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For a loop small bowel stoma, only the afferent limb is usually matured in Brooke
fashion while the efferent limb is sutured to the skin using simple interrupted
absorbable sutures. Sometimes a stoma rod is used to support a loop stoma until
adhesions form between the stoma and subcutaneous tissue. This is normally placed
through the mesenteric window where a penrose drain or umbilical tape was initially placed. The bowel should protrude 2–3cm for an end small bowel stoma or
the afferent limb of loop small bowel stoma and 1–2cm for a colostomy after a
stoma is successfully matured. A clear stoma appliance is then placed to facilitate
assessment in the early postoperative period.
D. Habib and F. Elabbasy
5 Postoperative Care
Stomas should be monitored regularly in the early postoperative period. Color, viability, and retraction should be noted. A good stoma should be pink, moist, and
protrude well. Stomas may become edematous in the early postoperative period and
return to their normal size after several weeks. Both small bowel and colonic stomas
may take time to function. Small bowel stomas usually start to function earlier than
colonic stomas. Small amounts of serosanguinous or bilious uid may be produced
in the immediate postoperative period and is usually followed by liquid efuent
which then gradually thickens. Colonic stomas usually produce gas initially which
is followed by stool. It is important to monitor the volume of efuent produced by
small bowel stomas especially in the early postoperative period. Normal small
bowel stoma output is 800–1200mL/day. Stoma output higher than 1200mL/day is
considered high and should be managed appropriately if persistent beyond the early
postoperative period. A common complication of a high-output stoma is dehydration and electrolyte derangements. This can usually be managed by a combination
of dietary and behavioral modications or medical means. Patients as well as family
members or other caregivers should be educated on and demonstrate competence in
stoma management and troubleshooting prior to discharge [6]. Special attention
should be given to proper stoma appliance tting to avoid peristomal skin complications. Studies show that perioperative teaching can reduce readmission rates in
patients with new stomas [7].
6 Early Complications
Ischemic complications can arise in the early postoperative period and can include:
• Necrosis
• Retraction
• Stenosis
ab
Stomas (Colostomy andIleostomy)
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Fig. 7 Ischemic stoma complications. (a) Acute postoperative stoma necrosis. (b) Chronic stoma
ischemia leading to retraction and stenosis
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An ischemic stoma will appear dusky and may slough or necrose depending on the
degree of ischemia. This typically results from arterial insufciency, although
venous congestion could rarely occur due to a tight trephine. End stomas are typically more prone to ischemic complications than loop stomas. Adherence to proper
stoma creation principles decrease ischemic complications. An ischemic stoma may
require revision or may be carefully managed nonoperatively depending on the
extent of ischemia and the stoma type (Fig.7).
Other early stoma complications include
• Leakage
• Peristomal dermatitis
• Dehydration
These can usually be mitigated with proper pouching techniques and education.
7 Late Complications
Late stoma complications include stenosis, parastomal hernia, prolapse, and peristomal skin disorders.
• Stenosis: can be a long term consequence of an ischemic stoma and may require
surgical revision depending on symptom severity.
• Prolapse: can occur due to intussusception of the bowel through the matured
stoma and can range from a minimally symptomatic inconvenience to an
emergency if the prolapsed bowel becomes incarcerated or strangulated. Topical
ice and table sugar are described as useful adjuncts for reducing a prolapse.
• Peristomal skin disorders: include skin irritation, excoriation, and ulceration
and are the most common complication for patients with stomas [8]. They usu-
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D. Habib and F. Elabbasy
abc
Fig. 8 a–c - Examples of peristomal pyoderma gangrenosum. (ASCRS Textbook of Colon and
Rectal Surgery)
ally arise from poorly tted stoma appliances and can usually be mitigated by
ensuring proper pouching. Fungal skin infections can also ensue as a result of
poor pouching and should be recognized and treated with the appropriate
antifungals.
• Pyoderma gangrenosum: is a rare inammatory condition that can affect peri-
stomal skin. This condition is typically associated with underlying inammatory
bowel disease (IBD), but some patients presenting with peristomal pyoderma
gangrenosum will not have an associated IBD diagnosis. The diagnosis is made
clinically with the characteristic purulent ulcers with raised borders (Fig.8).
There is no standard treatment for pyoderma. However, topical, intralesional, and
systemic steroids, immunomodulators, and antibiotics have been used. Peristomal
pyoderma can parallel intestinal IBD activity and aggressive control of the systemic
disease can be helpful in treating the skin manifestation. Peristomal varices can also
present as a stoma complication in the setting of portal hypertension and treatment
of the underlying cause is the most durable management strategy for this entity.
Peristomal abscess can be a rare complication especially in the setting of underlying
Crohn’s disease. If a drainage catheter is required, thoughtful placement must take
into account pouching to avoid skin complications.
References
1. McGee MF, Cataldo PA. Intestinal stomas. ASCRS Textbook of Colon
and Rectal Surgery, 2022. ASCRS U, www.ascrsu.com/ascrs/view/
ASCRS-Textbook-of-Colon-and-Rectal-Surgery/2285050/all/Intestinal_Stomas.
