Speaker 1Okay, in this class, we're going to begin our discussion of stomal complications. We're going to focus specifically on prevention and management of stomal necrosis, mucocutaneous separation, stomal retraction, stomal stenosis, and malignancy. So we're going to -- these are complications that are primarily found in the early post-op phase. Some of them can also be found in the late post-op phase. We're going to have another class where we're going to focus in more depth on things like prolapse and hernia, which is more likely to occur late postoperatively. So looking at stomal complications from big-picture perspective, they're amazingly prevalent. So incidence as high as 50 percent, that's a lot. It's like peristomal skin complications. We would wish that individuals having to undergo ostomy surgery, that's enough. We would wish they would never have peristomal complications, never have stomal complications. But the data says that the majority of people will have peristomal complications, and approximately half will have stomal complications. Some people are at higher risk. Any individual with obesity, morbid obesity, or advanced stage, because there are issues with stomal construction, there are issues with healing that place those individuals at greater risk. Some people with inflammatory bowel disease or ischemic colitis because they have ongoing underlying issues with bowel health. Any patient who underwent emergency surgery, any patient who required an ileostomy or a looped stoma, and we can understand that. If you had emergency surgery, you may not have been marked preoperatively. You may be undergoing surgery. But if you have an ileostomy because of perforation, that's going to increase your risk of complications. We know that ileostomies are associated with higher risk of lots of complications because now we're dealing with removal or bypass of the colon. And looped stomas, interestingly, are associated with higher risk of prolapse statistically. So, we know that if the patient is not seen by an ileostomy nurse preoperatively, if they did not get stoma site marking and preop education, they're higher risk. So one of the things we're always advocating for and fighting for. Is involvement with our patients preoperatively. Now, we said you can have early complications, late complications. They typically define early complications as those that can occur within the first 30 days. That usually involves necrosis, mucocutaneous separation, and stoma retraction. Late complications are more likely to involve prolapse, hernia, malignancy. But we'll cover them all, either in this class or the next class. So let's start with stoma necrosis. That is almost always an early complication. It's caused by impaired blood flow and that almost always is caused by the surgical procedure. So remember that, when they go to make a stoma, they trim the mesentery on the segment of bowel that they're going to feed through the abdominal wall. You can only trim so much mesentery without risking ischemia of the stoma, necrosis of the stoma. So they try to limit mesentery trimming to about 7 centimeters. If they're forced to trim more mesentery, then the risk of stoma necrosis rises. Also. If there is a lot of tension on the mesentery, you can end up with ischemic changes. If you throw a little clot to a mesentery vessel, you can end up with ischemic changes. So surgical trauma associated with stoma creation is the primary reason for stoma necrosis. Obesity is the primary risk factor. Because when the abdominal wall is thick. It turns out the mesentery is also thick and fat and immobile. And that increases the risk that you'll get tension on the mesentery when they're trying to mobilize the bowel to the desired site. Tension on the mesentery can cause ischemic changes. Also when the abdominal wall is very thick because of obesity, the surgeon's going to push the involuntary. I'm sorry. I'm sorry. in terms of trimming the mesentery, that's going to increase the risk of stoma necrosis post-op. Now clinical presentations exactly what you would think. Healthy mucosa is pink, red, moist, good turgor. A stoma with compromised blood flow, you're going to see changes in color. You're going to go from pink, red, to dark purple, or gray, or brown, black. You're going to get a change in hydration, so you're going to go from moist to dry, and you're going to get a change in turgor. So you'll go from a stoma that's standing proud and tall to a stoma that's very limp. Now you want to be aware that necrosis can involve just part of the stoma. If you've got some tension on the mesentery, and there's an area of the stoma that's not getting the normal amount of blood flow, you might have just that segment of the stoma that's involved. But if there's a significant portion of the stoma that loses blood flow, it can be like you see on the bottom, where the entire stoma is involved in the ischemic necrotic changes. The other thing you want to realize is that necrosis can involve just the stoma itself, or it can involve the proximal bowel. And that makes a huge difference in terms of management. So we'll get to that in just a minute. So let's talk about the ostomy nurse's role in management. We're usually the ones that are changing the pouch early, post-operatively. We're teaching the patient, here's what the stoma should look like. Here's what you're seeing. We're providing a visual tour of the stoma. So most of the time we're