Diseases associated with

pyoderma include ulcerative colitis, Crohn disease, arthritis, leukemia,

polycythemia vera, and multiple myeloma (127). Diagnosis of pyoderma

gangrenosum is a clinical one based on history and ulcer assessment (128).

Biopsy only serves to exclude disorders such as malignancy or vasculitis.

The principles of management include decreasing the inflammatory process and

maintaining the seal on the appliance for a predictable period of time (129).

61

Topical treatment may include anti-inflammatory agents such as steroid

preparations or topical immunomodulators. Systemic medical therapy may be

necessary if there is no improvement or worsening of symptoms using topical

therapy (130). The goals of pyoderma gangrenosum wound care include

moisture control, maintenance of a clean wound base, protection of the wound

base, delivery of topical anti-inflammatory/immunosuppressive preparations,

and achievement of a predictable pouching system seal of at least 24 hours

(131).

Treatment was based on local cures, proper fitting of ostomy devices,

topical tacrolimus and systemic corticosteroids, adalimumab and antibiotics

(28). Shallow ulcers may be filled with a skin barrier powder to absorb

moisture and promote a secure appliance seal. Hydrofiber or calcium alginate

dressings can be applied over the ulcers to contain wound drainage. The

frequency of appliance changes will be determined by the amount of drainage

system.

PSYCHOSOCIAL CHANGES

Stomal surgery changes the body image, and influences physical, mental,

emotional, and social life of the patients (133)

62

INCISIONAL HERNIA

Incisional hernia can occur after stoma reversal at either the stoma site or

at the midline incision. the incidence for stoma site incisional hernias is closer

to one in three and for midline incisional hernias is closer to one in two (134).

NEWER TECHNIQUE

A flexible endoscope can be used to identify complications occurs in the

distal colon (135) (136). Newer technique in stoma construction was gasless

stoma construction(137). The fiberoptic endoscope can be used as a diagnostic

and therapeutic tool. Pediatric endoscope was used after pouch lavage, and the

afferent loop of ileum, the pouch, and (by retroflexion) the nipple valve were

examined (79).

63

MATERIALS AND METHODS

64

MATERIALS AND METHODS

Place of study:

All surgical units of dept of general surgery, surgical gastroenterology and

paediatric surgery, govt. Stanley medical college & hospital, Chennai- 600 001

Study design: Prospective cum retrospective study

Study duration: May 2012 to Oct 2015

Sample size: 100 cases

Study tool:

Data was collected from all patients who was admitted in Government

Stanley medical college and patients was included those who come under the

inclusion criteria.

Inclusion criteria:

1. All patients male and female up to 70 years undergoing stoma construction.

2. All elective and emergency cases undergoing intestinal stoma construction.

Exclusion criteria:

1. Patients undergoing urinary stoma construction.

2. Patients undergoing stoma construction as an indication for gynecological

disorders.

3. Psychological and biochemical complications were excluded from the study.

Follow up:

Follow up of the patients will be done at 4 wks,8 wks,12 wks,18wks,24 wks,

either by phone or by interview

65

Statistical method:

Descriptive analysis has been carried out in the study. Significance was

analyzed by using Chi-square test. The statistical software used was SPSS 22.0

version and Microsoft and excel used for generate table and graph

INVESTIGATIONS

A. Routine investigations:

Complete blood count

Renal function test

Liver function test

Serum electrolytes

Widal test

X-ray erect abdomen, X-ray chest pa view

USG abdomen and pelvis.

Endoscopy ( upper GI endoscopy/lower GI endoscopy)

Diagnostic laparoscopy

B. Special investigations:

C.T.scan of abdomen and pelvis

Loopogram

MRI

Other investigation ( if needed)

66

RESULTS

67

RESULTS

This is observational study consisted of 100 patients who were admitted to

Department of general surgery, Department of surgical gastroenterology and

Department of paediatric surgery in Government Stanley medical college,

Chennai and underwent stoma during august 2012 to august 2014.

All cases underwent detailed preoperative assessment, their preoperative

findings, indications for stoma construction and post operative complication and

varies complications related to stoma formation were recorded meticulously as

per protocol. The findings were analyzed and tabulated. The following

observations were made

68

Table 1: Age distribution of patient studied

Age (years) Frequency Percent

Less than1 3 3.0

2-15 5 5.0

16-25 10 10.0

26-35 25 25.0

36-45 18 18.0

46-55 25 25.0

56-65 8 8.0

Above 65 6 6.0

Total 100 100.0

Our study included 100 patients who underwent surgery for varies indication and stoma

construction. The maximum number of patients were in the group of 26-35 and 46-55 (n=25)

69

Table 2: Sex distribution of patient studied

Sex of patient Number Percentage (%)

Female 39 39.0

Male 61 61.0

Total 100 100.0

Our study included 100 patients who underwent surgery for varies indication and stoma

construction. In this study, 61 were male patients and 39 were female patients.

70

Table 3: Mode of surgery

Mode of surgery Frequency Percent

Elective 21 21.0

Emergency 79 79.0

Total 100 100.0

Out of 100 patients 79 patients underwent stoma construction as an elective procedure

compared 21 patients underwent stoma construction as an elective procedure

71

Table: 4 Duration of hospital stay

Duration of hospital stay (Days) Frequency Percent

Less than 10 2 2.0

11-15 28 28.0

16-20 32 32.0

21-25 15 15.0

26-30 10 10.0

Above 31 13 13.0

Total 100 100.0

Duration of hospital stay were analysed for 100 patients, were most of the patients stayed in

hospital approximately 16-20 days (32%)

72

Table 5: Primary complaint

Primary Complaint Frequency Percent

Abdominal distension 14 14.0

Abdominal pain 33 33.0

Altered bowel habits 13 13.0

Bleeding PR 12 12.0

Constipation 9 9.0

Faecal discharge 4 4.0

Fever 1 1.0

Prolapse of bowel 14 14.0

Total 100 100.0

Out of 100 patients, primary complaints were analyzed. Most of the patients presented with

complaints of abdominal pain both in emergency setting as well as elective setting (33%)

73

Table 6: Duration of primary complaint

Duration of primary complaint

(Days)

Frequency Percent

Less than 5 days 39 39.0

6-10 days 18 18.0

11-20 days 16 16.0

21-30 days 7 7.0

More than 30 days 20 20.0

Total 100 100.0

For 100 patients durations of complaints range from less than 5 days to more than 30 days.

But most of the patients presented with complaints durations less than 5 days (39%).