2. Ayaz-Alkaya S, Sultan A-AC.Overview of psychosocial problems in individuals with stoma: a
review of literature. Int Wound J. 2019;16(1):243–9. https://doi.org/10.1111/IWJ.13018.
3. Chaudhri S, Brown L, Hassan I, Horgan AF.Preoperative intensive, community-based vs. tra-
ditional stoma education: a randomized, controlled trial. Dis Colon Rectum. 2005;48(3):504–9.
https://doi.org/10.1007/S10350- 004- 0897- 0.
4. WOCN Society, AUA, and ASCRS position statement on preoperative stoma site marking for
patients undergoing ostomy surgery. J Wound Ostomy Continence Nurs. 2021;48(6):533–6.
https://doi.org/10.1097/WON.0000000000000820.
Stomas (Colostomy andIleostomy)
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5. Hsu MY, Lin JP, Hsu HH, Lai HL, Wu YL. Preoperative stoma site marking decreases
stoma and peristomal complications: a meta-analysis. J Wound Ostomy Continence Nurs.
2020;47(3):249–56. https://doi.org/10.1097/WON.0000000000000634.
6. Person B, Ifargan R, Lachter J, Duek SD, Kluger Y, Assalia A.The impact of preoperative stoma
site marking on the incidence of complications, quality of life, and patient’s independence. Dis
Colon Rectum. 2012;55(7):783–7. https://doi.org/10.1097/DCR.0B013E31825763F0.
7. Nagle D, Pare T, Keenan E, Marcet K, Tizio S, Poylin V.Ileostomy pathway virtually eliminates
readmissions for dehydration in New Ostomates. Dis Colon Rectum. 2012;55(12):1266–72.
https://doi.org/10.1097/DCR.0B013E31827080C1.
8. Steinhagen E, Colwell J, Cannon LM. Intestinal stomas—postoperative stoma care and
peristomal skin complications. Clin Colon Rectal Surg. 2017;30(3):184–92. https://doi.
org/10.1055/S- 0037- 1598159/ID/JR00796- 32/BIB.
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Part VI
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Anorectal Surgery
Anorectal Abscess
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ChristineChoi
1 Presentation
Symptoms of perianal pain can range from mild discomfort to excruciating pain,
depending on the location and progression of the infection. The chronicity of this
pain can also give clues on the anatomic location of the abscess. Systemic signs of
infection may include fever, urinary retention (an early sign of pelvic sepsis), and
hemodynamic changes. In the most straightforward scenario of an acute perianal
abscess, there are hallmark signs of an infection: visualized erythema, uctuance or
palpable mass and localized tenderness. However, some anorectal abscesses may
present without systemic signs of infection, a normal anorectal external exam, and
chronicity to the symptoms of vague discomfort in the perineum.
2 Differential Diagnosis
Thorough history taking can help gather potential predisposing factors, although
inciting factors are not always present. Patients may report recent changes to bowel
habits (diarrhea or constipation), recent trauma resulting in skin breakage, or prior
anorectal abscess history. Immunocompromised patients (prior transplant or active
chemotherapy), diabetes, and Crohn’s disease should always be prioritized, as
infectious complications are generally more severe if treatment is delayed. It is also
important to rule out the common causes of acute perianal pain, such as thrombosed
hemorrhoids or anal ssure. The extent of gluteal erythema, or blanching skin with
C. Choi (*)
Department of Surgery, University of Hawaii, Honolulu, HI, USA
e-mail: csmchoi@hawaii.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_30
363© The Author(s), under exclusive license to Springer Nature
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palpation without obvious uctuance, could represent cellulitis or soft tissue infection. Chronic infectious skin complications of the perineum include hidradenitis
suppurativa.
The differential diagnoses of anorectal abscess include inammatory bowel disease, infectious complications from anorectal surgery, vaginal trauma from episiotomy, and malignancy. Less common infectious causes include tuberculosis,
lymphogranuloma venereum, and actinomycosis.
C. Choi
3 Etiology/Physiology/Anatomy
The majority of anorectal abscesses are recognized to result from cryptoglandular
pathology, in which an obstructed anal gland leads to an infection. The anal glands,
which are located in the intersphincteric plane, drain at the anal crypts found at the
dentate line. Once an infection starts to form, it can navigate in between spaces (see
Fig.1). The intersphincteric space lies between the internal and external sphincter muscle.
The ischioanal (also known as ischiorectal) space is bordered by the levator muscles superiorly, the transverse perineal septum inferiorly, ischial tuberosity laterally,
and the external sphincters medially. The levator ani muscle separates the deep postanal space and the supralevator space. The deep postanal space, which is located
between the levator ani muscle and anococcygeal raphe, allows communication
between the right and left ischiorectal spaces. When infection communicates in this
space, a “horseshoe” abscess can result. A horseshoe abscess may include the
ischioanal/ischiorectal space, intersphincteric space and supralevator space (see
Fig.2).
