Peristomal Dermatitis

Peristomal dermatitis is one of the most common skin complications in patients with stomas, with a reported frequency ranging from 18% to 55%. Patients with a loop ileostomy (14.0%) or loop colostomy (32.3%) are at particular risk for stoma-associated dermatitis. The manifestations of peristomal dermatitis vary from mild skin irritation to ulcers or concomitant local infections. Stomas placed in desirable locations, such as bony prominences, proposed incisions, previous scars, or skin creases, are at risk of developing peristomal dermatitis. In addition, peristomal dermatitis usually coexists with structural complications (33.9%) such as prolapse, retraction, and peristomal hernia.

Peristomal dermatitis is mainly caused by mechanical, chemical, and infectious factors. Leakage of stoma effluent affects up to 34% of ileostomy patients, resulting in chemical injuries. To avoid the complication, a surgeon can make a 2- to 3-cm high ileostomy to avoid contact with intestinal contents and peristomal skin. Most mechanical injuries are caused by improper fitting or frequent changes of an ostomy appliance. Repetitive replacement of the appliance can cause mechanical peeling of the surrounding epidermis. Using a sealant on the damaged area is beneficial in healing and preventing further peeling of the skin. A warm, humid, and dark environment is conducive to bacterial or fungal infection with cutaneous candidiasis being the most common peristomal skin infection. Antibacterial soap or antibacterial powder may be used for treating microbial infections in patients with peristomal dermatitis.

With proper placement and stomal care, peristomal dermatitis can usually be prevented. Conventional ostomy care and a suitable ostomy appliance covering the damaged skin will heal the skin around the membrane. However, due to the lack of ostomy incontinence care, patients may develop peristomal skin complications that would have been easy to manage, including hospitalization and more expensive treatments. Peristomal dermatitis caused by poor sitting or improper location for construction that is refractory to management by expert stomal care may require surgical revision or relocation of the stoma. Fortunately, only a few patients with peristomal dermatitis require surgical intervention for the skin disease per se .

Peristomal Pyoderma Gangrenosum

Pyoderma gangrenosum (PG) is characterized by painful, undermining, and peristomal ulcerations which mostly occur in patients with underlying IBD, arthritis, multiple myeloma, or malignancy. PG starts as small erythematous papules that coalesce into larger indurated ulcers with undermined edges and skin bridges, with an erythematous outer halo. For patients with IBD, the reported frequency ranges from 2% to 30%, but the incidence of peristomal PG has been reported as 0.6% in patients without autoimmune diseases. However, PG severity usually does not correlate with the activity of the underlying IBD.

The onset of parastomal PG ranges from 2 weeks to 3 years after the creation of a stoma. The basic principles for PG wound care are to create and maintain a dry skin surface by using nonadherent or absorbent dressings and carefully use pouching systems to ensure adequate sealing and minimization of local skin trauma inflicted by the appliance. Successful treatment of evolving PG requires topical wound care and stoma management by an enterostomal nurse assisted by gastroenterologists or IBD specialists who treat underlying disorders. Topical corticosteroids and antibiotics are the frequently used initial agents for the medical treatment of PG. Topical tacrolimus is also frequently used. Systemic high-dose steroids for up to 3 months can be used for the management of PG, with an acceptable response rate. Treatment with infliximab for PG has shown a 21% complete response rate and 31% no response rate.

For those with refractory PG, surgical intervention may be needed and can play an important role in the management. Surgical procedures for refractory PG include bowel resection with or without reconstruction of the stoma, relocation of the stoma, and stoma closure. Resection of actively diseased bowel has been shown to decrease the average healing time from 12.4 to 1.8 months. Relocation of the stoma site has also been proposed as an alternative, but in some cases, PG will likely recur at the new stoma. ^{, ,} Stoma closure is the last and best approach to cure ulcers in active PG, in selected patients.

Peristomal Psoriasis

Psoriasis is another common skin condition following stoma creation, affecting 1.3% to 2.2% of the patient population. The ostomy site provides a specific site for psoriasis to develop; this is especially commonly developed in patients with IBD. The prevalence of psoriasis is reported much higher in patients with IBD, with 11.2% in patients with Crohn’s disease (CD) and 5.7% in those with ulcerative colitis, respectively. Repeated trauma is considered a potential etiological factor of peristomal psoriasis. Interestingly, in a retrospective study of 1665 patients, 78 (4.7%) had peristomal psoriasis; these patients showed female predominance, implying that hormonal factors may play a contributing role.

