Fecal diversions: colostomy, ileostomy, and ileal pouch anal anastomoses

56 Fecal diversions: colostomy, ileostomy, and ileal pouch anal anastomoses




Overview/pathophysiology


For a discussion of ulcerative colitis (UC), see p. 447; for a discussion of Crohn’s disease (CD), see p. 410.



Health care setting


Acute care on surgical unit, primary care, home care after hospital discharge



Surgical interventions


It is sometimes necessary to interrupt continuity of the bowel because of intestinal disease or its complications. A fecal diversion may be necessary to divert stool around a diseased portion of the bowel or, more commonly, out of the body. A fecal diversion can be located anywhere along the bowel, depending on location of the diseased or injured portion, and it can be permanent or temporary. The most common sites for fecal diversion are the colon and ileum.




Colostomy:


Created when the surgeon brings a portion of the colon to the surface of the abdomen. An opening in the exteriorized colon permits elimination of flatus and stool through the stoma. Any part of the colon may be diverted into a colostomy.



Transverse colostomy:

Most commonly created stoma to divert feces on a temporary basis. Surgical indications include relief of bowel obstruction before definitive surgery for tumors, inflammation, or diverticulitis and colon perforation secondary to trauma. Stool can be liquid to pastelike or soft and unformed, and bowel elimination is unpredictable. A temporary colostomy may be double barreled, with a proximal stoma through which stool is eliminated and a distal stoma, called a mucus fistula, adjacent to the proximal stoma. More commonly, a loop colostomy is created with a supporting rod placed beneath it until the exteriorized loop of colon heals to the skin.



Descending or sigmoid colostomy:

Usually a permanent fecal diversion. Rectal cancer is the most common cause for surgical intervention. Stool is usually formed, and some individuals may have stool elimination at predictable times. In a permanent colostomy, the surgeon brings the severed end of the colon to the abdominal skin surface. The diseased or injured portion of the colon and/or rectum is resected and removed. To create the stoma, the colon above the skin surface is rolled back on itself to expose the mucosal surface of the intestine. The end of the cuff is sutured to the subcutaneous tissues with absorbable sutures to hold it in place as it heals.



Temporary colostomy:

Typically created when there is significant inflammation in the diseased portion of the bowel (e.g., perforated diverticulum or ulcerative colitis) or when rectum-sparing surgery is performed for colorectal cancer. When a temporary colostomy is created, the severed end of the colon is brought through the abdominal wall as for a permanent colostomy. The diseased or injured portion of the colon is resected and removed. The remaining rectum or rectosigmoid is oversewn and left in the peritoneal cavity; it is referred to as Hartmann’s pouch. After the inflammatory process has resolved (e.g., 3-6 mo), the colostomy is taken down and reattached to the bowel of Hartmann’s pouch, thus reconstructing continuity of the bowel and normal bowel elimination.



Cecostomy or ascending colostomy:

Not a common procedure. A temporary diverting colostomy is used to bypass an unresectable tumor. The stool from an ascending colostomy is soft, unformed, pastelike, semiliquid, or liquid, and bowel elimination is unpredictable. Surgical procedure is similar to that with transverse colostomies.



Ileostomy:



Conventional (brooke) ileostomy:

Created by bringing a distal portion of the resected ileum through the abdominal wall. A permanent ileostomy is created by the same procedure discussed with a permanent colostomy. Surgical indications include UC, CD, and familial adenomatous polyposis (FAP) requiring excision of the entire colon and rectum. For any ileostomy, the output is usually liquid (or, more rarely, pastelike) and is eliminated continually. The more proximal the ileostomy, the more active are digestive enzymes within the effluent (stool) and the greater their potential for irritation to exposed skin around the stoma. A collection pouch is worn over the stoma on the abdomen to collect gas and fecal discharge.



Temporary ileostomy:

Usually a loop stoma with or without a supporting rod in place beneath the loop of the ileum until the exteriorized loop of ileum heals to the skin. The purpose is to divert the fecal stream away from a more distal anastomotic site or fistula repair until healing has occurred.



