**5.9 Stenosis**

*Gastrointestinal Stomas*

**5.8 Parastomal hernia**

tension on the mesentery, excessive stripping of the mesentery, sutures too narrowly spaced, or constricting sutures. It also can result from interruption of blood flow secondary to embolization or because of abdominal structure anomalies such as thick abdominal wall secondary to edema, distention, or obesity. A higher rate of

Observation in cases of superficial or partial (less than one third of circumference) mucosal necrosis is the best approach. Debridement of the necrotic area can define the extension and deepness of necrosis. If the process compromises the whole intestinal wall or extends beyond the aponeurotic plan, a surgical intervention is indicated through the stoma opening or through the main surgical wound if a laparotomy had been performed. The use of two-piece pouch facilitates the daily observation of the stoma with no need of withdrawal of the skin attached piece. Postoperative nursing assessment and management also help prevent potential

The parastomal hernia, a protrusion of the bowel or loops of intestine through the fascial opening into the subcutaneous tissue around the stoma, occurs months to years after surgery because of surgical technical error or following gradual enlargement of the fascial defect. The incidence rate for parastomal hernia varies with the type and age of the stoma and with surgical technique. It is caused by lack of preoperative demarcation of stoma site with exteriorization outside the rectus abdominal muscle. The main risk factors are intra-abdominal pressure, advanced age, obesity, chronic cough, and long-term use of corticosteroids. If the cause is associated to slight peristomal weakness, a common finding in patients with colostomy, surgical correction is usually not necessary. However some hernias interfere with the proper

Parastomal hernia presents as a bulge around the stoma and may be partial or circumferential. In supine position the bulge may reduce in size, whereas sitting or standing position, Valsalva maneuver, or cough tends to protrude the hernia, whereas lying down and stoma manual compression intrude the hernia back to the abdomen. The hernia change in position makes the pouching seal more difficult. CT scan with oral contrast confirms the diagnosis. The patient may complain a feeling of discomfort or fullness, and if the stoma incarcerates, the patient presents with an acute obstructed abdomen. The use of support binders when prolonged episodes of

*Stoma necrosis. (A) Partial necrosis; (B) extensive necrosis. An endoscopy is useful to evaluate if the necrosis* 

*extends below the level of the fascia. Surgery may be necessary.*

necrosis has been reported in obese and acutely ill patients.

impairment of a good blood supply to the stoma [11, 16] (**Figure 8**).

use of the pouch, and surgery for hernia correction is mandatory [17].

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**Figure 8.**

Stenosis of the stomy opening is characterized by stricture or retraction which makes drainage of the intestinal effluent more difficult. Its incidence is related to the surgical technique itself or as a consequence of precocious complications such as partial necrosis, recurrent inflammatory processes, Crohn's disease, weight gain, and tumor recurrence. The symptoms include abdominal excess of gases, frequent cramps and diarrhea, as well as thin feces. The best option for the treatment of this complication is surgery, but increase of hydric ingestion and eating foods which favor the feces softening may improve the ostomy output [4, 5] (**Figure 10**).

**Figure 9.** *Parastomal hernia in a prolapsed stoma (A) and a huge parastomal hernia (B).*

#### **Figure 10.**

*Stoma stenosis. Note the retraction of skin (A) and the scar tissue around the stoma opening in a chronic stoma stenosis (B).*
