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What is an Ostomy?

An ostomy is a temporary or permanent surgical opening in the abdominal wall. The opening occurs on surgeries where the surgeon removes a portion of either the large or small intestine or extraction of the bladder. In the health field, an ostomate is an ostomy patient.

“An ostomy is a surgical procedure that involves the removal of diseased portions of the gastrointestinal or urinary system and creation of an artificial opening in the abdomen to allow for the elimination of body wastes.

It is a surgical opening in the abdomen where the intestine is brought up onto the skin and sutured in place to form a stoma. To bypass diseased intestine or bladder.”1

A small portion of the intestine protrudes through the stoma (about ½ inch). This section remains connected to the stomach. After surgery, depending on the type of ostomy, fecal matter or urine passes through the stoma. 

“In medicine, stoma/ostomy refers to a surgically created opening of a hollow organ on the surface of the body to enable excretions of waste products.”2

Ostomates lose their sphincter or control over urination or excretion, so ostomy patients must wear an ostomy bag to collect body waste. The ostomy might be temporary or permanent depending on the severity of the condition. 

“If temporary, stoma will be necessary until the disease portion can heal. Requires another surgery to reconnect.”1

 

Stoma and Ostomy Bag
Stoma and Ostomy Bag

 

Statistics

  • “More than 700,000 Americans – from infants to senior citizens – have had Ostomy surgery.
  • Over 120,000 people each year have fecal or urinary ostomies.”

Why an Ostomy?

A person may have an ostomy for different reasons, but it remains as the last resort for intestinal pathologies. Excruciating pain and the complications involved in continued bathroom runs make it a life-changing option for many patients suffering from Crohn’s disease and IBD (Inflammatory Bowel Disease). 

For those with colon, anal, or bladder cancer, it might be the only alternative for survival. Likewise, for those suffering from accidents or punctures (e.g.: stabbing) no other option might be available.

An ostomy procedure is essential for: 

  • Colorectal cancer, bladder cancer, Crohn’s disease, ulcerative colitis, birth defects, and other intestinal or urinary medical conditions. 
  • Also, ostomies are necessary in certain cases of severe abdominal and/or pelvic trauma.

For individuals suffering from such conditions, ostomy surgery is both lifesaving and life-changing.”1

Types of Ostomy Surgery

Surgeons can practice three types of ostomy surgeriescolostomyileostomy , and urostomy

The first two refer to the part of the intestinal system that is compromised in the procedure. When the procedure involves the bladder, it is called a urostomy. “Colostomies and ileostomies are created in the management of a variety of medical conditions, including cancer, diverticulitis, and inflammatory bowel disease.

Gastrointestinal ostomies may be performed for benign or malignant diseases, created under elective or emergency conditions, fashioned from small or large bowel, considered temporary or permanent, and made during curative or palliative intent operations.”3

A colostomy relates to the large intestine (colon) while an ileostomy to the small intestine (ileum). 

“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.”2

Construction of the Ostomy

“An ostomy can be constructed in one of many ways, including: 

  • End ostomy: One opening 
  • Loop ostomy: Two openings from the bowel which is split 
  • Double barrel: Complete dissection of the bowel with both sections forming end stomas.” 4

Colostomy

“A colostomy is the most common type of stoma formed and is positioned in the large bowel. It is usually round or oval in shape and should protrude approximately 0.5–1.0 cm. The output from a colostomy will differ depending on where in the large bowel the stoma is positioned. It may be formed, similar to a normal stool, or slightly looser. Having a colostomy means that you will need a bag to collect feces as control of defecation is lost.5

 

Colostomy Procedure
Colostomy Procedure

 

  • “Portion of the diseased large intestine (colon) is removed or by-passed
  • The remaining portion is brought through the abdominal wall to form the stoma
  • May be temporary or permanent
  • If temporary, stoma will be necessary until the disease portion can heal
  • Requires another surgery to reconnect.”1

“A temporary colostomy will allow the lower portion of the colon to rest or heal. It may have one or two openings (if two, one will discharge only mucus). 

  • May be required if the intestinal tract can’t be properly prepared for surgery because of blockage by disease or scar tissue. 
  • May be created to allow inflammation or an operative site to heal without contamination by stool. 
  • Usually be reversed with minimal or no loss of intestinal function.

A permanent colostomy usually involves the loss of part of the colon, most commonly the rectum. The end of the remaining portion of the colon is brought out to the abdominal wall to form the stoma. 

