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Problems with ileostomies. Mr Paul S Rooney Colorectal surgeon Royal Liverpool Hospital. ileostomy. End (Brown 1930) Everted (Brooke 1952) Loop (Turnbull 1961). Generic Problems. Eczema Poor seal Sweating Hygiene Psychological (unnecessary changing) Physical and metabolic.

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Problems with ileostomies

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Problems with ileostomies

Problems withileostomies

Mr Paul S Rooney

Colorectal surgeon

Royal Liverpool Hospital


Ileostomy

ileostomy

  • End (Brown 1930)

  • Everted (Brooke 1952)

  • Loop (Turnbull 1961)


Generic problems

Generic Problems

  • Eczema

  • Poor seal

  • Sweating

  • Hygiene

  • Psychological (unnecessary changing)

  • Physical and metabolic


Physical problems

Retraction

Ischaemia

Necrosis

Abscess

Fistula

Recurrent disease

Bleeding

Hernia

Pyoderma

Everting wrong end

Tension,obesity

Iatrogenic

Crohns,Cancer

Varicies

negligence

Physical problems


Varices

Varices

  • Portal hypertension

  • ALD

  • Sclerosing cholangitis

  • Liver mets


Treatment

Treatment

  • Injection of sclerosant , phenol,alcohol.

  • Needs repeat every 6weeks (Major 86)

  • Muco-cutaneous disconnection easy!

  • 20% recurrence in 30 months (Beck 88)


Hernia

Hernia

  • 10-40%

  • 20% require surgery (pain,obstruction etc)

  • Repair by non absorbables 50% recurrence rate.(Allen-Mersh (1988)


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

Mesh or Move?


Ileostomy flux

ileostomy Flux

  • Normal 3-800ml/day

  • >10cm resection significantly increases flow

  • Infection

  • Radiation

  • Crohns, cancer

  • Obstruction 4-5l/day!


Problems with ileostomies

Flux

  • Losses of >1L need replacing as saline

  • 1.5l need admitting

  • Can fatally induce Addisonian crisis

  • 100mg hydrocortisone qds (lifesaving)

  • Renal failure

  • Somatostatin PPI’s


Metabolic

Metabolic

  • Chronic dehydration

  • Anaemia ,low ferritin

  • Low B12, Na, K

  • Urate and calcium stones

  • Gall stones (loss of bile salts)


Closure

Closure

  • V easy or VV Hard

  • Try to avoid early closure wait 6 weeks at least

  • 50% complication rate inc death!

  • No one way of closure appears to be best

    (Hosie 1991)


Problems with ileostomies

Stoma problems:

Retraction

Excoriation

Prolapse

Necrosis


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