Intestinal stomas are created for a variety of reasons in patients with inflammatory bowel disease (IBD). The type of stoma, as well as its location and duration, depends on the specific disease process, the type of surgery performed, and individual patient characteristics.

An intestinal stoma is named for the segment of the gastrointestinal tract that is brought out through the abdominal wall to the skin; therefore, an ileostomy is a segment of ileum (usually distal) that is brought out through the rectus muscle onto the abdominal wall. The purpose, appearance, and function of each ostomy are best understood by the functional characteristics of the specific bowel segment involved. The most common ostomies are descending/sigmoid colostomies or ileostomies.

Surgeons choose between two stomal construction techniques when fecal diversion is necessary, the end and loop ostomies. An end ileostomy/colostomy is created by dividing the segment of bowel at the most distal unaffected portion and bringing it out through the skin. The stoma should ideally protrude approximately 1 to 2 cm to allow for adequate pouching. A loop ileostomy/colostomy is typically utilized when the ostomy is expected to be temporary. In this instance, the bowel is not divided; rather a loop of bowel is brought out and the proximal bowel is everted and sutured to the skin, thus exposing the mucosal surface. Patient morbidity, indication for stoma, urgency of operation, and patient age determine end versus loop stomal creation. End and loop ostomies are both considered reversible. The process of stomal creation is also referred to as “stomal maturation.” Further indications for end versus loop stomal creation are discussed later in the text.

Despite the differences in purpose, function, and construction, healthy stomas share common characteristics. Because the stoma is mucosa, a viable stoma should be pink, moist, and firm. Newly constructed ostomies might be dusky (congested) or edematous. When the bowel is introduced through the abdominal wall, its circulatory supply may be compromised, resulting in ischemia and necrosis of the externalized bowel segment. If a stoma appears dark or necrotic, it must be determined whether viable bowel exists above the level of the fascia. Bowel that has necrosed below the level of the fascia requires immediate surgical intervention to prevent contamination of intestinal contents into the peritoneal cavity. Bowel that has necrosed above the level of the fascia is often treated conservatively.

In addition to assessment of the stoma itself, attention should be paid to the mucocutaneous junction and the peristomal skin, as integrity of the peristomal skin is essential for secure placement of an ostomy pouch. The skin underneath the ostomy pouch should be assessed for fungal or bacterial overgrowth as well as chemical or mechanical injury. Peristomal skin conditions and their treatment will be discussed later in this chapter.

Ileostomies are most commonly seen in the setting of colonic disease requiring proximal diversion or as a result of perforating small bowel disease. Loop ileostomies are commonly constructed as a temporizing measure to divert the fecal stream from more distal areas of intestine; such diversion is common in the creation of an ileal pouch anal anastomosis (J-pouch) in ulcerative colitis. A loop ostomy will have a functional limb that is typically constructed 1 cm above the nonfunctional limb that serves as a mucous fistula. Loop ileostomies are typically reversed at a time determined by the surgeon. The procedure is straightforward and typically takes less than an hour of operative time.

Ileostomies are usually placed in the right lower quadrant. Initially after surgery, they typically drain up to 1 to 1.5 L of liquid effluent daily. A well-adapted ileostomy typically drains 800 to 1,000 mL/day. Because the colon has very little involvement in the absorption of nutrients, patients do not experience nutritional compromise; however, dehydration is a frequent problem. In order to maximize water absorption, patients can take insoluble fiber supplements to thicken the stool and medications, such as loperamide or diphenoxylate, to help slow bowel transit. These drugs are usually administered before meals and at bedtime, and are often titrated to maximize absorption. Other agents used to slow the bowel include opioids, kaopectate, and bismuth subsalicylate (Pepto-Bismol).

An ileostomy is expected to function continuously, whereas a colostomy functions intermittently depending on its location, the patient’s preoperative bowel function, and the integrity of the ileocecal valve. Stool consistency is determined by the portion of colon that is exteriorized. A sigmoid colostomy is usually located in the left lower quadrant, while a transverse colostomy is brought out to one of the upper quadrants.

Most colostomies are created by dividing the bowel and bringing an end up through the skin. Because the stool is semisolid in the colon, it is not critical for surgeons to create a protuberant stoma. Often, stomas are flush with the patient’s skin. Generally, the higher the protuberant stoma in the intestinal track (as in the case of ileostomies), the more desirable it is. This is related to the ease with which an ostomy pouching system contains the fecal matter. A loop colostomy is made by exteriorizing a contiguous segment of bowel and maturing the proximal end. This is often done as a temporizing measure to decompress a distal obstruction or to divert the stool away from uncontrolled perianal disease. The advantage of a loop ostomy is the ease with which it can be made and reversed, often through a minimally invasive or laparoscopic approach. This can decrease the need to reenter the abdominal cavity. The distal lumen can decompress bowel above a strictured or obstructed segment. One disadvantage of a loop ostomy is the tendency for the distal lumen to prolapse. Most end colostomies are created as definitive treatment for low-lying rectal cancers in the abdominal perineal resection. Intra-abdominal damage control surgery such as in the case of ruptured diverticulitis often results in end colostomy formation and stapling of the remaining nondiseased segment of rectum, which is often referred to as Hartmann’s procedure.

The placement of any intestinal stoma is determined both by the type of ostomy and by patient characteristics. Excessive stretching of the bowel mesentery can lead to circulatory compromise; therefore, the external stoma placement needs to roughly correspond to the segment of bowel that is exteriorized. Body habitus,
previous surgeries, and pelvic radiation are a few considerations that may impact stoma placement. Preoperative marking of potential stoma sites is essential to prevent placing an ostomy in a site that will be difficult to manage postoperatively. The enterostomal therapy nurse evaluates the patient in multiple body positions to appropriately mark the stoma site.

An appropriate pouching system is an essential component for any ostomy. Ostomy type, location on the body, body habitus, skill and manual dexterity of the patient, cost, availability of supply, and insurance status of the patient are addressed when considering a pouching system.

It is difficult to ascertain the incidence and prevalence of intestinal stomal complications. A review of the literature reveals wide variation in incidence, ranging from 6% to 70% (1, 2, 3, 4, 5, 6, 7, 8, 9, 10

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