Intestinal stomal creation is a commonly performed procedure in colorectal surgery as part of an operation for a variety of disease processes including inflammatory bowel disease, diverticular disease, and malignancy. In certain circumstances, a stoma is created in the setting of traumatic gastrointestinal injury. The ileostomy or colostomy and the stoma may be permanent or temporary. Although stoma formation is a relatively “straightforward” undertaking, the complications associated with a stoma can be complex and, at times, life threatening. Complication rates following stoma creation range between 21% and 70%. These complications are characterized as early or late; however, the period of greatest risk seems to be within the first 5 years. Specific complications include stenosis, prolapse, parastomal herniation, retraction, necrosis, and cutaneous excoriation.

Stomal stenosis has a reported incidence of 2-17%. It is considered a late complication of stoma creation. The etiologies are numerous and include ischemia, retraction from lack of sufficient intestinal mobilization at the time of creation (Fig. 48-1), inadequate fascial aperture (Fig. 48-2a and b), and poor positioning (Fig. 48-3a and b), specifically in morbidly obese patients. In general, symptoms are obstructive in nature; and at times, patients experience constipation followed by a large-volume explosive decompression.

Indications for repair include obstruction, inadequate pouching, or failure of general stomal care. The inability to adequately maintain the ostomy appliance because of explosive decompression may lead to severe skin irritation and chronic pain. Or, the reverse may occur, where the skin irritation next to the stenosis prevents adherence of a pouch.

Preoperative planning is dictated by the etiology of the stenosis. The enterostomal therapist should be involved early in the management of the patient. When an enterostomal therapist is involved with preoperative and postoperative teaching and care, complication rates are significantly reduced. A study of 164 patients showed that preoperative enterostomal therapist consultation reduced the incidence of stomal complications sixfold. Modification in pouching techniques may alleviate some of the patient’s symptoms. A stoma should be properly sited in relation to the patient’s body habitus. Stomas placed with skin creases may need to be relocated for the stoma appliance to stay properly attached to the skin. Stomas located in the lower abdomen in morbidly obese patients made need to be relocated to
the upper abdomen for the intestine to reach the skin with adequate length. Relocation of the stoma may also facilitate the patient’s ability to adequately reach the stoma and to provide self-care. During the preoperative planning stage, patients may need to be counseled on weight loss and modification of lifestyle factors that may reduce surgical risks.

Surgical management of stoma stenosis is predicated on the severity of symptoms and degree of stenosis. The degree of stenosis is assessed with digital and endoscopic examination. The ability or inability to introduce a finger and a flexible endoscope is noted. The length of the stenosis is assessed and the integrity of the intestinal mucosa is evaluated. Treatment may be as simple as performing digital dilation, local revision, or enlarging the opening with simple skin incisions. More complex procedures may be required, such as abdominal surgery with stoma relocation and intestinal resection.