Stomas of the colon (colostomy) or small bowel (ileostomy) are created for fecal diversion or as a permanent orifice for the passage of stool. In the setting of trauma, a stoma may be used for temporary diversion if the bowel is perforated with intra-abdominal fecal contamination. This is performed as an end colostomy, where the rectum is stapled off and the segment of colon is brought to the skin surface (Hartmann’s procedure), or as a loop ileostomy/colostomy, where a loop of bowel is brought up through the incision in the abdomen. An end ostomy has one lumen, whereas a loop ostomy has two lumens within the same stoma site (Fig. 13.2a, b). A red rubber catheter is initially placed between the lumens to maintain external positioning. With a loop ostomy, the afferent limb stoma is maintained for stool output, while the efferent limb stoma is connected to the distal bowel without expected output. After dissection of the abdominal wall is performed and the segment of bowel is everted, the enterocutaneous anastomosis is performed. The bowel should appear pink and viable extruding a few centimeters above the skin edge once the ostomy is completed [7].

The ostomy should begin to produce gas and stool within a few days after the operation. Early stoma-related complications include high output, obstruction, and ischemia. A high-output stoma, producing greater than two liters per day, is more common with an ileostomy than a colostomy [8]. Patients should be evaluated for signs of dehydration, and electrolytes should be regularly monitored during the first few weeks postoperatively. Patients may be started on antimotility agents such as loperamide or opiates such as a tincture of opium to slow gut transit. In addition, medications to reduce stomach acid production or bile acid-binding resins may be helpful in decreasing output [9]. Early obstruction can occur when the fascial incision for the stoma is too small, causing the rectus muscle to contract around the bowel. This is diagnosed clinically by inability to digitalize the ostomy and usually requires reoperation.

Other late complications include peristomal skin irritation due to a poor fitting appliance, peristomal hernia, prolapse, stenosis, and complications related to small bowel obstruction after surgery. Parastomal hernias may be managed conservatively with a belt appliance or repaired surgically with or without mesh, although recurrence rates are high. A prolapsed stoma will be evident by protruding mucosa beyond the usual stoma site and should be easily and gently reduced. If there is edema of the mucosa and a prolapsed stoma appears incarcerated, the use of sugar on the mucosa to draw out excess fluids and allow for reduction has been shown to be effective [10, 11]. Bleeding from the stoma site may occur with minor trauma to the tissue, but bleeding may also be related to parastomal varices. Minor bleeding may be managed with light pressure, although significant bleeding may indicate erosion into a larger vessel and a surgical emergency. Bleeding or mucous discharge from the rectum associated with abdominal or perianal pain after a colostomy may be a sign of diversion colitis. This is treated with short-chain fatty acid enemas and earlier reversal if possible. Bowel obstruction should be suspected if a patient stops producing gas and stool from the ostomy and begins to complain of abdominal pain and bloating. In this case, a CT scan with oral and intravenous contrast should be obtained, and the patient should be prepared for inpatient admission if obstruction is evident. In general, ostomies are reversed no earlier than 3 months after creation or last intra-abdominal surgery.

Because the body is in a hypercatabolic state after trauma, it is important to maintain optimal nutritional support for wound healing and immune function. Non-oral nutrition is recommended if the patient is in a malnourished state at baseline or is expected to be without nutrition for longer than 1 week. Nutritional needs will be determined based on pre-injury nutritional state and stress level. When the gastrointestinal tract is functional and safe to use, enteral nutrition (EN) is preferred over parenteral nutrition (PN). EN is more efficiently utilized by the body due to first-pass metabolism in the liver and helps support the functional integrity of the gut. However, parenteral nutrition may be used when enteral feeding is not tolerated, as with a mechanical bowel obstruction, severe gastrointestinal bleeding, short gut syndrome, or a proximal enterocutaneous or enteroatmospheric fistula [12].