  • May be required when disease, or its treatment, impairs normal intestinal function, or when the muscles that control elimination do not work properly or require removal. 
  • The most common causes of these conditions are low rectal cancer and inflammatory bowel disease.”4

Types of Colostomies 

“The name of the type of colostomy is indicative of the location in the colon where the stoma is formed. 

  • Descending Colostomy: The surgical opening created in the descending colon is brought to the surface of the abdomen. It is usually located on the lower left side of the abdomen. 
  • Transverse Colostomy: The surgical opening created in the transverse colon resulting in one or two openings. It is located in the upper abdomen, middle, or right side. 
  • Ascending Colostomy: A relatively rare opening in the ascending portion of the colon. It is located on the right side of the abdomen. 
  • Cecostomy: The surgical construction of an opening into the cecum. It is performed as a temporary measure to relieve intestinal obstruction in a patient who cannot tolerate major surgery. 
  • Sigmoidostomy: The most common location of an ostomy is in the sigmoid colon. A sigmoidostomy is the surgical construction of an opening into the sigmoid colon, and is commonly referred to as a sigmoid colostomy.”4

Location of Colostomies 

 

Location of various ostomy procedures
Location of various ostomy procedures

 

Ileostomy

“An ileostomy is the second most common type of stoma formed and is positioned in the small bowel. Diverts the ileum to a stoma. It is a surgically created opening in the small intestine, usually at the end of the ileum. The intestine is brought through the abdominal wall to form a stoma. They may involve the removal of all or part of the entire colon. 

It is usually round or oval in shape and protrudes approximately 2.0–3.0 cm from skin level to form a spout. The output from an ileostomy is usually loose watery stools. An ileostomy may be either temporary or permanent, depending on the type of surgery you have had. Having an ileostomy means that you will need a bag to collect feces as control of defecation is lost.”5

 

Ileostomy Procedure
Ileostomy Procedure

 

  • “Stoma that comes from the ileum
  • Usually on the lower right of abdomen
  • Effluent is loose to liquid with enzymes
  • More issues with leaking and break down in peristomal skin
  • More diet restrictions”1

Types of Ileostomies 

“Ileoanal Reservoir (J-Pouch): The colon and most of the rectum are surgically removed and an internal pouch is formed out of the terminal portion of the ileum. An opening at the bottom of this pouch is attached to the anus such that the existing anal sphincter muscles can be used for continence. This procedure should only be performed on patients with ulcerative colitis or familial polyposis who have not previously lost their anal sphincters. In addition to the “J” pouch, there are “S” and “W” pouch geometric variants. 

Continent Ileostomy (Kock Pouch): A reservoir pouch is created inside the abdomen with a portion of the terminal ileum. A valve is constructed in the pouch and a stoma is brought through the abdominal wall. A catheter or tube is inserted into the pouch several times a day to drain feces from the reservoir.”4

 

Different types of ostomy procedures
Different types of ostomy procedures

Types of Ostomy Procedures

Feces in various types of ostomy procedures
Feces in various types of ostomy procedures (4)

 

Urostomy

  • “The bladder is removed or bypassed
  • A conduit is made of small intestine tissue
  • Ureters are implanted into the ileum and on to the urostomy stoma
  • The urine flows from the stoma into the pouching appliance.”1

 

Urostomy Procedure
Urostomy Procedure

 

Continent Urostomy 

  • “This form of continent diversion does include a stoma. 
  • The reservoir or pouch is created inside the abdomen using a portion of either the small or large bowel. 
  • A valve is constructed in the pouch and a stoma is brought through the abdominal wall. 
  • This method requires the patient to empty the reservoir, the internal pouch, regularly through the stoma using a catheter or thin plastic tube. 
  • The two different pouches are the Indiana and Kock.”4

 Bricker is a form of an incontinent urostomy, and it is currently a common urine diversion procedure. “During a ‘bricker bladder’ procedure a section of bowel is isolated and made to act as an outlet for urine. The ureters are detached from the bladder and re-attached to a small section of bowel that has been isolated from the rest of the bowel. One end of the section is sewn up, while the other end is passed out to the abdominal skin as a stoma. The stoma usually protrudes 2.0 cm above the skin level. The section of the bowel is too small to function as a reservoir and there is no muscle or valve to retain urine and control urination. This means that you will need a urostomy bag to collect the constant flow of urine.”5

Differences between the Continent Urostomies 

 “Indiana pouch: The ileocecal valve that is normally between the large and small intestines is relocated and used to provide continence for the pouch which is made from the large bowel. 

