Colostomy – Indications, Contraindications

A stoma is the exteriorization of a loop of bowel from the anterior abdominal wall, done during a surgical procedure. It is done for diversion or decompression of the remaining bowel.

A colostomy is a type of stoma in which the colon? (ascending/transverse/descending/sigmoid) is exteriorized. This may be done to treat disease or to relieve an obstruction or to prevent the remaining bowel from contamination by fecal matter.

It may be temporary or permanent, depending on the indication? for which it was performed. Most stomas are incontinent, which means that there is no voluntary control over the passage of flatus and feces from the stoma.

This makes colostomy care a mandatory procedure after colostomy creation. Colostomy care, as the name suggests, is an all-encompassing term referring to colostomy management, from its creation to peristomal skin management, to colostomy appliance application and mental health management while dealing with a colostomy.

The purpose of colostomy care is for skin protection and care for patient acceptance and to prevent stoma-related complications.[rx][rx]

Anatomy? and Physiology

The large bowel starts at the cecum?, moves up to the ascending colon with the hepatic flexure, the transverse colon with the splenic flexure, the descending colon, and the sigmoid colon. As the content moves through the colon, it gets firmer inconsistency as a result of water and electrolyte absorption in the large bowel.

The most common type of colostomy is the sigmoid colostomy followed by the transverse colostomy while ascending and descending colostomies are rare and hardly performed.

There are different types of colostomies, including loop colostomy, double-barrel colostomy, and end colostomy. The different types of colostomies are created depending on the indication, length of the mesocolon, and amount of diseased and remaining normal bowel.

The content of effluent in the different types of colostomies varies from soft and loose, foul-smelling, oatmeal-like stool in the ascending and transverse colostomies to firmer, paste-like stool from the transverse and descending colostomies, to output resembling normal stool from a sigmoid colostomy. As the stool gets firmer along the colon, the output becomes easier to manage.

Colostomies are generally made in the anterior abdominal wall over the rectus abdominis muscle to either side of the linea alba, generally inferior to the umbilicus. Occasionally the site is cephalad to the umbilicus, particularly in obese patients, as the anterior abdominal wall has less subcutaneous fat in the upper part. During the procedure, a circular incision is created over the pre-identified stoma site. It needs a flat surface on the abdomen? of at least 2 to 3 inches and should be away from the beltline, any scars, as well as bony prominences to ensure a secure seal of the stoma appliance. The incision is deepened onto the anterior rectus sheath, which is incised in a cruciate fashion.

The rectus muscle is retracted sideways, without cutting into the muscle itself, and the posterior rectus sheath is again incised in a cruciate manner. The loop of the bowel that is identified for the stoma creation is pulled through the incision and exteriorized onto the skin. The identification of the bowel is aided by performing a diagnostic laparoscopy to ensure good mobility and reach the anterior abdominal wall without tension. However, the stoma can also be created in a trephine manner without a laparoscopic approach. It is important to consult cross-sectional imaging to pre-identify the most mobile segment of the bowel and mark the colostomy site in accordance. A transverse colostomy should be fashioned in the left upper quadrant, a sigmoid colostomy in the left iliac fossa.

Once it is exteriorized, a stoma rod can be eased through the mesocolon to reduce the risk of retraction into the abdominal cavity?. The colon is incised three-quarters of the circumference and the bowel edges fixed to the skin with interrupted sutures using an absorbable suture material and raising the stoma above the skin level slightly. In contrast to an ileostomy, colostomies generally do not require eversion and 3-point fixation, owing to the content having less enzymatic action.[rx]

Indications

The indications of a colostomy are divided on the basis of the type of colostomy:

A double-barrel colostomy is a type of colostomy done after bowel resections involving the mesentery and is done in conditions like colorectal cancers, after resection of gangrenous bowel segments, inflammatory bowel disease?, penetrating bowel injuries or after resection of gangrenous sigmoid volvulus.

A loop colostomy may be done in case of penetrating abdominal injury, colorectal cancer, intraoperative bowel injury, perineal injury, a diverticular disease with obstruction, blunt abdominal injury, protection of a distal anastomosis, anal incontinence? or perineal injury, Fournier gangrene involving the perianal region and perianal fistulas. They may also be done in case of anorectal malformations or Hirschsprung disease in the neonatal? population as a temporary emergency? measure before correction surgery can be performed.

An end colostomy, after the Hartmann procedure, is the most common type of colostomy worldwide. It is done in case of gangrenous sigmoid volvulus, colorectal cancer after abdominoperineal resection, also-sigmoid knotting, penetrating abdominal injury, ulcerative colitis?, intussusception, anastomotic leak, anorectal cancer, and perineal injury. It involves the closure of the distal segment with fixation to the abdominal wall. Stomal closure, in this case, requires midline exploration and is hence least preferred in case colostomy is planned as a temporary measure, when there is an adequate distal segment, but this is a rare scenario.[rxrx[rx][rx]

Contraindications

There are no contraindications to colostomy creation. They are often required when anastomosis cannot be achieved due to the emergency nature of the surgery or when the patient is not adequately nourished with inadequate serum albumin and protein levels. Likewise, when there is an inadequate length of bowel or mesentery after resection or the possibility of excessive tension at the anastomosis site.

