Cath Lab Digest

S toma complications can be classified into five major categories based on either the etiology or location: Poor Siting, Stoma Proper, Peri-Intestinal Area, Mucocutaneous Junction, and Iatrogenic. The categories are a modification of the framework presented by Celestine.¹ Stoma Proper complications are further subdivided into four types of complications: necrosis, retraction, prolapse, and bleeding. An example of a peri-intestinal area complication is herniation. Mucocutaneous junction complications are divided into subcategories of: bleeding, detachment or separation, and stenosis. The iatrogenic stoma complication most often noted in the literature is stomal laceration or trauma.

Poor Siting

A common and usually avoidable complication often seen in clinical practice relates to poor siting of the stoma during surgery. A "poor site" is one in which the stoma is sited in a location or position that makes it difficult if not impossible for a person to perform the necessary cleansing and pouching system management, conceal the stoma under clothing, and enjoy the normal freedom of movement without fear of leakage. Poor stoma siting clinically presents as a stoma sited close to prominent bones, in the vicinity of old scars or the umbilicus (see Figure 1), on the main incision (see Figure 2), or in deep peristomal creases. Leakage and the resultant peristomal irritant contact dermatitis are the clinical manifestations the patient most often experiences because of poor stoma siting.²

Prevention is the best management. Persons who are to have stoma surgery must have their stoma site selected preoperatively by a certified ostomy nurse or their surgeon. Stoma site selection is done while assessing the patient in various positions (eg, standing, sitting, and supine). Abdominal contours may change with position change and abdominal folds and creases become more pronounced in the sitting position. The basic rules for stoma site selection are to place the stoma through the rectus muscle, at the apex of the infra-umbilical fat mound, at least 4 inches from the planned incision, and far enough from umbilicus, bony prominences, scars, incision site, or skin creases to allow proper application and adherence of the pouching system. Waist- and beltline should be avoided for cosmetic reasons. It is also necessary to avoid selecting a stoma site on skin previously damaged from radiation, burns, or skin grafting. Once selected, the stoma site is either marked by an indelible marking pen or tattooed with indelible ink at the center of the selected site.^3,4 Certain situations such as obesity, cachectic patients, pendulous breasts, and physically challenged persons (such as those confined to wheelchairs or wearing braces) may require special considerations when selecting stoma sites.

Poor stoma siting often results in leakage beneath the pouching system. If a patient presents with leakage related to improper pouching system fit over deep peristomal creases, the clinician must correct the defect by matching the pouching system to the patient's contours - eg, using a flexible pouching system that folds with the patient's abdominal movements. When the patient has a soft abdomen, using a firm faceplate, convexity, and a belt supports the peristomal tissues and eliminates the crease. When the creasing is only on one side of the stoma, barrier strips or wedges can create an even pouching surface. If scars, gullies, or defects prevent a good pouching seal, filling these with barrier paste (small defects) or moldable barrier wedges or strips (large defects) will help prevent leakage beneath the pouching system. Measures to increase pouching system adherence also may help.