Problems withProblems withileostomiesileostomies

Mr Paul S Rooney

Colorectal surgeon

Royal Liverpool Hospital

ileostomyileostomy

End (Brown 1930)

Everted (Brooke 1952)

Loop (Turnbull 1961)

Generic ProblemsGeneric Problems

EczemaPoor sealSweatingHygienePsychological (unnecessary changing)Physical and metabolic

Physical problemsPhysical problems

Retraction Ischaemia Necrosis Abscess Fistula Recurrent disease Bleeding Hernia Pyoderma Everting wrong end

Tension,obesity

Iatrogenic

Crohns,Cancer Varicies

negligence

VaricesVarices

Portal hypertensionALDSclerosing cholangitisLiver mets

TreatmentTreatment

Injection of sclerosant , phenol,alcohol.Needs repeat every 6weeks (Major 86)

Muco-cutaneous disconnection easy!20% recurrence in 30 months (Beck 88)

HerniaHernia

10-40%20% require surgery (pain,obstruction etc)Repair by non absorbables 50% recurrence

rate.(Allen-Mersh (1988)

Mesh or Move?Mesh or Move?

Heamatoma Infection Erosion Low recurrence

rate<1%@5y (Bokey 2003)

Laporotomy risk? Poorly sited likely to

benefit

Decision depends on patient factors and number of previous repairs

ileostomy Fluxileostomy Flux

Normal 3-800ml/day>10cm resection significantly increases

flowInfectionRadiationCrohns, cancerObstruction 4-5l/day!

FluxFlux

Losses of >1L need replacing as saline1.5l need admittingCan fatally induce Addisonian crisis 100mg hydrocortisone qds (lifesaving)Renal failureSomatostatin PPI’s

MetabolicMetabolic

Chronic dehydrationAnaemia ,low ferritinLow B12, Na, KUrate and calcium stonesGall stones (loss of bile salts)

ClosureClosure

V easy or VV HardTry to avoid early closure wait 6 weeks at

least50% complication rate inc death!No one way of closure appears to be best

(Hosie 1991)

Stoma problems:Stoma problems:

Retraction

Necrosis

Excoriation

Prolapse