colostomy

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Colostomy

 

Definition

Ostomy is a surgical procedure used to create an opening for urine and feces to be released from the body. Colostomy refers to a surgical procedure where a portion of the large intestine is brought through the abdominal wall to carry stool out of the body.

Purpose

A colostomy is created as a means to treat various disorders of the large intestine, including cancer, obstruction, inflammatory bowel disease, ruptured diverticulum, ischemia (compromised blood supply), or traumatic injury. Temporary colostomies are created to divert stool from injured or diseased portions of the large intestine, allowing rest and healing. Permanent colostomies are performed when the distal bowel (bowel at the farthest distance) must be removed or is blocked and inoperable. Although colorectal cancer is the most common indication for a permanent colostomy, only about 10-15% of patients with this diagnosis require a colostomy.

Description

Surgery will result in one of three types of colostomies:
  • End colostomy. The functioning end of the intestine (the section of bowel that remains connected to the upper gastrointestinal tract) is brought out onto the surface of the abdomen, forming the stoma by cuffing the intestine back on itself and suturing the end to the skin. A stoma is an artificial opening created to the surface of the body. The surface of the stoma is actually the lining of the intestine, usually appearing moist and pink. The distal portion of bowel (now connected only to the rectum) may be removed, or sutured closed and left in the abdomen. An end colostomy is usually a permanent ostomy, resulting from trauma, cancer or another pathological condition.
  • Double-barrel colostomy. This colostomy involves the creation of two separate stomas on the abdominal wall. The proximal (nearest) stoma is the functional end that is connected to the upper gastrointestinal tract and will drain stool. The distal stoma, connected to the rectum and also called a mucous fistula, drains small amounts of mucus material. This is most often a temporary colostomy performed to rest an area of bowel, and to be later closed.
  • Loop colostomy. This colostomy is created by bringing a loop of bowel through an incision in the abdominal wall. The loop is held in place outside the abdomen by a plastic rod slipped beneath it. An incision is made in the bowel to allow the passage of stool through the loop colostomy. The supporting rod is removed approximately 7-10 days after surgery, when healing has occurred that will prevent the loop of bowel from retracting into the abdomen. A loop colostomy is most often performed for creation of a temporary stoma to divert stool away from an area of intestine that has been blocked or ruptured.

Preparation

As with any surgical procedure, the patient will be required to sign a consent form after the procedure is explained thoroughly. Blood and urine studies, along with various x rays and an electrocardiograph (EKG), may be ordered as the doctor deems necessary. If possible, the patient should visit an enterostomal therapist, who will mark an appropriate place on the abdomen for the stoma, and offer pre-operative education on ostomy management.
In order to empty and cleanse the bowel, the patient may be placed on a low residue diet for several days prior to surgery. A liquid diet may be ordered for at least the day before surgery, with nothing by mouth after midnight. A series of enemas and/or oral preparations (GoLytely or Colyte) may be ordered to empty the bowel of stool. Oral anti-infectives (neomycin, erythromycin, or kanamycin sulfate) may be ordered to decrease bacteria in the intestine and help prevent post-operative infection. A nasogastric tube is inserted from the nose to the stomach on the day of surgery or during surgery to remove gastric secretions and prevent nausea and vomiting. A urinary catheter (a thin plastic tube) may also be inserted to keep the bladder empty during surgery, giving more space in the surgical field and decreasing chances of accidental injury.

Aftercare

Post-operative care for the patient with a new colostomy, as with those who have had any major surgery, involves monitoring of blood pressure, pulse, respirations, and temperature. Breathing tends to be shallow because of the effect of anesthesia and the patient's reluctance to breathe deeply and experience pain that is caused by the abdominal incision. The patient is instructed how to support the operative site during deep breathing and coughing, and given pain medication as necessary. Fluid intake and output is measured, and the operative site is observed for color and amount of wound drainage. The nasogastric tube will remain in place, attached to low intermittent suction until bowel activity resumes. For the first 24-48 hours after surgery, the colostomy will drain bloody mucus. Fluids and electrolytes are infused intravenously until the patient's diet is can gradually be resumed, beginning with liquids. Usually within 72 hours, passage of gas and stool through the stoma begins. Initially the stool is liquid, gradually thickening as the patient begins to take solid foods. The patient is usually out of bed in 8-24 hours after surgery and discharged in 2-4 days.
A colostomy pouch will generally have been placed on the patient's abdomen, around the stoma during surgery. During the hospital stay, the patient and his or her caregivers will be educated on how to care for the colostomy. Determination of appropriate pouching supplies and a schedule of how often to change the pouch should be established. Regular assessment and meticulous care of the skin surrounding the stoma is important to maintain an adequate surface on which to apply the pouch. Some patients with colostomies are able to routinely irrigate the stoma, resulting in regulation of bowel function; rather than needing to wear a pouch, these patients may need only a dressing or cap over their stoma. Often, an enterostomal therapist will visit the patient at home after discharge to help with the patient's resumption of normal daily activities.

