Colostomy Surgery

About

Dr. Deepak Chhabra

Surgical Oncologist

MS. (Bom), DNB, M.R.C.S. (Edin. UK)

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The world knows this man as a consultant oncosurgeon with vast experience in Gastrointestinal and Hepatobiliary-Pancreatic cancers,who specializes in stapled anastomosis for bowel cancers and sphincter saving resections for rectal cancers. In short, he is the person to be contacted for all kinds of cancer related cases.

Richa AgrawalPancreatic Cancer

Thank you Dr Deepak for all you have done for mum, for putting the smile back of her face. I wish you success in all your future endeavors and know that you will continue to touch peoples lives and help them be healthy - the way you have done for my mum….. and me.

Nicola MathiasStomach Cancer

For 67years I've led a very healthy life and thank the "Almighty" for it. However as I said all good things come to an end some time and so be it. Out of the blues was detected the dreadful illness "C" which had shown no signs or symptoms whatsoever..... Time had now come for me to choose a very efficient Oncologist for my treatment.

Patient

My mother was diagnosed of colon cancer, and I was recommended to see Dr Deepak Chhabra for consultation.
The first impression of Dr Chhabra was… he is so young! But after consulting him we realized his level of experience and there was a sense of confidence he spilt over us.We knew we could trust him.....

Neelu GroverColon Cancer
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What is a colostomy?

In some cases the chemo is circulated through tubes in the abdomen after the abdomen has been closed (closed technique).

This type of chemotherapy is best at killing cancer cells that are too small to be seen with the naked eye- these include cancer cells that may have been released from larger tumors during the surgery or cells that have been released if the appendix has perforated or ruptured. Peritoneal chemotherapy prevents these cells from being left behind to form new cancerous tumors in the abdomen.

About

Colostomy surgery is done for many different diseases and problems. Some colostomies are done because of malignancy (cancer), others are not. A child, may need one because of a birth defect. Sometimes a colostomy is only needed for a short time, sometimes it is life-long. Some colostomies are large, some small; some are on the left side of the abdomen, some are on the right side, others may be in the middle.

When you look at a stoma, you are actually looking at the lining (the mucosa) of the intestine, which looks a lot like the lining of your cheek. The stoma will look pink to red. It is warm and moist and secretes small amounts of mucus. Unlike the anus, the stoma has no valve or shut-off muscle. This means you will not be able to control of the passage of stool from the stoma, although bowel movements can sometimes be managed in other ways.

The way the stoma looks depends on the type of colostomy the surgeon makes and on individual body differences. It may look quite large at first, but it will shrink to its final size about 6 to 8 weeks after surgery. The shape will be round to oval. Some stomas may stick out a little, while others are flush with the skin.

The output from the stoma is collected in specially designed pouches called colostomy bags.

A colostomy is not a disease, but a change in the way your body works. It surgically changes normal body function to allow stool to pass after a disease or injury. Although a colostomy is a big change for the patient, the operation itself is rather simple. The body’s chemistry and digestive function are not changed by having a colostomy.

After a colostomy has been created, the intestines will work just like they did before except that the passage of stools is now from a different area and the anus is no longer the exit for stool.

Since nutrients are absorbed in the small intestine, a colostomy does not change how the body uses food. The main functions of the colon are to absorb water, to move the stool toward the anus, and to store it in the rectum until it is passed out of the body.

The higher up in the colon the colostomy is made, the shorter the bowel is. The less time the bowel has to absorb water, the softer or more liquid the stool is likely to be. A colostomy further down in the colon, near the rectum, will discharge stool that has been in the intestine a longer time. Depending on the effects of illness, medicines, or other forms of treatment, the longer bowel can put out a more solid or formed stool.

Some people with colostomies find that they are able to pass this stool at certain times of the day with or without the help of irrigation. (Irrigation is discussed later)

After surgery, some people still may feel urges and even have some discharge from the anal area. This discharge is mucus, blood, and at times stool, left from the operation. If the rectum is left alone during surgery, it will keep putting out mucus that can be harmlessly passed whenever you have the urge.

Types

Types of Colostomy Surgery

A colostomy can be short-term (temporary) or life-long (permanent) and can be made in any part of the colon.