the first ones to identify that, hmm, I'm seeing ischemic changes. I don't like the color of the stoma from 12 o'clock to 6 o'clock, or the entire stoma appears dusky, or the entire stoma appears necrotic. So remember that if there's going to be ischemic changes, if you're going to develop stoma necrosis, it's probably going to be during the first couple of days post-operatively, because most often it's caused by surgical trauma, by stripping too much of the mesentery, by a mesentery under tension, or by a little clot that's thrown post-operatively. Now we've already said that necrosis can involve just the stoma itself, the most distal portion of the bowel, or it can extend to involve proximal bowel. How are you going to determine that? So I want you first to look at the illustration on top. So I want you to understand what we're talking about. So you can see that the mesentery has been trimmed along the length of bowel that's fed through the abdominal wall, and used to create the stoma. You can also see that the stoma itself, looking at that top illustration, the stoma itself is the most distal portion of the bowel. Now what you really want to know is, is the necrosis limited to the stoma, or does it involve the proximal bowel? Does it extend proximally past the fascia muscle layer and into the peritoneal cavity? And how are you going to determine that? Well there's a little test you can do that involves taking a laboratory tube, either a glass tube or a plastic tube, Lubricating the blunt end, putting it into the stoma, it's like a mini endoscopy, putting it into the stoma and shining the flashlight so you can visualize the proximal bowel and determine is the proximal bowel viable, is it pink, red, and moist, that's great. That means that the necrosis at this point is limited to the stoma itself. Or does the necrosis proceed proximally? Does it involve the bowel beyond the fascia muscle layer? Obviously, if the necrosis involves the proximal bowel, we have to notify the surgeon. So here's how it all shakes out in terms of management. If the necrosis is limited to the stoma itself. Or to the. Bowel just proximal to the stoma, then they're going to monitor it. They're just going to wait and see. They're going to allow the stoma itself to slough. If you end up with a lot of necrotic tissue, as you see in the third slide down, you might have to take a suture removal kit and trim some of that loose necrotic tissue. But the bottom line is they won't take the patient back to surgery if your assessment indicates that the proximal bowel is viable and the necrosis is limited to the stoma, or the stoma and the bowel just proximal to the stoma. So that little test you do with the lab tube and the flashlight is very important. It helps determine the extent of the necrosis, which in turn dictates management. If there's injury to the necrosis, then you have to take the patient back to surgery. evidence that the necrosis does involve the proximal bowel and may extend past the fascia muscle layer, then the surgeon's going to get involved and is going to make the determination as to whether or not the patient should go back to surgery. Now we've already said that if the necrosis involves just the stoma itself and everything beyond there looks okay, they will allow the necrotic stoma to slough, which then of course becomes a management issue. There's going to be pouching challenges because you end up with a skin level or a retracted stoma. You also end up with mucocutaneous separation because the stoma sloughs and you're going to fill in with scar tissue all the way around the stoma, so down the road this patient's higher risk for stoma. So let's talk about mucocutaneous separation. That's the other early complication, necrosis and mucocutaneous separation. So you think about when they make the stoma, they turn the bowel back on itself, they suture the mucosa to the dermis or to the sub-q tissue, and so the patient comes back from surgery and they have this little suture line. All the way around the stoma, that's where the stoma is attached to the skin. If that suture line breaks down, and you can see in the slide on top, you've got breakdown from about 12:00, 1:00 to about 3:00 to 4:00, it looks very minor. If you look at the slide on bottom, you have breakdown all the way from about 7:00 to 5:00. And you can see that the stoma is retracting. So you have very significant separation. So we know what it is. We know the risk factors include tension on the suture line. So if you have an obese patient and the surgeon had to really work to get the skin and the bowel to connect, and you end up with a lot of tension on the suture line, that patient's at high risk. Also, if my patient went to surgery on high-dose steroids, they're at high risk. If my patient is malnourished, he or she is also at high risk. So if your suture line's under tension, if your patient's on steroids, if your patient's malnourished, those are all known risk factors for mucocutaneous separation. Now, the significance is obvious. If I lose my mucocutaneous separation, if I lose my mucocutaneous suture line, then I lose support at the skin level. So then my stoma's going to retract, which is going to lead to pouching problems. And it's going to create a wound right around the stoma that is going to fill with scar tissue. So long term, this patient's at higher risk for stenosis. So you start with mucocutaneous separation, which leads to retraction, and