74

Table 6: Primary indications for intestinal stoma

Indication for stoma Frequency Percent

Abdominal sepsis 3 3.0

Abdominal trauma 22 22.0

Adhesive intestinal obstruction 4 4.0

Anastomotic leak 2 2.0

Congenital anomalies 3 3.0

Enteric fever 8 8.0

Enterocutaneous fistula 4 4.0

GIT malignancy 25 25.0

Hollow viscus perforation 12 12.0

Mesentric ischemia 2 2.0

Necrotising pancreatitis 3 3.0

Refractory ulcerative colitis 2 2.0

Strangulated hernia 4 4.0

TB abdomen 6 6.0

Total 100 100.0

Out of 100 patients undergoing stoma construction, the most common indications for stoma

construction was gastrointestinal malignancy (25%) followed by abdominal trauma (22%).

76

Table 8: SECONDARY CAUSE OF INTESTINAL STOMA

Frequency Percent

Anal growth 3 3.0

Anorectal malformations 2 2.0

Colonic perforation 22 22.0

GI fistula 1 1.0

Ileal perforation 29 29.0

Inflammatory disease 3 3.0

Intestinal gangrene 3 3.0

Intestinal obstruction 34 34.0

Sphincter injury 3 3.0

Total 100 100.0

Out of 100 patients underwent stoma construction the most common indications for which

stoma construction was intestinal obstruction (34%) followed by ileal perforation either

infective or traumatic (29%).

77

Table 9: Type of stoma

Type of stoma Frequency Percent

Caecostomy 1 1.0

End ileostomy with mucous fistula 20 20.0

End sigmoid colostomy 5 5.0

End transverse colostomy 1 1.0

Loop ileostomy 60 60.0

Loop sigmoid colostomy 7 7.0

Loop transverse colostomy 6 6.0

Total 100 100.0

Out of 100 patients the most common type of stoma constructed was ileostomy (80%). In

ileostomy loop ileostomy was most common (60%), followed by end ileostomy (20%). The

next most common stoma constructed was colostomy (19%). In colostomy most common

was loop sigmoid colostomy (7%), followed by loop transverse colostomy (6%)

78

Table 10: Stomal complication

Stomal complication Frequency Percent

Burst abdomen 1 1.2

Enterocutanous fistula 2 2.4

Gangrene of distal end 1 1.2

Intestinal obstruction 6 7.3

Wound infection 7 8.5

Mucosal prolapse 4 4.9

Parastromal abscess 1 1.2

Parastromal hernia 2 2.4

Skin excoriation 43 52.4

Stromal bleeding 1 1.2

Stromal diarrhea 1 1.2

Stromal necrosis 2 2.4

Stromal prolapse 2 2.4

Stromal retraction 7 8.5

Stromal stenosis 2 2.4

Total 82 100.0

79

Out of 100 patients 82 patients developed complications. The most common complication

observed in stoma construction was skin excoriations (52.4%), followed by laparotomy

wound infection (8.5%).

80

Table 11: Duration of stoma

Duration Frequency Percent

Less than 1 month 10 10.0

1-2 month 57 57.0

3-4 month 23 23.0

More than 5 month 6 6.0

Lifelong 4 4.0

Total 100 100.0

Duration of stoma was analyzed for 100 patients. Out of 100 patients, most of the patients

retained stoma for 1-2 months duration (57%).

81

Table 12: Onset of complication

ONSET OF COMPLICATIONS Frequency Percent

Less than 3 days 12 14.6

4-7 days 56 68.3

8-10 days 7 8.5

More than 11 days 7 8.5

Total 82 100.0

Out of 100 patients 82 patients developed complications. Most of the complications occur

within the week, mostly on 4-7 days (68.3%)

82

Table 13: Mortality

Mortality Frequency Percent

No mortality 98 98.0

Mortality 2 2.0

Total 100 100.0

Out of 100 patients, two patients developed mortality due to stoma related complications. So

the mortality rate was 2%.

83

Table 14: Age and Stoma cross table

Age * Stoma Cross tabulation

Age (years) Stoma Total

CAECOSTOMY END ILEOSTOMY

WITH MUCOUS

FISTULA

END SIGMOID

COLOSTOMY

END TRANSVERSE

COLOSTOMY

LOOP ILEOSTOMY LOOP SIGMOID

COLOSTOMY

LOOP

TRANSVERSE

COLOSTOMY

Less than1 0 1 0 0 0 2 0 3

2-15 0 2 0 0 3 0 0 5

16-25 1 1 0 0 8 0 0 10

26-35 0 6 1 0 17 0 1 25

36-45 0 3 2 0 11 2 0 18

46-55 0 3 1 0 15 2 4 25

56-65 0 4 1 1 2 0 0 8

above 65 0 0 0 0 4 1 1 6

Total 1 20 5 1 60 7 6 100

Value df Asymp. Sig. (2-

sided)

Pearson Chi-Square 64.126a 42 .016

Likelihood Ratio 50.373 42 .176

N of Valid Cases 100

All 100 patients were analyzed with relationship with stoma and age of patients. It show there is strong significant relationship between age of

the patient and stoma construction (p <0.01). Most of the patient’s age group between 26-55 years there are likely undergoes loop ileostomy.

Less than 1 year of age there are likely undergoes loop colostomy. More than 55 years of age there are likely undergoes end ileostomy with

mucous fistula.

84

Table 15: Sex and Stoma cross table

SEX * Stoma Cross tabulation

Stoma Total


WITH MUCOUS

FISTULA

END SIGMOID

COLOSTOMY

END

TRANSVERSE

COLOSTOMY

LOOP ILEOSTOMY LOOP SIGMOID

COLOSTOMY

LOOP

TRANSVERSE

COLOSTOMY

SEX FEMALE 1 10 0 1 19 4 4 39

MALE 0 10 5 0 41 3 2 61

Total 1 20 5 1 60 7 6 100

Chi-Square Tests

Value df Asymp. Sig. (2-

sided)




a. 10 cells (71.4%) have expected count less than 5. The minimum

expected count is .39.

All 100 patients were analyzed with relationship with stoma and sex of patients. . It show there is less significant relationship between sex of the

patient and stoma construction (p >0.05). So there is poor correlation with sex of the patient and stoma construction.

85

Table 16: Mode of surgery and stoma

MODE OF SURGERY Stoma


WITH MUCOUS

FISTULA

END SIGMOID

COLOSTOMY

END TRANSVERSE

COLOSTOMY

LOOP

ILEOSTOMY

LOOP SIGMOID

COLOSTOMY

LOOP

TRANSVERSE

COLOSTOMY

ELECTIVE 0 6 3 1 8 3 0

EMERGENCY 1 14 2 0 52 4 6

Total 1 20 5 1 60 7 6

Chi-Square Tests

Value Df Asymp. Sig. (2-

sided)




a. 10 cells (71.4%) have expected count less than 5. The minimum expected count is .21.

