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- 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.
- excessive bleeding
- surgical wound infection
- thrombophlebitis (inflammation and blood clot to veins in the legs)
- pulmonary embolism (blood clot or air bubble in the lungs' blood supply)
- 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.
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.
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.
colostomySurgery 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.
colostomy(ko-los'to-me) [ colon + -stomy]
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.