Colostomy

Description
A colostomy is a surgical opening from the colon (the part of the large intestine that extends from the small intestine to the anus) to the outside of the body. When necessary, the opening serves as a temporary or permanent exit for feces to leave the body.

Anatomy
The digestive tract includes the mouth, pharynx, esophagus, stomach, and small and large intestines. The upper gastrointestinal (GI) organs digest foods and reabsorb nutrients. After digested food, fiber and water enter the large intestine, the food and fiber may be further broken down and stored to be passed later as stool. Water is absorbed in the large intestine.

Purpose/indications
A colostomy is done when disease or trauma causes the large intestine, rectum (the end of the large intestine) or anus (the outlet of the rectum) to malfunction. Conditions that may require a colostomy include:
blockage in the intestine (from scar tissue for example)
benign or cancerous tumors
inflammatory disease of the colon, such as diverticulitis (inflammation of the diverticula -- small, protruding pouches that can develop in the gastrointestinal tract)
internal injury
trauma (such as stabbings, gunshot wounds and some cases of spinal cord injury)
Less common conditions that may require a colostomy include:

certain birth defects
an incomplete connection between the large intestine and other organs
a perforated (torn) intestine
an abscess (a collection of pus) in the intestine
Sometimes an ileostomy (a surgical opening through the abdominal wall into the ileum, the lower part of the small intestine) is needed to treat ulcerative colitis or other conditions of the colon. Ulcerative colitis -- a chronic disease characterized by diarrhea, inflammation and ulcers (open sores) of the colon and rectum -- affects only the colon.

In some cases, a temporary colostomy can give the bowel a chance to heal. When appropriate, a second surgery reverses the procedure and normal bowel movements are restored. When the end of the colon or rectum must be removed due to cancer or other conditions, a permanent colostomy may be needed.


Patient preparation
Before a colostomy, take the time to prepare yourself emotionally and physically. Your doctor will explain the procedure, how it will affect your bowel movements and appearance, and how to care for yourself. The doctor or other hospital personnel may arrange a consultation with a health professional who has special training in colostomy care (typically an ostomy specialist) to help you learn about and care for your colostomy. A local ostomy support group may be able to connect you with someone close to your age who's had the same procedure. Consider asking a family member to attend educational sessions to help give you support and encouragement.
A blood transfusion will be necessary only if you lose an excessive amount of blood during the procedure. The safest blood to receive in most cases would be your own, referred to as an autologous blood transfusion. It may be possible to donate your own blood if the surgery is elective and planned several weeks in advance. Ask your doctor for details.

You'll need to sign a surgical consent form before the procedure. Your hospital may have its own standard protocol regarding routine diagnostic tests for surgical patients. Your admitting physician is responsible for ordering these tests, which may include:

blood tests, including complete blood cell count, blood chemistries, and blood type and cross match
urinalysis
a chest X-ray and electrocardiogram (a recording of the electrical activity of the heart) depending on your age and general health
You may also need other specialized tests, including:

stool testing for minute quantities of blood
barium enema (an X-ray of the bowel after you drink a solution of barium sulfate, a compound often used for gastrointestinal testing)
colonoscopy (a procedure that helps doctors see the inside of the colon with a colonoscope, a flexible tube equipped with a camera lens and light)
To help prepare for surgery, your doctor may recommend a diet of low-residue foods for a certain period of time. You may not be allowed anything by mouth the night before the procedure. In the case of emergency surgery, of course, there may not be time for the special diet or tests. In these circumstances, arrangements can be made for you to meet with an ostomy specialist and local support groups after your surgery.

You'll also want to discuss all surgical procedure options with your doctor. Sometimes, the surgeon will recommend removing the appendix during the colostomy.


Procedure
Although every surgery has its own standard procedure, your individual health history could play a role in any variation to the procedure. Discuss these issues with your doctor.
The traditional colostomy is done under general anesthesia. The type of colostomy you will have depends on several factors, including where the diseased part of the bowel is located, if you've had prior abdominal surgeries, and your general health status.

For the traditional colostomy, the doctor begins by making an incision into the abdomen to examine the bowel. A special rod and rubber tubing are used to secure the colon while the healthy tissue closest to the abdomen is stitched to the opening made in the abdomen.

The stoma, or the opening of the colon, is formed by turning the colon back on itself a little -- like folding back a sock to make a cuff. The stoma is made in a place where it can easily be cared for and there will be minimal interference with clothing. Stool will be expelled through the stoma and collected in a plastic pouch called a colostomy bag.

Types of stomas include:

End stoma: When the diseased part of the colon is removed, the colon is in two pieces. The lower section is removed or sewn shut. An opening or stoma is formed with the upper section.

Double-barrel stoma: When the diseased part of the colon is removed, both of the remaining pieces are made into stomas on the abdomen. Stool drains from the upper part of the large intestines, while mucus drains from the lower part. This type of stoma is often for temporary use.

