Stomal Ischemia/Necrosis

Stomal Ischemia/Necrosis

David Ray Velez, MD

Table of Contents

Definitions
Risk Factors
Management

See Also:
*See Ostomy

Definitions

Stomal Ischemia/Necrosis: Inadequate Blood Supply (Ischemia) of the Stoma that Can Cause Tissue Death (Necrosis)

  • Causes a Dusky/Dark Appearance

Incidence: 2-16%

Venous Congestion

  • Stomas Can Frequently Appear “Dusky” Shortly After Surgery without Overt Arterial Compromise
  • Swelling and Constriction Causes Venous Congestion
  • Venous Congestion Causes Further Swelling and Cyanosis (Appearing Ischemic)
  • Normal Color Returns Once Postoperative Edema Resolves and Venous Outflow Improves
  • *Caution: Venous Congestion Can Progress with Worsening Swelling that Eventually Causes Ischemia with Impairment of Arterial Inflow

Stomal Ischemia

Stomal Necrosis

Risk Factors

Patient Factors

  • Obesity
  • IBD
  • Vascular Disease
  • Diabetes

Surgical Factors

  • Tension
  • Devascularization/Inadequate Blood Supply to the Conduit
  • Inadequate Size of Fascial/Skin Opening
  • Colostomy – Worse Blood Supply than the Small Bowel
  • End Ostomy – Loop Ostomies Have a Dual Blood Supply from Both the Proximal and Distal Limbs
  • Emergency Surgery

Management

The First Step Must Be to Evaluate the Extent of Necrosis (Determine if it Extends Above or Below the Level of the Fascia)

  • Test-Tube Evaluation: A Lubricated Test Tube Inserted into the Stoma and a Flashlight is Directed Through to Evaluate the Surrounding Mucosa
  • Endoscopic Evaluation: Anoscope or Flexible Sigmoidoscopy Inserted into the Stoma

Superficial (Distal) to Fascia: Observe and Monitor Progression

  • Can Progress and Extend Past the Fascia Eventually Requiring Surgical Revision
  • Can Cause Mucocutaneous Separation or Stomal Stenosis/Stricture as it Heals

Extends Beyond (Proximal to) Fascia: Immediate Surgical Revision

  • Generally Requires Laparotomy with Ostomy Revision
  • Risk for Necrosis with Potential Stool Spillage if Not Revised