Repair of Stomal Stenosis

Jared C. Frattini

Jorge E. Marcet

Introduction

Intestinal stomas have been used for decades as a means of temporary or permanent diversion of the fecal stream in the setting of colorectal cancer, inflammatory bowel disease, diverticulitis, and trauma. A colostomy or ileostomy can be a loop, end, or end loop with each type of stoma having advantages and disadvantages. Creation of intestinal stomas is often thought of as a common and basic procedure and is frequently left to be created by a less experienced member of the surgical team (1). Complications resulting from a poorly fashioned stoma can negatively impact not only the patient but the health care system (2).

The complication rate associated with stomas ranges between 20–60% (2,3). These complications are characterized as early and late; the time period of greatest risk is within the first 5-years postoperatively (1,2). Various complications include poor location, stenosis, prolapse, parastomal herniation, retraction, necrosis, and skin excoriation. (Table 43.1) The rate of stomal complications is equivalent regardless of the nature of surgery, elective or emergent and regardless of the type of stoma, colostomy, or ileostomy (1). When an enterostomal therapist is involved with preoperative and postoperative stoma teaching and care, the complication rate is significantly reduced (3,5). In one study of 164 patients, an enterostomal therapist reduced stomal complications by six fold (3).

Stomal Stenosis

Stomal stenosis or narrowing of the stomal lumen has been reported to occur in 2–17% of intestinal stomas and can occur at the fascial or skin level (1,3,4). It is considered to be a late complication of stoma creation. Stenosis can be caused by ischemia, a small fascial or skin opening, tension, obesity, prolonged peristomal excoriation, peristomal sepsis, or peristomal Crohn’s disease. (4) (Table 43.2) Several studies have demonstrated an increase in stoma stenosis in patients with Crohn’s disease compared to those with
ulcerative colitis when a permanent ileostomy was created (6,7). Generalized symptoms of stomal stenosis can be obstructive in nature or constipation followed by large volume output. Symptoms of stomal stenosis at the skin or fascial level include narrow stools, pain upon evacuation, and excessive, explosive, high-pitched gas (4) (Table 43.3).

Table 43.1 Common Complications of Stomas