A new concept in the treatment of stomal stenosis

Human papillomavirus-negative ileostomal chronic papillomatous dermatitis

BACKGROUND

Papillomatous stoma-related skin lesions may result from irritant reactions or infection with epidermodysplasia verruciformis human papillomavirus (HPV) types.

METHODS

We report upon a papillomatous lesion at the ileostoma of a 63-year-old male with familial adenomatous polyposis and colorectal adenocarcinoma. We thoroughly tested the lesion for HPV using immunohistochemistry, transmission electron microscopy, and polymerase chain reaction analyses.

RESULTS

The lesion was a fleshy, multilobulated, and verrucous plaque, with hyperkeratosis, hypergranulosis, acanthosis and marked papillomatosis. The clinical and light microscopic features were suggestive of a condyloma. However, no HPV was detected.

CONCLUSIONS

We suggest that the lesion most likely represents chronic papillomatous dermatitis, a reaction to mechanical and/or chemical irritation usually associated with urostomies and only rarely observed with ileostomies. This case highlights the clinical, diagnostic and therapeutic aspects of an unusual cutaneous morbidity associated with ileostomies.

Island pedicle graft in stomal stenosis: a new technique

Pinpoint obstructive stenosis of the urinary stoma was treated in 5 patients after ileal conduit urinary diversion and in 2 with cutaneous ureterostomy. All 7 patients underwent a single-stage stomal revision with the use of 1 or more island pedicle skin grafts to increase stomal diameter. In each instance the stomal opening was enlarged sufficiently to relieve obstruction and morbidity. During patient followup from 18 months to 7 years no revised stoma has required subsequent intubation nor has stenosis recurred.

Skin flap technique in formation of urinary conduit stoma

Stomal stenosis following ileal loop diversion is a significant complication to warrant attention. One of the predisposing factors remains the circular nature of the stoma itself, often in conjunction with chronic skin irritation. Surgical revisions predispose one not only to the usual hazards of operation, but also tend to be multiple or involve extensive surgical reconstruction. A skin flap technique in the initial formation of the stoma avoids the incidence of stenosis related to the circular nature of the stoma. The procedure is simple and does not increase the surgical time. No significant stomal complications developed in 28 patients who had urinary diversions, followed for a mean of 30.6 months.

Chronic papillomatous dermatitis as a peristomal complication in conduit urinary diversion

In 76 patients with conduit urinary diversion, the skin in the stomal area was studied with regard to complications. No such complications had occurred in 39 cases. Superficial erosive dermatitis was present or had been a transient episode in 27 cases. The immediate peristomal area was found in ten cases to show a different type of complication. This was characterized by hyperplastic, papillomatous skin lesions of a chronic nature. A rubber urinary collecting device for long-term use had been fitted in nine of the ten patients, and none of them had a protruding nipple stoma. The clinical, microbiologic and histologic features of these hyperplastic lesions are described and aetiologic factors are discussed. Change to another type of collecting device was followed within three to six weeks by healing of the lesions.

A technique for correction of ileocutaneous stomal stenosis

A technique for the revision of the ileal stoma is described. The technique is based on the skin flap interposition procedure reported by Smith for the prevention of stomal stenosis.

Extensive shortening of ileal conduit through peristomal incision

A conservative procedure is described for shortening the redundant ileal segment through a peristomal incision. The procedure may be used to complement a stomal revision.

A new surgical procedure for revision of ileal conduit stoma in children

The etiology of hypertrophic keratotic peristomal lesions is discussed and a new simple, cosmetic and functional operative procedure for excision of peristomal keratosis and revision of ileal loop stoma is described. This advancement (full skin and subcutaneous fat) triangular flap is also useful in the surgical management of other stomal problems, such as prolapsed bud, peristomal hernias and peristomal scarring. Postoperative use of the proper size and type of collecting device, and the importance of achieving sterile acid urine are stressed to prevent further stomal complications.

Spiral advancement skin flap for stomal revision

The spiral advancement skin flap procedure for stomal revision is a simple technique when the size of the skin defect must be reduced. The technique is described herein.