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Reasons why :
Topics to be discussed :
Stoma :
1.
2.
3.
4.
5.
STOMA
Gastrostomy
Jejunostomy
Ileostomy Physiology
IIeostomy Output :
Day 1-3 : bilious, liquid,
each day output
Day 3-5 : output stabilizes,
slightly
6-8 weeks : steadily ,
200 - 700 ml/day
Correlation with body mass :
- 40 kg : effluent 300 - 400 ml/d
- 80 kg : effluent 800 ml/day
4 - 6 months post op :
- volume varies little
- porridge like
- yellow - brown
- food particles
Ileostomy Physiology
Nutrients are readily absorbed from small intestine
< 100 cm terminal ileal resection :
Bacteriological environtment :
Ileostomy Patients
Adaptation
Slowing small bowel transit time
Gastrointestinal Transit After Proctocolectomy
Control
Ileostomy
Parameter (min ) ( n = 8 )
(n=5)
p value
______________________________________________________
Gastric emptying
120 22
109 10
NS
Small bowel transit 243 32
348 12
0.01
______________________________________________________
<
Colostomy Physiology
Ileal content Colon :
Efficient absorption
Colostomy Physiology
Colostomy begins to function :
- output is liquid
- steadily increases in volume
- expelled : irregular
After 10 - 14 days :
- effluent : quite viscous
Slowly a pattern of stool evacuation
develop more predictable
Proximal Colostomy
Right colon :
- mixing
- water & electrolyte
absorption
Ascending or proximal
transverse colostomy :
- effluent :
high volume liquid
- high Na
- expelled :
frequent & irregular
Middle Colostomy
Distal Transverse &
Descending
Colostomies :
- volume <
- less liquid
Distal Colostomy
Sigmoid Colostomy :
Permanent colostomy
- Sigmoid
- Descending Colon
Permanent colostomy
in Transverse or
Ascending colon :
strongly consider
Preoperative
Considerations
Ostomy Triangle
Patient Attitudes :
- education &
counseling
Anatomical
considerations :
- can be visualized by
the patient
- 5 - 7 cm skins area
remains relatively
flat
- rectus muscle
- below belt line
Preoperative
Considerations
Enterostomal Therapist
ETN :
- provide specific information
regarding stoma appliances, dietary &
clothing, & pouch management
- help select the appropriate abdominal
wall for the stoma
Preop Considerations
Appropriate stoma placement :
postop complications :
ostomates well being
Bass 1997 :
Stomas Sites
QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Wheelchaired patient :
- marked while in the chair
Complex case :
- after siting, leave stoma bag in place
for 24 hours
Types Of Ostomies
1. End Ileostomy
End Ileostomy
Loop Ileostomy
End-loop ileostomy
End Ileostomy :
Technique
End Colostomy :
Technique
Hartmanns
procedure
Abdominoperineal
resection
Loop Colostomy :
Indication & Technique
Created to prevent the fecal stream reaching
obstructing tumour
End-Loop Stoma
Diverting stoma to divert the fecal
Benefits :
Make stoma management easier
Can be created with remote sections of intestine :
end loop ileotransverse colostomy
Do not require formal laparotomy for stoma take
down
Loop Colostomy :
Technique
Double Barrelled
Colostomy
Postoperative
Management
Wound Healing :
The process by which a damaged
tissue is restored, as closely as
possible to its normal state.
Local
Factors
Extent of damage
General state of health
Systemic
Factors
Tissue is viable
No Foreign Bodies
Wound Problems =
Barriers
1. Necrotic Tissue
2. Bacterial Infection
3. Exudate
Necrotic Tissue
Debridement
2.
3.
Exudate
Moisture Control
Facilitate Healing
1. Debridement
= The removal procedure of
Procedure of removal:
Surgical,
Mechanical,
Chemical,
Autolytic
Surgical Debridement
Sharp debridement uses a scalpel, scissors, or
Surgical Debridement
Non vital tissue breaks into parts of what it
LPC
Inflammation
Inflammatory mediator
Surgical Debridement :
General Consideration
Bedside
Minor sized, superficial
No anesthesia or
local anesthesia
Control of hemostatic <
Effectiveness <
Low cost
Operating theater
Deep
General anesthesia
Good lighting for best
assessment and
evaluation
Control of hemostatic >
Effectiveness >
High cost
Mechanical Debridement
Saline-moistened dressing is allowed to dry
Chemical Debridement
The use of certain enzymes and other compounds
Enzymatic Debridement
Traditional Collagenase :
- Bromelain : nanas
- Papain
: papaya
- Maggots
Maggots Therapy
Autolytic Debridement
Autolytic debridement takes advantage of the
2. Bacterial Load
Management
Antibiotic ?
Antiseptic ?
Observed
Bacterial count
No host reaction
Local
antimicrobial
treatment
Systemic
antibiotics and
local antimicrobial
treatment
Critically colonised
Contaminated
Colonised
Infected
3. Moisture Control
Moist wound healing is twice as fast as