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  1. 1. Dr Phillipo Leo Chalya MD, M.Med (Surg) Senior Lecturer – Department of Surgery CUHAS-Bugando COLOSTOMY
  2. 2. Leaning objectives  Definition  Indications  Classifications  Colostomy formation  Colostomy care  Colostomy closure  Complications of colostomy and its closure  Conclusion
  3. 3. DEFINITION  A colostomy is a surgical procedure that brings a portion of the large intestine through the anterior abdominal wall to divert faeces and flatus to the exterior, where it can be collected in an external appliance (colostomy bag)
  4. 4. INDICATIONS  Congenital diseases  Acquired diseases
  5. 5. Congenital diseases  Ano-rectal malformations (ARM)  Hirschsprung ‘s disease  Intestinal Atresia, Stenosis and Webs  Meconium ileus  Intestinal malrotation
  6. 6. Acquired diseases  Traumatic  Neoplastic  Inflammatory  Mechanical  Vascular  Surgical  Others
  7. 7. Traumatic  Penetrating colonic or ano- rectal injuries
  8. 8. Neoplastic  Colorectal cancer  Anal cancer
  9. 9. Inflammatory  Inflammatory bowel diseases  Necrotizing Enterocolitis  Diverticular disease
  10. 10. Mechanical  Intestinal obstruction e.g. Sigmoid Volvulus
  11. 11. Vascular  Gangrene of part of colon due to strangulation or interference with its blood supply
  12. 12. Surgical  Protecting an anastomosis after bowel resection
  13. 13. Other indications  High fistula in ano
  14. 14. CLASSIFICATION  According to the purpose  According to the function  According to the site/location  According to the type of colostomy  According to the nature of operation
  15. 15. According to the purpose  Temporary colostomy  Permanent colostomy
  16. 16. Temporary colostomy  Temporary colostomies are created to divert stool from injured or diseased portions of the large intestine, allowing rest and healing and later closed to maintain the bowel continuity  Commonly loop or double barrel colostomies
  17. 17. Permanent colostomy  Permanent colostomies are performed when the distal bowel (at the farthest distance) must be removed or is blocked and inoperable  Permanent colostomy are usually formed after resection of the rectum for a carcinoma by the abdominoperineal technique [APR]  They are usually end colostomy
  18. 18. According to the function  Decompressing colostomy  Defunctioning /diverting colostomy
  19. 19. Decompressing colostomy  Intended to decompress the colon  It does not completely defunction the bowel as some faeces can travel into the distal loop  It is inadequate in conditions in which defunctioning is essential  Example of this is a loop colostomy
  20. 20. Defunctioning /diverting colostomy  Intended to defunction or to divert the colon i.e. to prevent faecal material traveling into the distal segment  In this case the bowel is transected and the two ends [proximal and distal ends] need to be separated  Include end , spectacle or double-barrel colostomy
  21. 21. According to the site/location  Transverse colostomy  Sigmoid colostomy  Caecostomy
  22. 22. According to the type  Loop colostomy  Double – barrel colostomy  End colostomy  Spectacle colostomy
  23. 23. Loop colostomy  This colostomy is created by bringing a loop of bowel through an incision in the abdominal wall  A loop colostomy is made by bringing a loop of colon to the surface, where it is held in place by a plastic bridge passed through the mesentery
  24. 24. Double – barrel colostomy  The bowel is transected and the two ends are brought together through one incision  The proximal end is the functional end that is connected to the upper GI and will drain stool; the distal stoma, connected to the rectum and also called a mucous fistula, drains small amounts of mucus material
  25. 25. End colostomy  The functioning proximal end of the intestine is brought out onto the surface of the abdomen, forming the stoma (colostomy)  The distal portion of bowel (now connected only to the rectum) may be removed, or sutured closed and left in the abdomen
  26. 26. Spectacles colostomy  The proximal and distal limbs are separated by small bridge of skin  The two limbs are opened through a separate skin incision  With the introduction of end colostomy with Hatmann procedure, spectacles colostomy is no longer performed
  27. 27. According to the nature of operation  Emergency colostomy  Elective colostomy
  28. 28. CLOSTOMY FORMATION  Principles of colostomy formation  Pre-operative care  Intra-operative care  Post-operative care
  29. 29. Principles of colostomy formation  The colostomy site should be selected to avoid fat folds, scars, umbilicus and bony prominences  The colostomy should be brought through a separate skin incision and not through a laparotomy incision  Tension on the mesentery should be avoided during construction of a colostomy i.e. the bowel should be mobile enough to be brought through the abdominal wall
  30. 30. Pre-operative care  Colostomies are created in both elective and emergency settings  Pre-operative care in involves:-  Counseling  Correction of intercurent infections, anemia and other co- morbid conditions  Bowel preparation  Pre-anesthetic visit  Signing of a written informed consent  Enterostomal therapist visit
