“There are over one million individuals in the U.S. living with an ostomy, and over 130,000 ostomy surgeries occur annually to treat rectal, bladder, gynecologic, and other gastrourinary cancers. An ostomy refers to the surgically created opening in the body for the discharge of body wastes. For cancer, ostomies are most commonly placed for rectal cancers (colostomy, ileostomy), followed by bladder cancers (urostomy). Ostomies may be needed in other cancers for the management of bulky, metastatic disease or for emergencies such as perforation or obstructions. In 90% of low-mid rectal cancers, an anastomosis is accompanied by a temporary (“protective”) diverting ileostomy; this is later reversed in a second surgery. A temporary ostomy allows the anastomosis to heal, and prevents catastrophic complications. In some cases, temporary ostomies may become permanent long-term as a result of underlying comorbidities and complications, such as anastomotic leaks or strictures. The treatment decision-making process for ostomy surgery is complex. It involves treatment intent, careful consideration of the functional sequelae of surgery, and whether to maintain or restore bowel or urinary continence.”1
“An ostomy can be deﬁned as any surgical procedure resulting in the external diversion of feces and urine through a stoma. The most common ostomies are a colostomy and ileostomy for diversion of the fecal stream, and urostomy for diversion of the urinary stream. Persons living with ostomies require specialized care and management to sustain physical health and quality of life (QOL). The provision of specialized ostomy care begins preoperatively and continues throughout the postoperative and rehabilitative period and throughout the patient’s lifetime with an ostomy. Ongoing stoma and ostomy appliance sizing, the treatment of peristomal skin complications, ostomy appliance modiﬁcations, access to ostomy products and financial assistance, dietary consultation, and emotional support are just a few of the health management issues that require ongoing management following creation of an ostomy.”2
“Intestinal ostomies are classified according to the segment of the intestine that is brought out to the surface of the body. Small-bowel ostomies (ileostomies) can be distinguished from large-bowel ostomies (colostomies), and end ostomies from loop ostomies. Ileostomies are preferentially created in the right abdomen, colostomies mostly in the left abdomen. In end (terminal) ostomies, the bowel is divided and the proximal stump is brought out. In the case of a loop ostomy, the intestine is not transected; rather the anterior wall is opened to create the ostomy. Both kinds of openings can be temporary or permanent.”3
“Pouches come in a variety of styles and sizes that do not show under clothing. They are made of disposable materials and designed to be worn once and then discarded. Many colostomates wear a pouch. For example, those who have a transverse colostomy, those who do not wish to irrigate and those who have some output between irrigations. Basically, they all do the same job. They collect stool that may expel expectantly or unexpectedly. Some are open at the bottom for easy emptying. Others are closed and are removed when filled. Others allow the adhesive face plate or flange to remain on the body while the pouch may be detached, emptied or replaced. Pouch flanges are available in both convex and flat surfaces. Everyone, including those who irrigate, needs some type of stoma pouch on hand, if only for emergency purposes.”5
A closed ostomy system is one of the types of ostomy pouches available to patients. The main considerations made when choosing this system include those listed below.
- Patient’s comfort
- Patient’s safety
- Patient’s ability to apply the pouch
- Frequency of pouch emptying
- Consistency of the discharge
- Location of the stoma
- Duration of wear
- Height of the patient
- Abdominal contours
- State of the peristomal skin
- Shape of the stoma
- Cost of the ostomy supplies
“Choosing one ostomy appliance over another for the individual with a stoma can be problematic. There are numerous appliances to choose from and manufacturers often claim that their products are the best on the market without providing objective, clinical evidence of the actual performance of the products. Consequently, most choices of appliances are based on habit or the clinical experience of nurses. During the 1990s, an increasing need for evidence-based decisions within ostomy care led to numerous calls for more ostomy research. Both health authorities and ostomy product manufacturers should support the need of stoma care professionals for clinical research to enable evidence-based decisions to be made.”7
Nature of the closed-end ostomy systems
Available as one- or two-piece pouch systems. The closed-end ostomy system is disposed after each pouch change because it is completely sealed, unlike the drainable type where the contents can be discharged. In the latter there is a feature for emptying the pouch, rinsing and reusing it. The closed ostomy bags are used mainly in patients with less discharge and one that has a more solid consistency. Most closed systems have a special filter that reduces odor and gas accumulation by absorbing target odors while allowing gas to escape. Closed pouch systems are also available with pre-cut or cut-to-fit flanges.
“Since nutrients are absorbed in the small intestine, a colostomy does not affect the body’s ability to be nourished. When a colostomy interrupts the passage of stool, storage becomes more difficult. The higher up in the colon the colostomy is made, the less time the bowel has to absorb water and the more liquid (or soft) the stool is likely to be. Therefore, a colostomy in the transverse colon will discharge a softer and more voluminous stool and will require the use of a collection pouch.