which eventually leads to stenosis. Now, severity of mucocutaneous separation is variable. Sometimes it's pretty minor. There's just a small area of the suture line that breaks down, and the separation only involves the epidermal and dermal layer. But sometimes it's circumferential or almost circumferential, and sometimes it exceeds to the fascia. So, management is going to be dictated by the severity and extent of the separation. So if I have a small superficial defect, a lot of times I can just clean. I can just fill that with ostomy powder. I can cover it with a barrier ring in my pouch and just monitor it. And long term, there's minimal impact. But if I have a large defect, like you see on the bottom, if it involves 50 percent or more of the stoma, if it extends to the fascia muscle layer, then I'm going to end up with a significant wound. Usually I'm going to need to select an absorptive dressing, like an alginate or a hydrofiber. I'm going to need to tuck that into the defect all the way around the retracted stoma. Then I'm going to need to take something like a hydrocolloid to cover my dressing and to create a pouching surface. If I have a defect that extends beyond the fascia level, which is extremely rare, then they would have to take the patient back to surgery because now we would be dealing with intra-abdominal contamination. That's extremely rare. Most of the time you're dealing either with a very minor separation that you can manage just with ostomy powder and a barrier ring, or with significant separation that's limited to the sub-Q tissue layer where you're using some kind of filler dressing and a hydrocolloid to create a pouching surface. Now you're going to select your pouch based on the peristomal contour. So, if you look at the slide on top, you're like, "Well, I could use a flat pouch, an all-flexible pouch. That would be fine because my stoma protrudes and my os is centrally located." But if you look at the slide on bottom, you're like, "Well, I'm going to need a convex pouching system because my stoma is retracted, is located in a concave defect, and the os is going to be emptying very close to wound level." We said that necrosis and mucocutaneous separation can both result in stoma retraction, which is another early complication. Sometimes you'll see the patient come back from surgery and the stoma's already retracted. So, retraction, of course, means that you do not have any significant protrusion of the stoma. It does not stick up above skin level. It's emptying at skin level or even below skin level. Now the risk factors, we've kind of talked about them as we've gone through. If the stoma site was not marked pre-op and the surgeon just has to pick blindly, there's higher risk that it will end up being in a fat fold and that retraction will be an issue. If I have a patient who's obese or morbidly obese, then I'm going to end up with tension on the suture line. The surgeon's going to work to bring the bowel through the abdominal wall and to suture the stoma to the abdominal wall. There's going to be a lot of tension, and the patient could come back from surgery with a stoma that's already contracted and with peristomal dimpling. And that's what you see in both of these. These patients came back from surgery. Their stomas are already retracted. They're already emptying at or below skin level. Right at skin level on top, below skin level on bottom. Another risk factor is if you have adhesions that significantly limit the surgeon's ability to mobilize the bowel and bring it out at the desired site, then again, you might end up bringing the bowel through a very thick layer of the abdominal wall, and you might end up with stoma retraction at the time surgery is concluded. And then, as we have already discussed, if you end up with stoma necrosis and the stoma sloughs, you end up with retraction. If you end up with mucocutaneous separation. And the stoma retracts, same outcome. Stoma retraction is primarily a management issue. It's going to come down to us and the patient working together to find a management system that works. So we've got to evaluate the stoma, the os, the contours, lying, sitting, twisting, standing, and sitting. We're going to have to modify our pouching system in order to get a secure seal. Almost always, we will need convexity. So our decisions will be, do I need shallow convexity or deep convexity? Should it be round or oval in shape? Should it be soft or firm? In general, if I have a soft abdomen, I want firm convexity, if I have a firm abdomen, I want soft. Soft convexity. Should I add a belt? And usually, a belt is helpful. What if I have significant retraction, an os that empties at or below skin level, and I'm unable to come up with an effective pouching system? I've tried convexity, I've tried different forms of convexity, I've tried different levels of convexity, I've tried it with or without a belt, I cannot establish. A secure pouching system, then I'm going to do a surgical consult to see if the surgeon can revise the stoma or relocate the stoma to provide this patient with better outcomes and better quality of life. Now we're moving into late stoma complications, stoma stenosis can occur early but is more likely to occur. It can occur in the early stages of stoma stenosis, and it can occur in the early stages of stoma stenosis, and it can occur in the early stages of stoma stenosis, and it can occur in the early stages of stoma