 Kock pouch: A “nipple” valve is made from the small bowel and it plicated to provide continence for the pouch. In both procedures, the valve is located at the pouch outlet to hold the urine until the catheter is inserted.”4

Postoperative Period

Assuming a successful ostomy surgery, physical complications after discharge are manageable. The main issues are psychological and are important to address so as not to frustrate and get depressed. After the procedure, it is critical to receive training from an ostomy nurse (ET) or ostomy professional on how to deal and manage the stoma.

“Ostomy surgery radically alters urine or fecal elimination, forcing the client to learn new physical skills in order to manage the ostomy itself, fecal or urinary effluent produced by the ostomy and the peristomal skin. Clients with a new ostomy must master multiple psychomotor skills to remove their pouch, clean the stoma and peristomal skin and empty and dispose of effluent from the pouch.”6

Ostomy Care and Management

“Early education related to ostomy care and management prior to surgery can offer reduced anxiety levels in the postoperative setting. These reduced anxiety levels may assist the patient during these critical postoperative days in learning to manage their ostomy at home. Early acceptance and involvement by patients may assist in the reduction of hospital days of stay and hospital readmissions associated with a lack of support.

Patients should be referred for preoperative education prior to ostomy surgery. This preoperative education can be done in the outpatient setting or at the bedside. For patients arriving to the hospital in an emergent need, time may not allow for patient education but may be offered to the family prior to surgery. 

These patients have specialized needs that include acceptance of altered body image, psychological stress, learning of difficult tasks, and occasionally an ominous diagnosis leading to the need for surgery. In addition to pre-surgical stoma site marking on the abdomen, ostomy nurses have identified early education to be an important factor in the long-term success and management of the patient. Early education and stoma site marking may assist with a better-situated stoma leading to fewer complications related to appliance adherence and leakage. New ostomy patients that are well prepared may be able to adapt to the new body image and are more successful in management following ostomy surgery.”7

Patients also appreciate and require support from family, friends, and ostomy groups. Ostomy communities are a safe place where patients can share with and learn from others.

How to make appliance fit 

  • “Use the correct size of appliance 
  • Cut to fit each individual stoma 
  • The wafer (adhesive barrier) should fit snugly around the stoma, 1/8” close ν Use barrier ring or paste only if necessary 
  • Some newer wafers are “form to fit” and the turtle neck up to stoma.

Measure stoma

They can change in size 

  • After surgery 
  • Weight gain
  • Weight loss

Ostomy care

  • Empty pouch when 1/3 to ½ full
  • Change pouching system 2x/week or immediately for any leaking
  • May shower with the appliance on or off
  • Do not use baby wipes to clean around the stoma, a new wafer may not stick.
  • Clean peristomal skin with a moist washcloth.”1

An ostomy is considered as a harsh alternative. However, a considerable number of advances in ostomy supply have emerged, especially regarding ostomy bags. Currently, several ostomy bags are available to meet almost any necessity or activity, making the notion of living with an ostomy no longer a limiting condition.

 

Reference:

(1)  Ostomy Care. https://coc.unm.edu/common/training/OstomyCareHattler.pdf 

(2) Intestinal Ostomy. https://www.researchgate.net/publication/323871430_Intestinal_ostomy-classification_indications_ostomy_care_and_complication_management

(3) Clinical practice guidelines for_ostomy_surgery, https://www.fascrs.org/sites/default/files/downloads/publication/clinical_practice_guidelines_for_ostomy_surgery.pdf

(4) Ostomy Overview.1913.pdf https://lms.rn.com/getpdf.php/1913.pdf 

(5) Dialogue Education. Ostomy Care – Stoma Formation. https://www.coloplast.us/Global/US/Ostomy/Professional/CPOC_DialogueEducation_SurgicalPads.pdf 

(6) Ostomy Care Management. https://rnao.ca/sites/rnao-ca/files/Ostomy_Care__Management.pdf 

(7) Does Preoperative Ostomy Education Decrease Anxiety. https://scholarworks.sjsu.edu/cgi/viewcontent.cgi?article=1095&context=etd_doctoral 

 

María Laura Márquez
13 October, 2018

Written by

María Laura Márquez, general doctor graduated from The University of Oriente in 2018, Venezuela. My interests in the world of medicine and science, are focused on surgery and its breakthroughs. Nowadays I practice my profession...read more:

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