Intestinal Obstruction Colostomy

1. Dr Phillipo Leo Chalya MD, M.Med (Surg)
Senior Lecturer – Department of Surgery
CUHAS-Bugando
COLOSTOMY

2. Leaning objectives
 Definition
 Indications
 Classifications
 Colostomy formation
 Colostomy care
 Colostomy closure
 Complications of colostomy and its
closure
 Conclusion

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. INDICATIONS
 Congenital diseases
 Acquired diseases

5. Congenital diseases
 Ano-rectal malformations (ARM)
 Hirschsprung ‘s disease
 Intestinal Atresia, Stenosis and Webs
 Meconium ileus
 Intestinal malrotation

6. Acquired diseases
 Traumatic
 Neoplastic
 Inflammatory
 Mechanical
 Vascular
 Surgical
 Others

7. Traumatic
 Penetrating
colonic or ano-
rectal injuries

8. Neoplastic
 Colorectal cancer
 Anal cancer

9. Inflammatory
 Inflammatory bowel diseases
 Necrotizing Enterocolitis
 Diverticular disease

10. Mechanical
 Intestinal obstruction
e.g. Sigmoid
Volvulus

11. Vascular
 Gangrene of part of colon due to strangulation
or interference with its blood supply

12. Surgical
 Protecting an anastomosis after bowel
resection

13. Other indications
 High fistula in ano

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. According to the purpose
 Temporary colostomy
 Permanent colostomy

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. 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. According to the function
 Decompressing colostomy
 Defunctioning /diverting colostomy

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. 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. According to the site/location
 Transverse
colostomy
 Sigmoid colostomy
 Caecostomy

22. According to the type
 Loop colostomy
 Double – barrel colostomy
 End colostomy
 Spectacle colostomy

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. 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. 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. 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. According to the nature of operation
 Emergency colostomy
 Elective colostomy

28. CLOSTOMY FORMATION
 Principles of colostomy formation
 Pre-operative care
 Intra-operative care
 Post-operative care

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. 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. 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. Correction of associated disease conditions
 Intercurent infections [e.g. chest infections,
diarrhoea], anemia and other pre-existing
conditions should be controlled before surgery

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. Pre-anesthetic visit
 This should be done to be able to assess the
patient’s general condition and fitness for
surgery and anesthesia

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. 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. Intra-operative care
 This depends on the pathology, purpose,
site/location and type of the colostomy

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. COLOSTOMY CARE
 Psychological care
 Mechanical care
 Dietary care
 Gas and odor care
 Peristomal skin care
 Pharmacological care

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. 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. 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. 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. 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. 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. COLOSTOMY CLOSURE
 Prerequisites of colostomy closure
 Timing of colostomy closure
 Preoperative preparation
 Types of colostomy closure
 Post operative care

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. 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. 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. Types of colostomy closure
 Extraperitoneal colostomy closure
 Intraperitoneal colostomy closure

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. 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. COLOSTOMY COMPLICATIONS
 Complications related to colostomy
formation
 Complications related to colostomy closure

54. Complications of colostomy formation
 Skin irritation
 Colostomy necrosis
 Colostomy bleeding
 Colostomy prolapse
 Colostomy retraction
 Colostomy stenosis
 Parastomal hernia
 Intestinal obstruction

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. 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. 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. 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. 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. 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. 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. 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. Complications of colostomy closure
 Enterocutaneous fistula
 Intestinal obstruction
 Adhesions
 Wound-related complications – surgical site
infection, separation, dehiscence

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”