The term enterostoma is the medical term for an “artificial intestinal outlet”. This is called either anus praeter naturalis (Latin) or intestinal stoma, or stoma for short (Greek : mouth, opening). The creation of an enterostoma is a visceral surgical procedure (abdominal surgery) and is often a partial measure of intestinal surgery, e.g. in the removal of a carcinoma (malignant tumor) in the intestine. The goal is to drain stool and gases produced during digestion through the abdominal wall via a segment of intestine that is surgically passed to the surface. An enterostomy is needed when physiological intestinal passage is not possible or not maintained, or when inflammatory diseased or recently operated intestinal segments need to be spared.
Indications (areas of application)
- Inflammatory diseases of the colon – ulcerative colitis (chronic inflammatory bowel disease (CED)), complicated diverticulitis (inflammation of the intestinal diverticula in the context of diverticulosis – diverticula are small outpouchings of the intestinal wall), radiation colitis (during radiotherapy treatment of, for example, carcinoma, inflammation of the intestine may occur).
- Removal of the sphincter muscle (sphincter ani) in the anal region.
- Suture insufficiency (leakage of the suture) after anastomosis (joining) of two ends of the intestine, for example, after tumor resection.
- Mechanical colonic ileus (large bowel obstruction) due to neoplasia (new formation) in: Rectal carcinoma / rectal cancer (distal), anal carcinoma, peritoneal carcinomatosis (synonyms: carcinosis peritonei, peritonitis carcinomatosa; extensive infestation of the peritoneum with malignant tumor cells) with obstruction (narrowing) of the colon (large intestine).
- Postoperative (after surgery) – To improve the healing of affected sections of the intestine.
- Fecal incontinence (inability to withhold diapers or bowel movements arbitrarily).
- Trauma (injury) to the colon, such as impalement injuries.
Contraindications
The therapeutic decision for an enterostomy is usually a situation without alternative. The creation of an enterostomy is indicated (indicated) when other therapeutic measures have been exhausted. If the indication is correct, general contraindications apply to the abdominal surgical procedure. It should be noted that any patient undergoing abdominal surgery must be informed of the basic possibility that an enterostomy will need to be created.
Before surgery
Before surgery, the patient must be fully informed or educated about the procedure and any risks or side effects and must give written consent. Anticoagulants (blood-thinning medications) such as Marcumar or acetylsalicylic acid (ASA) should be discontinued in advance and coagulation levels checked. Preoperatively (before surgery), the location of the stoma should be determined on the abdominal wall to facilitate subsequent care; for example, it should not be located in an abdominal crease.
The procedures
The positioning of a transversostoma (artificial anus praeter of the transverse colon) is particularly favorable because of its location. For this reason, the surgical placement of an enterostoma is described here using the transversostoma as an example. If the enterostoma is the sole object of the operation, a small upper abdominal cross-section is sufficient. If the enterostoma is created as part of an operation, e.g. a tumor resection (removal of a tumor), the surgical access is made according to this operation. First, the subcutis (lower skin), muscle fascia (connective tissue surface of the muscle) and musculature must be cut. Then, the surgeon looks at the peritoneum (peritoneum), which he carefully cuts under vision so as not to injure deeper structures. This part of the procedure is called a laparotomy. The next step is to expose (“expose”) the transverse colon. This must then be mobilized and advanced toward the abdominal wall. A rider is then placed to pass under the colon loop and hold it at the surface by securing it to the skin surface with single button sutures. Then the abdominal wall is closed. Here, special attention is paid to the blood supply to the advanced colonic loop.Finally, the intestinal loop is opened (colotomy) and also fixed with some sutures. If a terminal enterostomy is created, there is no need to use a rider and the terminal piece of bowel is passed out directly through the abdominal wall.
After surgery
Immediately after stoma creation, the stoma system (e.g., stripping bag) is placed on the previously cleansed skin, observing skin protection. Following the operation, the stoma must be checked daily for eight days in order to detect complications at an early stage. The rider as well as non-absorbable skin sutures are removed after 10 days. Findings during this period may include bleeding, swelling, retraction or prolapse, necrosis, bluish-livid discoloration of the mucosa, or an allergic reaction to the care materials. Furthermore, the suture site must be cleaned when changing the supply system.
Possible complications [therapeutic measures]
Early complications (in the first 30 days).
- Postoperative bleeding (including mucosal bleeding).
- Skin irritation, possibly also ulceration (ulceration) [can be improved by skin and stoma care], stoma necrosis (death of tissue) [only in need of revision in case of functional disorders of the stoma].
- Hematoma formation (bruise)
- Infections
- Abscess (encapsulated collection of pus)
- Stoma edema (occurs when the tissue of the intestine during the surgical procedure was too much stress; note: swelling should go down within four to six days, at the latest after removal of foreign bodies (suture material, riders, etc.).
- Sromanecrosis (due to pressure, traction or circulatory problems).
- Suture insufficiency (leakage of the intestinal suture) with subsequent peritonitis (peritonitis).
- Fistula formation
- Perforation of the intestine (intestinal rupture) with subsequent peritonitis.
- Postoperative ileus (intestinal obstruction after surgery).
Note: The most common causes of most early complications are suboptimal stoma placement and improper stoma care. Late complications (after postoperative day 30).
- Dehydration/body loses more fluid than it absorbs (with electrolyte disturbances/deviations from normal electrolyte concentrations) → exsiccosis (dehydration due to decrease in body water) (approximately 20% of ileostomy patients)
- Allergic contact reaction with a sharply circumscribed redness of the skin [recognition of the allergenic substance and avoidance or removal of this substance].
- Infectious skin complications
- Folliculitis (patchy, inflammatory change in the skin due to hair follicle inflammation).
- Mycoses (fungal diseases)
- Nahtrdehiszenz – partial to complete detachment of the stoma from the skin; wound edges gape open [filling the dehiscence with hydrocolloid powder and sealing, for example, with a PU foam].
- Stoma retraction (retraction of the stoma below the skin level) [only in need of revision if the stoma is dysfunctional]
- Parastomal hernia (risk factors: Obesity and increased intra-abdominal pressure; steroid treatment secondary stoma creation; most common stoma complication: affects 40-50% of all stoma patients; leads to defecation disorders up to mechanical ileus).
- Peristomal dermatitis (skin inflammation that occurs around the stoma).
- Late abscess
- Stomastosis (narrowing of the stoma until closure; settling of so-called “pencil stools”) [usually stoma aneurysm].
- Stomaprolapse (prolapse of the bowel (bowel pushes outward through the stoma); risk factors: Obesity and increased intra-abdominal pressure).
- Late complications in the outpatient setting.
- Dehydration/body loses more fluid than it absorbs (with electrolyte disturbances/deviations from normal electrolyte concentrations)
- Failure to cut out the stoma plate for an accurate fit
- Stoma plate cut out too large can cause skin irritation
- Too small cut out stoma plate leads to erosion of the mucosa / intestinal mucosa (with possible bleeding)
- Incorrect temporal change of the stoma plate.
Note: Surgical revision is required only when symptoms persist and stoma function is impaired with concomitant failure of conservative measures.
