t‭hat it is safe and further work on case selection has been‬

‭recommended. Adjuvant chemotherapy improves survival after‬

‭surgery in patients with node-positive colon cancer (stage III/Dukes’‬
‭C). Fluoropyrimidine regimes are often used, with the addition of‬
‭oxaliplatin in patients who are otherwise fit and have high-risk stage‬
‭III disease. Patients with stage II disease show less benefit in overall‬
‭survival with adjuvant chemotherapy, thus it is reserved for those with‬
‭high-risk stage II disease. Presence of MSI (in the tumor histology)‬
‭also affects tumor recurrence and is taken into account when making‬
‭decisions with patients about chemotherapy (see Chapter 12).‬

‭STOMA:‬

‭ .‬ ‭What are the prinicples of Stoma use?‬

1
‭●‬ ‭Stoma are an alternative route for discharge of excretion‬

‭ .‬ ‭What are the indications of Stoma?‬

2
‭●‬ ‭Congenital → Distal Obstruction (Atresia)‬
‭●‬ ‭Inflammatory disease → Ulcerative Colitis, Crohn's disease,‬
‭Diverticulitis‬
‭●‬ ‭Neoplasms → Rectal cancer, Colon cancer‬
‭●‬ ‭Traumatic → Colorectal injuries‬

‭ .‬ ‭What are the 3 types of Stoma construction?‬

3
‭●‬ ‭Double barrel‬
‭●‬ ‭End stoma → Hartmann procedure or abdominoperineal resection of‬
‭rectum‬
‭●‬ ‭Loop stoma‬

‭4.‬ ‭Highlight the differences between Colostomy and Illeostomy‬

 ‭Colostomy‬ ‭Illeostomy‬
‭Site‬ ‭Anywhere >> LIF‬ ‭Anywhere‬
‭Surface‬ ‭Flat opening‬ ‭ pout to prevent‬
S
‭irritation of the skin by‬
‭bile‬

‭Opening‬ ‭Single/Double‬ ‭Single/Double‬

‭Colour‬ ‭Darker and brown‬ ‭Yellowish‬
‭Content‬ ‭Soft / Hard stool‬ ‭Semi solid and fluid‬
‭Odour‬ ‭Have a bad odour‬ ‭No odour‬

‭Permament‬ ‭Temporary‬ ‭Stoma‬

‭Panproctocolectomy‬ ‭Anterior resection‬ ‭Illeostomy‬
‭ nterior perineal‬
A ‭Hartmann Procedure‬ ‭Colostomy‬
‭resection‬

‭ eneral Overview of Stomas:‬

G
‭A stoma is an artifcial opening made in the bowel to divert‬
f‭aeces and fatus outside the abdomen, where they can be‬
‭collected in an external appliance. Depending on the purpose a stoma is an‬
‭artificial opening made in the bowel to divert‬
‭faeces and flatus outside the abdomen, where they can be‬
‭collected in an external appliance. Depending on the purpose for which the‬
‭diversion has been necessary, a stoma may be‬
‭temporary or permanent (Summary box 74.5).‬

‭Ileostomy:‬
‭●‬ ‭A loop ileostomy is often used for defunctioning a low rectal‬
‭anastomosis or an ileal pouch. A knuckle of ileum is exteriorly used‬
‭through a skin trephine in the right iliac fossa. An incision is made in‬
‭the distal part of the knuckle, and this is then pulled over the top of‬
‭the more proximal part to create a spout on the proximal side of the‬
‭loop with a flush distal side still in continuity. This allows near perfect‬
‭defunctioning, but also the possibility of restoration of continuity, by‬
‭taking down the spout and reanastomosing the partially divided ileum.‬
‭The advantage of a loop ileostomy over a loop colostomy is the ease‬
‭with which the bowel can be brought to the surface. Care is needed‬
‭when the ileostomy is closed such that suture line obstruction does‬
‭not occur. Closure of a loop ileostomy can be a technically‬
 c‭ hallenging procedure, particularly if there are dense adhesions‬
‭resulting from previous surgery‬

