Colostomy

A colostomy is an opening (stoma) in the large intestine (colon), or the surgical procedure that creates one. The opening is formed by drawing the healthy end of the colon through an incision in the anterior abdominal wall and suturing it into place. This opening, often in conjunction with an attached stoma appliance, provides an alternative channel for feces to leave the body. Thus if the natural anus is not available for that job (for example, in cases where it has been removed in the fight against colorectal cancer or ulcerative colitis), an artificial anus takes over. It may be reversible or irreversible, depending on the circumstances.

Colostomy
Diagram showing a colostomy with a bag CRUK 061
Diagram showing a colostomy
ICD-9-CM46.1
MeSHD003125
MedlinePlus002942

Indications

There are many reasons for this procedure. Some common reasons are:

  • A section of the colon has been removed, e.g. due to colon cancer requiring a total mesorectal excision, diverticulitis, injury, etc., so that it is no longer possible for feces to exit via the anus.
  • A portion of the colon (or large intestine) has been operated upon and needs to be 'rested' until it is healed. In this case the colostomy is often temporary and is usually reversed at a later date, leaving the patient with a small scar in place of the stoma. Children undergoing surgery for extensive pelvic tumors commonly are given a colostomy in preparation for surgery to remove the tumor, followed by reversal of the colostomy.
  • Fecal incontinence that is non-responsive to other treatments.

Options

Blausen 0247 Colostomy
Illustration depicting various types of colostomy

Placement of the stoma on the abdomen can occur at any location along the colon, but the most common placement is on the lower left side near the sigmoid where a majority of colon cancers occur. Other locations include the ascending, transverse, and descending sections of the colon.[1]

Types of colostomy:[2][3]

  • Loop colostomy: This type of colostomy is usually used in emergencies and is a temporary and large stoma. A loop of the bowel is pulled out onto the abdomen and held in place with an external device. The bowel is then sutured to the abdomen and two openings are created in the one stoma: one for stool and the other for mucus.
  • End colostomy: A stoma is created from one end of the bowel. The other portion of the bowel is either removed or sewn shut (Hartmann's procedure).
  • Double barrel colostomy: The bowel is severed and both ends are brought out onto the abdomen. Only the proximal stoma is functioning.Most often,double-barrel colostomy is a temporary colostomy with two openings into the colon (distal and proximal). The elimination occurs through the proximal stoma.

Colostomy surgery that is planned usually has a higher rate of long-term success than surgery performed in an emergency situation.

People with colostomies must wear an ostomy pouching system to collect intestinal waste. Ordinarily the pouch must be emptied or changed a couple of times a day depending on the frequency of activity; in general the further from the anus (i.e., the further 'up' the intestinal tract) the ostomy is located the greater the output and more frequent the need to empty or change the pouch.[4]

Colostomy and irrigation

People with colostomies who have ostomies of the sigmoid colon or descending colon may have the option of irrigation, which allows for the person to not wear a pouch, but rather just a gauze cap over the stoma, and to schedule irrigation for times that are convenient.[5] To irrigate, a catheter is placed inside the stoma, and flushed with water, which allows the feces to come out of the body into an irrigation sleeve.[6] Most colostomates irrigate once a day or every other day, though this depends on the person, their food intake, and their health.

Alternatives

A man in the UK has been given a remote-controlled bowel.[7] Colostomy or ileostomy is now rarely performed for rectal cancer, with surgeons usually preferring primary resection and internal anastomosis,[8] e.g. an ileo-anal pouch. In place of an external appliance, an internal ileo-anal pouch is constructed using a portion of the patient's lower intestine, to act as a new rectum to replace the removed original.

Routine care

Pouches and the stick-on appliances to which they attach must be changed regularly. Sometimes an odor neutralizer and lubricant is squirted into a new pouch before it is attached. Two types of pouches are available: one disposable, and one drainable. Most pouches are opaque, and filter out air through a charcoal filter. Recommended practice is to empty such pouches when one-third full. [9] Appliances, in contrast with pouches, are usually replaced every three to seven days except in cases where their seals have broken contact with the skin, when they should be replaced immediately.[9]

Even as long ago as the 1940s, surgeons conducting a review at the Cleveland Clinic (Jones and Kehm, 1946)[10] could summarize the routine care of the permanent colostomy as usually quite satisfactory, stating that after patients recover from the initial worry prompted by the need for a colostomy, most of them learn to manage their colostomy quite well.[10] "These patients come from all walks of life and carry on their daily work as usual. One patient stated that he could see no advantage of the normal anus over a colostomy. While this may be somewhat overstated, it is true that most people with a permanent colostomy can live a useful, happy life."[10] They found that, just as in anyone else, dietary indiscretion was the usual factor in occasional bowel habit disruption.[10] This historical experience has been borne out, as today the conclusion still stands that most patients can successfully manage a colostomy as part of their activities of daily living.