Risks

Potential complications of colostomy surgery include:
  • excessive bleeding
  • surgical wound infection
  • thrombophlebitis (inflammation and blood clot to veins in the legs)
  • pneumonia
A colostomy is a surgical procedure in which a portion of the large intestine, or colon, is brought through the abdominal wall to carry feces out of the body. There are three types of colostomies: end colostomy, double-barrel colostomy, and loop colostomy. The loop colostomy is featured in the illustration above.
A colostomy is a surgical procedure in which a portion of the large intestine, or colon, is brought through the abdominal wall to carry feces out of the body. There are three types of colostomies: end colostomy, double-barrel colostomy, and loop colostomy. The loop colostomy is featured in the illustration above.
(Illustration by Electronic Illustrators Group.)
  • pulmonary embolism (blood clot or air bubble in the lungs' blood supply)

Normal results

Complete healing is expected without complications. The period of time required for recovery from the surgery may vary depending of the patient's overall health prior to surgery. The colostomy patient without other medical complications should be able to resume all daily activities once recovered from the surgery.

Abnormal results

The doctor should be made aware of any of the following problems after surgery:
  • increased pain, swelling, redness, drainage, or bleeding in the surgical area.
  • headache, muscle aches, dizziness, or fever.
  • increased abdominal pain or swelling, constipation, nausea or vomiting or black, tarry stools
Stomal complications to be monitored include:
  • Death (necrosis) of stomal tissue. Caused by inadequate blood supply, this complication is usually visible 12-24 hours after the operation and may require additional surgery.
  • Retraction (stoma is flush with the abdomen surface or has moved below it). Caused by insufficient stomal length, this complication may be managed by use of special pouching supplies. Elective revision of the stoma is also an option.
  • Prolapse (stoma increases length above the surface of the abdomen). Most often results from an overly large opening in the abdominal wall or inadequate fixation of the bowel to the abdominal wall. Surgical correction is required when blood supply is compromised.
  • Stenosis (narrowing at the opening of the stoma). Often associated with infection around the stoma or scarring. Mild stenosis can be removed under local anesthesia. Severe stenosis may require surgery for reshaping the stoma.
  • Parastomal hernia (bowel causing bulge in the abdominal wall next to the stoma). This is due to placement of the stoma where the abdominal wall is weak or creation of an overly large opening in the abdominal wall. The use of an ostomy support belt and special pouching supplies may be adequate. If severe, the defect in the abdominal wall should be repaired and the stoma moved to another location.

Resources

Organizations

United Ostomy Association, Inc. (UOA). 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. http://www.uoa.org.

Key terms

Diverticulum — Pouches that project off the wall of the intestine, visible as opaque on an x ray after the patient has swallowed a contrast (dye) substance.
Embolism — Blockage of a blood vessel by any small piece of material traveling in the blood. The emboli may be caused by germs, air, blood clots, or fat.
Enema — Insertion of a tube into the rectum to infuse fluid into the bowel and encourage a bowel movement. Ordinary enemas contain tap water, mixtures of soap and water, glycerine and water, or other materials.
Intestine — Commonly called the bowels, divided into the small and large intestine. They extend from the stomach to the anus. The small intestine is about 20 ft (6 m) long. The large intestine is about 5 ft (1.5 m) long.
Ischemia — A compromise in blood supply delivered to body tissues that causes tissue damage or death.
Ostomy — A surgically created opening in the abdomen for elimination of waste products (urine or stool).

colostomy

 [kah-los´tah-me]
an artificial opening (stoma) created in the large intestine and brought to the surface of the abdomen for evacuating the bowels. It may be necessary in intestinal obstruction, perforation of the bowel, cancer, birth defects, and occasionally ulcerative colitis. The altered patterns of discharge created by colostomy may be permanent or temporary, depending on the primary condition being treated. The most common types of colostomy are transverse, descending, and sigmoid, the name being derived from the site of the disorder and the location of the stoma.

A transverse colostomy may be located on the right, left, or midline of the abdomen. This type of colostomy usually is done as a temporary measure, allowing for discharge of feces while the diseased portion of the intestine returns to normal. Later, the two ends are anastomosed to restore continuity of the bowel. In most transverse colostomies a loop of the colon is brought out through an abdominal incision and an opening made through the intestine. Observation of the stoma as it functions can determine which side of the colostomy leads from the functioning colon and which side leads to the lower, nonfunctioning segment.

