Complications - Ileostomy placement

• Marked site not usable in situ due to anatomical conditions → Relocation to a site more difficult for the patient to access or more disruptive: preoperative marking of an alternative site by the stoma therapist!
• Failure to locate the previously marked excision site: Mark with a waterproof pen, careful preoperative sterile washing of the patient!
• Injuries to other sections of the intestine: Locate the injured site and suture!
• Injuries to vessels: Avoid pulling on the mesentery!
• Injuries due to trocar positioning: Trocar insertion under vision, mini-laparotomy!
• Thermal damage to the intestine or skin: Avoid monopolar coagulation!
• Obstruction of stoma placement due to adhesions (even with open technique)

General Complications:

• General surgical risks (bleeding, rebleeding, thrombosis, embolism, HIT)
• Subcutaneous emphysema
• Post-laparoscopic shoulder pain syndrome
• Wound healing disorder
• Postoperative ileus
• Adhesions

Specific Complications:

Stoma complications are generally common and often result from avoidable technical deficiencies. However, even with proper placement, not all complications can be avoided.

• Circulatory disorders/necrosis of the stoma due to a too narrow stoma channel or vascular injury during extensive mesenteric preparation.
• Mucocutaneous dehiscence due to stoma necrosis, stoma retraction, or an excessively large skin excision. In cases of partial dehiscence, absorbent wound dressings such as calcium alginate, hydrofibers, skin protection powder, or paste are used. Circular dehiscence leads to the formation of circular granulation tissue, which can later result in stoma stenosis. Therefore, surgical correction is often necessary.
• Incorrect positioning with corresponding supply problems.
• Peristomal skin irritations with sore skin and redness are most common (18-55%) either due to predisposition or patient-specific supply problems; ranging from mild eczema to ulcerations and severe infections. Conservative therapy through adjustment of care and patient education.
• Parastomal abscess/stoma fistula; when stitching the seromuscular suture (3-point fixation), care should be taken that it does not occur completely transmural.
• Parastomal hernia → Fascia opening preferably < 25 mm; evaluate prophylactic mesh implantation for permanent stoma placements.
• Stoma prolapse: The irreducible or only temporarily reducible prolapse only indicates surgery if it leads to bleeding, incarceration, and obstruction or if stoma care is no longer ensured.
• Stoma stenosis with too narrow stoma channel or after circular mucocutaneous dehiscence.
• Stoma retraction (retraction below skin level) can result from insufficient bowel mobilization or as a late complication in inflammation or peritoneal carcinomatosis with stoma retraction. Obese patients with short mesentery are particularly at risk.
• Mucosal bleeding

→ Exhaust conservative possibilities as much as possible to avoid or delay surgical revision.

→ For reversible stoma placements, consider the possibility of stoma reversal.

A BMI > 30 is an independent risk factor for skin irritations, parastomal hernia, and stoma retraction. The higher the BMI, the higher the risk of complications.

A common (16-26%) very serious functional problem, which almost exclusively affects small bowel stomas, is the High-output Syndrome (HOS) with a mortality rate of 12%.

Due to the loss of the absorptive function of the colon, there are massive water and electrolyte losses, weight loss, kidney failure, electrolyte imbalance up to circulatory failure. Close monitoring of electrolyte balance and kidney function in the early postoperative phase is mandatory. The adaptation phase lasts 2-4 weeks postoperatively. A stoma output of a maximum of 1000 ml per day is aimed for to safely avoid parenteral fluid substitution. The sodium requirement is significantly increased in ileostomy patients, and a low-salt diet is contraindicated.

For long-term parenteral substitution, consider placing a port system or a Hickman catheter.

In the case of high stoma output, early dietary, phytotherapeutic, and pharmacological measures for stool modulation must be taken. If these are insufficient, parenteral fluid substitution must be performed.

Normal stoma output is 0.2-0.7 l per day. With losses > 2000ml over 24h, kidney failure threatens.

A bacterial overgrowth should be excluded after the adaptation phase in case of persistently high stoma output, otherwise antibiotic treatment.

An additional risk for the occurrence of HOS is simultaneous chemotherapy.

About 50% of those affected need long-term medication support to avoid dehydration.

The therapy is similar to short bowel syndrome:

Stool-thickening, highly salted foods. Limit hypotonic drinks to 1l. Due to high sodium loss, additional oral fluid intake with isotonic drinks. Overall, oral fluid intake should be a maximum of 2-3l. Additional fluid needs must be replaced parenterally. An elemental diet (astronaut food) can also be tried in exceptional situations.

Phytotherapeutics: Plant-based bulking agents such as Plantago ovata preparations (psyllium)

Pharmacological Therapy:

by influencing intestinal motility

• Tinctura opii: By binding to the µ2-morphine receptors of the intestinal wall, intestinal motility is inhibited, secretion from the intestinal mucosa is reduced, and absorption is increased. Due to minimal enteral absorption, there are no systemic symptoms. Dose increase and reduction should be done slowly. You can start with 4 times 3 drops and increase individually up to 4 times 20 drops if needed.
• Loperamide: synthetic opioid analog that is not absorbed enterally. It also binds to the µ2-receptors. The effect seems to be significantly less than that of Tinctura opii.

by influencing intestinal secretion

• Budesonide: 3 times 3 mg per day. Influencing the absorptive capacity of the small intestinal mucosa through the topically acting steroid, which is probably independent of its anti-inflammatory effect.
• H2-blockers, PPIs (proton pump inhibitors): Reduction of gastric juice production
• Somatostatin analogs (Octreotide): Reduction of the secretion of pancreatic juice, bile fluid, and small intestinal secretion, only short-term use due to side effects and tachyphylaxis