Jones and Kehm preferred tissue paper as a colostomy cover (held in place with a band or garment) rather than a colostomy bag.[10] They found that irrigation of the colostomy varied with each patient's bowel habit but that most patients developed a routine of every-other-day irrigation, whereas a few needed no irrigation.[10]

Complications

Colostomy and parastomal hernia
Patient with a colostomy complicated by a large parastomal hernia, which is when tissue protrudes adjacent to the stoma tract.
Colostomy and parastomal hernia - CT
CT scan of same patient, showing intestines within the hernia.

Parastomal hernia is the most common late complication of stomata through the abdominal wall, occurring in about 48% of the patients.[11] Prolapse of bowel wall through the stoma occasionally happens and can require reoperation to repair.

Other common complication of colostomy are high output, skin irritation, prolapse, retraction, ischemia and parastomal hernia (PH).

See also

References

  1. ^ Potter et al. Canadian Fundamentals of Nursing 3rd ed.2006, Elsevier Canada.p1393
  2. ^ Potter et al. Canadian Fundamentals of Nursing 3rd ed.2006, Elsevier Canada. p1393-1394
  3. ^ "Archived copy". Archived from the original on 2015-12-10. Retrieved 2015-06-09.CS1 maint: Archived copy as title (link)
  4. ^ "Colostomy irrigation: Colostomy Guide" (PDF). United Ostomy Associations of America. Retrieved 4 February 2013.
  5. ^ Rooney, Debra. "Colostomy irrigation: A personal account managing colostomy" (PDF). Ostomy. Retrieved 7 September 2012.
  6. ^ Wax, Arnold. "What is colostomy irrigation?". WebMed. Retrieved 7 September 2012.
  7. ^ Man-uses-remote-to-control-his-bionic-bottom The Telegraph]
  8. ^ al.], senior editors, Bruce G. Wolff ... (2007). The ASCRS textbook of colon and rectal surgery. New York: Springer. p. 417. ISBN 0-387-24846-3.
  9. ^ a b Taylor, C. R., Lillis, C., LeMone, P., Lynn, P. (2011) Fundamentals of nursing: The art and science of nursing care. Philadelphia: Lippincott Williams & Wilkins, page 1327.
  10. ^ a b c d e f Jones, Thomas E.; Kehm, Ray W. (1946), "Management of the permanent colostomy" (PDF), Cleveland Clinic Quarterly, 13 (4): 198–203, PMID 20274022.
  11. ^ Paul H. Sugarbaker (2013). "Paraostomy Hernias: Prosthetic Mesh Repair". Abdominal Surgery. American Society of Abdominal Surgeons.
Circumostomy eczema

Circumostomy eczema frequently occurs after an ileostomy or colostomy in which there is eczematization or autosensitization of the surrounding skin.

Colectomy

Colectomy (col- + -ectomy) is bowel resection of the large bowel (colon). It consists of the surgical removal of any extent of the colon, usually segmental resection (partial colectomy). In extreme cases where the entire large intestine is removed, it is called total colectomy, and proctocolectomy (procto- + colectomy) denotes that the rectum is included.

Colostomy Association

The Colostomy Association is a British health charity formed in 2005 to replace the British Colostomy Association. Its goal is to represent the interests of people with a colostomy through providing support, information and advice as well as raising public awareness of life with a stoma.

Colostomy reversal

A colostomy reversal, also known as a colostomy takedown, is a reversal of the colostomy process by which the colon is reattached to the rectum or anus, providing for the reestablishment of flow of waste through the gastrointestinal tract.

