“Surgically-created opening in the body between the skin and a hollow viscus”

  • Can be permanent or temporary.
  • Stoma surgery can be:
    • Laparoscopic
    • Open
Types of Stoma
  • Ileostomy:
    • Made with ileum after removal of the entire colon distal to it
    • Usually located in RIF
    • Watery contents (removal of colon = lack of water reabsorption from gut contents)
    • Has spout to allow faeces to drain without touching skin, as enzymes in the small bowel can irritate the skin (due to more alkali secretions)
    • An alternative to ileostomy is ileoanal pouch anastomoses
    • Temporary end-ileostomy
      • During emergency bowel resection where the anastomosis is considered unsafe to perform with remaining bowel at the time (e.g. bleeding or sepsis)
    • Permanent end-ileostomy
      • Following panproctocolectomy for ulcerative colitis or familial adenomatous polyposis (FAP)
    • Loop ileostomy
      • Protect distal anastomoses
      • Done similarly to loop colostomy with 2 visible openings
  • Colostomy:
    • Made with large bowel
    • Found in LIF
    • Solid contents as faeces has had time to travel through colon where water absorption occurs
    • Positioned flush to the skin (no spout) as enzymes in large bowel are less alkali = less skin irritation
    • Not usually painful due to lack of nerve supply
    • Temporary end-colostomy
      • Done to rest the bowel e.g. in diverticulitis or obstruction.
      • Part of 2-stage Hartmann’s procedure, where rectum and bowel are anastomosed at a later date
    • Permanent end-colostomy
      • Done for abdominoperineal resection of large rectal cancers which lead to the removal of the entire rectum
    • Loop colostomy
      • Usually temporary and is easier to reverse (after 7 days)
      • Done to protect distal anastomoses after recent surgery
      • Loop of bowel exteriorised and half-opened, then stitched to skin to form two stoma openings
      • Faeces drains into stoma bag without reaching distal anastomoses
Colostomy Bag
Source: Cancer Research UK
  • Urostomy:
    • Done following cystectomy (bladder removal)
    • Usually located in RIF
    • Contains urine
    • Ileal conduit used to route urine out of the abdomen into the bag. This involves resection of a portion of ileum which is then attached to the skin with a protruding spout
    • Ureters then attached to one end of resected ileum
Source: Hollister
Function
  • Divert faeces outside the body where distal bowel has been removed or is unable to be joined back with proximal bowel
  • Defunction certain areas of the bowel so that they are allowed to heal
  • Relieve inflammation of the colon in those with inflammatory bowel disease
  • Allow for complex surgery to be done on anus and rectum
Indications
  • Ileostomy:
    • Inflammatory bowel disease
    • Bowel cancer
    • Familial adenomatous polyposis
    • Bowel obstruction
    • Significant trauma or injury to the colon
  • Colostomy:
    • Bowel, rectum or anal cancer
    • Crohn’s disease
    • Diverticulitis
    • Bowel incontinence
Complications
  • Early:
    • Bleeding
    • Ischaemia – stoma can change colour from dusky grey to black
    • Stoma retraction – sinking of stoma below level of skin after initial reduction of swelling
    • High output (can lead to low K+ due to excess loss of gut contents) – May need loperamide + codeine
    • Obstruction – secondary to adhesions or failure to close lateral space around stoma during time of surgery
  • Late:
    • Fistulae
    • Stoma stricture/stenosis
    • Prolapse
    • Intussusception – where one segment of intestine telescopes inside another to cause obstruction
    • Parastomal hernia – where viscus pushes through a weakness in the muscle or surrounding tissue wall of stoma
    • Obstruction
    • Psychological problems e.g. anxiety, depression, self-consciousness
      • Can lead to food avoidance → poor nutrition → worsening skin problems
  • Ileostomy:
    • Dermatitis
    • Malnutrition or malabsorption
      • Removal of up to 50cm of small bowel can cause poor absorption of B12 → B12 deficiency
    • Dehydration
    • Phantom rectum – still feel need to go to toilet despite not having working rectum
Stoma Care
  • Early referral to stoma nurse essential
    • Help with keeping area around stoma clean
    • How to empty and change bag
    • Advice on preventing infection
    • How to get new supplies
    • Managing psychological distress
  • Avoid heavy lifting or strenuous activity just after a colostomy procedure
  • Irritation can occur with the bag, and a simple change of equipment may alleviate it

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