Transverse colostomy

A transverse colostomy is made from the transverse or the horizontal part of the colon. The transverse colostomy is in the upper abdomen, either in the middle or toward the right side of the body. Colon problems like diverticulitis, inflammatory bowel disease, cancer, obstruction (blockage), injury, or birth defects can lead to a transverse colostomy. This type of colostomy allows the stool to leave the colon before it reaches the further portion of colon called the descending colon.

When the problems are in the lower bowel, the affected part of the bowel might need time to rest and heal. A transverse colostomy may be used to keep stool out of the area of the colon that is inflamed, infected, diseased, or newly operated on – this allows healing to take place. This type of colostomy is usually temporary. Depending on the healing process, the colostomy may be needed for a few weeks, months, or even years. If you heal over time, the colostomy is likely to be reversed (closed) and you will go back to having normal bowel function.

The type of discharge from a transverse colostomy varies from time to time and from person to person. A few transverse colostomies discharge firm stool at infrequent intervals, but most of them move fairly often and put out a soft or loose stool. It is important to know that the stool contains digestive enzymes that are very irritating, so the nearby skin must be protected. Despite the colostomy, the resting part of the colon keeps making mucus that will come out either through the stoma or through the rectum and anus. This is normal and expected.

Your colostomy does not have a sphincter muscle or control mechanism like your anus does. For this reason, you will need to wear a pouch over your colostomy to collect the output. Your ostomy nurse or doctor will help you find a pouching system that is right for you. The pouch does not usually bulge, and it’s not easy to see under your clothes.

Sigmoid colostomy

A sigmoid colostomy is made from the lower portion of the intestine called Sigmoid colon. Because there is more working colon, it may produce more solid stool more regularly. The sigmoid colostomy is the most common type of colostomy.

The stoma or the opening of the end colostomy is either sewn flush with the skin or it is turned back on itself (like the turned-down top of a sock).

The stool of a descending or sigmoid colostomy is firmer than that of the transverse colostomy. It does not have as much of the irritating digestive enzymes in it. Output from these types of colostomies may happen as a reflex at regular, expected times. The bowel movement will take place after a certain amount of stool has collected in the bowel above the colostomy. Two or 3 days may go between movements. Spilling may happen between movements because there is no anus to hold the stool back. Many people use a lightweight, disposable pouch to prevent accidents. A reflex to empty the bowel will set up quite naturally in some people. Others may need mild stimulation, such as juice, coffee, a meal, a mild laxative, or irrigation.

While many descending and sigmoid colostomies can be trained to move regularly, some cannot. Training, with or without stimulation, is likely to happen only in those people who had regular bowel movements before they became ill. If bowel movements were irregular in earlier years, it may be hard, or impossible, to have regular, predictable colostomy function.

Many people think that a person must have a bowel movement every day. In truth, this varies from person to person. Some people have 2 or 3 movements a day, while others have a bowel movement every 2 or 3 days or even less often. Figure out what is normal for you.

Initially it is necessary to have colostomy bags for output from a descending or sigmoid colostomy but with proper irrigation care you may be able to avoid a colostomy bag altogether (see irrigation in colostomy care).

Changing Bag

Disposable pouches

Pouches come in many styles and sizes, but they all do the same job – they collect stool drainage that comes out of the stoma. Some can be opened at the bottom for easy emptying. Others are closed and taken off when they are full.

There are 2 main types of systems available. Both kinds include a part that sticks to your skin, called a faceplate, flange, skin barrier, or wafer, and a collection pouch. One-piece pouches are attached to the skin barrier.

Two-piece systems are made up of a skin barrier and a pouch that can be removed from the barrier

The face plate or flange of the pouch may need a hole cut out for the stoma, or it may be sized and pre-cut. It is designed to protect the skin from the stoma output and to be as gentle to the skin as possible.

Changing the colostomy bags

There may be less bowel activity at certain times in the day. It is easiest to change the bag system during these times. You may find that early morning before you eat or drink is best.

You don’t have to use sterile supplies. For instance, facial tissue or cotton balls can be used in place of gauze pads. The stoma and nearby skin are clean but not sterile. Regular tap water is good enough to clean the soiled areas of skin around the colostomy and you need not have saline bottles at home as you may have seen doctors or nurses using this in the hospital.