All 100 patients were analyzed with relationship with stoma and mode of surgery. It show there is strong significant relationship between mode

of surgery and stoma construction (p <0.01). Most of the patient undergoes stoma as an emergency procedure rather than elective procedure.

Most of the emergency procedure was loop ileostomy followed by end ileostomy. In elective procedure, the most common stoma was loop

ileostomy followed by end ileostomy

86

Table 17: Primary cause and stoma

CAECOSTOMY END

ILEOSTOMY

END SIGMOID

COLOSTOMY

END TRANSVERSE

COLOSTOMY

LOOP

ILEOSTOMY

LOOP SIGMOID

COLOSTOMY

LOOP

TRANSVERSE

COLOSTOMY

ABDOMINAL SEPSIS 1 1 0 0 0 0 1

ABDOMINAL TRAUMA 0 3 1 0 15 3 0

ADHESIVE INTESTINAL

OBSTRUCTION 0 1 0 0 3 0

0

ANASTOMOTIC LEAK 0 2 0 0 0 0 0

CONGENITAL

ANOMALIES 0 1 0 0 0 2

0

ENTERIC FEVER 0 1 0 0 7 0 0

ENTEROCUTANEOUS

FISTULA 0 0 0 0 4 0

0

GIT MALIGNANCY 0 4 4 1 10 2 4

HOLLOW VISCUS

PERFORATION 0 1 0 0 11 0

0

MESENTRIC ISCHEMIA 0 1 0 0 1 0 0

NECROTISING

PANCREATITIS 0 0 0 0 3 0

0

REFRACTORY

ULCERATIVE COLITIS 0 2 0 0 0 0

0

STRANGULATED

HERNIA 0 3 0 0 1 0

0

TB ABDOMEN 0 0 0 0 5 0 1

Total 1 20 5 1 60 7 6

87

Chi-Square Tests

Value Df Asymp. Sig. (2-sided)





All 100 patients were analyzed with relationship with stoma and the primary cause for stoma construction. It show there is very strong

significant relationship between indication for stoma and stoma construction (p <0.01). Most of the patient undergoes stoma construction for

trauma was high followed by hollow viscus perforation.

88

Table 18: Secondary cause and Stoma

CAECOSTOMY END

ILEOSTOMY

END SIGMOID

COLOSTOMY

END

TRANSVERSE

COLOSTOMY

LOOP

ILEOSTOMY

LOOP SIGMOID

COLOSTOMY

LOOP

TRANSVERSE

COLOSTOMY

ANAL GROWTH 0 0 2 0 0 1 0

ANORECTAL

MALFORMATIONS 0 0 0 0 0 2

0

COLONIC PERFORATION 0 3 1 0 17 0 1

GI FISTULA 0 0 0 0 1 0 0

ILEAL PERFORATION 0 5 0 0 24 0 0

INFLAMMATORY DISEASE 1 2 0 0 0 0 0

INTESTINAL GANGRENE 0 1 0 0 1 1 0

INTESTINAL OBSTRUCTION 0 9 2 1 16 1 5

SPHINCTER INJURY 0 0 0 0 1 2 0

Total 1 20 5 1 60 7 6

All 100 patients were analyzed with relationship with stoma and the secondary cause for stoma construction. It show there is very strong

significant relationship between indication for stoma and stoma construction (p <0.01).

Chi-Square Tests

Value df Asymp. Sig. (2-sided)





89

Table 19: Stoma type and Complication

Stomal complication * Stoma Cross tabulation

Stoma Total


WITH MUCOUS

FISTULA

END SIGMOID

COLOSTOMY

END TRANSVERSE

COLOSTOMY

LOOP

ILEOSTOMY

LOOP SIGMOID

COLOSTOMY

LOOP

TRANSVERSE

COLOSTOMY

0 0 2 1 5 7 3 18

BURST ABDOMEN 0 0 0 0 1 0 0 1

ENTEROCUTANOUS FISTULA 0 0 1 0 1 0 0 2

GANGRENE OF DISTAL END 0 0 0 0 1 0 0 1

INTESTINAL ONSTRUCTION 0 2 1 0 1 0 2 6

LAPROTOMY WOUND

INFECTION 1 0 0 0 6 0 0 7

MUCOSAL PROLAPSE 0 1 0 0 3 0 0 4

PARASTROMAL ABSCESS 0 0 0 0 1 0 0 1

PARASTROMAL HERNIA 0 1 0 0 1 0 0 2

SKIN EXCORIATION 0 11 1 0 31 0 0 43

STROMAL BLEEDING 0 1 0 0 0 0 0 1

STROMAL DIARRHEA 0 0 0 0 0 0 1 1

STROMAL NECROSIS 0 1 0 0 1 0 0 2

STROMAL PROLAPSE 0 0 0 0 2 0 0 2

STROMAL RETRACTION 0 2 0 0 5 0 0 7

STROMAL STENOSIS 0 1 0 0 1 0 0 2

Total 1 20 5 1 60 7 6 100

90

Chi-Square Tests

Value df Asymp. Sig. (2-sided)





All 100 patients were analyzed with relationship with stoma and complications due to stoma construction. It show there is significant

relationship between indication for stoma and complications due to stoma construction (p <0.05). the most common complication was skin

excoriation, which is more significant in loop ileostomy.

91

Table 20: Stoma and Duration of stoma

Stoma * Duration of stoma Cross tabulation

Duration of stoma Total

Less than 1 month 1-2 month 3-4 month More than 5 month Lifelong

CAECOSTOMY 0 1 0 0 0 1

END ILEOSTOMY WITH

MUCOUS FISTULA 0 10 7 3 0 20

END SIGMOID COLOSTOMY 0 1 0 1 3 5

END TRANSVERSE

COLOSTOMY 0 1 0 0 0 1

LOOP ILEOSTOMY 9 36 13 2 0 60

LOOP SIGMOID COLOSTOMY 1 4 1 0 1 7

LOOP TRANSVERSE

COLOSTOMY 0 4 2 0 0 6

Total 10 57 23 6 4 100

Chi-Square Tests

Value Df Asymp. Sig. (2-sided)



Linear-by-Linear Association 6.382 1 .012



All 100 patients were analyzed with relationship with stoma and duration of stoma. It show there is very strong significant relationship between

indication for stoma and duration of stoma (p <0.01). The most commonly the stoma was retained for 1-2 month duration, which is very high in

loop ileostomy.

92

DISCUSSION

From ancient time stoma formation was an important life saving

procedure. Indication for stoma formation varies from olden days to current era.

Olden days, the most common indication for stoma construction was intestinal

obstruction and warfare injuries. Now indication varies from malignant

conditions like colonic malignancies and colorectal malignancies. Because of

the complications and associated morbidity and mortality related to stoma were

high. Now it is an era for primary anastomosis rather than stoma formation. But

still stoma has a value for prevention of anastomosis leak and diversion of

faeces in inoperable cases.

