Colyte

Definition

A colostomy is a surgical procedure that brings a portion of the large intestine through the abdominal wall to carry feces 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 to form a stoma (an artificial opening) by cuffing the intestine back on itself and suturing the end to the skin. 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 colostomy, 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, 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 placed 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 seven to 10 days after surgery, after healing has occurred that will prevent the loop of bowel from retracting into the abdomen. A loop colostomy is most often performed for the creation of a temporary stoma to divert stool away from an area of intestine that has been blocked or ruptured.

Preparation

The physician will outline the procedure, possible side effects, and what the patient may experience after surgery. The physician or an enterostomal therapist will explain the general aftercare to the patient before surgery, so the patient has all of the information necessary to make an informed decision about surgery and medical care.

Blood and urine studies, along with various x rays and an electrocardiograph (EKG), may be ordered as necessary. If possible, the patient should visit an enterostomal therapist, who makes the decision about the appropriate place on the abdomen for the stoma and who offers pre-operative education on colostomy management.

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. 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 prescribed to decrease bacteria in the intestine and help prevent post-operative infection. On the day of surgery or during surgery, a nasogastric tube is inserted into the nose to connect it to the stomach to remove gastric secretions and prevent nausea and vomiting. A urinary catheter may also be placed to keep the bladder empty during surgery, giving more space in the surgical area and decreasing the risk of accidental injury.

Preparation

Post-operative care for the patient with a new colostomy involves monitoring of blood pressure, pulse, respirations, and temperature. 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 to 48 hours after surgery, the colostomy will drain bloody mucus. Fluids and electrolytes are infused intravenously until the patient's diet 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 eight to 24 hours after surgery and discharged in two to four days.

A colostomy pouch or bag will generally have been placed on the patient's abdomen, around the stoma, during surgery. During the hospital stay, the patient and the caregivers will be educated on how to care for the stoma and the colostomy bag. 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. Patients will be instructed in daily irrigation of the stoma about seven to 10 days after surgery. This results in the regulation of bowel function. Some patients with colostomies may need only a dressing or cap over the stoma and do not wear a colostomy pouch. Often, an enterostomal therapist will visit the patient at home after discharge to help with the patient's resumption of normal daily activities.

Complications

Potential complications of colostomy surgery include:

• excessive bleeding

• surgical wound infection

• thrombophlebitis (inflammation and blood clot in veins in the legs)

• pneumonia

• pulmonary embolism (blood clot or air bubble in the lungs' blood supply)

• cardiac stress due to allergic reaction to the general anaesthetic

• if the colostomy becomes blocked

• if the stoma extends too far out from the abdomen, presenting the potential for physical damage or infection

The physician should be made aware of any of the following problems after surgery:

• increased pain, swelling, redness, drainage, or bleeding in the surgical area

• flu-like symptoms such as 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:

• Necrosis (death) of stomal tissue. Caused by inadequate blood supply, this complication is usually visible 12 to 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 the 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, this 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, this is associated with infection around the stoma or scarring. Mild stenosis can be removed under local anesthesia, while severe stenosis may require surgery for reshaping the stoma.

• Parastomal hernia (bowel causing bulge in the abdominal wall next to the stoma). Usually, this is due to placement of the stoma where the abdominal wall is weak or the creation of an overly large opening in the abdominal wall. The use of a colostomy support belt and special pouching supplies may be adequate. If severe, the defect in the abdominal wall should be repaired surgically, and the stoma moved to another location.

Psychological complications may result from colostomy surgery because of the fear of the social stigma attached to wearing a colostomy bag. Patients also may be depressed and have feelings of low self-worth because of the change in their lifestyle and their appearance. Some patients may feel sexually unattractive and may worry that their spouse or significant other will no longer find them desirable. Counseling and education regarding surgery and the inherent lifestyle changes are often necessary.

Results

Complete healing is expected without complications. The period of time required for recovery from the surgery may vary, depending on 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.

Health care team roles

A team of doctors, surgeons, specialists, technicians, and nurses are involved in the care of a patient who has a colostomy. While the skills of each health care provider are necessary, it is education and support that may be the most critical in affecting a successful outcome for the patient. Understanding what is involved in the procedure, what the results will be, and the ramifications of the surgery outcome are all considerations for the patient in order to make informed decisions. A thorough understanding of the implications of the surgical procedure and trust in the medical team enable the patient to face the change in lifestyle in a more positive fashion.

Key Terms

Diverticulum

Pouches that project off the wall of the intestine.

Embolism

Blockage of a blood vessel by any small piece of material traveling in the blood.

Enema

Insertion of a tube into the rectum to infuse fluid into the bowel and encourage a bowel movement.

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 feet (6 m) long; the large intestine is about 5 feet (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).