stenosis, and it can occur in the early stages of stoma stenosis, and it can occur in the early stages of stoma stenosis, and it can occur in the early stages of stoma stenosis, and it can occur in the early stages of stoma stenosis, and it can occur in the early stages of stoma stenosis, and it can occur in the early stages fascia level because that's the two points at which you have a firm surface that is not elastic. So you think when you feed the bowel through the abdominal wall, first you go through the muscle layer. Okay, well muscle will stretch and give, but muscle is covered with fascia and fascia is a tough, thin membrane that does not stretch. So you can get stenosis at the fascia level because typically when they're making the stoma, the surgeon takes one or two fingers through the fascia muscle layer to create enough of an opening, but as with any healing process, you can get scar tissue forming right there at fascia level and causing abnormal narrowing of the fascia. So it goes through fascia muscle, muscle not an issue, fascia is, then it goes through sub-q tissue, sub-q tissue will always give, and then through the skin. But especially the dermal layer of the skin has a lot of collagen, and you can end up with a tight band around the stoma at skin level. So stenosis can occur either at fascia level or at skin level. And when we're doing our assessment, we have to remember that because it's going to take a digital exam to rule out stenosis at fascia level. We can visualize to some extent what's going on at skin level. So what are the risk factors for stoma stenosis? Well, we've already talked about several of these. We've talked about mucocutaneous separation. If you get break down of the suture the stoma will pull away from the skin. That wound will fill with scar tissue, and now you have a sleeve of scar tissue around your stoma that can cause progressive narrowing, because you know scar tissue continues to contract. If you have stoma necrosis, what will happen? The stoma will slough. You end up with a hole in the skin instead of a true stoma. And it's going to fill again with scar tissue all the way around, and then you're high risk for stenosis. Occasionally you'll see late stenosis occurring in patients with Crohn's or patients with chronic irritant dermatitis because of ongoing inflammation that causes ongoing collagen deposits and progressive narrowing of the stoma. And finally, the last bullet point, we don't see this much anymore. But in the past, some surgeons did routine repeated stoma dilatations. They believed that was necessary to keep the bowel patent, to keep the stoma patent. Now we know that is not necessary, and it is not a good idea, because if you keep dilating the stoma, every time you do it, you risk trauma. When you force your finger or force a dilator through the stoma, you're causing stretching and tearing anywhere there is narrowing. So you're causing stretching and tearing at the level of the dermis, at the level of the fascia. That will repair with more scar tissue and more narrowing. So routine dilatations are not recommended. Now how would we know that we had stenosis to a level interfering with function? Well, if it's a fecal diversion, the patient might report pain when stool is eliminated. If it's a colostomy, they might report small ribbon-like output. If it's an ileostomy, they might report periods of no output, and then explosive output associated with intense cramping pain. If it's a urinary diversion, urine is so thin that you have to have extensive stenosis before it really interferes with elimination. But that does occasionally occur, and then the patient is likely to report projectile elimination of urine, chronic UTIs, possibly chronic flank pain. Objectively, you may see a very narrow stomal opening. Like if you look at the slide in the middle, you can see that the stoma looks small, and it's surrounded by scar tissue. And then you see that, gosh, look at the incision itself. You have hypertrophic scar at the level of the incision. So now it's like I can see evidence of stenosis at skin level. I need to do a gentle digital exam to see what's going on at fascia level. So anytime you have a patient who is symptomatic, you're going to do a digital exam to determine how patent the bowel is at skin level and at fascia level. Anytime you see a stoma that looks very narrow at skin level, yes, you should do a digital to see does it open up with digital exam. And what's going on at fascia level. How do you manage stenosis? Well, it depends on the severity. Is it mild? Is it severe? If you have mild stenosis, so the patient's like, well, I never have really bad pain. Sometimes I have cramping. Sometimes it seems like I don't go for a little while, and then I have a lot of output. And on exam, I find that it's tight at skin level or tight at fascia level. But I can get my little finger in. I can dilate the bowel to that extent. Then basically, I want to make sure that that that patient maintains adequate fluid intake. I'm going to recommend a low fiber diet. I don't want them eating a lot of high fiber foods that could result in an undigested bolus that gets stuck just proximal to the stoma. We might recommend stool softeners. We'd be more likely to recommend low dose polyethylene glycol like Miralax or Clearlax to pull fluid into the gut to keep the stool very soft, very mushy. If the patient has a colostomy, we might recommend routine irrigations. So