Digital rectal exam may help indicate the location of the abscess. Description of
the location should be limited to the following descriptors: anterior, posterior, lateral, right, left, or distance to anal verge. It is important to avoid the tendency to
describe anorectal pathology using the clock face.
a
l
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Supralevator Intersphincteric
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Ischional
Perianal Submucosal
b
Retrorectal
Supralevator
Deep postana
Superficial
postanal
Fig. 1 Anorectal spaces (a) coronal section; (b) sagittal section
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Fig. 2 Anorectal spaces
C. Choi
4 Diagnostics
Laboratory workup includes complete blood count, basic metabolic panel, and lactate. With localized anorectal abscesses, leukocytosis may not always be present.
Hemodynamics that are suggestive of systemic infection may warrant blood cultures. The severity of the systemic infection can be categorized with lactic acidosis
as well as signs of acute kidney injury and hyponatremia. These values can be used
to calculate the LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis)
score, which can categorize clinical severity of potential soft tissue infection initiated from anorectal region.
Imaging modalities include Computed Tomography scan (CT) and Magnetic
resonance imaging (MRI). In the emergent setting, CT abdomen/pelvis scans are
performed in patients who have an unclear diagnosis or to evaluate the anatomy of
the infection. It is important to make sure that the pelvis CT shows the entire
perineum. A lower threshold for imaging should be set for those patients in whom
the physical exam and clinical exam do not match, and in those patients who have
known immunocompromised comorbidities. Generally, MRI is reserved to identify
the anatomy of complex perianal stulas, such as those patients who have a history
of recurrent perianal drainage. MRI is also helpful in patients with chronic vague
symptoms or normal external anorectal exam, such as supralevator abscesses or
anorectal abscesses that have a blind sinus tract. Sometimes these chronic abscesses
take months before an eventual external stula tract or spontaneous drainage occurs
in the perineum. Ultrasound may have a role to help identify uid collections as
well, but generally there is limited use in the emergent setting.
If imaging does not show an abscess collection to be drained, then initial management may be limited to intravenous antibiotic therapy. The borders of the cellulitis (based on erythema and pain) should be marked upon the initial presentation.
This will allow a better clinical assessment of the progression or improvement of the
soft tissue infection. If the clinical picture (including examination, vitals, labs) does
not improve over a few days, a repeat CT scan may be indicated to assess the formation of an abscess.
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5 Treatment
The stability of the patient, exposure, tolerability and operating room availability
are factored into the decision of whether the initial drainage can be done at bedside
or the operating room. Based on the location of the anorectal abscess, bedside procedure may be considered if the position for best exposure is lateral decubitus.
Analgesia at the bedside includes local anesthetic and IV narcotics in a monitored
setting. However, the efcacy of the local anesthetic may be limited due to the pH
differences of the abscess. Depending on the comfort of the emergency room physician or anesthesiologist, bedside sedation may also be considered. Other important
tools includes setting up the bedside suction, and obtaining a headlight for exposure.
Large bore needle aspiration should be done to help localize the deeper anorectal
abscesses. This helps gure out the direction and depth of the abscess. Aspirated pus
may be sent off for wound culture. A cruciate incision is made with a scalpel, and
the corners of the skin are excised to prevent premature closure. The location of the
incision should be close to the anal verge in order to minimize the length of a potential stula tract. A small blunt clamp can help to open up the deep abscess cavity. If
the abscess cavity is large, it is important to place drains to prevent re-accumulation
or inadequate drainage (penrose, malencott, or Pezzar mushroom tip catheter).
Drains are preferably secured with a 2-0 nylon at the wound edges. It is preferable
to avoid packing the wound as part of wound care, as it is more difcult for patients
to comply to such a regimen.
If the exposure of the anorectal abscess is best with prone jack-knife or lithotomy, the operating room may be best. Lithotomy can be positioned with candy-cane
or the yellow-n stirrups. Copious irrigation with saline could also be mixed with
betadine, hydrogen peroxide or Dakin solution in order to achieve a thorough
washout.
Horseshoe abscess drainage is preferably positioned in lithotomy with candy
cane stirrups. Large bore needle aspiration should be directed in between the tips of
coccyx and posterior midline of anal verge with care to avoid the sphincter muscles.
Once pus aspiration is conrmed, a sharp incision is made at the skin. A blunt tip
clamp is used to dissect the soft tissue until the pus cavity is opened. A simultaneous
digital rectal exam may assist with guidance to this space.
Anoscopy with hydrogen peroxide injection into the external wound should be
performed in order to investigate the presence of an internal stula opening.
However, generally it is not easily seen during an acute infection.
6 Postoperative Management
Antibiotics are generally reserved for patients with cellulitis or soft tissue infection
and those who have immunocompromising comorbidities such as diabetes or
Crohn’s disease. Patients with complex abscesses with persistent induration may
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