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

From the Guidelines

The correct management for a dusky, non-functioning ileostomy after 24 hours following exploration for intestinal obstruction is refashioning (option A). When an ileostomy appears dusky and is not functioning properly within 24 hours of creation, 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 requires returning to the operating room, removing the compromised portion of bowel, and creating a new, viable stoma with healthy intestinal tissue.

Key Considerations

• Expectant treatment or hot fomentation would be inadequate as they don't address the underlying vascular compromise.
• Closing the stoma would be contraindicated as it doesn't resolve the immediate problem and could lead to further intestinal obstruction or peritonitis.
• Early intervention with refashioning is essential to prevent complications such as peritonitis, sepsis, or the need for more extensive bowel resection later, as suggested by the principles of managing complicated colorectal cancer emergencies, including obstruction, where the goal is to balance the need for definitive treatment with the patient's clinical status and the risk of anastomotic leakage 1.

Management Approach

• The management approach should prioritize minimizing surgical trauma and avoiding procedures that may exacerbate the patient's unstable condition, as outlined in guidelines for colon and rectal cancer emergencies 1.
• Refashioning the ileostomy aligns with the principle of performing life-saving procedures that the patient can tolerate, especially in emergency settings where patients often have poorer prognoses due to advanced tumors and coexisting factors like volume depletion, electrolyte disorders, and potential sepsis 1.

From the Research

Management of Dusky, Non-Functioning Ileostomy

• The management of a dusky, non-functioning ileostomy after 24 hours due to intestinal obstruction involves several considerations:
  • Refashioning of the ileostomy may be necessary if there is evidence of ischemia or necrosis 2.
  • Trans-stomal decompression may be effective in relieving small bowel obstruction (SBO) at the stoma site 2, 3.
  • Early stoma closure may be needed in cases of stoma-related obstruction (SRO) 3.
• The following options are not directly relevant to the management of a dusky, non-functioning ileostomy:
  • Hot fomentation is not a recommended treatment for ileostomy complications 2, 4.
  • Expectant treatment may not be appropriate for a non-functioning ileostomy with signs of ischemia or obstruction 2, 3.
  • Closing the stoma may be considered in some cases, but it is not the primary management option for a dusky, non-functioning ileostomy 3, 5.

Key Considerations

• The presence of a defunctioning ileostomy can increase the risk of major Low Anterior Resection Syndrome (LARS) and impair bowel function after low anterior resection for rectal cancer 5.
• A prolonged time to stoma closure can reinforce the negative effect on bowel function, making early reversal an important part of the patient pathway 5.
• Intestinal obstruction can be caused by various factors, including intra-abdominal adhesions, malignancy, and herniation, and requires prompt evaluation and management to prevent complications 6.