Golytely

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 colsotomy 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
• 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). Uusually 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, 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).

Further Reading

For Your Information

Books

• Doughty, Dorothy. Urinary and Fecal Incontinence. St. Louis: Mosby-Year Book, Inc., 1991.
• Hampton, Beverly and Ruth Bryant. Ostomies and Continent Diversions. St. Louis: Mosby-Year Book, Inc., 1992.
• Monahan, Frances. Medical-Surgical Nursing. Philadelphia: W. B. Saunders Company, 1998.
• Suddarth, Doris. The Lippincott Manual of Nursing. Philadelphia: J. B. Lippincott, 1991.

  Organizations

• United Ostomy Association, Inc. 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (714)660-8624 or (800)826-0826, Fax:(714)660-9262. uoa@deltanet.com. hhtp://www.uoa.org.
• Wound Ostomy and Continence Nurses Society. 2755 Bristol Street, Suite 110, Costa Mesa, CA 92626. (714)476-0268. http://www.wocn.org.

  Other

• Colostomy. www.thriveonline.com (20 April 1998).

Gale Encyclopedia of Medicine. Gale Research, 1999.