What is the management of a dusky, non-functioning ileostomy (intestinal stoma) after 24 hours due to intestinal obstruction?

From the Guidelines

The correct management for a dusky, non-functioning ileostomy after 24 hours of exploration due to intestinal obstruction is A. Refashioning. When an ileostomy appears dusky and is not functioning after surgery, this indicates compromised blood supply to the stoma, which can lead to stoma necrosis and serious complications if not addressed promptly. Refashioning involves surgical revision of the stoma to establish adequate blood supply and proper function. This procedure typically includes removing the compromised portion of the bowel and creating a new, viable stoma. Expectant treatment or hot fomentation would be inappropriate as they don't address the underlying vascular compromise, while closing the stoma would be contraindicated in the setting of intestinal obstruction where bowel decompression is needed. The urgency for refashioning is based on the risk of complete stoma necrosis, peritonitis, and sepsis that can develop if a poorly perfused stoma is left untreated, as seen in emergency abdominal surgery for patients with advanced cancer, where the prognosis is poorer and the risk of complications is higher 1. Early intervention with refashioning provides the best chance for restoring proper stoma function and preventing these potentially life-threatening complications. Some key points to consider in the management of such cases include:

• The importance of addressing the compromised blood supply to the stoma promptly to prevent further complications
• The need for surgical revision to establish adequate blood supply and proper function
• The risks associated with expectant treatment, hot fomentation, and closing the stoma in this context
• The consideration of the patient's overall clinical status and the potential for high postoperative mortality and complications in emergency settings, as highlighted in the 2017 WSES guidelines on colon and rectal cancer emergencies 1.

From the Research

Management of Dusky, Non-Functioning Ileostomy

• The management of a dusky, non-functioning ileostomy after 24 hours for exploration due to intestinal obstruction is primarily focused on addressing the underlying cause of the obstruction and ensuring the ileostomy is functioning properly.
• According to 2, small bowel obstruction (SBO) is a common complication that can occur at the stoma site, and trans-stomal decompression is often the most effective treatment.
• In cases where the ileostomy is not functioning, it may be necessary to explore the stoma site to rule out any complications such as ischemia, necrosis, or retraction, as discussed in 3.
• The study 4 highlights the importance of early diagnosis and aggressive medical therapy, including rehydration, antibiotics, and nil per os, in managing SBO.
• In terms of specific management options, refashioning the ileostomy (option A) may be necessary if the stoma is not functioning properly due to complications such as ischemia or necrosis.
• Hot fomentation (option B) is not a recommended treatment for a dusky, non-functioning ileostomy.
• Expectant treatment (option C) may be appropriate in some cases, but it is not the most effective approach for managing a non-functioning ileostomy.
• Closing the stoma (option D) may be considered in some cases, but it is not typically the first line of treatment for a dusky, non-functioning ileostomy, as discussed in 5 and 6.

Key Considerations

• Early diagnosis and treatment of intestinal obstruction and ileostomy complications are crucial to prevent further complications and improve patient outcomes, as emphasized in 2 and 4.
• A systematic approach to managing ileostomy complications, including SBO, is essential to ensure optimal patient care, as discussed in 3 and 5.