STOMA
Definition
A minute opening or pore.
An artificial opening between two cavities or canals, or
between such and the surface of the body
Indications
1. Anorectal malformations
2. Inflammatory bowel diseases such as ulcerative colitis or
Crohn's disease
3. Certain types of bowel or bladder cancer
4. An injury to your bowel
5. A problem with your kidneys, where the urine can't leave
your body (this is rare)
Types of stoma
Organ involved
Different kinds of ostomies are named for the organ
involved.
The main types of stoma are:
1. Ileostomy
An opening from the small bowel, to allow faeces to leave
the body without passing through the large bowel
2. Colostomy
An opening from the large bowel, to allow faeces to leave
the body without passing through the anus
3. Urostomy
An opening from the ureters, to allow urine to leave the
body without passing through the bladder
Duration
An ostomy may be temporary or permanent.
A temporary ostomy may be required if the intestinal tract
can't be properly prepared for surgery because of
blockage by disease or scar tissue.
A temporary ostomy may also be created to allow
inflammation or an operative site to heal without
contamination by stool.
Temporary ostomies can usually be reversed with minimal
or no loss of intestinal function.
A permanent ostomy may be required when disease, or its
treatment, impairs normal intestinal function, or when the
muscles that control elimination do not work properly or
require removal.
The most common causes of these conditions are low
rectal cancer and inflammatory bowel disease.
Care of stoma
Diet
Early: Drink plenty of fluids, especially water and fruit
juices
Eat regular meals, to help you get into a routine
Eat a healthy, balanced diet; for the first couple of months
only eat small amounts of fibre
After a few months, you should: carry on eating a healthy
balanced diet with plenty of fluids
Slowly increase the amount of fibre in your diet - this
includes fruit and vegetables, wheat cereals, and
wholemeal pasta and rice
Check with your stoma nurse or surgeon if you still need
to eat extra salt and/or potassium
With any type of stoma, you may need to eat carefully.
If you have had an ilesotomy, it's important that you chew
properly, eat high-fibre foods in small mouthfuls, and
don't eat foods that can cause blockages.
These foods include celery, nuts, coconut, mushrooms and
sweetcorn.
You can carry on eating these foods if they don't cause
you any problems, but you should only have small
amounts at first and make sure you chew them well.
This is because your ileum is narrow, and could become
blocked temporarily.
If you have had a colostomy, your nurse or surgeon may
advise you not to eat wind-producing foods such as beans,
broccoli and cabbage.
He or she may also advise you to eat slowly and not to
talk and eat at the same time, to prevent you swallowing
too much air, which could cause wind.
With all types of stoma, it's important keep up your intake
of fluids and eat foods that are rich in fibre, to make sure
you don't become constipated.
Skin care
A number of different protective pastes, membranes and
powders are available.
Traveling
It's best to carry your pouch spares in your hand luggage
when you travel by plane as gases within your bowel will
expand during the flight because of the reduced
atmospheric pressure.
You may need to carry a special certificate for carrying
your pouch spares.
If you are planning a long journey, it's best to irrigate your
pouch just before your leave, and then again when you
arrive.
Psychological support
Just as importantly, your nurse or stoma therapist will
provide support for the emotional aspects of having a
stoma.
This help will start before the operation, with your stoma
therapist working with your surgeon to decide on the best
place for your stoma so that it suits your body shape and
is in an area you can reach easily.
At some hospitals, former patients who have experience
of living with a stoma are on hand to provide information
and advice.
There are also patient support groups, which can give you
advice and support
Colostomy
A colostomy is an artificial opening made in the large
bowel to divert faeces and flatus to the exterior, where it
can be collected in an external appliance.
Depending on the purpose for which the diversion has
been necessary a colostomy may be temporary or
permanent
a) Temporary colostomy
This is most commonly established to defunction an
anastomosis after an anterior resection, to prevent faecal
peritonitis developing following traumatic injury to the
rectum or colon, and to facilitate the operative treatment
of a high fistula in ano.
It is now less commonly used for patients with distal
obstruction of the sigmoid colon as a result of carcinoma
or diverticular disease
A temporary colostomy is made bringing a loop of colon to
the surface (loop colostomy) where it is held in place by a
plastic bridge passed through the mesentery.