Our study the total number of patent includes was 100. This study was

conducted from august 2012 to august 2014 in Government Stanley medical

college.

This study was undertaken for following reasons.

1. To study the various types of intestinal stomas and their indications. 2. To

identify the various complications encountered that occur after the construction

of intestinal stomas. 3. To assess the ways in which these complications can be

minimized and managed in a better way. Based on the study we made following

observations:

93

Age:

Our study included 100 patients who underwent surgery for varies

indication and stoma construction. The maximum number of patients were in

the group of 26-35 and 46-55 (n=25)

All 100 patients were analyzed with relationship with stoma and age of patients.

It show there is strong significant relationship between age of the patient and

stoma construction (p <0.01). Most of the patient’s age group between 26-55

years there are likely undergoes loop ileostomy. Less than 1 year of age there

are likely undergoes loop colostomy. More than 55 years of age there are likely

undergoes end ileostomy with mucous fistula.

Sex:

In this study, 61% were male patients and 39% were female patients.

This indicates male patients underwent more stoma construction compares to

female population. All 100 patients were analyzed with relationship with stoma

and sex of patients. . It show there is less significant relationship between sex of

the patient and stoma construction (p >0.05). So there is poor correlation with

sex of the patient and stoma construction.

94

Name Author Results

a clinical study of intestinal stomas: its

indications and complications

AHMAD Z et al.

Male-70%

Female-30%

Bowel stomas in najaf, indications and

complications

AKEEL M. A. AL-FAHAM et all

Male-65%

Female-35%

A prospective audit of post operative

complications of construction of loop

ileostomy

SYED ASAD ALI et all

Male-74.52%

Female-25.47%

Temporary Loop Ileostomy: Prospective

Study of Indications and

Complications

AKRAM RAJPUT et all

Male-69.64%

Female-30.35%

Timing of surgery (elective/emergency)

Out of 100 patients 79 patients underwent stoma construction as an

elective procedure compared 21 patients underwent stoma construction as an

elective procedure. Stoma was constructed both in elective and emergency

setting. But mostly it was undertaken as a emergency procedure.

All 100 patients were analyzed with relationship with stoma and mode of

surgery. It show there is strong significant relationship between mode of surgery

and stoma construction (p <0.01). Most of the patient undergoes stoma as an

emergency procedure rather than elective procedure. Most of the emergency

procedure was loop ileostomy followed by end ileostomy. In elective procedure,

the most common stoma was loop ileostomy followed by end ileostomy.

95

Duration of hospital stay

Duration of hospital stay were analysed for 100 patients, were most of the

patients stayed in hospital approximately 16-20 days (32%). Because of stoma

formation and associated morbidity and complications there is prolonged

hospital staying and it indirectly increases expenditure.

Primary complaint and duration of complaint

Out of 100 patients, primary complaints were analyzed. Most of the

patients presented with complaints of abdominal pain both in emergency setting

as well as elective setting (33%). For 100 patients durations of complaints range

from less than 5 days to more than 30 days. But most of the patients presented

with complaints durations less than 5 days (39%).

Indication for stoma construction

Out of 100 patients undergoing stoma construction, the most common

indications for stoma construction was gastrointestinal malignancy (25%)

followed by abdominal trauma (22%).The most common indication for which

stoma was constructed was malignancies like colorectal and colonic

malignancies.

All 100 patients were analyzed with relationship with stoma and the

secondary cause for stoma construction. It show there is very strong significant

relationship between indication for stoma and stoma construction (p <0.01).

96

a clinical study of intestinal

stomas: its indications and

complications

AHMAD Z et al. Tuberculosis- 18%

Enteric fever- 38%

Complications of colostomies PORTER JA et all Malignant- 66%

Benign- 34%

Bowel stomas in najaf, indications

and complications

AKEEL M. A. AL-FAHAM et all malignancy- 64 %

cong megacolon- 15 %

A prospective audit of post

operative complications of

construction of loop ileostomy

SYED ASAD ALI et all Tuberculosis- 9.43%

Enteric fever- 81.13%

Temporary Loop Ileostomy:

Prospective Study of Indications and

Complications

AKRAM RAJPUT et all Enteric fever- 66%

Iatrogenic- 10.7%

Type of stoma:

Out of 100 patients the most common type of stoma constructed was

ileostomy (80%). In ileostomy loop ileostomy was most common (60%),

followed by end ileostomy (20%). The next most common stoma constructed

was colostomy (19%). In colostomy most common was loop sigmoid colostomy

(7%), followed by loop transverse colostomy (6%).

Indication and complications of

intestinal stomas- a tertiary care

hospital experience

QAMAR A. AHMAD et all

Ileostomy- 42 %

Colostomy- 58 %

a clinical study of intestinal

stomas: its indications and

complications

AHMAD Z et al. Ileostomy- 64 %

Colostomy- 20 %

Complications of colostomies PORTER JA et all Sigmoid colostomy- 76%

Transverse colostomy- 24%

97

Complications of stoma:

Out of 100 patient’s 82 patients developed complications. The most

common complication observed in stoma construction was skin excoriations

(52.4%), followed by laparotomy wound infection (8.5%).

All 100 patients were analyzed with relationship with stoma and

complications due to stoma construction. It show there is significant

relationship between indication for stoma and complications due to stoma

construction (p <0.05). The most common complication was skin excoriation,

which is more significant in loop ileostomy.

Complication occurs in both ileostomy and colostomy. Colostomy

associated with high parastomal hernia and other stomal complication,

compared to peristomal skin related complications are high in ileostomy.

Most common early complication was skin excoriation associated with

ileostomy. Peristomal skin related complications less in colostomy. Next to skin

excoriation stomal prolapse were most common. Parastomal hernia and

peristomal hernia most common in colostomy compared to ileostomy. Most of

the complications are managed by conservative treatment like skin care and

endostomal therapist. But few complications need surgical intervention like

stomal retraction and intestinal obstruction.

98

a clinical study of

intestinal stomas: its

indications and

complications

AHMAD Z et al. Skin excoriations – 36%

Wound infections- 13 %

Complications of

colostomies.

PORTER JA et all Strictures- 16%


Bowel stomas in najaf,

indications and

complications

AKEEL M. A. AL-

FAHAM et all


Prolapsed- 30%

Various Complications in Ileostomy Construction

AMBREEN MUNEER et all Skin excoriations – 17.64% Wound infections-

5.80 %

7. Temporary Loop

Ileostomy: Prospective

Study of Indications and

Complications

AKRAM RAJPUT et all Skin excoriations – 21.4%

Poor sitting of stoma- 7.1%

Duration of stoma:

Duration of stoma was analyzed for 100 patients. Out of 100 patients,

most of the patients retained stoma for 1-2 months duration (57%).

