lmSurgical stomas

An intestinal stoma is the surgical opening of the bowel onto the surface of the abdomen. Jejunostomy, gastrostomy caecostomy are commonly temporary while colostomy, ileostomy and urinary tract stomas are usually permanent.

Colostomies and ileostomies a) Colostomy Definition:

This is a surgical operation in which part of colon is surgically fixed onto the abdominal wall to divert stool and flatus. This is either temporary or permanent

Indications
Evacuation of stools following removal of rectum and colon (end colostomy in colorectal ca) To divert the fecal stream in preparation for resection of an inflammatory, obstructive, or perforated lesion or following traumatic injury; To protect a distal anastomosis following resection. Decompress an obstructed colon In inoperable distal tumor of colon or rectum Imperforate anus as a temporary fecal diversion awaiting definitive management Hirschsprungs disease

Classification
Temporary and Permanent or by nature of stoma (loop, double barreled and end colostomy)

Loop colostomy
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. -The loop is held in place outside the abdomen by a plastic rod slipped beneath it. -An incision is made in the loop 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. Common sites transverse colon and sigmoid attached in RUQ, LLQparaumblical,

End colostomy or terminal colostomy Hartman's colostomy

The colon is divided and the proximal end is brought out (functional part) while the distal end closed and left intra abdominal (dysfunctional part) -This is commonly done for colorectectal cancer that is not resectable.

Double barreled colostomy(Divided colostomy /Paul-Mickulicz)

Involves creation of two separate stomas on the abdominal wall by exteriorizing both ends of the divided colon. The proximal 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

Stoma management
General postoperative mgt principles should be followed. The patient is instructed on how to support the operative site during deep breathing and coughing. Counseling patient about lifestyle and occupation therapy Colostomy bags application and how often to change bags. These should be affordable and accessible Control odor by hygiene +/- perfumes Diet is individualized Skin care and colostomy irrigation Integrate in family and community Explain and treat complications and when to close in temporary colostomies

Complications of colostomy
These account for 20% of cases and 15% of these require surgical intentions Gangrene of stoma (inadequate blood supply to stoma) Stoma stenosis Retraction (inwards) Parastomal Hernia Prolapse Parastomal abscesses Infection/sepsis Skin irritation Diarrhea Fecal impaction Bleeding from granulomas Necrosis of distal end Psychological

Ileostomy
This is when part of the ileum is used to divert stools via a surgical procedure that fixes it on the abdominal wall. Ileostomy can be permanent as in proctocolectomydone in patients with Crohns disease, ulcerative colitis and Familial polyposis. Temporary ileostomy (loop) is commonly used in ileoanalanaestomosis. An ileostomy discharges small quantities of liquid all the time so no irrigation is required.

Ileostomy is normally positioned in the right lower quadrant. Effluent of an ileostomy is about 1-2L initially and this diminishes to about 500mls after 1-2 months. Patients tend to have normal serum electrolytes however intracellular stores are deficient. Patients with high output stomas require supplemental salts in their diet. Complication rate is approximately 40% though only 15% require surgical intervention. Some other complications include; Diarrhea, bad smell, urinary tract calculi (5-10%), gall stones (X 3), Ileitis.

Caecostomy
Rarely used except in moribund patients as a temporary measure when there obstruction or part of caecal wall has been damaged.