Colyte

Definition

Ostomy is a surgical procedure used to create an opening for urine or feces to be released from the body. Colostomy refers to a surgical procedure in which 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 result of treatment for 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. These temporary colostomies are removed at a later date, with restoration of normal bowel function. 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 to 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, and it has no pain sensation. 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. An incision is made in the bowel to allow the passage of stool through the loop colostomy. In the past, a plastic rod was used to hold the loop in place, and this supporting rod was removed approximately 7-10 days after surgery, when healing had occurred. The use of the plastic supporting rod is becoming less common. 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 (ECG) 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 antibiotics (neomycin, erythromycin, or kanamycin sulfate) may be given to decrease bacteria in the intestine and help prevent post-operative infection. A nasogastric tube may be 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 involves monitoring of blood pressure, pulse, respiration, and temperature. Breathing tends to be shallow because of the effect of anesthesia and the patient's reluctance to breathe deeply and experience pain 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.

Two to three days after the operation, the patient will be able to resume eating. For both open and laparoscopic resections, most patients are discharged from the hospital in five to seven days. Healing may take one to two months.

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 caregivers will be educated about 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 the patient resume 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

• 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 varies 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.

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). Usually 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.

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, glycerin 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).