Diversion colitis

Diversion colitis is an inflammation of the colon which can occur as a complication of ileostomy or colostomy, often occurring within the year following the surgery. It also occurs frequently in a neovagina created by colovaginoplasty, with varying delay after the original procedure. Despite the presence of a variable degree of inflammation the most suggestive histological feature remains the prominent lymphoid aggregates. A foul smelling, mucous rectal discharge may develop from the inflamed mucosa of the distal, unused colon.

The diagnosis cannot be safely reached without knowing the clinical story. In many milder cases after ileostomy or colostomy, diversion colitis is left untreated and disappears naturally. If treatment is required, possible treatments include short-chain fatty acid irrigation, steroid enemas and mesalazine.

Diverticulitis

Diverticulitis, specifically colonic diverticulitis, is a gastrointestinal disease characterized by inflammation of abnormal pouches—diverticula—which can develop in the wall of the large intestine. Symptoms typically include lower abdominal pain of sudden onset, but onset may also occur over a few days. In North America and Europe the abdominal pain is usually on the left lower side (sigmoid colon), while in Asia it is usually on the right (ascending colon). There may also be nausea; and diarrhea or constipation. Fever or blood in the stool suggests a complication. Repeated attacks may occur.The causes of diverticulitis are uncertain. Risk factors may include obesity, lack of exercise, smoking, a family history of the disease, and use of nonsteroidal anti-inflammatory drugs (NSAIDs). The role of a low fiber diet as a risk factor is unclear. Having pouches in the large intestine that are not inflamed is known as diverticulosis. Inflammation occurs in between 10% and 25% at some point in time, and is due to a bacterial infection. Diagnosis is typically by CT scan, though blood tests, colonoscopy, or a lower gastrointestinal series may also be supportive. The differential diagnosis includes irritable bowel syndrome.Preventive measures include altering risk factors such as obesity, inactivity, and smoking. Mesalazine and rifaximin appear useful for preventing attacks in those with diverticulosis. Avoiding nuts and seeds as a preventive measure is no longer recommended since there is no evidence these play a role in initiating inflammation in diverticula. For mild diverticulitis, antibiotics by mouth and a liquid diet are recommended. For severe cases, intravenous antibiotics, hospital admission, and complete bowel rest may be recommended. Probiotics are of unclear use. Complications such as abscess formation, fistula formation, and perforation of the colon may require surgery.The disease is common in the Western world and uncommon in Africa and Asia. In the Western world about 35% of people have diverticulosis while it affects less than 1% of those in rural Africa, and 4 to 15% of those may go on to develop diverticulitis. The disease becomes more frequent with age, being particularly common in those over the age of 50. It has also become more common in all parts of the world. In 2003 in Europe, it resulted in approximately 13,000 deaths. It is the most frequent anatomic disease of the colon. Costs associated with diverticular disease were around US$2.4 billion a year in the United States in 2013.

Elise Sørensen

Elise Sørensen (July 2, 1903 – July 5, 1977) was the inventor of the colostomy bag. Sørensen was a nurse in 1954 when her sister had an ostomy operation (a procedure that takes the end of the intestine out through the abdomen, allowing waste to exit via a surgically created stoma). After the operation, Sørensen's sister was uncomfortable going outside due to fear that stoma might leak, due to the metal/glass capsules or fabric/rubber bags that people used at the time. Sørensen then created the world's first disposable ostomy bag attachable through an adhesive ring, very similar to the devices used today.

Hartmann's operation

A proctosigmoidectomy, Hartmann's operation or Hartmann's procedure is the surgical resection of the rectosigmoid colon with closure of the anorectal stump and formation of an end colostomy. It was used to treat colon cancer or inflammation (proctosigmoiditis, proctitis, diverticulitis, etc.). Currently, its use is limited to emergency surgery when immediate anastomosis is not possible, or more rarely it is used palliatively in patients with colorectal tumours.The Hartmann's procedure with a proximal end colostomy or ileostomy is the most common operation carried out by general surgeons for management of malignant obstruction of the distal colon. During this procedure, the lesion is removed, the distal bowel closed intraperitoneally, and the proximal bowel diverted with a stoma.