again, we're adding water to the mix and keeping the stool fluidized. If it's a urinary stoma, we're going to focus on hydration. We're gonna monitor that patient very closely for any evidence of recurrent urinary tract infections. We're gonna do routine labs to monitor renal function. We wanna make sure the patient's not getting into hydronephrosis. Now, if they have symptoms of severe stenosis, so severe cramping pain, periods of no output, then projectile output, flank pain, any of those things, they're gonna either, surgically revise that stoma or relocate that stoma so that you eliminate the stenosis. You eliminate the obstruction. What about stoma dilatation? They used to use that a lot. Now it would be used only on a short-term basis to get the patient through until surgery can be scheduled and done. It is not recommended on a routine, or a long-term basis. The last complications that we're gonna talk about in this class are malignancy and trauma. Now, malignancy involving the stoma and the peristomal skin is very rare, but it does occur and you never want to miss it. So these two top slides are actually from a patient that I was taking care of. The patient came back for their post-op visit. We knew they had a very aggressive pelvic sarcoma. And when they came back for their initial post-op visit, we took a photo and it's what you see on top. And there was this dark lesion. We're like, is that trauma? The patient thought that he might have traumatized the stomas. We're like, is that a hematoma? What is that? The surgeon was out of town, so we took a photo. And we brought the patient back in two weeks. And look what we saw in two weeks. It's what you see the second slide down. So the surgeon was there for that visit. The surgeon's like, I'm not sure what this is. I'm gonna schedule this patient an OR slot. I'm gonna take the patient to surgery. I'm gonna do a biopsy and size that lesion and see what's going on underneath. I wanna be sure we're in the operating room with access to a pathologist and access to everything I need in case I get into major bleeding. And it turned out to be recurrent sarcoma. So all you have to know, all we have to know as ostomy nurses is if we see something we don't understand, we involve the surgeon in making a decision as to what is going on and whether or not a biopsy should be done. What about stoma trauma? Again, not common. But it can happen, especially if the patient isn't meticulous in measuring the stoma and cutting the opening in the pouching system. If they only partially seat the pouching system and part of the pouch is rubbing against the stoma, we can also see it as a result of seat belt trauma. Now, the way stoma trauma presents, you'll usually see a white line. So the bottom left, you see white lines from stoma trauma. Occasionally, you'll have a dusky area that bleeds very readily, which is what you see on the bottom right. So if you see anything that looks like trauma, you're like, okay, let's see what's going on here. So then you ask the patient to walk you through exactly how, how they size, cut, and apply the pouching system so that you can rule out trauma from the pouching system. You wanna ask them about where the seat belt hits them and whether or not they use any kind of cushion to protect against seat belt trauma. So once you identify the source of the injury, then you can eliminate it. So in summary, we've covered early complications, and we've moved into late complications. Early complications include stoma necrosis, which almost always occurs in the first one to three days post-operatively. Critical responsibilities for the ostomy nurse is to do our test with the lab tube to determine whether or not necrosis is limited to the stoma itself, or whether it involves a proximal bowel. If it's limited to the stoma, they're going to allow it to slough and we'll end up with a pouching challenge. If the necrosis involves the proximal bowel, then the patient's going back to surgery. Mucocutaneous separation, more likely if the stoma's under tension, which occurs in our obese and morbidly obese patients, also more likely in patients on steroids, patients who are malnourished, we're going to dress them, dress the area of separation, and we're going to select a pouching system that matches the contours. If we end up with significant separation, we're also going to end up with significant scar tissue, the risk for stenosis, and we're going to end up with a retracted stoma and pouching challenges. If we have a retracted stoma, it's all about pouching modifications. Typically the addition of convexity and a belt, and we may have to get the surgical team involved for assessment and possible revision or residing of the stoma. The late complications that we discussed in this class include stomal stenosis. Patients who are higher risk for stenosis if they have necrosis and sloughing, if they have mucocutaneous separation. The issues with stenosis. Is the stenosis severe enough to interfere with function? Does it occur at the skin level or at fascia level? Mild stenosis, we're all focused on maintaining function. Severe stenosis, they're going to require surgery. Malignancy, we're going to monitor for any unusual, unexplained lesions. We're going to get a biopsy. Trauma, our whole focus is identifying and eliminating the source. Thank you, and we'll talk about other complications in a later class.
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