Treatment strategies for peristomal psoriasis include topical and systemic corticosteroids and systemic biological agents. Hydrocolloid applied to peristomal skin of psoriasis was shown to be beneficial in clearing psoriasis and the majority of localized psoriasis plaques (41%, 14/34) achieved improvement with the application and 47% (16/34) resolved with prolonged application. Topical corticosteroids may also be effective, as shown in a retrospective study in which 75 out of 78 patients with peristomal psoriasis (96.2%) were able to be managed with topical corticosteroids. Systemic treatment is reserved for severe generalized peristomal psoriasis refractory to topical treatments. Infliximab, adalimumab, and ustekinumab were approved for the treatment of both psoriasis and IBD by the U.S. Food and Drug Administration (FDA). In patients with IBD, peristomal psoriasis is considered an extraintestinal manifestation of IBD. Antitumor necrosis factor and antiinterleukin biologics can be alternatives in patients with both psoriasis and CD or ulcerative colitis.

Surgical intervention is typically reserved for patients with severe and refractory peristomal psoriasis. Surgical options for peristomal psoriasis include ulcer debridement and intralesional steroid injection. For those patients who fail all the above methods, stoma relocation can be attempted. It should be noted that stoma relocation did not reduce the risk of recurrent peristomal psoriasis. Recurrence of peristomal psoriasis around the stoma is common after stoma relocation. The most effective treatment for peristomal psoriasis is stoma closure with re-establishment of intestinal continuity.

Stomal Infection

Stomal infection is uncommon as compared with other stoma-associated complications. The warm, dark, and moist environment under pouch adhesive is particularly hospitable to fungal infection. Cellulitis from typical skin flora bacteria like Staphylococcus aureus can present as an erythematous peristomal plaque. Exposure to stools due to a large skin-barrier aperture may further increase the risk of peristomal fungal infection. Fungal infection is more common in ileostomy patients, particularly those in a debilitated or immunocompromised state than those relatively healthier. Fungal lesions are moist and bright red and can be papules, vesicles, pustules, or erosions. These satellite lesions are characteristics of fungal infections, distinguishing them from dermatitis.

Peristomal cellulitis can initially be treated with oral antibiotics, but severe soft tissue infection may require intravenous antibiotics or rarely surgical debridement. A properly fitting skin barrier along with topical antifungal powder is generally helpful. Oral antifungal agents are required only for recalcitrant infection. When bacterial skin infections are present, it is important to rule out a deeper peristomal abscess. The latter can be confirmed by ultrasound, computed tomography, or magnetic resonance imaging. Surgical intervention is indicated for deeper peristomal abscesses, especially for those larger than 3 cm. In most cases, surgical drainage is only performed in patients with larger and deeper peristomal abscesses unamenable or refractory to percutaneous drainage. Of note, the peristomal fistula should be precluded before surgical treatment, especially in patients with IBD. A deeper peristomal abscess caused by penetrating intestinal disease such as a fistula usually requires the medical or surgical management of the diseased bowel.

Parastomal Hernia

A parastomal hernia is a form of incisional hernia that occurs at ostomy sites. The frequency of parastomal hernia varies with stoma type and configuration. Reports indicate that the prevalence of parastomal hernia for end ileostomies ranges from 1.8% to 28.3%, and for loop ileostomies it varies from 0% to 6.2%. Similarly, end colostomies have a reported parastomal hernia rate between 4% and 48%, while loop colostomies range from 0% to 30.8%. ^, Most parastomal hernias occur within the first 2 years after stoma creation but can occur up to 10 years after the ostomy. Risk factors for the development of parastomal hernias include obesity, malnutrition, advanced age, collagen abnormalities, corticosteroid use, postoperative sepsis, abdominal distention, constipation, obstructive uropathy, and chronic lung disease.

