How should a stenotic stoma be managed?

Management of Stenotic Stoma

Begin with conservative measures using convex appliances and barrier products, but proceed directly to surgical revision if stenosis prevents adequate catheterization or causes persistent leakage despite optimal appliance management. 1, 2

Initial Conservative Approach

For mild to moderate stenosis where the stoma remains functional:

• Apply convex appliances to create outward pressure on the stenotic stoma and improve the seal between the appliance and peristomal skin 1, 2
• Use an ostomy belt in conjunction with the convex appliance to maintain consistent pressure and prevent leakage 1, 2
• Apply paste or barrier rings around the stoma base to fill gaps and create a level surface for appliance adhesion 1, 2
• Ensure complete dryness of peristomal skin before applying any pouching system—this is critical for adhesion 2
• Cut the appliance opening one-eighth inch larger than the stoma to prevent mucosal irritation while minimizing skin exposure to effluent 1

Interventional Options for Refractory Stenosis

When conservative measures fail, consider these interventions before proceeding to surgery:

• Endoscopic balloon dilation is safe and effective for late stomal stenosis, particularly in gastric stomas, with 10 of 15 patients remaining asymptomatic following dilation 3
• Triamcinolone injection (40 mg/ml) achieves a 72% success rate with a single injection for continent catheterizable channels, with patients maintaining ease of catheterization for a median of 11.6 months 4
  • This represents only 0.3% of the cost of surgical revision when performed as an office-based procedure 4
  • No adverse effects or complications have been reported with this technique 4
  • Repeat injections can be performed at approximately 5 months if stenosis recurs 4

Important caveat: Dilation provides no benefit when stoma torsion is present—these cases require surgical correction 3

Surgical Revision

Proceed to surgical intervention when:

• Persistent leakage causes significant financial hardship from frequent appliance changes and skin damage 1
• Complete obstruction prevents stoma function 3
• Stoma torsion is identified as the underlying cause 3

Surgical Technique Options:

• W-plasty reconstruction creates consecutive small triangular skin flaps that interdigitate with corresponding mucosal margins, achieving excellent results with no recurrent stenosis at median 12.5 months follow-up and high patient satisfaction 5
• Avoid relocating the stoma to a new site during revision, as this creates significant risk of complications at the new location 1

Monitoring and Ongoing Assessment

• Measure stoma size at each appliance change for the first 8 weeks, as the stoma continues to change during this period 1
• Monitor for secondary complications including peristomal skin breakdown from leakage 1
• Consult wound ostomy continence (WOC) specialists as they are invaluable resources in managing stenotic stomas 2

Common Pitfalls to Avoid

• Do not persist with repeated dilations if they fail to achieve long-term resolution—this delays definitive treatment 5
• Do not ignore stoma torsion—this anatomic problem will not respond to dilation and requires surgical correction 3
• Do not overlook the financial burden of persistent leakage on patients, as this alone may justify surgical intervention 1