Colostomy

A colostomy may be formed in the sigmoid colon, descending colon, transverse colon or ascending colon, and the type of output will depend on the location of the colostomy. When a colostomy is situated in the ascending colon or the transverse colon, the faecal output may vary from a fluid output to a semi-formed stool. For these stomas the optimal appliance to use is a drainable appliance such as would be used if the stoma were an ileostomy. Transverse loop colostomies are often positioned in the upper right quadrant of the abdomen and are usually temporary. Often the size of the stoma when in the transverse position is large, often a loop, and causes difficult management problems for the nurse and patient. Finding a suitable appliance that the patient can use may also cause problems. Often this type of stoma is done on the elderly patient who is debilitated and admitted during the early hours of the morning with a bowel obstruction or problem such as diverticular disease. Emergency surgery is necessary as a result of distal bowel obstruction and to resuscitate the patient. Often, in this situation, the stoma is large and elliptical and the normal plan is to return the patient home to recover in order to readmit later for definitive surgery and closure or revision of the stoma. Although the patient may just be well enough to go home he or she often does not make sufficient recovery to return to hospital for further surgery and the patient and community nurse are left trying to cope with a large and difficult stoma, Today, specialist nurses in stoma care encourage surgeons not to undertake stomas such as these unless it is really necessary.

A colostomy placed in the descending or sigmoid colon will have a faecal output that is generally formed and is easier for the patient to cope with. The appliance will be closed at the bottom and there will be a flatus patch at the top of the appliance that also has charcoal in it. This patch allows gas to escape slowly from the appliance while in wear to prevent the appliance ballooning. The charcoal helps to absorb odours. There are also many other products on the market available to patients who worry about the possibility of odour and that it may offend. These can take the form of powders, capsules, drops or suppository-shaped additives. These additives are put into each new, clean appliance on application and react with the faecal content to help absorb some of the odour. Some of these additives also help with odour when the appliance is being changed (Black, 2000).

Patients who have a colostomy often find it difficult to empty and dispose of stoma appliances, at home or when they are away from home. These patients may benefit from a colostomy appliance disposable in the toilet. Although modern colostomy appliances are one use only, they are not toilet flushable; however, now two colostomy appliances are available that can be flushed down the toilet. One can be removed, folded together and flushed down the toilet. This may take several flushes of the cistern and some help with a toilet brush because the appliance has trapped air inside and tends to float. The other appliance looks like a conventional colostomy appliance but possesses an inner lining. When the appliance needs changing, patients can remove the inner liner and flush it down the toilet and dispose of the plastic outer coat in the normal manner.

Appliances for a sigmoid colostomy or Hartmann's procedure, resulting in an end-colostomy for diverticular disease, may be: a one-piece or two-piece appliance, clear or opaque, with or without a soft cover, with an opaque soft cover over a clear bag but with a slit in the cover to allow the patient to site the appliance correctly, with a cut to fit the aperture or a ready-cut sized aperture. Such are the choices for the patient with a colostomy that most patients expect the nurse to guide them to the correct appliance for the first stage of their rehabilitation.

When the nurse has taken into account the needs of the patient in the use of a colostomy appliance, such as manual dexterity, sight and any other potential problems, it may be suitable to use a one-piece appliance if the nurse considers that it may make changing the appliance easier. A one-piece appliance has an integral adhesive skin wafer, which may have a single release paper or be combined with a microporous collar. In hospital the appliance is clear, without a cover, to allow inspection of the stoma and contents whenever necessary by the doctors and nurses. Often patients do not like being able to see the content of the appliance and choose to have an opaque appliance once at home. Many older patients choose to remain with a transparent appliance because it enables them to place the appliance over the stoma correctly. The aperture in hospital will be cut to fit with the nurse helping the patient by using a template. It is not until the patient has been at home for some time after surgery that the stoma settles to its final size after surgery. At this time the patient is able to use ready-cut apertures, which then does away with the need to cut each aperture on each appliance. If the stoma is not circular, the appliances may need to be cut specially and this can be done by the delivery service that the patient uses for supplies or the chemist from which the patient collects his or her supplies (see 'Discharge and community care' below).