Symptoms related to parastomal hernias include mild peristomal discomfort, abdominal pain, difficulty in maintaining an adequate appliance skin seal, obstruction or strangulation, and failure to thrive, leading to poor Qol. ^, Most parastomal hernias can be diagnosed by a thorough clinical examination after removing the stoma appliance with the patient in a standing position. If a clinical examination is not conclusive, computed tomography may be performed to confirm the diagnosis.

Although the incidence of parastomal hernia is considerable, more than 20% of patients with parastomal hernias require surgical repair. The ideal treatment of parastomal hernia is to eliminate the stoma and restore intestinal continuity. Surgical options for correcting a parastomal hernia are local primary repair, relocation, and repair with mesh.

Mucocutaneous Separation and Stoma Dehiscence

Mucocutaneous separation (MCS) is a common early complication after stoma formation with the reported frequency ranging from 3.96% to 25.3%. ^{, ,} MCS is characterized by partial or circumferential detachment of the mucosa from the peristomal skin. The reported causes of MCS include infection, diabetes mellitus, the use of corticosteroids, malnutrition, excessive tension on the stoma, and stoma necrosis. ^,

Mucocutaneous separation can be treated conservatively by topical wound care. The separated area around the stoma should be initially irrigated with saline, and skin barrier powder is then used to absorb exudates and fill the defect before applying the pouching system. ^{, ,} Other treatments for MCS include packing the separated area with a filling paste or powder and covering the separated area with the stoma appliance. With early detection and appropriate wound care, most cases with MCS would be successfully treated with appropriate management. Circumferential MCS is treated similarly. However, we should pay attention to the sequelae of MCS such as stoma retraction and stenosis. The latter conditions may eventually require surgical intervention with stoma revision ( Fig. 21.2 ) or stoma closure.

Stomal Ischemia and Necrosis

Stomal ischemia and necrosis is an early postoperative complication resulting from inadequate stomal blood supply with a considerable frequency of up to 13% in patients with stoma creation. ^, Partial or superficial necrosis of stoma is more common, with a frequency of 2% to 20%. Complete or deep necrosis caused by serious ischemia can occur in 0.37% to 3% of patients with stomas. ^{, , , ,} The main cause of stoma necrosis is devascularization of the bowel conduit used for stoma creation. The risk factors for stoma necrosis are colostomies, emergent operations, and obesity. For early detection of stoma ischemia or necrosis, it is important to distinguish the stoma between early venous congestion and arterial insufficiency. Generally, inadequate arterial inflow causes full-thickness necrosis.

If ischemia is noted in the operating room, urgent surgical interception is required with the stoma being immediately revised. Techniques for stomal revision are dependent upon the length of the ischemic bowel segment. Shorter segments (i.e., <5 cm) of ischemia limited to the distal stoma aspect can be ameliorated with simple mobilization to bring viable bowel to the skin surface. Longer ischemic segments of the bowel may require additional resection of the intestine. In cases with left-side colostomy, the surgical procedure may include mesentery division and full splenic flexure mobilization. Often, full-thickness stoma necrosis does not become evident until days postoperatively. The management strategy of delayed postoperative stomal ischemia depends upon the proximal extent of bowel ischemia. Failure in the recovery of arterial inflow or stoma necrosis below the fascial level would ultimately require laparotomy and stoma revision.

Stomal Retraction

The overall reported frequency of stomal retraction ranges from 1.4% to 30% after stoma formation. ^{, , ,} It affects all configurations of the stoma, including ileostomy and colostomy. ^, Stomal retraction can be an early complication occurring when insufficient bowel length is procured in stoma creation or a constructed stoma is not well healed postoperatively. Stomal retraction may also result from MCS or comorbidities such as rapid weight gain after surgery. A retracted stoma discharges effluent at the skin level, causing peristomal leakage and irritation. Early postoperative MCS and stomal retraction would commonly result in late adverse outcomes including stomal stenosis.