Many factors affect the integrity of the colostomy bag seal and the most important of this is that the surrounding skin needs to be absolutely dry immediately prior to the application of the bag. Small amount of wetness may be sufficient enough to lessen the adhesive power of the bag and may cause frequent leaks of the bag.

Ensure that the hole in the colostomy bag is just enough to accommodate the size of the colostomy or else there may be a rim of skin that will be continuously exposed to the stools and cause ulceration. This may further affect a proper application of the bag subsequently.

Protecting the skin around the stoma

The skin around your stoma should always look the same as skin anywhere else on your abdomen. A colostomy that puts out firm stool usually causes few, if any skin problems. If the stool is loose, as is often the case with transverse colostomies, it can make the nearby skin tender and sore. As you get stronger and get better at handling your equipment, skin irritation will become less of a problem. Here are some ways to keep your skin healthy:

  • Use the right size pouch and skin barrier opening. An opening that is too small can cut or injure the stoma and may cause it to swell. If the opening is too large, output could get to and possibly irritate the skin. In both cases, change the pouch or skin barrier and replace it with one that fits well.
  • Change the pouching system regularly to avoid leakage and skin irritation. Itching and burning are signs that the skin needs to be cleaned and the pouching system should be changed.
  • Do not rip the pouching system away from the abdomen or remove it more than once a day unless there is a problem. Remove the face plate gently by pushing your skin away from the sticky barrier rather than pulling the barrier from the skin..
  • Clean the skin around the stoma with water. If needed, you can use a mild soap and rinse very well. Pat dry before putting on the cover or pouch. You can clean your stoma in the shower or tub.

Spots of blood on the stoma

Spots of blood are not a cause for alarm. Cleaning around the stoma as you change the pouch or skin barrier may cause slight bleeding. The blood vessels in the tissues of the stoma are very delicate at the surface and are easily disturbed. The bleeding will usually stop quickly. If it does not, call your ostomy nurse or your doctor.

Shaving hair under the pouch

Having a lot of hair around the stoma can make it hard to get the skin barrier to stick well and may cause pain when you remove it. Shaving with a razor or trimming hair with scissors is helpful. Extreme care should always be taken when using a straight edge or razor. A mild soap or shaving cream may be used. Rinse well.

Colostomy Care

Learning to take care of your colostomy may seem hard at first, but with practice and time it will become second nature, just like shaving or bathing.

Think of your colostomy’s function as you did your natural bowel movements. You still have the same bowel, just a little less of it. The real change is having the stool come out of an opening made on your belly (abdomen). Learning how to care for your colostomy will help you adjust.

There is no one way to take care of a colostomy. As colostomies differ; so does taking care of them. Give new things a fair trial but do not keep doing them if they do not make you more comfortable. What is good for someone else may not be good for you. Use your recovery time to learn and try different things so that you can find what works best for you. In our society, bathroom needs are kept private. This is the same for a person with a colostomy. A little common sense is also needed when changes in body function take place. Be confident. You can learn the new system.

In the beginning, it will be hard to tell what your stools will be like or when they will come out. The doctor and ostomy nurse will work with you to find the best way to contain the stool so you will not be surprised or embarrassed. There are many ways that this can be done. The choice depends on your type of colostomy, your usual bowel function, and your personal preference.

Caring for a transverse colostomy

Care of any colostomy is really not very hard to do, but getting to the point where you feel comfortable takes a lot of learning, a lot of practice, the right supplies, and a positive attitude. Keep in mind the following points:

  • An appliance that will keep you from soiling your clothing is the right one for you.
  • The colostomy will put out stool no matter what you do, but the firmness of your stool is affected by what you eat and drink.
  • Gas and odour are part of the digestive process and cannot be prevented. Still, they can be controlled so that you will not feel embarrassed.
  • Empty the appliance often during the day to keep it from leaking or bulging under your clothes.
  • Change the pouch system before there is a leak. It is best to change it no more than once a day and not less than once every 3 or 4 days.
  • The ostomy should not irritate your skin. You can prevent skin problems by having a correctly fitted pouch system and by using special materials for ostomy care.