  31. 31. Counseling  Colostomy is a frightening procedure and exposes the patient and her/his family to psychosocial trauma  Adequate counseling should be part and parcel of the entire management strategy to enable the patient and his/her family to cope with the stress and to adjust their life styles  A physician, enterostomal therapist, or nurse specialist should counsel the patient undergoing elective colostomy as well as their families  This psychological preparation reduces their anxiety and makes postoperative management easier  The patient should be counseled properly on how to live with a colostomy and how to take care of it
  32. 32. Correction of associated disease conditions  Intercurent infections [e.g. chest infections, diarrhoea], anemia and other pre-existing conditions should be controlled before surgery
  33. 33. Bowel preparation  Preoperative bowel preparation is important to avoid colostomy-related complications  This include:-  Mechanical bowel preparation  Enema  Nasogastric tube on the day of operation or intraoperatively to remove gastric secretions and prevent nausea and vomiting  Dietary management  Low residue diet for several days prior to surgery  A liquid diet may be ordered for at least the day before surgery, with nothing by mouth after midnight  Pharmacological management  Oral anti-infectives (neomycin, erythromycin, or kanamycin sulfate) may be ordered to decrease bacteria in the intestine and help prevent postoperative infection
  34. 34. Pre-anesthetic visit  This should be done to be able to assess the patient’s general condition and fitness for surgery and anesthesia
  35. 35. Written informed consent  As with any surgical procedure, the patient will be required to sign a consent form after the procedure is explained thoroughly
  36. 36. Enterostomal therapist visit  If possible, the patient should visit an enterostomal therapist, who will mark an appropriate place on the abdomen for the stoma and offer preoperative education on colostomy management
  37. 37. Intra-operative care  This depends on the pathology, purpose, site/location and type of the colostomy
  38. 38. Post-operative care  Like in any major surgery postoperative care for the patient with a new colostomy, involves:-  Fluids and electrolytes are infused intravenously until the patient's diet can gradually be resumed, beginning with liquids [usually up to 72 hrs]  The nasogastric tube will remain in place, until bowel activity resumes  For the first 24–48 hours after surgery, the colostomy will drain bloody mucus  Analgesics to relieve pain  Antibiotics given parenterally  Monitoring of blood pressure, pulse, respirations, and temperature [vital signs]  A colostomy pouch will generally have been placed on the patient's abdomen around the stoma during surgery
  39. 39. COLOSTOMY CARE  Psychological care  Mechanical care  Dietary care  Gas and odor care  Peristomal skin care  Pharmacological care
  40. 40. Psychological care  Counseling should continue during treatment and follow up to enable the patient to cope to their life style  Often, an enterostomal therapist will visit the patient in the hospital or at home after discharge to provide counseling and to help the patient with stoma care
  41. 41. Mechanical care  Use of colostomy bags [pouches]  Colostomy irrigation [i.e. putting a fluid into the stoma to empty the bowel]also called colostomy enema
  42. 42. Dietary care  Dietary counseling is necessary for the patient to maintain normal bowel function and to avoid constipation, impaction, and other discomforts  Need to avoid foods that cause gas and odor e.g. fish, onions, garlic, broccoli, asparagus, and cabbage produce odor
  43. 43. Gas and odor care  Limit foods such as broccoli, cabbage,onions, fish, and garlic in diet to help reduce odor  Each time you empty your pouch, carefully clean the opening of the pouch, both inside and outside, with toilet paper  Rinse your pouch one or two times daily after you empty it  Add deodorant (such as Super Banish or Nullo) to your pouch.  Use air deodorizers in your bathroom
  44. 44. Care of peristomal skin  Local irritation, skin excoriation, and yeast infections can be treated with appropriate topical medication and skin care  Protect skin from effluent using:-  Wafers eg Duoderm, Coloplast  Pastes eg Karaya, Softpaste  Lotions eg Cavilon,Dansac- use as spray or spread  Powders e.g. Orahesive- removes fluid from moist skin  Stoma bags
  45. 45. Pharmacological care  Once the colostomy has been established no pharmacological treatment is required  Pharmacological care is reserved in case of complications e.g. colostomy diarrhoea, wound infections, constipation etc
  46. 46. COLOSTOMY CLOSURE  Prerequisites of colostomy closure  Timing of colostomy closure  Preoperative preparation  Types of colostomy closure  Post operative care
  47. 47. Prerequisites of colostomy closure  The following must be taken into account before closing a colostomy:-  The original reason for the colostomy  Whether the patient is able to undergo more surgery  Patient’s general condition  The presence of stoma-related complications  Colostomy closure should be performed when the patient has recovered from original operation, his general condition is good and his colostomy wound is healthy
  48. 48. Timing of colostomy closure  Timing of colostomy closure depends on factors such as:-  the underlying disease  the general medical condition of the patient  the presence of colostomy-related complications  The state of the colostomy wound  Understanding the anatomy prior to colostomy closure is crucial  Colostomy closure usually done in 2-6 weeks when the colostomy wound is healthy and the patient has recovered from his original operation