A colostomy far down in the colon, near the rectum, will discharge stool that has been in the intestine a longer time and barring the effects of illness, medications or other forms of treatment, may produce a more formed stool. Some colostomates find that they are able to pass this stool at regulated times with or without the help of irrigation (an enema through the stoma). After the operation, if the rectum is intact, patients may feel urges and even have some discharge from the anal area. It may continue to secrete mucus that can be harmlessly passed whenever the urge occurs.”8
Advantages of Closed Ostomy Pouch Systems
- They are quick to change
- Some brands offer flushable options that are readily available and can, therefore, be environmentally friendly.
- Increases patient confidence as chances of accidental leakage diminishes. Complicated drainable systems increase the risk of something going wrong before it is time to drain the bag.
Closed Ostomy Pouch Systems are ideal for
- Patients who perform stoma irrigation
- Ideal for patients who find cleaning and reusing too cumbersome.
- Patients with well-formed stools
Disadvantages of Closed Ostomy Pouch Systems
- Not ideal for liquid discharge. This makes it inappropriate for use in urostomy.
- Stressful for the patient when traveling or when in social settings. Appropriate disposal facilities may not be available in places away from home.
- If a one-piece pouch system is used, the repeated changing of pouches can increase the risk of skin irritation and inflammation.
Closed pouch systems are made in various sizes and shapes depending on the manufacturer. There are different colors and shades to cater to different patients’ tastes.
“Ostomy bag users regularly experience problems, such as peristomal skin disorders, leakage of stoma effluent onto the peristomal skin, excess air in the bag (ballooning) and odor. The quality of life of the individual with a stoma appears to be related to his or her anxiety about the bag adhesive loosening or leaking, odors emanating from the bag and skin complications in the peristomal area. Although the one-piece closed ostomy bags already established on the European and US markets are of a high standard, improvements in the performance of the bags, primarily in relation to the adhesives and the filters, are still needed.”9
Precautions to take with a Closed Ostomy Pouch System
- Avoid the pouch from becoming distended with gas. An incorporated charcoal filter can help prevent this situation.
- If the discharge should change to a looser consistency, a switch to a drainable type is usually recommended. It is also important to identify the cause of changes in the discharge consistency by consulting with a physician whether it is due to a nutritional cause or a disease process.
- The pouch should ideally be emptied when 2/3 to 1/2 full.
A patient can feel overwhelmed at the options available in the search for the right ostomy pouch type. Speaking to an ostomy nurse before leaving the hospital will help the patient make a decision on whether a closed pouch system is the best for them or not. It also assists the patient in understanding why the ostomy nurse or physician has recommended a particular type of ostomy system instead of others.
“Ostomy care comprises a broad spectrum of preoperative and postoperative tasks covering the management of the various types of ostomy. For enterostomies, the principal preoperative task is the provision of professional advice and training to the potential ostomy bearer and family members. Together with direct stoma care, the psychosocial and nutritional aspects must be discussed.”10
(1) Ostomy Telehealth for Cancer Survivors: Design of the Ostomy Self-Management Training (OSMT) Randomized Trial. Sun, V., Ercolano, E., McCorkle, R., Grant, M., Wendel, C.S., Tallman, N.J., Passero, F., Raza, S., Cidav, Z., Holcomb, M., Weinstein, R.S., Hornbrook, M.C. & Krouse, R.S. Contemporary Clinical Trials. 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6252251/
(2) Ostomy Care and Management A Systematic Review. Recalla, S., English, K., Nazarali, R., Mayo, S., Miller, D. & Gray, M. Journal of Wound Ostomy Continence Nurse. 2013. https://www.researchgate.net/publication/251568692_Ostomy_Care_and_Management_A_Systematic_Review
(3, 4, 10) Intestinal Ostomy: Classification, Indications, Ostomy Care and Complication Management. Ambe, P.C., Kurz, N.R., Nitschke, C., Odeh, S.F., Möslein, G. & Zirngibl, H. Deutsches Ärzteblatt. 2018. https://www.aerzteblatt.de/int/archive/article?id=196925
(5, 6, 8) Colostomy Guide. Hooper, J. & Gutman, N. United Ostomy Associations of America. 2017. https://www.ostomy.org/wp-content/uploads/2018/03/ColostomyGuide.pdf
(7, 9) Ostomy bag management: comparative study of a new one-piece closed bag. Voergaard, L.L., Vendelbo, G., Carlsen, B., Jacobsen, L., Nissen, B., Mortensen, J., Hansen, G., Bach, K. & Bæch, S.B. British Journal of Nursing. 2007. https://www.magonlinelibrary.com/doi/abs/10.12968/bjon.2007.16.2.22767