Caring for a Descending or Sigmoid Colostomy with Irrigation

Irrigating to have regular, controlled bowel movements is up to each person, but you should fully discuss it with your doctor or ostomy nurse before a decision is made. The irrigation procedure is taught and may be done a little differently depending on the experience of the doctor or nurse teaching you.

Special equipment includes a plastic irrigating container with a long tube and a cone or tip to put water into the colostomy. An irrigation sleeve is worn to take the irrigation output into the toilet.

Basic irrigation tips

Choose a time in the day when you know you will have the bathroom to yourself. Irrigation may work better if it is done after a meal or a hot or warm drink. Also, consider irrigating at about the same time of day you usually moved your bowels before you had the colostomy.

Put 1,000 cc of lukewarm (not hot) water in your irrigating container. You may need a little less. NEVER connect the tube directly to the faucet.

Hang the container at a height that makes the bottom of it level with your shoulder when you are seated.

Sit on the toilet or on a chair next to it. Sit up straight.

Put on the plastic irrigation sleeve and place the bottom end in the toilet bowl.

Wet or lubricate the end of the cone with water-soluble lubricant.

To remove air bubbles from the tubing, open the clamp on the tubing and let a small amount of water run into the sleeve. Re-clamp the tubing and put the cone into the stoma as far as it will go, but not beyond its widest point. Slowly open the clamp on the tubing and allow the water to flow into your bowel.

The water must go in slowly. You may shut the clamp or squeeze the tube to slow or stop the water flow. It takes about 5 minutes to drip in 1,000 cc of water. Hold the cone in place for 10 more seconds.

The amount of water you need depends on your own body. You may need less, but do not use more than 1,000 cc. The purpose of irrigating is to remove stool, not to be strict about the amount of water used.

You should not have cramps or nausea while the water flows in. These are signs that the water is running in too fast, you are using too much water, or the water is too cold. After the water has been put in, a bowel movement-type cramp may happen as the stool comes out.

After the water has run in, remove the cone. Output or “returns” will come in spurts over the next 45 minutes or so. As soon as the major portion has come, you may clip the bottom of the irrigating sleeve to the top with a clasp. This allows you to move around, bathe, or do anything you wish to pass the time.

In time you will know when all the water and stool have all come out. A squirt of gas may be a sign that the process is done, or the stoma may look quiet or inactive.

Diet Changes

Everything we eat and drink serves as building blocks for the body. To stay in good health, the body needs carbohydrates, proteins, fats, minerals, and vitamins. Water is also a key part of good health. At least 8 to 10, glasses of water per day are recommended. Having a balanced diet helps maintain good nutrition and keep the bowel’s activity normal.

There is no such thing as a colostomy diet. After healing is complete and the ostomy is working normally, most people with colostomies can return to foods they normally eat. Foods act differently in different people. It is good to try to return to your former normal diet. Chew well and see how each food affects your colostomy. Those foods that have disagreed with you most of your life may still do so.

If you wear an appliance all the time, you will suffer no embarrassment if something you have eaten produces an unexpected discharge. You will soon learn which foods produce gas or odor, which cause diarrhoea, and which lead to constipation. As you learn these things you can regulate the bowel’s behaviour to a large extent.

Flatulence (gas)

Right after surgery it may seem that you have a lot of gas almost all the time. Most abdominal surgery is followed by this uncomfortable, embarrassing, yet harmless symptom. As the tissue swelling goes down, you will have less gas. But certain foods, such as eggs, cabbage, broccoli, onions, fish, beans, milk, cheese, and alcohol may cause gas.

Eating regularly will help prevent gas. Skipping meals to avoid gas or output is not smart. You cannot prevent the intestine from moving by not eating. Some people find it best to eat smaller amounts of food 4 to 5 times a day.

Odour

Many factors, such as foods, normal bacterial action in your intestine, illness, different medicines, and vitamins can cause odour. Some foods can produce odour: eggs, cabbage, cheese, cucumber, onion, garlic, fish, dairy foods, and coffee are among them. If you find that certain foods bother you, avoid them. Some people with colostomies have more trouble with odours than others. Learning by experience is the only solution to this problem. Odours may be worse with transverse colostomies.