A double-barreled colostomy is one in which there are two separate stomas. The proximal or right-sided stoma provides an opening for the active segment of the colon; the distal or left-sided stoma opens into the inactive segment. The double-barreled colostomy may later be joined by anastomosis and returned to the abdominal cavity.

Permanent colostomies are usually made at the level of the descending and sigmoid colon. The colostomy is formed and the diseased portion of the colon and anus are removed (abdominoperineal resection) in a single operation. The stoma created in the descending colon and in the sigmoid colon is usually located on the left side of the abdomen. Hernias may occur around colostomies if there is a weakness of the fascia around the stoma. These can be troublesome and should be repaired surgically, but the success of such repairs is limited.
Patient Care. Unless otherwise prohibited by physical weakness or mental incompetence, colostomy care is directed toward helping the patient become totally self-sufficient in the care of the colostomy. Patients are taught to care for the physical aspects of a colostomy and are assisted in adjusting psychologically to a new method of handling solid body waste. This is accomplished in stages, doing for patients those things they cannot do, showing them the way they can be done, and encouraging them to accept responsibility for their own care. Once having overcome initial shock and apprehension at the prospect of colostomy care, most patients welcome the opportunity to care for themselves in privacy.

Prior to surgery the operative procedure is explained and the patient is encouraged at this time to ask questions that are of concern to him. The idea of an artificial anus in the abdominal wall may well be overwhelming to someone who has never heard of the operation. It is best to be open and matter-of-fact in discussing this with patients, remembering that they cannot be expected to absorb too much information at one time. They should be assured that their questions will be answered as they occur to them, that there will be someone to listen to them when they want to talk, and that there are many sources of information available to help with adjustment.

When the patient is ready to learn about caring for his own colostomy, printed information and teaching aids can be obtained through local offices of national health agencies. For example, the Rehabilitation Program of the American Cancer Society publishes a pamphlet entitled Colostomies: A Guide, and the United Ostomy Association provides pamphlets, audiovisual material, a quarterly bulletin, and a monthly newsletter. Many times it is helpful to have the patient talk with someone who has a colostomy and is living a normal active life. Certified Enterostomal Therapists are specially trained to work with colostomy patients and others who have permanent stomas.

Devices for collection of waste passing through the stoma vary in design according to the patient's progress. An open-ended bag is needed until bowel control is developed and then a closed pouch is used. Eventually some patients may need nothing more than a simple dressing over the stoma. Selection of a drainage pouch should be based on the size of the stoma. As the stoma shrinks following surgery, the pouch size is changed so that it fits correctly, not so small as to constrict the stoma, and not so large as to permit leakage around the stoma.

Skin care around the stoma is planned so that the area is kept clean and protected from the enzymes and acid in the digestive fluid. The area is washed with soap and water, dried thoroughly, and then a medicated skin barrier such as Stomahesive is applied. (See also stoma.)

Irrigation of a colostomy is prescribed on an individual basis. Not all patients require irrigation to regulate fecal discharge. When irrigation is needed, the cone-shaped device is less hazardous and easier for most patients to use. Catheters sometimes cause difficulties in that the patients do not know how far to insert them, they may perforate the intestine, and there often is leakage of the irrigating fluid around the catheter during irrigation.

The diet of patients with a colostomy need not be severely restricted. They will need to notice which foods produce gas, diarrhea, and constipation and then adjust their diet to reduce difficulties arising from individual problems with certain foods. Food must be chewed well. Odors may be a source of worry for the patient until they are controlled with cleanliness, avoidance of gas-producing foods, and proper application of the pouch. Commercially produced deodorants are available.

Patients with temporary colostomies may undergo barium studies of the intestines. Preparation of the bowel for these radiologic studies should be carried out with care as the fluid and electrolyte balance of an ostomate can be easily upset. When the studies are completed, the barium must be removed in order to avoid intestinal obstruction.