Out of 100 patient’s 82 patients developed complications. Most of the

complications occur within the week, mostly on 4-7 days (68.3%)

It show there is very strong significant relationship between indication for

stoma and duration of stoma (p <0.01). The most commonly the stoma was

retained for 1-2 month duration, which is very high in loop ileostomy.

Complications occur in early stage and late stage of stomal maturation. As the

day progress and stomal maturation occurs few complications decrease but the

complication even occur at later stage.

Mortality:

Out of 100 patients, two patients developed mortality due to stoma related

complications. So the mortality rate was 2%.

99

SUMMARY

The study was done with 100 patients in all surgical units of dept of general

surgery, surgical gastroenterology and paediatric surgery, govt. Stanley medical

college & hospital, Chennai from august 2012 to august 2014. The purpose of

the study was to identify the various types of intestinal stomas and their

indications and identify the various complications encountered and assess the

ways in which these complications can be minimized and managed in a better

way.

All patients male and female up to 70 years undergoing stoma

construction were included in the study.

The observations of study summarized below

The maximum number of patients were in the group of 26-35 and 46-55

(n=25). It show there is strong significant relationship between age of the

patient and stoma construction (p <0.01). Most of the patient’s age group

between 26-55 years there are likely undergoes loop ileostomy. Less than

1 year of age there are likely undergoes loop colostomy.

All 100 patients were analyzed with relationship with stoma and sex of

patients. . It show there is less significant relationship between sex of the

patient and stoma construction (p >0.05). So there is poor correlation with

sex of the patient and stoma construction.

All 100 patients were analyzed with relationship with stoma and mode of

surgery. It show there is strong significant relationship between mode of

surgery and stoma construction (p <0.01). Most of the patient undergoes

stoma as an emergency procedure rather than elective procedure.

100

Duration of hospital stay were analysed for 100 patients, were most of the

patients stayed in hospital approximately 16-20 days (32%).

Out of 100 patients undergoing stoma construction, the most common

indications for stoma construction was gastrointestinal malignancy (25%)

followed by abdominal trauma (22%).

All 100 patients were analyzed with relationship with stoma and the

cause for stoma. It show there is very strong significant relationship

between indication for stoma and stoma construction (p <0.01).

Out of 100 patients the most common type of stoma constructed was

ileostomy (80%). In ileostomy loop ileostomy was most common (60%),

followed by end ileostomy (20%). The next most common stoma

constructed was colostomy (19%). In colostomy most common was loop

sigmoid colostomy (7%), followed by loop transverse colostomy (6%)

Out of 100 patient’s 82 patients developed complications. The most

common complication observed in stoma construction was skin

excoriations (52.4%), followed by laparotomy wound infection (8.5%).It

show there is significant relationship between indication for stoma and

complications due to stoma construction (p <0.05).

It show there is very strong significant relationship between indication for

stoma and duration of stoma (p <0.01). The most commonly the stoma

was retained for 1-2 month duration, which is very high in loop

ileostomy.

101

CONCLUSIONS

The results of the study support stoma construction most common in the

age group between 26-55 years there are likely undergoes loop ileostomy.

Less than 1 year of age there are likely undergoes loop colostomy.

Most of the patient undergoes stoma as an emergency procedure rather

than elective procedure. Duration of hospital stay approximately 16-20

days, even prolonged when complications occurs. The most common

indications for stoma construction were gastrointestinal malignancy

followed by abdominal trauma.

The most common type of stoma constructed was ileostomy. The next

most common stoma constructed was colostomy. The most common

complication observed in stoma construction was skin excoriations,

followed by laparotomy wound infection.

In conclusion the study showed stoma construction high in adult and old

age group, mostly done as an emergency procedure compared to elective

procedure. Mostly done for diversion for obstruction or perforation in

malignancy and perforation in trauma patients. Most common stoma

constructed was loop ileostomy followed by end ileostomy with mucus

fistula. There is high incidence of peristomal complication related to that.

The complication better managed with proper preoperative planning with

effective stoma care in post operative period.

102

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113

ANNEXURES

114

PROFORMA

NAME: AGE/SEX:

OCCUPATION: IP NO:

SL.NO: ADDRESS WITH CONTACT NO:

DATE OF ADMISSION: DATE OF SURGERY:

DATE OF DISCHARGE:

CHIEF COMPLAINT:

HISTORY OF PRESENTING ILLNESS:

PAST HISTORY:

PERSONAL HISTORY:

OCCUPATIONAL HISTORY:

FAMILY HISTORY:

TREATMENT HISTORY:

GENERAL EXAMINATION:

LOCAL EXAMINATION:

CLINICAL DIAGNOSIS:

INVESTIGATIONS

A. Routine investigations:

Complete blood count

Renal function test

Liver function test

Serum electrolytes

Widal test

X-ray erect abdomen, X-ray chest pa view

USG abdomen and pelvis.

Endoscopy ( upper GI endoscopy/lower GI endoscopy)

Diagnostic laparoscopy

115

B. Special investigations:

C.T.scan of abdomen and pelvis

Loopogram

MRI

Other investigation ( if needed)

Operative procedure:

Indications for stoma:

Type of stoma:

Intra operative complications:

Early complications:

Late complications:

Duration of stoma:

Closure of stoma:

Follow up:

Type of complication:

Complication Management Complication Management

1. Stoma bleeding

9. Prolapse

2. Stenosis

10. Parastomal Hernia

3. Necrosis

11. Stoma Diarrhea

4. Retraction

12. Intestinal obstruction

5. Local skin problems

13. Parastomal abscess

6. Lap. Wound infection

14. Mucosal prolapse

7. Gangrene of distal end

15. others

8. Fistula formation

116

GOVT.STANLEY MEDICAL COLLEGE, CHENNAI- 600 001

INFORMED CONSENT

DISSERTATION TOPIC: “A STUDY OF INDICATIONS, COMPLICATION AND ITS

MANAGEMENT OF INTESTINAL STOMA”.

PLACE OF STUDY: GOVT. STANLEY MEDICAL COLLEGE, CHENNAI

NAME AND ADDRESS OF PATIENT:

I, _____________________ have been informed about the details of the study in my own

language.

I have completely understood the details of the study.

I am aware of the possible risks and benefits, while taking part in the study.

I understand that I can withdraw from the study at any point of time and even then, I will

continue to receive the medical treatment as usual.

I understand that I will not get any payment for taking part in this study.

I will not object if the results of this study are getting published in any medical journal,

provided my personal identity is not revealed.

I know what I am supposed to do by taking part in this study and I assure that I would

extend my full co-operation for this study.