  49. 49. Preoperative preparation  The patient should be prepared as for any other major surgery  The general condition of the patient and his colostomy wound should be assessed for fitness to surgery  Enema to his proximal and distal ends for 2-3 days before surgery to washout his gut   Magnesium sulphate to help empty his proximal gut and to make sure that the next feces he passes is soft  Neomycin, metranidazole may be given perioperativelly
  50. 50. Types of colostomy closure  Extraperitoneal colostomy closure  Intraperitoneal colostomy closure
  51. 51. Extraperitoneal colostomy closure  Colostomy closure without need to open the abdomen  It is easy and avoids the risk of contaminating the peritoneal cavity  Only applied to loop and double-barrel colostomies
  52. 52. Intraperitoneal colostomy closure  The colostomy is closed by opening the peritoneal cavity  Difficulty procedure as laparotomy is needed in order to close the colostomy  It has high risk of contaminating the peritoneal cavity
  53. 53. COLOSTOMY COMPLICATIONS  Complications related to colostomy formation  Complications related to colostomy closure
  54. 54. Complications of colostomy formation  Skin irritation  Colostomy necrosis  Colostomy bleeding  Colostomy prolapse  Colostomy retraction  Colostomy stenosis  Parastomal hernia  Intestinal obstruction
  55. 55. Skin irritation  Skin irritation and infection are the most common complications with colostomy  Excoriation from stoma effluent, candidal infection and dermatitis are frequent  Improper location or construction of the stoma and poor stoma care are often responsible  Local wound care and patient or caretaker education often corrects the problem
  56. 56. Colostomy necrosis  This is death of the colostomy tissue  Caused by inadequate blood supply, this complication is usually visible 12–24 hours after the operation  Usually requires additional surgery
  57. 57. Colostomy bleeding  Minor bleeding can occur with overly vigorous stomal cleansing  Major bleeding from the stoma itself is uncommon and usually indicates either a stomal laceration from a poorly fitting appliance or the development of peristomal varices in the patient with portal hypertension  Initial management of stomal bleeding involves direct pressure and AgNO3 cauterization or suturing of the bleeder if required  Definitive management depends upon the etiology of the bleeding.
  58. 58. Colostomy prolapse  Both proximal and distal bowel segments can protrude many centimeters  Colostomy prolapse commonly occurs in end or loop colostomies  Most often results from an overly large opening in the abdominal wall or inadequate fixation of the bowel to the abdominal wall  Colostomy prolapse can occur in patients with elevated intraabdominal pressure, especially if there was inadequate fixation of the bowel to the internal abdominal wall  Surgical correction is required when blood supply is compromised and in case of obstruction, ulceration, or chronic bleeding
  59. 59. Colostomy retraction  In this case the colostomy is drawn back into the abdomen  Caused by insufficient stomal length, this complication may be managed by use of special pouching supplies  Retraction of a loop colostomy results in a blowhole configuration that allows proximal contents to spill into the distal segment  Revision may be required if distal diversion is necessary  Permanent colostomy that have retracted may require surgical revision
  60. 60. Colostomy strictures /stenosis  Colostomy strictures can occur at the skin and/or fascial levels  Often associated with infection around the colostomy or scarring  Mild stenosis can be removed under local anesthesia  Severe stenosis may require surgery for reshaping the stoma  Attempts at dilating the colostomy are usually unsuccessful and may cause intestinal perforation
  61. 61. Parastomal hernia  Protrusion of viscus in the abdominal wall next to the colostomy wound  Predisposing factors  Weak abdominal wall  Large stoma aperture  Obesity  Prior abdominal incisions  Malnutrition  Wound infection  Parastomal hernias usually require surgical intervention  If severe, the defect in the abdominal wall should be repaired and the stoma moved to another location
  62. 62. Intestinal obstruction  Can occur due to adhesion, volvulus, stricture or internal hernia  Obstruction is usually obvious, and the diagnosis is based on the patient's history and findings at physical examination and on plain radiography  In all patients with a bowel obstruction, a nasogastric tube should be placed for decompression and the patient should receive intravenous hydration  Prompt surgical exploration is required in patients with suspected ischemic or gangrenous bowel, clinical deterioration, or obstruction that does not rapidly resolve with nonsurgical therapy
  63. 63. Complications of colostomy closure  Enterocutaneous fistula  Intestinal obstruction  Adhesions  Wound-related complications – surgical site infection, separation, dehiscence
  64. 64. CONCLUSION  In the last century, there have been dramatic improvements in surgical techniques for the creation of colostomy  Life with a colostomy has also changed dramatically  The development of enterostomal therapy and the improvement of colostomy management systems have made life with a stoma nearly as routine as life with an anus.  “care and expertise are important in creating intestinal stomas because some patients must live with the technical result for the rest of their lives”