‭End Illeostomy:‬
‭●‬ ‭An end-ileostomy is formed after a colectomy without anastomosis,‬
‭when it may later be reversed, or after panproctocolectomy, when it is‬
‭permanent. The ileum is normally brought through the rectus‬
‭abdominis muscle. Careful attention should be paid to the terminal‬
‭ileal mesentery to ensure that it is not too bulky. The use of a spout‬
‭was originally described by Brooke; this should project some 2–4 cm‬
‭from the skin surface (Figure 74.7). A disposable appliance is placed‬
‭over the ileostomy so that it is a snug ft at skin level. There may be‬
‭an ‘ileostomy fux’ while the ileum adapts to the loss of the colon.‬
‭While ileostomy output can amount to 4–5 litres per day, losses of‬
‭1–2 litres are more common. A consistent ileostomy output in excess‬
‭of 1.5 litres is usually associated with dehydration and sodium‬
‭depletion in the absence of intravenous therapy. Up to 20% of‬
‭patients may require readmission for the treatment of dehydration‬
‭after creation of an ileostomy but the stools thicken in a few weeks‬
‭and are usually semisolid in a few months. The help, skill and advice‬
‭of the stoma care nurse specialist are essential. Modern appliances‬
‭have transformed stoma care and skin problems are unusual (Figure‬
‭74.8). Complications of an ileostomy include prolapse, retraction,‬
‭stenosis, bleeding, fstula and parastomal hernia.‬
‭Stoma and their indications:‬
‭Type of Stoma‬ ‭Indication‬ ‭Characteristic‬ ‭Procedure‬ ‭Complications‬

‭ oop‬
L ‭ efunctioning low‬
D I‭leostomy effluent‬ ‭-‬ I‭f 24 hour stoma‬
‭Ileostomy‬ ‭rectal anastomosis‬ ‭usually has no‬ ‭output is greater‬
‭or ileal pouch‬ ‭odor, in contrast to‬ ‭than 1000 mL,‬
‭colostomy effluent,‬ ‭patient is at high‬
‭ oop ileostomies‬
L ‭which usually‬ ‭ rior to hospital‬
P ‭risk of hospital‬
‭are often chosen‬ ‭has odor‬ ‭discharge, one‬ ‭admission‬
‭for temporary‬ ‭associated with‬ ‭must consider that‬
‭diversion due to‬ ‭colonic flora‬ ‭the 24 hour stoma‬
‭their lack of odor,‬ ‭output is less than‬
‭ease of care, and‬ I‭n contrast to‬ ‭1000 mL‬
‭ease of closing‬ ‭Colostomy, an‬
‭Ileostomy will‬
‭Ileostomies are‬ ‭empty continuously‬
‭usually preferred‬ ‭and has a high rate‬
‭by Colorectal‬ ‭of associated‬
‭surgeons for fecal‬ ‭chemical dermatitis‬
‭diversion as they‬ ‭due to the more‬
‭are easier to‬ ‭alkaline pH‬
‭construct,‬ ‭associated with‬
‭especially in obese‬ ‭small bowel‬
‭individuals, usually‬ ‭effluent as‬
‭easier to close,‬ ‭opposed to the‬
‭and do not risk‬ ‭stool of the colon‬
‭compromising the‬
‭marginal vessels of‬
‭the colon that are‬
‭so important for the‬
‭viability of low and‬
‭ultra-low colorectal‬
‭and colonal‬
‭anastomoses‬

‭End Ileostomy‬ ‭ n end-ileostomy‬

A I‭leostomy effluent‬
‭is formed after a‬
‭colectomy without‬
‭anastomosis, when‬
‭it may later be‬
‭reversed, or after‬
‭panproctocolectom‬
‭y, when it is‬
‭permanent‬
I‭leostomies are‬
‭usually preferred‬
‭by Colorectal‬
‭surgeons for fecal‬
‭diversion as they‬
‭are easier to‬
‭-‬ I‭f 24 hour stoma‬
‭usually has no‬ ‭output is greater‬
‭odor, in contrast to‬ ‭than 1000 mL,‬
‭colostomy effluent,‬ ‭patient is at high‬
‭which usually‬ ‭ rior to hospital‬
P ‭risk of hospital‬
‭has odor‬ ‭discharge, one‬ ‭admission‬
‭associated with‬ ‭must consider that‬
‭colonic flora‬ ‭the 24 hour stoma‬
‭output is less than‬
I‭n contrast to‬ ‭1000 mL‬
‭Colostomy, an‬
‭Ileostomy will‬
‭empty continuously‬
‭and has a high rate‬
‭of associated‬
‭chemical dermatitis‬
‭due to the more‬
‭alkaline pH‬
 c‭ onstruct,‬ ‭ ssociated with‬
a
‭especially in obese‬ ‭small bowel‬
‭individuals, usually‬ ‭effluent as‬
‭easier to close,‬ ‭opposed to the‬
‭and do not risk‬ ‭stool of the colon‬
‭compromising the‬
‭marginal vessels of‬
‭the colon that are‬
‭so important for the‬
‭viability of low and‬
‭ultra-low colorectal‬
‭and colonal‬
‭anastomoses‬