Name and Address of the Volunteer: Signature/Thumb impression of the Volunteer Date: Witnesses: (Signature, Name & Address) Date: Name and signature of investigator: Date:

117

& , : , : : . . , , , , , . . . , , , , . . 30 . 30 . : 1. . 2. 3.

118

, - 600 001

& ,

:

cxix

MASTER CHART

SL NO NAME AGE SEX IP NO MODE STAY DURATION PRIMARY CAUSE SECONDARY CAUSE TYPE OF STOMA COMPLICATION

1 JAYA 50 F 24820 EL 32 DAYS 2 MONTHS CA SIGMOID COLON INTESTINAL OBSTRUCTION LOOP ILEOSTOMY WOUND INFECTION, EXCORIATION

2 VIJAY 35 M 32047 EM 13 DAYS 5 DAYS ENTERIC FEVER ILEAL PERFORATION END ILEOSTOMY SKIN EXCORIATION

3 KARTHIGA 24 M 24403 EM 30 DAYS 3 DAYS TB ABDOMEN ILEAL STRICTURE LOOP ILEOSTOMY SKIN EXCORIATION

4 ANJALAI 64 F 34656 EM 21 DAYS 3 DAYS STRANGULATED INCISIONAL HERNIA GANGRENOUS ILEUM END ILEOSTOMY SKIN EXCORIATION

5 MOHAMEED ALI 54 M 31658 EL 27 DAYS 1 MONTH CA SIGMOID COLON INTESTINAL OBSTRUCTION LOOP ILEOSTOMY STROMAL PROLAPSE

6 MOHANA SUNDARAM 27 M 32227 EM 43 DAYS 10 DAYS NECROTISING PANCREATITIS COLONIC PERFORATION LOOP ILEOSTOMY STROMAL PROLAPSE, EXCORIATION

7 SELVI 33 F 54737 EL 16 DAYS 10 DAYS RECURRENT CA STOMACH INTESTINAL OBSTRUCTION LOOP ILEOSTOMY MUCOSAL PROLAPSE

8 SAMATHANAM 53 F 33440 EM 20 DAYS 5 DAYS CA ANAL CANAL INTESTINAL OBSTRUCTION LOOP SIGMOID COLOSTOMY NIL

9 KUPPAN 55 M 55218 EM 33 DAYS 15 DAYS ENTERIC FEVER ILEAL PERFORATION LOOP ILEOSTOMY WOUND INFECTION, EXCORIATION

10 GANESAN 57 M 30882 EL 13 DAYS 15 MONTHS REFRACTORY ULCERATIVE COLITIS REFRACTORY ULCERATIVE COLITIS END ILEOSTOMY MUCOSAL PROLAPSE, EXCORIATION, OBSTRUCTION

11 RUKUMANI 50 F 13472 EM 1O DAYS 1 DAY ANAL CANAL LACERATIONS SPHINCTER INJURY LOOP ILEOSTOMY SKIN EXCORIATION

12 BALAJI 31 M 37220 EM 15 DAYS 14 DAYS HOLLOW VISCUS PERFORATION ILEAL PERFORATION LOOP ILEOSTOMY EXCORIATION

13 VIJAYA 38 F 38744 EM 26 DAYS 5 DAYS STRANGULATED FEMORAL HERNIA ILEAL GANGRENE END ILEOSTOMY STROMAL BLEEDING, EXCORIATION

14 MURUGAVALLI 30 F 44006 EM 25 DAYS 6 DAYS TB ABDOMEN INTESTINAL OBSTRUCTION LOOP TRANVERSE COLOSTOMY NIL

15 KANNAMMAL 70 F 12741 EM 52 DAYS 1 MONTH CA CEACUM CEACAL PERFORATION LOOP ILEOSTOMY 1. SKIN EXCORIATION

16 JAYANTHI 32 F 13171 EM 17 DAYS 1 MONTH TB ABDOMEN INTESTINAL OBSTRUCTION LOOP ILEOSTOMY STROMAL RETRACTION,EXCORIATION

17 RAJESH 29 M 16941 EM 16 DAYS 5 DAYS TB ABDOMEN INTESTINAL OBSTRUCTION LOOP ILEOSTOMY BURST ABDOMEN, SKIN EXCORIATION

18 BALAN 55 M 18012 EM 19 DAYS 1 MONTH CA CEACUM CEACAL PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

19 RAJESH 27 M 14214 EM 18 DAYS 7 DAYS ENTERIC FEVER ENTEROCUTANEOUS FISTULA LOOP ILEOSTOMY SKIN EXCORIATION

20 BALAJI 36 M 32018 EM 39 DAYS 7 DAYS HOLLOW VISCUS PERFORATION ILEAL PERFORATION LOOP ILEOSTOMY RETRACTION, EXCORIATION, OBSTRUCTION

21 ABDUL MALIK 52 M 53170 EM 14 DAYS 10 DAYS HOLLOW VISCUS PERFORATION ILEAL PERFORATION LOOP ILEOSTOMY WOUND INFECTION, EXCORIATION

22 MOOZA 51 M 24946 EM 14 DAYS 4 DAYS STRANGULATED INGUINAL HERNIA ILEAL GANGRENE END ILEOSTOMY RETRACTION, EXCORIATION

23 MARIAMMAL 55 F 24578 EM 16 DAYS 45 DAYS CA CEACUM CEACAL PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

24 SYED 23 M 32028 EM 12 DAYS 1 DAY STAB INJURY ABDOMEN TRANVERSE COLON PERFORATION LOOP ILEOSTOMY NIL

25 MUNUSAMY 65 M 41255 EL 13 DAYS 5 MONTHS CA ANAL CANAL INTESTINAL OBSTRUCTION END SIGMOID COLOSTOMY INTESTINAL ONSTRUCTION

26 PREM KUMAR 37 M 50037 EM 28 DAYS 3 DAYS HOLLOW VISCUS PERFORATION ILEAL PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

27 NARAYANAN 35 M 52941 EM 17 DAYS 1 DAY STAB INJURY ABDOMEN TRANVERSE COLON PERFORATION LOOP ILEOSTOMY NIL

28 KUMAR 47 M 49200 EM 16 DAYS 5 DAYS HOLLOW VISCUS PERFORATION ILEAL PERFORATION LOOP ILEOSTOMY INTESTINAL OBSTRUCTION

29 RAJIM 35 M 33411 EM 20 DAYS 1 DAY BLUNT INJURY ABDOMEN HEPATIC FLEXURE GANGRENE END ILEOSTOMY SKIN EXCORIATION

30 MOHAN 38 M 16094 EM 35 DAYS 1 DAY STAB INJURY ABDOMEN RECTAL PERFORATION LOOP SIGMOID COLOSTOMY NIL

31 KIRUBA 27 M 24274 EM 19 DAYS 1 DAY STAB INJURY ABDOMEN TRANVERSE COLON PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

