Overview
Definition:
Stoma complications are adverse events occurring after the creation of a surgical opening (stoma) onto the abdominal wall
Retraction refers to the stoma sinking below the skin level
Necrosis involves tissue death of the stomal segment, often due to compromised blood supply.
Epidemiology:
Retraction occurs in 5-40% of stomas, with higher rates in loop colostomies and due to factors like obesity and poor surgical technique
Necrosis is less common, occurring in 1-10% of stomas, primarily early postoperatively
Risk factors include excessive tension, inadequate vascular supply, and local trauma.
Clinical Significance:
These complications significantly impact stoma function, patient quality of life, and can lead to serious sequelae like infection, sepsis, and electrolyte imbalances
Prompt recognition and appropriate management are crucial for favorable outcomes in DNB and NEET SS preparation.
Clinical Presentation
Symptoms:
Retraction: Inability to apply stoma appliance securely
Leakage of effluent
Skin irritation around the stoma
Necrosis: Discoloration of the stoma (black or dusky)
Foul-smelling discharge
Abdominal pain
Fever
Systemic signs of sepsis.
Signs:
Retraction: Stoma lies flush with or below the skin peristomal surface
Difficulty in lifting the stoma
Necrosis: Visible gangrenous or devitalized stomal tissue
Purulent drainage
Tenderness and induration of peristomal tissues
Signs of peritonitis in severe cases.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on visual inspection of the stoma and peristomal skin
Stoma retraction is confirmed when the stomal mucocutaneous junction is at or below the abdominal wall level
Stoma necrosis is evident by the color and viability of the stomal tissue.
Diagnostic Approach
History Taking:
Elicit onset and progression of symptoms
Assess stoma appliance management challenges
Inquire about any preceding surgical events or trauma
Screen for signs of infection or systemic illness
Review surgical technique and stoma creation details.
Physical Examination:
Thorough examination of the stoma and peristomal skin
Assess stoma height and relationship to the abdominal wall
Evaluate stoma tissue viability and color
Palpate for tenderness or induration
Assess for signs of leakage or excoriation
Examine for abdominal distension or tenderness.
Investigations:
Generally, investigations are not required for uncomplicated retraction or early, localized necrosis
However, if sepsis is suspected: Complete blood count (leukocytosis)
Blood cultures
Peristomal wound swab for culture and sensitivity
Imaging (e.g., CT abdomen) may be considered for suspected intra-abdominal complications or abscess formation.
Differential Diagnosis:
For retraction: False impression due to appliance fit issues
For necrosis: Stoma mucositis or inflammatory changes
Stoma prolapse
Parastomal hernia
Localized peristomal cellulitis.
Management
Initial Management:
Retraction: Reposition stoma appliance with appropriate convexity and seals to create a seal
Consider peristomal pastes or rings
Necrosis: NPO status
Intravenous fluids
Broad-spectrum antibiotics
Analgesia
Surgical assessment is paramount.
Medical Management:
Primarily supportive
Wound care for any skin breakdown
Topical antiseptics for minor peristomal skin issues
Management of associated dehydration or electrolyte disturbances
Prophylactic antibiotics may be considered in high-risk cases of necrosis.
Surgical Management:
Retraction: Surgical revision is indicated if conservative measures fail and symptoms persist, or if associated with hernia
Techniques include stoma lengthening, fascial plication, or even stoma relocation
Necrosis: Requires debridement of necrotic tissue
If only a small segment is involved, it may slough off
If extensive necrosis or associated with bowel ischemia, stoma reversal or creation of a new stoma may be necessary
Resection of the ischemic bowel segment and anastomosis is an option if feasible.
Supportive Care:
Patient education on stoma care and appliance management
Nutritional support to optimize healing
Regular stoma nurse review
Psychological support
Monitoring for signs of infection or deterioration.
Complications
Early Complications:
Retraction: Stoma appliance leakage
Peristomal skin irritation and breakdown
Increased risk of wound infection
Necrosis: Sepsis
Peritonitis
Stoma stricture
Bowel obstruction
Rectal prolapse (if ileostomy).
Late Complications:
Retraction: Chronic skin excoriation and pain
Psychological distress
Difficulty in appliance wear
Necrosis: Stoma stenosis
Stoma stricture
Incisional hernia
Adhesions
Fistula formation.
Prevention Strategies:
Meticulous surgical technique: Adequate stoma length (e.g., 2-5 cm for colostomy, 5-7 cm for ileostomy)
Viable blood supply to the stomal segment
Avoidance of excessive tension on the bowel mesentery
Appropriate stoma site selection (away from skin creases, bony prominences)
Secure stoma fixation
Postoperative stoma care education and prompt appliance adjustment.
Prognosis
Factors Affecting Prognosis:
Extent of retraction/necrosis
Presence of infection or sepsis
Patient's overall health status
Timeliness and appropriateness of management
Surgical expertise.
Outcomes:
Mild retraction is manageable with conservative measures
Significant retraction may require surgical correction with good functional outcomes
Localized necrosis managed promptly has good outcomes
Extensive necrosis or sepsis carries significant morbidity and mortality risks.
Follow Up:
Regular follow-up with the surgical team and stoma nurse
Ongoing monitoring of stoma function and peristomal skin health
Education for self-monitoring by the patient
Assessment for signs of recurrence or new complications.
Key Points
Exam Focus:
Differentiate between retraction and necrosis based on clinical presentation
Understand the principles of conservative vs
surgical management for retraction
Recognize immediate surgical indications for stoma necrosis (debridement, potential stoma revision/re-creation)
Factors predisposing to these complications are high-yield.
Clinical Pearls:
Always check stoma length intraoperatively
A well-molded peristomal seal is key for retracted stomas
Consider bowel viability with the "string test" if in doubt for necrosis
Early consultation with stoma therapy nurses is invaluable
Never underestimate the risk of sepsis with stomal necrosis.
Common Mistakes:
Delaying surgical intervention for stoma necrosis
Inadequate length of stoma created
Over-reliance on conservative management for significant retraction without assessing functional impact
Poor stoma site selection
Failure to educate patient on self-monitoring and immediate reporting of warning signs.