Technically, retraction of a stoma is caused by excess tension placed upon the matured segment of the bowel, typically resulting from inadequate mobilization. This situation is often seen in colostomy and those with significant postoperative weight gain. Therefore, several preventive measures can be taken as initial steps. For the treatment of left-sided colostomies, simple division of the sigmoidal vessels may not be sufficient. The stoma will be tethered by the inferior mesenteric artery (IMA) pedicle, especially in obese patients. Ligation of the IMA proximal to the left colic artery takeoff and division of the inferior mesenteric vein (IMV) usually provide a significant length. In patients with IBD or other abdominal inflammatory conditions, the use of a segment of the bowel that is edematous or inflamed is also discouraged because the stoma-associated mesentery will lack pliability and is often foreshortened. Other useful measures in preventing colonic stomal retraction include the complete dissection of the colon from its lateral peritoneal attachments and mobilization of the splenic flexure. Retraction of the stoma would require surgical management which includes stoma closure with the restoration of intestinal continuity and stoma revision.

Stomal Prolapse

Stoma prolapse is defined as the full-thickness protrusion of the bowel through a stoma. Common symptoms associated with stomal prolapse are pain, skin irritation, and difficulty in maintaining an appliance. In some cases, stomal prolapse can lead to bowel obstruction, incarceration, or strangulation. The reported prevalence of stomal prolapse is 3% in ileostomies and 2% in colostomies. Stomal prolapse occurs more frequently with loop ileostomy/colostomy than with end-ostomy and the prolapse most frequently involves the efferent (distal) limb. Stomal prolapse can be divided into sliding prolapse which occurs intermittently with increased intraabdominal pressure and fixed prolapse which is present constantly. Older age, obesity, and bowel obstruction at the time of stoma creation are reported risk factors for developing subsequent stomal prolapse.

Surgical options for stomal prolapse repair include resection, revision, or relocation. If it is possible and feasible, stomal prolapse can be managed via the reversal of a temporary stoma. Resection of the prolapsed segment is performed by incising the mucocutaneous junction, mobilizing and amputating the prolapsed segment, and reconstructing a new stoma. A prolapsed loop stoma can be remedied by converting it into an end ostomy or an end-loop ostomy. Conversion of loop ostomy to an end-loop ostomy is an alternative procedure that is performed by incising the mucocutaneous junction and transecting the bowel used to create the loop ostomy into a distal and proximal segment. The prolapsed bowel segment, usually involving the efferent limb, can be returned to the abdominal cavity or matured as a mucous fistula. Stomal relocation can be considered when a prolapsed stoma is located at a suboptimal site which results in pouching issues or associated skin complications.

Stoma Site Stenosis

Stoma site stenosis occurs in 2% to 17% in ileostomy and 1% to 14% in colostomy. However, stenosis of a transverse colostomy is less commonly seen. It is often caused by an underlying disease and is more common in patients with CD due to the disease process and progression after stoma formation. ^, Early MCS and retraction frequently can cause stomal stenosis from the effect of secondary wound healing and constricture. Fascial stenosis and underlying disease such as CD can also lead to the development of stoma site stenosis. Surgical techniques can also contribute to stoma stenosis, which is often seen in fascial strictures resulting from the creation of an inadequately sized fascial aperture. ^,

Skin-level stomal stenosis can be fixed by a local procedure. However, if the underlying problem is ischemic necrosis of the bowel, tension, or CD, laparotomy with surgical revision would be required. Local revision of the stoma can be attempted. In some cases, laparotomy, resection of the stenotic bowel, and creation of a neostoma are often required. The possibility of cancer should be kept in mind when we evaluate stomal strictures in patients undergoing surgical resection for GI cancer. Tissue biopsy is required in these patients.

Stoma-Related Bleeding

Bleeding is one of the most common complications in patients with an ostomy. The incidence of stomal bleeding is not well described, as this phenomenon can occur immediately, early, or late after stoma construction. Abrasive trauma to the stoma is the most important cause followed by a poorly fitting appliance. In addition, IBD-associated ulcers can also result in stomal bleeding, which is often seen in patients with active disease, and those with stomas created at the site of an inflamed intestine. Management of stoma-related bleeding may involve direct pressure application, cauterization of the affected mucosa, or suturing of any identifiable bleeding vessels. Stoma-related bleeding can initially be managed with direct pressure or suture ligation; medical therapy to reduce portal pressures is effective in decreasing the risk of recurrent bleeding. Topical and systematic medical management of underlying diseases such as IBD is required for stoma bleeding due to ulcers. Surgical treatment is only reserved for patients with uncontrolled stoma bleeding, and the procedure includes stoma revision and resection with neostoma creation.