The indications for this procedure include:

a. Localized or generalized peritonitis caused by perforation of the bowel secondary to the cancer

b. Viable but injured proximal bowel that, in the opinion of the operating surgeon, precludes safe anastomosis

c. Complicated diverticulitisUse of the Hartmann's procedure initially had a mortality rate of 8.8%. Currently, the overall mortality rate is lower but varies greatly depending on indication for surgery. One study showed no statistically significant difference in morbidity or mortality between laparoscopic versus open Hartmann procedure.

Hirschsprung's disease

Hirschsprung's disease (HD or HSCR) is a birth defect in which nerves are missing from parts of the intestine. The most prominent symptom is constipation. Other symptoms may include vomiting, abdominal pain, diarrhea, and slow growth. Symptoms usually become apparent in the first two months of life. Complications may include enterocolitis, megacolon, bowel obstruction, and intestinal perforation.The disorder may occur by itself or in association with other genetic disorders such as Down syndrome or Waardenburg syndrome. About half of isolated cases are linked to a specific genetic mutation and about 20% occur within families. Some of these occur in an autosomal dominant manner. The cause of the remaining cases is unclear. If otherwise normal parents have one child with the condition, the next child has a 4% risk of being affected. The condition is divided into two main types, short-segment and long-segment, depending on how much of the bowel is affected. Rarely, the small bowel may be affected, as well. Diagnosis is based on symptoms and confirmed by biopsy.Treatment is generally by surgery to remove the affected section of bowel. The surgical procedure most often carried out is known as a "pull through". Occasionally, an intestinal transplantation may be recommended. Hirschsprung's disease occurs in about one in 5,000 of newborns. Males are more often affected than females. The condition is believed to have first been described in 1691 by Frederik Ruysch.

Imperforate anus

An imperforate anus or anorectal malformations (ARMs) are birth defects in which the rectum is malformed. ARMs are a spectrum of different congenital anomalies in males and females which vary from fairly minor lesions to complex anomalies. The cause of ARMs is unknown; the genetic basis of these anomalies is very complex because of their anatomical variability. In 8% of patients, genetic factors are clearly associated with ARMs. Anorectal malformation in Currarino syndrome represents the only association for which the gene HLXB9 has been identified.

Jejunostomy

Jejunostomy is the surgical creation of an opening (stoma) through the skin at the front of the abdomen and the wall of the jejunum (part of the small intestine). It can be performed either endoscopically, or with formal surgery.A jejunostomy may be formed following bowel resection in cases where there is a need for bypassing the distal small bowel and/or colon due to a bowel leak or perforation. Depending on the length of jejunum resected or bypassed the patient may have resultant short bowel syndrome and require parenteral nutrition.A jejunostomy is different from a jejunal feeding tube which is an alternative to a gastrostomy feeding tube commonly used when gastric enteral feeding is contraindicated or carries significant risks. The advantage over a gastrostomy is its low risk of aspiration due to its distal placement. Disadvantages include small bowel obstruction, ischemia, and requirement for continuous feeding.

National Accreditation Program for Rectal Cancer

The National Accreditation Program for Rectal Cancer (NAPRC) was formed to address the differences between patient outcomes in the United States as compared to Europe. According to the American College of Surgeons, outcomes for rectal cancer patients in Europe have for years been significantly better than for those in the U.S. Characterized by the use of multidisciplinary teams to make treatment decisions, the NAPRC standards aim to decrease the average circumferential resection margins, decrease the overall colostomy rate, and increase quality of life as reported by recovering patients.

Two statistics illustrate the difference in treatment. A decade ago, the colostomy rate in Europe ranged from 25 percent to 35 percent, while today’s colostomy rate in the U.S. is about 50 percent, meaning that many more patients in the U.S. have colostomies as compared to Europeans. Rectal cancer cases in the U.S. have an average circumferential resection margins (CRMs) rate of 17 percent, significantly higher than the 3 percent to 11 percent range for European countries.