Suppositories can be inserted into a colostomy stoma. If the patient has had a double-barreled colostomy, the choice of stoma for insertion of the suppository will depend on the desired action of the drug. A glycerine suppository to facilitate passage of fecal material through the stoma would be inserted into the proximal limb to achieve the desired action. Conversely, a drug that is to be absorbed from the intestine, for example for the relief of pain, is inserted into the distal limb, from which it will not be expelled through the stoma. Before inserting any kind of medication or a catheter for irrigation, the stoma should be digitally examined. The gloved finger is gently inserted into the stoma to determine the direction of the lumen of the intestine.

co·los·to·my

(kō-los'tō-mē),
Establishment of an artificial connection between the lumen of the colon and the skin.
[colo- + G. stoma, mouth]

colostomy

/co·los·to·my/ (kah-los´tah-me) the surgical creation of an opening between the colon and the body surface; also, the opening (stoma) so created.
dry colostomy  that performed in the left colon, the discharge from the stoma consisting of soft or formed fecal matter.
ileotransverse colostomy  surgical anastomosis between the ileum and the transverse colon.
wet colostomy  colostomy in (a) the right colon, the drainage from which is liquid, or (b) the left colon following anastomosis of the ureters to the sigmoid or descending colon so that urine is also expelled through the same stoma.

colostomy

(kə-lŏs′tə-mē)
n. pl. colosto·mies
1. Surgical construction of an artificial excretory opening from the colon.
2. The opening created by such a surgical procedure.

colostomy

[kəlos′təmē]
Etymology: Gk, kolon + stoma, mouth
surgical creation of an artificial anus on the abdominal wall by incising the colon and bringing it out to the surface, performed for cancer of the colon, benign obstructive tumors, and severe abdominal wounds. A colostomy may be single-barreled, with one opening, or double-barreled, with distal and proximal loops opening onto the abdomen. The latter is performed for complete blockage of the lower bowel or in paraplegia to simplify daily management. A temporary colostomy may be done to divert feces after surgery, as in the repair of Hirschsprung's disease, or from an inflamed area; it is repaired when the colon has healed or the inflammation subsides. Preoperative nursing care focuses on teaching the patient what to expect after surgery. A high-calorie, clear liquid diet is given. An antibiotic, usually neomycin, is prescribed to reduce the bacterial count in the bowel, and bowel-cleansing methods are used. Immediate postoperative care is the same as for abdominal surgery. The color of the stoma is checked: a dark blue-black (rather than bright red) indicates a circulation block, and the surgeon is notified. If needed, saline irrigations are begun on the fourth or fifth day. A type of colostomy is loop colostomy. Compare enterostomy.
enlarge picture
Types of colostomies

colostomy

Surgery A hole in the abdominal wall at which the colon communicates directly with the outside; colostomies are created as an artificial anus and required when surgery mandates temporary or permanent loss of the rectum, anal function Indications Diverticulitis, Crohn's disease, ulcerative colitis, for diverting fecal stream in colon cancer, intestinal obstruction, anorectal defects. See Ileostomy, Urostomy.

co·los·to·my

(kō-los'tŏ-mē)
Establishment of an artificial cutaneous opening into the colon.
[colo- + G. stoma, mouth]

colostomy

(ko-los'to-me) [ colon + -stomy]
Enlarge picture
COLOSTOMY SITES
The opening of a portion of the colon through the abdominal wall to its skin surface. A colostomy is established in cases of distal obstruction, inflammatory process, including perforation, and when the distal colon or rectum is surgically resected. A temporary colostomy is performed to divert the fecal stream from an inflamed or operative site. See: illustration; ostomy for colostomy care

Patient care

Preoperative: When the possibility exists that a patient will need to have a colostomy created (even when surgery is performed in an emergency), the patient and family are advised about the nature of the colostomy, including temporary versus permanent stoma and general principles of aftercare. The patient is assured that he or she will be able to resume a normal lifestyle with a stoma. A stomal therapist works with patient and family throughout this experience. Except in an extreme emergency (e.g., perforation, penetrating trauma, etc.), preparation for colon surgery with laxatives, enemas, and antibacterial agents is coordinated with the surgery's starting time. Intravenous hydration is instituted.

Postoperative: Routine care, including the use of various monitors, pneumatic hose, incentive spirometry, and pulmonary toilet measures, along with special attention given to inspecting the stoma for viability and the surrounding skin for irritation and excoriation. The stoma should be smooth and cherry red, and may be slightly edematous. Any discoloration or excessive swelling is documented and reported. The stoma and surrounding skin are gently cleansed and dried thoroughly. A drainage bag is applied by fitting a karaya adhesive ring (or other appliance) before the patient leaves the operating room to ensure a firm seal and to prevent leakage without constricting the stoma. Nonirritating skin barriers are used as appropriate.