Once the abdomen has been closed the colostomy is
opened and the edges of the colonic incision are sutured
to the adjacent skin margin
When firm adhesion of the colostomy to the abdominal
wall has taken place, after 7 days the bridge can be
removed
A loop of colon can most easily be brought to the surface
using large bowel that has a mesentery.
Most loop colostomies are made in the transverse colon
but the sigmoid colon can also be suitable.
Following the surgical cure or healing of the distal lesion
for which the temporary stoma was constructed, the
colostomy can be closed.
It is usual to perform a contrast examination (distal
loopogram) to check that there is no distal obstruction or
continuing problem at the site of previous surgery.
Colostomy closure is most easily and safely accomplished
if the stoma is mature, that is, after the colostomy has
been established for 2 months.
Closure is usually performed by an intraperitoneal
technique which is accompanied by fewer closure
breakdowns with faecal fistulae
b) Double-barreled colostomy
This colostomy was designed so that it could be closed by
crushing the intervening ‘spur’ using an enterotome or a
stapling device.
It is rarely used now but occasionally the colon is divided
so that both ends can be brought separately to the
surface ensuring that the distal segment is completely
defuntioned
c) Permanent colostomy
This is usually formed after excision of the rectum for a
carcinoma by the abdominoperineal technique
It is formed by bringing the distal end (end colostomy) of
the divided colon to the surface in the left iliac fossa,
where it is sutured in place joining the colonic margin to
the surrounding skin
The best site is usually through the lateral edge of the
rectus sheath, 6 cm above and medial to the bony
prominence
An important point after the colostomy has been made is
to close the lateral space between the intraperitoneal
segment of the sigmoid colon and the peritoneum of the
pelvic wall, to prevent internal herniation of strangulation
of loops of small bowel through the deficiency.
Alternatively a retroperitoneal tunnel for the colostomy
avoids creating lateral space
Colostomy bags and appliances
Faeces from a permanent colostomy are collected in
disposable adhesive bags.
A wide range of such bags is currently available.
Many now incorporate a stomahesive backing, which can
be left in place for several days
Complications of colostomies
The following complications can occur to any colostomy
but are more common after poor technique:
1. Prolapse
2. Obstruction
3. Infection
4. Skin irritation
5. Retraction
6. Necrosis of the distal
7. Stenosis of the orifice
8. Colostomy hernia
9. Bleeding (usually from granulomas around the
margin of the colostomy);
10. Colostomy ‘diarrhoea’: this is usually an infective
enteritis and will respond to oral metronidazole 200
mg three times daily.
Many of these complications require revision of the
colostomy.
Sometimes this can be achieved with an incision
immediately around the stoma but on occasion reopening
the abdomen and freeing up the colostomy may be
necessary.
Occasionally transfer to the opposite side of the abdomen
may be necessary
Loop ileostomy
An ileostomy is used by some surgeons as an alternative
to colostomy, particularly for defunctioning a low rectal
anastomosis.
The creation of a loop ileostomy from a knuckle of
terminal ileum has already been described.
The advantages of a loop ileostomy over a loop colostomy
are the ease with which the bowel can be brought to the
surface and the absence of odour.
Care is needed, when the ileostomy is closed, that suture
line obstruction does not occur
Caecostomy
In desperately ill patients with advanced obstruction, a
caecostomy may be useful.
In late cases of obstruction the caecum may become so
distended and ischaemic that rupture of the caecal wall
may be anticipated.
This can occur spontaneously giving rise to faecal
peritonitis or at operation when an incision in the
abdominal wall reduces its supportive role and allows the
caecum to expand.
In such a situation it should be decompressed by suction
as soon as the abdomen is opened.
In thin patients it may then be possible to carry out direct
suture of the incised or perforated caecal wall to the
abdominal skin of the tight iliac fossa, although a
resection of this area is really the best treatment.
Following on-table lavage, via the appendix stump the
irrigating catheter can be left in place as a tube
caecostomy.
Caecostomy is only a short-term measure to allow a few
days for the condition of the patient to improve.
Reoperation should normally follow fairly soon thereafter
and a proper surgical procedure carried out