Ostomy pouching system

An ostomy pouching system is a prosthetic medical device that provides a means for the collection of waste from a surgically diverted biological system (colon, ileum, bladder) and the creation of a stoma. Pouching systems are most commonly associated with colostomies, ileostomies, and urostomies.Pouching systems usually consist of a collection pouch plastic bag, known as a one-piece system or, in some instances involves a mounting plate, commonly called a flange, wafer or a baseplate, and a collection pouch that is attached mechanically or with an adhesive in

an airtight seal, known as a two-piece system. The selection of systems varies greatly between individuals and is often based on personal preference and lifestyle. Ostomy pouching systems collect waste that is output from a stoma. The pouching system allows the stoma to drain into a sealed collection pouch, while protecting the surrounding skin from contamination.Ostomy pouching systems are air- and water-tight and allow the wearer to lead an active lifestyle that can include all forms of sports and recreation.Ostomy pouching systems are also sometimes referred to as an appliance, where the term appliance refers to a prosthesis, as a mechanical replacement for a biological function.

Pelvic exenteration

Pelvic exenteration (or pelvic evisceration) is a radical surgical treatment that removes all organs from a person's pelvic cavity. The urinary bladder, urethra, rectum, and anus are removed.

The procedure leaves the person with a permanent colostomy and urinary diversion. In women, the vagina, cervix, uterus, fallopian tubes, ovaries and, in some cases, the vulva are removed. In men, the prostate is removed.

Pouch

Pouch may refer to:

A small bag such as a Packet (container), teabag, money bag, sporran, fanny pack, etc.

Brood pouch, especially pouch (marsupial), an anatomical feature in which young are carried

Cadaver pouch, a body bag

Diplomatic pouch

Electric heating pouch, medical apparatus, electric heating device for curative treatment

Indiana pouch, a surgically created urinary diversion used to create a way for the body to store and eliminate urine for patients who have had their urinary bladders removed

Ileo-anal pouch, a surgically created intestinal reservoir

Ostomy pouching system (colostomy bag), medical prosthetic that provides a means for the collection of waste from a diverted biological system

Pouch laminator, lamination system that utilizes pouches

Retort pouch, food and drink pouch

Spout pouch, Liquid flexible packaging

Buffalo pouch, a small pouch worn on the wrist, carried from a strap around the neck, or from the waist like a fanny pack

(U+1F45D) unicode symbol "POUCH", see Emoji

Rectovestibular fistula

A rectovestibular fistula, also referred to simply as a vestibular fistula, is an anorectal congenital disorder where an abnormal connection (fistula) exists between the rectum and the vulval vestibule of the female genitalia.

If the fistula occurs within the hymen, it is known as a rectovaginal fistula, a much rarer condition.

Stoma (medicine)

In anatomy, a stoma (plural stomata or stomas) is any opening in the body. For example, a mouth, a nose, and an anus are natural stomata. Any hollow organ can be manipulated into an artificial stoma as necessary. This includes the esophagus, stomach, duodenum, ileum, colon, pleural cavity, ureters, urinary bladder, and renal pelvis. Such a stoma may be permanent or temporary. Surgical procedures that involve the creation of an artificial stoma have names that typically end with the suffix "-ostomy", and the same names are also often used to refer to the stoma thus created. For example, the word "colostomy" often refers either to an artificial anus or the procedure that creates one. Accordingly, it is not unusual for a stoma to be called an ostomy (plural ostomies), as is the norm in wound, ostomy, and continence nursing.

Total mesorectal excision

Total mesorectal excision (TME) is a standard technique for treatment of colorectal cancer, first described in 1982 by Professor Bill Heald at the UK's Basingstoke District Hospital. A significant length of the bowel around the tumour is removed, as is the surrounding tissue up to the plane between the mesorectum and the presacral fascia (Heald's "holy plane"). Dissection along this plane facilitates a straightforward dissection and preserves the sacral vessels and hypogastric nerves. It is possible to rejoin the two ends of the colon; however, most patients require a temporary ileostomy pouch to bypass the colon, allowing it to heal with less risk of perforation or leakage.TME has become the "gold standard" treatment for rectal cancer in the West.An occasional side effect of the operation is the formation and tangling of fibrous bands from near the site of the operation with other parts of the bowel. These can lead to bowel infarction if not operated on.TME results in a lower recurrence rate than traditional approaches and a lower rate of permanent colostomy. Postoperative recuperation is somewhat increased over competing methods. When practiced with diligent attention to anatomy there is no evidence of increased risk of urinary incontinence or sexual dysfunction. However, there can be partial fecal incontinence and/or "clustering" – a series of urgent trips to the toilet separated by a few minutes, each trip producing only a very small yield.It is usually combined with neoadjuvant radiotherapy.

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