‭ nd-loop‬
E ‭-‬
‭Ileostomy‬
I‭leostomies are‬
‭usually preferred‬
‭by Colorectal‬
‭surgeons for fecal‬
‭diversion as they‬
‭are easier to‬
‭construct,‬
‭especially in obese‬
‭individuals, usually‬
‭easier to close,‬
‭and do not risk‬
‭compromising the‬
‭marginal vessels of‬
‭the colon that are‬
‭so important for the‬
‭viability of low and‬
‭ultra-low colorectal‬
‭and colonal‬
‭anastomoses‬
I‭leostomy effluent‬ ‭-‬ I‭f 24 hour stoma‬
‭usually has no‬ ‭output is greater‬
‭odor, in contrast to‬ ‭than 1000 mL,‬
‭colostomy effluent,‬ ‭patient is at high‬
‭which usually‬ ‭ rior to hospital‬
P ‭risk of hospital‬
‭has odor‬ ‭discharge, one‬ ‭admission‬
‭associated with‬ ‭must consider that‬
‭colonic flora‬ ‭the 24 hour stoma‬
‭output is less than‬
I‭n contrast to‬ ‭1000 mL‬
‭Colostomy, an‬
‭Ileostomy will‬
‭empty continuously‬
‭and has a high rate‬
‭of associated‬
‭chemical dermatitis‬
‭due to the more‬
‭alkaline pH‬
‭associated with‬
‭small bowel‬
‭effluent as‬
‭opposed to the‬
‭stool of the colon‬

‭ emporary‬
T ‭ nastomotic‬
A
‭Stoma‬ ‭healing‬

‭Sepsis‬

‭ ther conditions‬
O
‭where it is not safe‬
‭to perform an‬
‭unprotected‬
‭anastomosis‬

‭ scending‬
A ‭ igher amount of‬
H ‭ ery large and‬
V
‭Colostomy‬ ‭fluid effluent‬ ‭more prone to‬
‭prolapse and can‬
‭be difficult to‬
‭maintain pouch‬
 ‭adherence‬

‭ escending/‬
D ‭ ost of Colon is in‬
M ‭ ery large and‬
V
‭Left-sided‬ ‭circuit, allowing for‬ ‭more prone to‬
‭colostomy‬ ‭more colonic water‬ ‭prolapse and can‬
‭absorption, with a‬ ‭be difficult to‬
‭more formed‬ ‭maintain pouch‬
‭effluent, while still‬ ‭adherence‬
‭providing proximal‬
‭diversion‬

‭ oop‬
L ‭ raditional loop‬
T
‭Colostomy‬ ‭colostomies are‬
‭not always‬
‭completely‬
‭diverting.‬

‭ nd‬
E
‭Colostomy‬

‭ nd-loop‬
E I‭n Obese patients‬ ‭ ame as loop-end‬
S
‭Colostomy‬ ‭where fecal‬ ‭ileostomy whereby‬
‭diversion is‬ ‭a loop of‬
‭required‬ ‭mesentery is‬
‭brought up, rather‬
I‭f one wishes total‬ ‭than an end of a‬
‭diversion, an‬ ‭mesentery‬
‭end-loop stoma‬
‭with tacking of the‬
‭distal limb in close‬
‭proximity of the‬
‭stoma site, may be‬
‭the preferable‬
‭option‬