32 KALAIARASAN 14 M 3 8481 EM 12DAYS 5 DAYS HOLLOW VISCUS PERFORATION ILEAL PERFORATION LOOP ILEOSTOMY MUCOSAL PROLAPSE

33 THENMOZHI 55 F 39478 EM 15 DAYS 1 DAY STAB INJURY ABDOMEN COLONIC PERFORATION LOOP ILEOSTOMY WOUND INFECTION, EXCORIATION

34 PARIMALA 40 F 27303 EL 20 DAYS 3 MONTHS CA SIGMOID COLON INTESTINAL OBSTRUCTION LOOP ILEOSTOMY NIL

35 KARTHIKEYAN 21 M 38268 EL 26 DAYS 3 MONTHS FECAL FISTULA HEPATIC FLEXURE GANGRENE LOOP ILEOSTOMY SKIN EXCORIATION

36 DEIVAIYANI 70 F 15761 EM 14 DAYS 2 MONTHS CA SIGMOID COLON INTESTINAL OBSTRUCTION LOOP ILEOSTOMY SKIN EXCORIATION

37 SARANYA 19 F 8 8491 EM 20 DAYS 12 DAYS GANGRENOUS APPENDICITIS CEACAL PERFORATION CAECOSTOMY STROMA SITE INFECTIONS

38 BALASUNDARAM 54 M 19293 EM 26 DAYS 3 MONTHS CA RECTUM INTESTINAL OBSTRUCTION END SIGMOID COLOSTOMY ENTEROCUTANOUS FISTULA

39 KARUNA 36 M 2 4841 EM 22 DAYS 6 DAYS ENTERIC FEVER ILEAL PERFORATION LOOP ILEOSTOMY STROMAL STENOSIS

40 SHANMUGAM 55 M 3 4601 EM 14 DAYS 14 DAYS MESENTRIC ISCHEMIA ILEAL PERFORATION LOOP ILEOSTOMY GANGRENE OF DISTAL END

41 MOHANAMMAL 54 F 41321 EM 16 DAYS 2 MONTHS ADVANCED CA OVARY INTESTINAL OBSTRUCTION LOOR TRANSVERSE COLOSTOMYNIL

42 SOMASUNDARI 47 F 26400 EM 26 DAYS 3 MONTHS CA RECTUM INTESTINAL OBSTRUCTION LOOP TRANVERSE COLOSTOMY STOMAL DIARRHEA

43 VENI 63 F 73674 EM 22 DAYS 2 MONTHS CA CEACUM CEACAL PERFORATION LOOP ILEOSTOMY PARASTROMAL ABSCESS

44 ARAVINDHAN 32 M 42003 EM 15 DAYS 8 DAYS ENTERIC FEVER ILEAL PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

45 ANBAZHAGAN 43 M 86540 EL 45 DAYS 2 MONTHSS NECROTISING PANCREATITIS COLONIC PERFORATION LOOP ILEOSTOMY STROMAL NECROSIS

46 SERAFIN 55 M 29278 EM 23 DAYS 10 DAYS RUPTURED LIVER ABSCESS COLONIC PERFORATION LOOP TRANVERSE COLOSTOMY INTESTINAL ONSTRUCTION

47 ARIVU 54 M 77543 EM 40 DAYS 20 DAYS NECROTISING PANCREATITIS COLONIC PERFORATION LOOP ILEOSTOMY ENTEROCUTANOUS FISTULA

48 CHINNA PONNU 48 F 45432 EL 23 DAYS 3 MONTHS CA CEACUM INTESTINAL OBSTRUCTION END ILEOSTOMY PARASTOMAL HERNIA

49 VIJAY 39 F 36199 EM 20 DAYS 7 DAYS HOLLOW VISCUS PERFORATION ILEAL PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

50 MEENA 22 F 59231 EM 13 DAYS 9 DAYS HOLLOW VISCUS PERFORATION ILEAL PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

120

51 CHINNA PAYAN 52 M 24 90 0 EM 18 DAYS 5 DAYS HOLLOW VISCUS PERFORATION ILEAL PERFORATION LOOP ILEOSTOMY STROMAL RETRACTION

52 LOGANATHAN 47 M 50033 EL 24 DAYS 3 MONTHS CA SPLENIC FLEXURE INTESTINAL OBSTRUCTION LOOP ILEOSTOMY SKIN EXCORIATION

53 JANNATH BEE 48 M 60 68 4 EM 14 DAYS 5 DAYS STRANGULATED INGUINAL HERNIA ILEAL PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

54 SABRA 65 F 70523 EL 17 DAYS 20 DAYS CA SPLENIC FLEXURE INTESTINAL OBSTRUCTION END TRANSVERSE COLOSTOMY NIL

55 THENESA 68 F 45046 EM 12 DAYS 13 DAYS HOLLOW VISCUS PERFORATION ILEAL PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

56 KALAIVANI 60 F 26972 EM 25 DAYS 10 DAYS MESENTRIC ISCHEMIA INTESTINAL GANGRENE END ILEOSTOMY STROMAL NECROSIS

57 ALLI 36 F 2 24 8 1 EM 18 DAYS 12 DAYS ADHESIVE INTESTINAL OBSTRUCTION CEACAL PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

58 YESUDOSS 60 M 69180 EM 21 DAYS 12 DAYS ADHESIVE INTESTINAL OBSTRUCTION ILEAL GANGRENE END ILEOSTOMY SKIN EXCORIATION

59 MANIKANDAN 19 M 33213 EM 13 DAYS 1 DAY STAB INJURY ABDOMEN TRANVERSE COLON PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

60 VANAJA 40 F 42576 EL 23 DAYS 3 MONTHS HEPATIC FLEXURE GROWTH INTESTINAL OBSTRUCTION END ILEOSTOMY STROMAL RETRACTION

61 VEERASAMY 54 M 37633 EM 32 DAYS 12 DAYS CA RECTUM SIGMOID COLON PERFORATION LOOP TRANVERSE COLOSTOMY NIL

62 SELVI 35 F 36 00 2 EM 22 DAYS 20 DAYS TB ABDOMEN INTESTINAL OBSTRUCTION LOOP ILEOSTOMY NIL

63 MURUGAN 65 M 10136 EM 23 DAYS 12 DAYS TB ABDOMEN INTESTINAL OBSTRUCTION LOOP ILEOSTOMY STROMAL RETRACTION

64 RAJ KUMAR 29 M 10934 EM 20 DAYS 10 DAYS ADHESIVE INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION LOOP ILEOSTOMY NIL

