Ostomies

Bowel diversion surgery allows stool to safely leave the body when—because of disease or injury—the large intestine is removed or needs time to heal. Bowel is a general term for any part of the small or large intestine. Some bowel diversion surgeries—those called ostomy surgery—divert the bowel to an opening in the abdomen where a stoma is created. A surgeon forms a stoma by rolling the bowel’s end back on itself, like a shirt cuff, and stitching it to the abdominal wall. An ostomy pouch is attached to the stoma and worn outside the body to collect stool.

Other bowel diversion surgeries reconfigure the intestines after damaged portions are removed. For example, after removing the colon, a surgeon can create a colonlike pouch out of the last part of the small intestine, avoiding the need for an ostomy pouch.

The terms ostomy and stoma are general descriptive terms that are often used interchangeably though they have different meanings. An ostomy refers to the surgically created opening in the body for the discharge of body wastes. A stoma is the actual end of the ureter or small or large bowel that can be seen protruding through the abdominal wall. The most common specific types of ostomies are described below.

TYPES OF OSTOMIES

• Colostomy- The surgically created opening of the colon (large intestine) which results in a stoma. A colostomy is created when a portion of the colon or the rectum is removed and the remaining colon is brought to the abdominal wall.
• Temporary Colostomy - Allows the lower portion of the colon to rest or heal. It may have one or two openings (if two, one will discharge only mucus).
• 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.
  
• Sigmoid or Descending Colostomy - The most common type of ostomy surgery, in which the end of the descending or sigmoid 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.
• Loop Colostomy Usually created in the transverse colon. This is one stoma with two openings; one discharges stool, the second mucus.
• Ascending Colostomy A relatively rare opening in the ascending portion of the colon. It is located on the right side of the abdomen.

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• Ileostomy- 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. Ileostomies may be temporary or permanent, and may involve removal of all or part of the entire colon.
• Ileoanal Reservoir (J-Pouch)- This is now the most common alternative to the conventional ileostomy. Technically, it is not an ostomy since there is no stoma. In this procedure, 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.
• Continent Ileostomy (Kock Pouch) - In this surgical variation of the ileostomy, 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. This procedure has generally been replaced in popularity by the ileoanal reservoir . A modified version of this procedure called the Barnett Continent Intestinal Reservoir (BCIR) is performed at a limited number of facilities.

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• Urostomy- This is a general term for a surgical procedure which diverts urine away from a diseased or defective bladder. The ileal or cecal conduit procedures are the most common urostomies. Either a section at the end of the small bowel (ileum) or at the beginning of the large intestine (cecum) is surgically removed and relocated as a passageway (conduit) for urine to pass from the kidneys to the outside of the body through a stoma. It may include removal of the diseased bladder.
• Continent Urostomy- There are two main continent procedure alternatives to the ileal or cecal conduit (others exist). In both the Indiana and Kock pouch versions, a 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. A catheter or tube is inserted several times daily to drain urine from the reservoir.
• 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. With a Kock pouch version, which is similar to that used as an ileostomy alternative, the pouch and a special “nipple” valve are both made from the small bowel. In both procedures, the valve is located at the pouch outlet to hold the urine until the catheter is inserted.
• Orthotopic Neobladder A replacement bladder, made from a section of intestine, that substitutes for the bladder in its normal position and is connected to the urethra to allow voiding through the normal channel. Like the ileoanal reservoir, this is technically not an ostomy because there is no stoma. Candidates for neobladder surgery are individuals who need to have the bladder removed but do not need to have the urinary sphincter muscle removed.

Parts of the Gastrointestinal Tract Affected by Bowel Diversion Surgeries?

Bowel diversion surgeries affect the large intestine and often the small intestine.

Small Intestine

The small intestine runs from the stomach to the large intestine and has three main sections: the duodenum, which is the first 10 inches; the jejunum, which is the middle 8 feet; and the ileum, which is the final 12 feet. Bowel diversion surgeries only affect the ileum.

Large Intestine

The large intestine is about 5 feet long and runs from the small intestine to the anus. The colon and rectum are the two main sections of the large intestine. Semisolid digestive waste enters the colon from the small intestine. Gradually, the colon absorbs moisture and forms stool as digestive waste moves toward the rectum. The rectum is about 6 inches long and is located right before the anus. The rectum stores stool, which leaves the body through the anus. The rectum and anus control bowel movements.

Social, and Psychological Issues related to Ostomy

The reaction to intestinal or urinary diversion surgery varies from one individual to the other. To some, it will be a problem, to other, a challenge; where one person considers its life-saving, another finds it a devastating experience. Each person will adapt or adjust in their own way and in their own time.

Important - About Bowel Diversion Surgeries (Ostomies)

• Bowel diversion surgery allows stool to safely leave the body when—because of disease or injury—the large intestine is removed or needs time to heal.
• Bowel is a general term for any portion of the small or large intestine.
• The type, degree, and location of bowel damage, and personal preference, are all factors in determining which bowel diversion surgery is most appropriate.
• An ostomy nurse can help patients deal with the practical, social, and psychological issues related to bowel diversion.