‭ iverting‬
D ‭Crohn’s Disease‬
‭stoma‬
‭ iverticular‬
D
‭Disease‬

I‭ntestinal‬
‭Obstruction‬

‭Low Rectal Cancer‬

‭Characteristics of Stoma:‬

‭Spout-like stoma‬ ‭Flattened stoma‬

‭Useful in situations‬
‭ here patient is more‬
w
‭likely to have a fluid‬
‭effluent (eg.‬
‭Chemotherapy) →‬
‭Permits easier pouch‬
‭placement and‬
‭adherence‬

‭Factors affecting consistency and amount of Stoma effluent:‬

‭●‬ ‭Whether the small bowel or the colon is selected for stoma‬
‭construction‬
‭●‬ ‭If the colon is selected, upon which site of the colon is selected‬
‭●‬ ‭for stoma construction‬
‭●‬ ‭What types of treatment (radiation) the patient has undergone‬
‭●‬ ‭Previous bowel resection(s) the patient may have had‬

‭ toma bags and appliances:‬

S
‭Stoma output is collected in a disposable adhesive bag. Ileostomy‬
‭appliances tend to be drainable bags that are left in place for‬
‭48 hours, while colostomy appliances are simply changed two‬
‭or three times each day. A wide range of such bags is currently‬
‭available. Many now incorporate an adhesive backing, which‬
‭can be left in place for several days. In most hospitals, a stoma‬
‭care service is available to offer advice to patients, to acquaint‬
‭them with the latest appliances and to provide the appropriate‬
‭psychological and practical help.‬

‭ omplications of stomas:‬
C
‭Stoma complications are underestimated and common‬
‭(Summary box 74.6). On occasion, these complications‬
‭require surgical revision. Sometimes, this can be achieved with‬
‭an incision immediately around the stoma, but on occasion‬
r‭ eopening the abdomen and freeing up the stoma may be‬
‭necessary. Repair of parastomal hernias is particularly technically‬
‭challenging and the recurrence rate is high. Simple suture of the‬
‭parastomal hernia is associated with an almost‬
‭100% risk of recurrence and transfer to the opposite side of‬
‭the abdomen, or insertion of a piece of prosthetic material‬
‭within the abdominal wall around the stoma may be necessary‬
‭(see Chapter 64).‬
‭Stoma Examination:‬

‭Stoma station:‬
‭●‬ ‭Inspection - positive findings and negative findings‬
‭●‬ ‭Positive findings → Skin irritation, Skin excoriation, Leakage of stool,‬
‭●‬ ‭Palpation‬
 ‭●‬ F ‭ inger palpation- check the patency of stoma with lubricated index‬
‭finger‬
‭●‬ ‭Indications‬
‭●‬ ‭Complications‬
‭●‬ ‭Types, identifying features of each type of stoma‬
‭●‬ ‭Indications for stoma reversal/contraindication etc in a given patient‬
‭●‬ ‭Investigation to do before reversal of stoma (loopogram)‬

‭Conditions and their Surgical management:‬

‭Condition‬ ‭Definitive Surgery‬

‭ lcerative Colitis, Famililal Adenomatous‬

U ‭Panproctocolectomy + End Ileostomy‬
‭Polyposis‬

‭ eft sided colon carcinoma, Left Sided‬

L ‭Left Hemicolectomy‬
‭colon cancer with complications such as‬
‭bleeding or obstruction, Left colonic‬
‭Malignant polyp‬

‭ omplicated Diverticulitis (Stage III and IV‬

C ‭ artmann’s Procedure (Proctosigmoidectomy) +‬
H
‭which usually involve Peritonitis),‬ ‭Colostomy‬
‭Colorectal carcinoma (particularly‬
‭rectosigmoid carcinoma)‬

‭Large Bowel Obstruction‬

‭ omplications of Inflammatory Bowel‬

C
‭Disease‬

‭Trauma‬

‭Rectal Prolapse‬

‭Crohn’s disease‬ ‭Right Hemicolectomy‬

‭ leeding secondary to Diverticulosis or‬

B
‭Arteriovenous malformation‬

‭Diverticulitis‬

‭Obstruction‬

‭Colon tumors‬
‭LGIB that cannot be controlled‬ ‭Total Colectomy‬

‭Large Bowel Obstruction‬

‭Colon Cancer‬

‭CD and UC‬

‭Diverticulitis‬

‭Extras:‬

‭E1 - Bedsores‬

‭1.‬ ‭Explain the grading of Pressure sores and Bedsores‬

‭Pressure sore grading:‬