65 KUMARAVEL 32 M 55916 EM 14 DAYS 1 DAY STAB INJURY ABDOMEN SIGMOID COLON PERFORATION HARTMANN PROCEDURE NIL

66 ETHIRAJ 42 M 86 00 4 EM 12 DAYS 1 DAY STAB INJURY ABDOMEN TRANVERSE COLON PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

67 KAATHAR 47 M 10679 EM 18 DAYS 1 DAY STAB INJURY ABDOMEN TRANVERSE COLON PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

68 MURALI 34 M 12099 EM 12 DAYS 1 DAY STAB INJURY ABDOMEN TRANVERSE COLON PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

69 DURGA 18 F 18773 EM 17 DAYS 12 DAYS ENTERIC FEVER ILEAL PERFORATION LOOP ILEOSTOMY MUCOSAL PROLAPSE

70 DHEENA 52 M 31238 EM 28 DAYS 7 DAYS HOLLOW VISCUS PERFORATION ILEAL PERFORATION END ILEOSTOMY INTESTINAL ONSTRUCTION

71 SHIEK AMEEN 27 M 49310 EM 13 DAYS 1 DAY STAB INJURY ABDOMEN COLONIC PERFORATION END ILEOSTOMY SKIN EXCORIATION

72 KALYANI 27 F 49811 EM 18 DAYS 6 DAYS RUPTURED MESENTRIC ABSCESS ILEAL PERFORATION END ILEOSTOMY SKIN EXCORIATION

73 SATHYA 29 F 33 43 3 EM 36 DAYS 3 DAYS ANASTOMOTIC LEAK ILEAL PERFORATION END ILEOSTOMY SKIN EXCORIATION

74 RAJAVARMAN 36 M 65132 EL 34 DAYS 40 DAYS ENTEROCUTANEOUS FISTULA COLONIC PERFORATION LOOP ILEOSTOMY PARASTROMAL HERNIA

75 ABDUL KATHAR 29 M 58132 EM 26 DAYS 30 DAYS FECAL FISTULA CEACAL PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

76 NANDHA KUMAR 36 M 59029 EL 24 DAYS 1 YEAR REFRACTORY ULCERATIVE COLITIS REFRACTORY ULCERATIVE COLITIS END ILEOSTOMY INTESTINAL ONSTRUCTION

77 MALAVIKA 10 DAYSF 32143 EL 20 DAYS SINCE BIRTHANORECTAL MALFORMATIONS IMPERFORATE ANUS LOOP SIGMOID COLOSTOMY NIL

78 PALLAVAN 8 DAYSM 87652 EL 18 DAYS SINCE BIRTHHIRSCHPRUNG DISEASE HIRSCHPRUNG DISEASE LOOP SIGMOID COLOSTOMY NIL

79 AJEETHA 2 MONTHSF 2 24 8 1 EM 14 DAYS 2 DAYS ILEOCAECAL VOLVULUS INTESTINAL OBSTRUCTION END ILEOSTOMY SKIN EXCORIATION

80 PUNITHA 8 F 22746 EM 16 DAYS 4 DAYS ENTERIC FEVER ILEAL PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

81 SARAVANAN 5 M 11212 EM 12 DAYS 1 DAY BLUNT INJURY ABDOMEN TRANVERSE COLON PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

82 TAMIL ARASAN 28 M 12121 EM 16 DAYS 1 DAY BAROTRAUMA ABDOMEN TRANVERSE COLON PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

83 SELVI 33 F 55260 EM 19 DAYS 1 DAY BLUNT INJURY ABDOMEN MULTIPLE COLONIC PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

84 SAGUNTHALA 68 F 20718 EM 25 DAYS 12 DAYS CA SIGMOID COLON INTESTINAL OBSTRUCTION LOOP TRANVERSE COLOSTOMY INTESTINAL ONSTRUCTION

85 BALASUBRAMANIAN 36 M 60 405 EM 20 DAYS 1 DAY STAB INJURY ABDOMEN MULTIPLE COLONIC PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

86 PADMA 48 F 51519 EL 28 DAYS 2 MONTHS CA ANAL CANAL LOOP SIGMOID COLOSTOMY NIL

87 LOGANATHAN 42 M 53679 EL 15 DAYS 18 DAYS CA ANAL CANAL END SIGMOID COLOSTOMY NIL

88 SARAVANAN 40 M 53735 EL 23 DAYS 6 MONTHS CA ANAL CANAL END SIGMOID COLOSTOMY SKIN EXCORIATION

89 BALAJI 31 M 37220 EM 17 DAYS 6 DAYS HOLLOW VISCUS PERFORATION ILEAL PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

90 RAMA MOORTHY 71 M 31093 EM 15 DAYS 1 DAY PERIANAL INJURY SPHINCTER INJURY LOOP SIGMOID COLOSTOMY NIL

91 CHITHRA 30 F 42713 EM 13 DAYS 1 DAY STAB INJURY ABDOMEN ILEAL PERFORATION LOOP ILEOSTOMY STROMAL RETRACTION

92 KUMAR 14 M 41250 EL 14 DAYS 2 MONTHS FAMILIAL ADENOMATOUS POLPYPOSIS COLIMULTIPLE POLYPS END ILEOSTOMY SKIN EXCORIATION

93 KARTHI 11 F 22121 EL 17 DAYS 1 MONTH FAMILIAL ADENOMATOUS POLPYPOSIS COLIMULTIPLE POLYPS END ILEOSTOMY SKIN EXCORIATION

94 VIJAYALAKSHMI 32 F 42 24 0 EM 34 DAYS 1 MONTH ANASTOMOTIC LEAK ILEAL PERFORATION END ILEOSTOMY SKIN EXCORIATION

95 RAJ KUMAR 39 M 58515 EM 18 DAYS 2 MONTHS ENTEROCUTANEOUS FISTULA COLONIC PERFORATION LOOP ILEOSTOMY WOUND INFECTION,EXCORIATION

96 RADHA KRISHNAN 20 M 42522 EM 12DAYS 10 DAYS ENTERIC FEVER ILEAL PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

97 SARAVANAN 23 M 41837 EM 10 DAYS 1 DAY STAB INJURY ABDOMEN TRANVERSE COLON PERFORATION LOOP ILEOSTOMY SKIN EXCORIATION

98 SALEEM 67 M 12421 EM 31 DAYS 5 DAYS CA CEACUM COLONIC PERFORATION LOOP ILEOSTOMY WOUND INFECTION, EXCORIATION

99 RANJITH KUMAR 20 M 42522 EM 16 DAYS 1 DAY STAB INJURY ABDOMEN SMALL BOWEL LACERATIONS END ILEOSTOMY STROMAL STENOSIS

100 PARAMASIVAM 36 F 3 82 4 1 EM 13 DAYS 1 DAY PERIANAL INJURY SPHINCTER INJURY LOOP SIGMOID COLOSTOMY NIL

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