Avoidance of dehydration and maintenance of electrolyte balance are emphasized until the patient is able to eat a normal diet. Stool consistency is observed. If colostomy irrigations are prescribed, the patient is advised that the procedure is similar to an enema. The patient is advised to return to a normal diet judiciously, adding new foods gradually while observing their effect. He or she should avoid gas-forming, odoriferous, spicy, and irritating foods. Colostomy requires a difficult adjustment by both patient and family; they are encouraged to verbalize their fears and concerns, and support is offered. The patient is reassured of the ability to regain continence with dietary control and bowel retraining. Usual physical activities should be gradually resumed, avoiding heavy lifting and activities that could cause injury to the stoma and surrounding tissues. Abdominal muscle strengthening should be part of a supervised exercise program. Both patient and partner are encouraged to discuss their feelings and concerns about body image changes and about resumption of sexual relations, and they should be assured that the appliance will not dislodge if empty. The patient should avoid food and fluids a few hours before sexual activity. Participation in a local “ostomates” support group help the patient and significant others to manage the stoma and associated concerns. Depression is not uncommon after ostomy surgery, and psychological counseling is recommended if depression persists.

ascending colostomy

A colostomy typically connected to the right side of the abdomen, in which the proximal large intestine (rather than the descending bowel or sigmoid) empties through a stoma fashioned in the right lower quadrant of the abdomen.

decompressive colostomy

, decompressing colostomy
A colostomy between the proximal colon and the abdominal wall. It is used to drain intestinal contents when an obstruction in the distal colon might otherwise cause the organ to perforate or rupture.

descending colostomy

A colostomy in which part of the descending colon or the sigmoid colon is brought to the abdominal wall to empty its contents into a collection device. It is the most common colostomy.
Synonym: sigmoid colostomy

double-barrel colostomy

Most often a temporary colostomy with two openings into the colon: one distal and one proximal. Elimination occurs through the proximal stoma, allowing the distal length of the colon to rest and heal. When healing is complete, the two ends are rejoined and returned to the peritoneal cavity, and normal bowel function resumes. In colitis, resection rather than reanastomosis is performed.

sigmoid colostomy

Descending colostomy.

temporary colostomy

A colostomy between the colon and the exterior abdominal wall, used for a few months until the proximal colon and a more distal part of the large bowel can be joined safely. It is created typically when inflammation in the distal colon needs time to resolve.

terminal colostomy

A colostomy in which the proximal cut end of the colon is formed into a stoma and the distal colon is either resected or closed.

wet colostomy

1. A colostomy in the right side of the colon. The drainage from this type of colostomy is liquid.
2. A colostomy in the left side of the colon distal to the point where the ureters have been anastomosed to it. Thus the urine and fecal material are excreted through the same stoma. Ureterocolostomy has been abandoned in favor of other extra-intestinal urinary diversion procedures.

colostomy

An artificial anus on the front wall of the abdomen, formed when the cut upper end of the colon is brought to the exterior. This is often necessary when the colon has to be cut through, as in the treatment of cancer. Evacuated bowel contents are collected in a waterproof bag. Colostomies are often temporary.

colostomy (k·lˑ·st·mē),

n incision made in the abdominal wall, intended to draw the intestine out and create an artificial anus. Often done after cancer surgery.
Enlarge picture
Colostomy.

colostomy

an artificial opening (stoma) created in the large intestine and brought to the surface of the abdomen for the purpose of evacuating the bowels; also the opening (stoma) so created. Has been used successfully in the treatment of rectal tears in horses.
References in periodicals archive ?
Ten colon resections and 7 sigmoid colostomies were performed laparoscopically at Baylor University Medical Center between March 1995 and January 2000 (Table).
They are the first in what we believe will be a large family of patents that will protect our proprietary ostomy management technology, a technology that will improve the Quality of Life of tens of thousands of individuals with colostomies by freeing them from 24/7 dependence on ostomy bags.
Research Corporation Technologies (RCT) and Zassi Medical Evolutions, a Florida-based company, have entered into a partnership via the formation of Leto Medical, LLC, to develop a novel electrical stimulation technology designed to restore continence control to individuals with colostomies.
With capital from RCT and intellectual property from Zassi and University Technologies International, Leto's mission is to improve the quality of life of individuals with colostomies by developing a system of products that will free these individuals from constant dependence on an ostomy bag.
Leto's Continence Ostomy System (COS) will employ an innovative electrical stimulation technology along with proprietary, single use disposables to restore continence control to individuals with colostomies for eight to 12 hours per day and in so doing, free these individuals from the burden of having to wear an ostomy pouch for these eight to 12 hours.
Permanent colostomies, genital mutilation, infertility and unsightly scars are common consequences of aggressive cancer surgery.
Hemaseel APR also is indicated as a sealant in the closure of colostomies.