Colostomy care must be done in all cases of colostomy. Some procedures like irrigation or enema should be avoided in case of stoma prolapse, chemotherapy?, pelvic or abdominal radiation treatments, diarrhea?-producing medication, or in case of an irregular functioning stoma and may lead to dependence.[rx][rx]

Equipment

Managing a colostomy is generally done by a nurse or an entero-stomal therapist, but providers should be aware of the condition of the stoma in case intervention may be required.

There are different types of colostomy bags or appliances available, depending on the type of stoma. The 2-piece system consists of a base plate attached to the skin with a removable ostomy bag. Although it is very durable and long-lasting, it requires an amount of skill to use and has a weaker adhesive, and does not fit very well. The one-piece system consists of a single unit wherein the skin barrier and the pouch are joined. It is simpler to use but must be replaced every 1 to 3 days. The closed pouch system is generally used by patients who have a constant elimination pattern and have to be discarded after a single use.

The open-ended pouches are also commonly used and consist of a single piece attached to the skin around the stoma with a drainable pouch and can be left attached to the skin while removing stomal content. Generally in a colostomy, as compared to an ileostomy, a closed bag must be required, unless the content is excessively fluid, when a drainable bag may also be used. In an end colostomy, like after a Hartmann procedure, a colostomy plug can also be used.

Differently sized bags are available, and they may be used by different people or by the same person at different times during the day or during different activities. For example, a larger-sized bag may be used while sleeping at night, whereas a smaller-sized bag may be used during sexual activity or while exercising. Pediatric-sized stoma bags are also available.

Stoma caps are like lids applied over the stoma. They may be worn by certain people like those with continent ileostomies or those who require stomal irrigation for movement at their discretion, for short intervals during the day.[rx]

Personnel

Stoma care begins in the elective setting before the actual surgery and stomal creation. It begins when the patient is diagnosed and informed about the possibility of stoma creation. It requires mental health and guidance counselors to address any concerns the patient may have about their self-image and societal status. It also requires an entero-stomal therapist to discuss with the surgeon the location of the possible creation of the stoma and to go on and mark the colostomy site in the preoperative period.

In the immediate postoperative period, the colostomy may need dilatation and application of hyperosmotic agents like glycerine by the nursing staff so as to reduce stomal edema?.

When the stoma becomes functional, generally between postoperative days 2 and 4, the colostomy will need a colostomy bag or appliance application. In the initial days, it is either done by the nursing staff or in larger hospitals, by an entero-stomal therapist. This is done with a view to teaching patients or in case of children, their guardians, how to do it themselves at home. They are informed about the various devices available, about the functioning of these devices, about their own colostomy and the kind of effluent that would be seen, about the complications of the stoma and the colostomy bags.

The most important person involved in colostomy care is the patient himself. Once the patient is discharged from the hospital, they are in charge of their own colostomy care. The patient must regularly change their colostomy bag as required and should visit the provider regularly to assess the stoma in the normal run, or in case of any complications. As a rule, the stoma bag should be emptied when it is filled up to 1/3rd to prevent peeling off of the baseplate from the skin and leaks.[rx]

Preparation

Marking of the stoma preoperatively by an entero-stomal therapist helps to place the stoma in an appropriate location away from the beltline and away from folds of skin on the anterior abdominal wall to prevent repeated colostomy bag peel-off and leak.

A nasogastric tube may be placed in the pre or intraoperative period for bowel decompression, and a Foley catheter must also be placed to keep the bladder? empty to prevent intraoperative injury and also to monitor urine output, especially during emergency procedures.

Mechanical bowel preparation may or may not be done, depending on the indication and the surgeon’s preference.

Antibiotics must be given just prior to the surgery.

For colostomy care preparation, a nurse or attendant is equipped with all the required equipment, including the appliance, the paste, and the scissors. A Macintosh sheet is placed under the patient, and gloves are worn.

Technique

The colostomy appliance should be changed every 5-7 days, depending on the appliance. Patients generally do this themselves or with the help of the primary caregiver, or parent in case of children. Any case of skin breakdown or skin irritation or difference in stomal appearance should be seen by a health worker.

Before starting the procedure, all supplies should be arranged, and handwashing and donning of gloves should be done. The used stoma bag should be first emptied of all content, and then the flange removed by gentle traction on the bag or flange towards the stoma with counter-traction on the skin. An adhesive remover may also be used. The stoma and parastomal area should be gently cleaned with water, dabbed rather than scrubbed, without using soap. The stoma should be assessed and must be moist, above skin level, and pink to red in color, and the peristomal skin should be normal. Any deviation from this should be notified to the surgeon. The stoma should be measured, or the previous measurement remembered and size should not be more than 1/16-1/8.

The peristomal skin should be dried appropriately to allow good seal formation. Adhesive pastes or powders may also be applied personally. The paper cover on the back of the flange is then removed with the border tape in place. It is then placed around the stoma and held in place for 1 to 2 minutes to create an adequate seal. If it is a 2-piece bag, the bag is then clipped onto the flange. A belt may be applied around the abdomen and clipped to the sides of the flange to hold it in place. After this, safe disposal of the stoma bag, handwashing, and documentation of the procedure must be done.

Another integral aspect of colostomy care is mental health support through a thorough assessment? of the patients’ psychomotor status as to how they are coping and dealing with the stoma. Poor body image perception, sexual dissatisfaction, and depression are common in patients with colostomies. Reassurance, psychiatric, and behavioral counseling may be needed to alleviate these symptoms.