Complications of Stoma and The Management

The stoma is the common surgical condition for general surgeons. The word “Stoma” comes from the Greek word meaning mouth or opening [3]. An intestinal stoma is an opening of the intestine on anterior abdominal wall made surgically [4]. Stomas are used to divert the fecal stream away from distal bowel in order to allow a distal anastomosis to heal as well as to relieve obstruction in emergencysituation. It may be temporary or permanent; depending on their role [5]. Though a lifesaving procedure, it may result in significant number of complications. Complications are divided into early complications (up to 30 days after operation) and late complications (more than 30 days after operation) [6,7]. Littre of Paris was the first to make a ventral colostomy in 1710 for a baby with imperforate anus [8]. Statically reported rates of complications of stomas vary widely in the literature [9]. Several reports focus solely on ileostomies or colostomies, making it even more difficult to make definitive conclusions about the overall incidence. Furthermore, conflicting data exists as to whether complication rates are equivalent with colostomies and ileostomies [10-12]. or are higher incidences with ileostomies [13]. Complication rates specific to loop ileostomies can be significant, ranging from 5.7% to 41% [14-16].and reoperation rates for loop ileostomies vary widely [16-19]. Complications of stoma rates obviously also vary depending on the circumstances surrounding stoma creation. Although it seems intuitive that emergency operations with gross peritoneal soiling, gangrenous or perforated intestine, and creation of stomas in debilitated or malnourished patients would be associated with increased postoperative morbidity, this has not been borne out in several studies [10-12] [20-22]. The very common complications of stoma creation include improper selection of site, vascular complications, retraction, peristomal skin irritation, peristomal infection/abscess/fistula, parastomal herniation, and postoperative bowel obstruction [9]. Each of these will be discussed individually


Introduction
The stoma is the common surgical condition for general surgeons. The word "Stoma" comes from the Greek word meaning mouth or opening [3]. An intestinal stoma is an opening of the intestine on anterior abdominal wall made surgically [4]. Stomas are used to divert the fecal stream away from distal bowel in order to allow a distal anastomosis to heal as well as to relieve obstruction in emergencysituation. It may be temporary or permanent; depending on their role [5]. Though a lifesaving procedure, it may result in significant number of complications. Complications are divided into early complications (up to 30 days after operation) and late complications (more than 30 days after operation) [6,7]. Littre of Paris was the first to make a ventral colostomy in 1710 for a baby with imperforate anus [8]. Statically reported rates of complications of stomas vary widely in the literature [9]. Several reports focus solely on ileostomies or colostomies, making it even more difficult to make definitive conclusions about the overall incidence.
or are higher incidences with ileostomies [13]. Complication rates specific to loop ileostomies can be significant, ranging from 5.7% to 41% [14][15][16].and reoperation rates for loop ileostomies vary widely [16][17][18][19]. Complications of stoma rates obviously also vary depending on the circumstances surrounding stoma creation. Although it seems intuitive that emergency operations with gross peritoneal soiling, gangrenous or perforated intestine, and creation of stomas in debilitated or malnourished patients would be associated with increased postoperative morbidity, this has not been borne out in several studies [10][11][12] [20][21][22]. The very common complications of stoma creation include improper selection of site, vascular complications, retraction, peristomal skin irritation, peristomal infection/abscess/fistula, parastomal herniation, and postoperative bowel obstruction [9]. Each of these will be discussed individually

Stoma Site Selection
The proper selection of site is important and it hasto be done properly in preoperative period. In preoperative period, the surgeon and ET nurse haveto select the site and mark it by marker.

Parastomal Hernias
Parastomal hernias are almost a type of incisional hernia located adjacent to stoma due to weakness muscles which are in the stoma and adjacent to stoma. Studies designed with very careful follow-up suggest that a paracolostomy hernia develops in more than 50% of patients followed for longer than 5 years. Most parastomal hernias occur in the first 2 years but can occur up to 10 years after stoma creation [26]. Surgical options for correcting a parastromal hernia are local primary repair, relocation, and repair with mesh. Local primary repair does not require a laparotomy and dissection can be minimal. The fascial defect around the stoma is strengthened by plication, and its technical ease is appealing. The results, however, are disappointing, with recurrence rates ranging from 46 to 100% [27]. Prophylactic synthetic mesh placement while performing stoma, would prevent these parastromal hernia. Laparoscopic parastomal hernia repair offers advantages of avoiding a large incision while providing a superior view of the hernia defect and facilitating wide intraperitoneal mesh placement [28].

Necrosis of Stoma/Gangrene
Usually it is more common in early postoperative period and associated with emergency surgeries. Poor vascularity and poor technique would be the causes. Recognition of stomal ischemia is important by observing colour in the operation theatre. Early revision in the operation theatre itself would settle the issues.
Alternatively, a stoma with small areas of questionable ischemia found within days following creation may be observed expectantly.

Mucocutaneous separation may occur resulting in a small open
wound that will usually heal by secondary intention if appropriate stoma care is employed. Poor vascular supply that does not cause acute complications may also lead to delayed complications, such as stomal stenosis and/or stricture [7]. Negligence of gangrene of stoma may lead to septicaemia which is high mortality condition.

Retraction of Stoma
The causes of stoma retraction are inadequate bowel mobilization, a heavy and bulky mesentery in the case of obesity.
This may leads to adhesion of muco cutaneous which may leads to contamination of gastro intestinal content not only to skin but also to peritoneal cavity. The best method of avoiding these complications are adequate mobilization. Sothat the blood supply to the stoma segment of bowel would not be affected. Chronic

Electrolyte Imbalances with Dehydration
It is more common in Ileostomies patients of early postoperative periods. Bowel mucosa is exposed to air and gets infected which leads to mucosal oedema and this impairs fluid absorption across the mucosal surface can lead to high volume output (colostomy diarrhoea). Hypokalaemia, hypomagnesemia, and hypocalcaemia are common findings and renal impairment is a reported complication [31,32]. Patients are to be monitored properly by repeated laboratory inventions. There may be signs and symptoms such as nausea, dizziness, malaise and fatigue. The