Fluid and Electrolyte Imbalances From High-Output Enterostomy

A newly created ileostomy usually functions within 24 hours and produces more than 1200 mL of watery stool per day. However, the amount of ileostomy output can be maintained at 300 to 700 mL/day after a while; this is called ileostomy adaptation. When the amount of fluid from the stoma exceeds 10,002,000 mL/day, it is called a high-output stoma, which occurs in 16% of patients with stoma creation, and this is often seen in patients with a stoma of the proximal small bowel such as jujenostom. High stoma output may be caused by partial bowel obstruction, intraabdominal sepsis, the use of prokinetic drugs (e.g., metoclopramide), the sudden withdrawal of steroids or opiates, and Clostridium difficile – associated enteritis. Diuretics, coexisting diabetes mellitus, and total proctocolectomy are also the reported risk factors for high stoma output. ^,

Generally, the risk of developing severe dehydration is high in the immediate postoperative period when the oral intake of fluids is insufficient. Prolonged hyperaldosteronism can result in hypokalemia and hypomagnesemia which can lead to acute kidney injury. In clinical practice, dehydration is the major cause of readmission after stoma creation. ^{, ,} Intravenous supplement fluids and electrolytes, avoiding intake of hypotonic drinks (tea, coffee, and fruit juice), and antidiarrheal or antiperistaltic medications are the recommended treatment protocol. ^, Stoma closure with the restoration of intestinal continuity is ideally performed to resolve high enterostomy output.

Stomal Abscesses and Fistulas

Stoma abscesses and fistulas mostly occur in patients with ileostomies. A stoma fistula can arise from trauma or other specific etiologies such as CD. The fistula may arise from an everting suture placed in a full-thickness fashion through the side of the bowel at the time of stoma construction, an appliance flange causing pressure necrosis at the edge of the everted spout, or disease processes such as recurrent CD. Stoma-related fistula raised from CD affects 7% to 10% of ileostomy patients with CD. ^, Stomal abscesses are more commonly seen in ostomates with CD and may harbor a peristomal fistula. When bacterial skin infections are present, it is critical to rule out a deeper peristomal abscess.

Abscesses can be painful and fluctulate and may spontaneously drain. If a peristomal abscess is confirmed, drainage should be considered. This can be performed through an incision at the mucocutaneous junction or >4 cm away from the mucocutaneous junction to avoid interference with the stomal pouch. While medical therapy with biologics has a promising role in the management of CD-related fistulas, surgical intervention is reserved for patients receiving but being refractory to medical management. Laparotomy with resection of the terminal ileum and revision of the ileostomy is required in patients who failed to abscess drainage and those with complicated fistula or abscess. Technically, distal stoma fistulas can be managed by a local operative revision with limited resection of the involved distal bowel.

Stoma Reconstruction in the Same Location

Surgical intervention such as stoma reconstruction is often required in patients with stoma complications ( Fig. 21.1 ). If the patient is satisfied with the positioning, functionality, and appliance fit of their initial stoma, an indicated approach is a local repair, which may or may not involve the use of a mesh. Stoma reconstruction in the same location is performed if there is a need to avoid the use of prosthetic material or more major surgery. Stoma reconstruction in the same location includes a local exploration around the stoma site and primary closure of the defect with either absorbable or nonabsorbable sutures. Potential advantages of this approach are avoidance of formal laparotomy and the ability to maintain stoma in the same location. Local repair using prosthetic mesh has been popularized in the past few decades. If required, the defect is repaired with mesh. This is specifically performed in stomal hernia. It should be noted that stoma-related fistulas or abscesses are relative contraindications for stoma reconstruction in the prior location, as postoperative complications including separation, stoma dehiscence, and stoma retraction are common due to local sepsis.

Stoma stenosis resulting from constriction of tight mesh may be treated with a surgical incision of the mesh from the side of the stoma (personal communication from Dr. Bo Shen, Columbia University Irving Medical Center, New York, United States.) ( Fig. 21.2 ).

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