Stoma Management in the Philippines

Pointers in avoidance of complications

Skin irritation

Peristomal infection

Gangrene

Retraction of stoma

Stenosis

Prolapse and intussusception

Parastomal hernia and peristomal evisceration

Skin irritation

Skin irritation due to allergic reaction to adhesive of the appliance	Skin irritation due to abrasive effects of effluents

Skin irritation is almost always seen in ostomate patients at one time or another. It varies in degrees.

The two basic causes of peristomal skin irritation and excoriation are the abrasive effects of the effluent itself, which can be aggravated by maceration on prolonged contact, and the allergic response to the appliance.

Treatment and prevention of skin irritation consist of the following:

1. Proper construction of the stoma

a. If possible, choose the more distal portion of the intestinal tract for the construction of the stoma. Stomas with solid or semi-solid effluents are easier to take care of.

b. If possible, construct an end intestinal stoma rather than a loop stoma. An end stoma is easier to take care of compared to a loop stoma, which is bulkier.

c. As much as possible, construct a protruded stoma. Avoid a flush or retracted stoma.

Protruded stoma	Flush stoma	Flush stoma	Flush stoma

d. Choose the site of the stoma that is a good distance away from the iliac crest, coastal margin, umbilicus, inguinal crease, scars, or anything on the abdominal wall that may contribute to an insecure and difficulty placement of appliances.

Ideal site	NOT on the incision site	NOT near iliac crest	NOT on incision site

2. Proper use of appliance

a. Do not use appliance which may cause allergic reactions to the skin.

b. Keep the area of peristomal skin exposed to the effluents as minimal as possible.

c. Avoid leakage from the appliance seal.

d. Change all faulty appliance.

e. Use proper appliance to avoid skin irritation as well as to avoid further skin breakdown. An appliance with a skin protective device, either built-in or add-on, like karaya gum or wafer may be used.

3. Keep the peristomal skin always clean and dry.

4. Use antibiotics as necessary.

Peristomal infection

Peristomal infection refers to subcutaneous infection around the stoma. It may occur because of fecal contamination, especially in those with retracted stoma.

Treatment and prevention consist of:

1. Proper construction of stoma

2. Drainage and cleansing

3. Antibiotics, as indicated

Gangrene

Gangrene is almost always caused by a compromised blood supply. Treatment is by resection.

Retraction

The basic problem with retraction is tension associated with inadequate length of intestine that will be used for stomal construction.

A retracted stoma is difficult to manage. It may cause skin irritation, peristomal infection, and even intraabdominal infection, if it is retracted below the fasciaperitoneal level. Thus, as a rule, all retracted stoma should be revised. It should be transformed into a protruded stoma.

Stenosis

Stenosis is usually caused by skin-level stricture which may be due to inadequate skin opening and fibrosis as a result of secondary colocutaneous healing.

Treatment and prevention include

1. Adequate skin opening for the stoma

2. Primary stoma-cutaneous suturing

Peristomal Evisceration and Parastomal Herniation

The basic problems are too large a fascial and/or skin defect created and absence or breakdown of a fascial-serosal and stoma-cutaneous anchorage or suturing.

Peristomal evisceration	Parastomal herniation

Prevention: NOT too big fascial defect; fascial anchorage

Prolapse and Intussusception

Prolapse	Intussusception

These are related to bowel distention at the time of initial surgery, which necessitates creating an abdominal wall opening larger than the normal caliber of the bowel.

Prevention: NOT too large an abdominal wall opening