Loop stoma: The bowel is not divided. Instead, an opening is made into the abdomen and a loop of bowel is brought through the opening and secured with a support device. An opening is made in the top part of the loop to let the bowel empty. A plastic rod holds the loop in place for seven to 10 days. This type of colostomy is usually temporary.
If the rectum is left in place, it will be stitched closed. It may still produce mucus from time to time, however.

Although every surgery has its own standard procedure, your individual health history could play a role in any variation to the procedure. Discuss these issues with your doctor.


Postprocedure care
After surgery, you'll be taken to the recovery room and frequently monitored as the anesthesia wears off and consciousness returns. With general anesthesia, nausea and vomiting are possible. Once stable, you'll be taken to your hospital room.
You will have an intravenous (IV) infusion to give you fluids, nourishment and probably medication. There will also be a tube through your nose, known as a nasogastric tube or NG tube, that extends through the esophagus and into the stomach. This may remain in place for a few days so the contents of your stomach may be suctioned out, allowing the colon to rest and heal faster.

Your doctor will discuss an individualized postoperative diet with you. Usually, clear liquids are given first. When you can eat regular foods, remember to chew thoroughly to avoid swallowing too much air.

Initially, the stoma will be red and swollen. However, the swelling should go down within a few days. The bowel should begin to function about five or six days after surgery, with overall healing taking place in one to two months. Your doctor will review specific activity restrictions, such as driving, vigorous exercise or heavy lifting.

If you have a colostomy in the descending or sigmoid part of the colon, flushing the colostomy with water may give you some control over the timing of elimination of fecal material from the stoma. If you have a colostomy in the ascending or transverse part of the colon (which are closer to the small intestine), your stool may be too watery to regulate bowel movements through irrigation. The awareness of passing gas or other signs help some people anticipate a bowel movement and go to the bathroom in time to discard the stool in the toilet. As it does with bowel movements in general, the number and frequency of bowel movements will vary with each person.

Regulating the passage of stool is easier if you carefully plan balanced meals at regular intervals and plan a regular time for irrigation and evacuation. Although nutritional deficits after colostomy are rare, the hospital's dietitian and ostomy specialist can help you plan meals to avoid any potential dietary problems.


Benefits
By providing a temporary or permanent alternative route for elimination of fecal material from the body, the colon is allowed to heal which might not otherwise have been possible. Long-term bowel symptoms may be reduced, better controlled or eliminated.

Risks
As with any surgery, there may be complications from anesthesia, infections or bleeding. The colostomy may become narrowed, blocked or extend too far from the abdomen. There may be inadequate blood and oxygen to the stoma, resulting in death of stoma tissue. The skin around the stoma may become irritated or eroded. In some cases, additional surgery is required.
The risk of surgical complications is higher if you have a chronic illness, such as heart, lung or liver disease. Other risk factors include poor nutritional status, obesity, excess alcohol or drug use, smoking, recent illness, stress and use of various prescription medications.


Considerations
When you have a colostomy, skin care is extremely important. Every day, you'll need to examine your skin, especially around the stoma where the bag is attached. If your skin becomes irritated, use a barrier gel before putting the bag in place. Once the stoma is healed, bag changes can be done every few days. Preventing leakage will reduce odor, and pouch deodorants are also available. To be on the safe side, always carry an extra bag. Your ostomy specialist or pharmacist can answer specific questions, as well as give you a list of companies to order the supplies you'll need. You may also be given the names of reputable ostomy Internet sites and information regarding ostomy groups in your area.
For most people with colostomies, a well-balanced diet and optimal fluid intake are important. Keeping a journal of what you eat and how your bowel responds may help. For example, you may want to avoid foods that cause odor, gas or diarrhea. Here are a few examples:

common odor-producing foods: vegetables from the cabbage family, alcohol, onions, fish, eggs, broccoli and asparagus
common gas-forming foods: vegetables from the cabbage family, beer, onions, carbonated beverages, beans, strong cheeses and sprouts
common diarrhea-causing foods: vegetables from the cabbage family, alcohol, coffee, spinach, spicy foods and raw fruits
If you have a problem with constipation, call your doctor. Don't take a laxative because it may cause dehydration or additional problems if you develop a blockage.

It may take several months to become adjusted to your colostomy. A colostomy should not prevent you from social activities (such as dating), or from marriage or having children, however. If your work involves heavy lifting or you enjoy heavy contact sports, consult your doctor about adjustments that may be needed. Although it may be difficult at first, self-care can help you regain your independence and sense of well-being.


Pregnancy-specific information
Your ability to become pregnant does not change if you have a colostomy. A normal pregnancy and delivery can typically be expected. If you're thinking about becoming pregnant, however, discuss with your doctor any possible health problems.

Senior-specific information
The risk for colon cancer increases with age. A colostomy may be recommended in your treatment plan if you have colon cancer. Care of the colostomy may be particularly challenging if you have poor eyesight or arthritis in your hands.