A two-piece appliance consists of an adhesive flange that can have a single release paper and/or a microporous collar. The colostomy appliance attaches to the flange either by clipping together or by adhering to the flange, so making the appliance less bulky and easier for the patient to use. Currently, in the UK, the prevalence of use of one-piece appliances is 82% against 18% of patients who use a two-piece appliance (IMS, 2003). Often for patients who undergo emergency surgery without siting of the stoma, as may be the case in emergency surgery for diverticular disease, the stoma may be in an awkward position and a one-piece appliance with a flexible skin wafer may be the appliance of choice to accommodate the badly placed stoma. Many patients who have badly placed stomas or stomas that have become flush with or retracted below the abdominal surface may benefit from using a flange or one-piece appliance that has convexity built into it. Convexity produces an outward curve on the flange when applied to the stoma and has the effect of pushing the stoma out, which helps the output fall into the appliance rather than leaking out under the flange and causing damage to the peristomal skin. Convexity is available for all types of stomas, but if the stoma is sited preoperatively there should not be a need for convexity. It must be used under supervision of the specialist or community nurse because inappropriate use can cause damage to the stoma (Black, 1996).

For the patient who has an end-colostomy after a Hartmann's procedure for diverticular disease, there are possible alternatives to care of the colostomy that do not need an appliance. Unfortunately, many of the patients who have a colostomy for diverticular disease fall into the older age group and may have other age-associated difficulties that would preclude them from using the following alternatives.

First, provided that the patient is confident with his or her stoma management and if the faecal output is formed, the continent ostomy system is a plug that is inserted into the colostomy. The plug is lubricated and seals off the colostomy by adhering to either the skin or a base plate or flange. When the plug, which has the appearance of a large mushroom, is inserted into the colostomy and secured to the skin or base plate, the lubricated stalk expands with body fluid to block the colostomy outlet. Faecal matter goes on forming and comes up behind the cap. On removal of the plug, an appliance can be put on to secure the collection of faecal output or, if the patient is adept, he or she may be able to excrete into the toilet. At each removal of the plug a new plug has to put in. Often this form of management is useful for social situations with the patient returning to a standard appliance at all other times. The plug can remain in situ for up to 12 hours. Patient education is needed before commencing to use the plug and this can be obtained from the specialist stoma care nurse.

For some patients with an end-colostomy there is a way of emptying the bowel daily that also alleviates the wearing of a colostomy appliance. This is irrigation. To do this the patient must be motivated and have the uninterrupted use of a bathroom and toilet each day for at least an hour. There are strict criteria and the irrigation method should be taught by a stoma care nurse or other qualified practitioner in the comfort of the patient's own home. A specialized set to irrigate the bowel is needed and a starter set is usually obtained from one of the ostomy companies; any further replacement pieces are available on prescription. The set comprises a 2-litre bag to hold the hypotonic solution (tap water) to wash out the bowel, tubing and a specialized silicone cone to conduct the water into the colostomy, and a special long bag known as a sleeve to conduct the water from the colostomy into the toilet pan. The patient sits on the toilet and applies the long sleeve to the stoma. The sleeve can be a one- or two-piece item. The bottom of the sleeve is put into the toilet pan. The fluid holder bag is hung on a hook above shoulder height when the patient is sitting on the toilet and the tubing and cone attached. The cone is lubricated and placed through the opening in the top of the sleeve into the colostomy. The fluid control is turned on and up to 1500 ml of water is allowed to flow into the stoma quickly. The patient may start to feel distended at this stage. If the patient feels pain the flow of water should be stopped. Once the cone is removed from the colostomy there will be an immediate return of the water, under pressure, from the colostomy down the sleeve into the toilet. After the initial output the bowel will have a quiet period of 10-15 minutes before the next, slower output of faecal matter. If irrigation is done regularly every 24 hours, within 10 days or so the whole procedure can take as little as 30 minutes to do each day. Patients then can wear a stoma cap each day as opposed to wearing a colostomy bag. All the equipment for irrigation is reusable and needs to be replaced on a yearly basis.

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