When the patient is unable to tolerate oral feeding, enteral nutrition may be administered through a nasogastric, nasojejunal, gastrostomy, or jejunostomy tube. Generally, nasogastric or nasojejunal tubes are used as a temporary measure until the patient is able to take in oral nutrition, e.g., patients with altered mental status or dysphagia. For patients who are expected to take no oral nutrition for 4 weeks or more, placement of a gastrostomy or jejunostomy tube is recommended [13]. This may include patients with neurological disorders such as stroke or traumatic brain injury, patients presenting after significant trauma, with cancer or recent surgery of the upper gastrointestinal tract [7]. A gastrostomy tube is sufficient for most patients, but a jejunostomy tube is preferred in patients requiring post-pyloric feeding due to injury or gastroparesis (Fig.13.6, Fig 13.7).

Enteral access procedures can be performed in a variety of settings, including at the bedside, in the endoscopy or interventional radiology suite, or in the operating room. The options for long-term feeding tube placement include laparoscopic or open gastrostomy or jejunostomy tube placement, percutaneous endoscopic gastrostomy (PEG) tube placement, and laparoscopic-assisted PEG tube placement (Fig. 13.3a, b). Open or laparoscopic gastrostomy and jejunostomy feeding tubes allow for fixation of the bowel wall to the anterior abdominal wall (see Box for procedure details). While a PEG tube is the preferred method, anatomic considerations may require open or laparoscopic techniques. After the procedure, the tubing is left to drain, and feedings are gradually begun the next day. The tubing should not be changed for 4–8 weeks to allow time for an epithelialized tract to form. When the patient recovers and feeding assistance is no longer needed, the tube can be removed, leaving the tract to granulate and heal.

Nutrition and electrolytes should be assessed while the patient is receiving enteral or parenteral nutrition. Early complications include surgical site bleeding and tube dislodgement, both of which require urgent surgical consultation. If tube dislodgement occurs after the 4 weeks, it can be carefully replaced with a Foley or red rubber catheter and intraluminal placement confirmed with radiologic contrast study.

Other complications after gastrostomy tube placement include infection or bleeding around the tubing site, “buried bumper” syndrome, ulceration or peristomal leakage, and gastric outlet obstruction [14]. A relatively common feeding tube problem is blockage of the tubing, which occurs more often with jejunostomy tubes. The first step in management is flushing the tube with warm water, carbonated beverages, juices, or an enzymatic solution. If this fails to unclog the tube, mechanical unclogging may be performed at the bedside with an approved device. To prevent blockage, the tubing should be flushed with 15–30 cc of water prior to and after each use, and all medications should be given as liquids or crushed thoroughly prior to administration.

Gastric outlet obstruction may be suspected when a patient complains of abdominal pain and nausea with emesis. In this case, the gastrostomy tube should be placed to gravity to allow stomach contents to drain. There are commercially available gastrostomy–jejunostomy (G–J) tubes so that the jejunostomy tube can be used for feeding, while the gastrostomy tube is used for gastric decompression. “Buried bumper” syndrome occurs when the inner bumper becomes impacted between the gastric wall mucosa and the skin. This may lead to infection or necrosis and can be managed endoscopically or surgically. To help prevent buried bumper syndrome, ulceration, or peristomal leakage, the distance markers along the tubing should be used to ensure that there is not undue tension or too much slack in the appliance. In general, these markings are at 2–3 cm at the skin, but this length can vary depending on the depth of a patient’s abdominal wall thickness. Marker placement should be confirmed with the physician performing the tube placement.

Wound complications after surgery range from a benign seroma to a life-threatening necrotizing fasciitis. A seroma is a clear, yellow fluid composed of liquefied fat, lymphatic drainage, or serous fluid. Procedures with large skin flaps and deep soft tissue pockets, such as axillary or groin dissection, mastectomy, or mesh repair, may be prone to developing seromas. Clinically, this appears as a small, localized swelling near the incision site. A seroma may be left alone, and the body will resorb the fluid, or the collection may be sterilely drained. A pressure dressing and the use of drains can prevent a seroma from recurring [6].