Continent (kock pouch) ileostomy:

An intraabdominal pouch constructed from approximately 30 cm of distal ileum. Intussusception of a 10-cm portion of ileum is performed to form an outlet nipple valve from the pouch to the skin of the abdomen, where a stoma is constructed flush with the skin. The intraabdominal pouch is continent for gas and fecal discharge and is emptied approximately four times daily by inserting a catheter through the stoma. No external pouch is needed, and a Band-Aid or small dressing is worn over the stoma to collect mucus. Surgical indications include UC and FAP requiring removal of the colon and rectum. CD is generally a contraindication for this procedure because the disease can recur in the pouch, necessitating its removal. A long-term complication of Kock pouch is pouchitis. See under ileal pouch anal anastomosis (IPAA) next, with the exception that tenesmus is not a symptom for a patient with a Kock pouch.



Ileal pouch anal anastomosis (IPAA) or restorative proctocolectomy:


A two-stage surgical procedure developed to preserve fecal continence and prevent the need for a permanent ileostomy. During the first stage after total colectomy and removal of the rectal mucosa, an ileal reservoir or pouch is constructed and lowered into position in the pelvis just above the rectal cuff. Then the ileal outlet from the pouch is brought down through the cuff of the rectal muscle and anastomosed to the anal canal. The anal sphincter is preserved, and the resulting ileal pouch provides a storage place for feces. A temporary diverting ileostomy is required for 2-3 mo to allow healing of the anastomosis. The second stage occurs when the diverting ileostomy is taken down and fecal continuity is restored. Initially, the patient experiences fecal incontinence and 10 or more bowel movements per day. After 3-6 mo, the patient experiences decreased urgency and frequency with 4-8 bowel movements per day. This procedure is an option for patients requiring colectomy for UC or FAP. Its use is controversial in patients with CD. It is contraindicated with incontinence problems. Pouchitis is a long-term complication of IPAA. Its cause is unknown but may be due to stasis of bacteria in the ileal pouch. Symptoms include increased stool frequency, cramping, tenesmus, and bleeding. Pouchitis is effectively treated with metronidazole or ciprofloxacin. Probiotics also may be effective in preventing and maintaining remission in patients with recurrent pouchitis.


Note: Consult wound, ostomy, continence (WOC)/enterostomal therapy (ET) nurse, if available, since he or she has expertise in all aspects of fecal diversion management and related patient care.





Nursing diagnoses:


Risk for impaired skin integrity: peristomal

related to exposure to effluent or sensitivity to appliance material



Impaired tissue integrity: stomal (or risk for same)

related to improperly fitted appliance resulting in damage to stomal tissue and/or impaired circulation


Desired Outcomes: Patient’s peristomal skin remains nonerythremic and intact. Patient’s stoma remains red, moist, viable and intact.






























ASSESSMENT/INTERVENTIONS RATIONALES
After colostomy or conventional ileostomy (permanent or temporary)
Assess stoma for viability q8h. Stoma should be red in color, moist, and shiny with mucus. A stoma that is pale, dark purple to black, or dull in appearance may indicate circulatory impairment and should be documented and reported to health care provider immediately.
Apply a pectin, gelatin, methylcellulose-based, or synthetic solid-form skin barrier around stoma. This barrier will protect peristomal skin from irritation caused by contact with stool or small bowel effluent.
Cut an opening in the skin barrier the exact circumference of the stoma or as recommended by manufacturer. Remove release paper and apply sticky surface directly to peristomal skin. For some pouching systems, the skin barrier may be a separate barrier to be used with an adhesive-backed pouch, part of a two-piece system, or an integral part of a one-piece pouch system. Pectin-based paste also may be used to “caulk” around the barrier and compensate for irregular surfaces on peristomal skin. A pectin-based paste may prevent undermining of the barrier with effluent and protect skin immediately adjacent to the stoma.
Remove the skin barrier and inspect skin q3-4d. Monitor peristomal skin for erythema, erosion, serous drainage, bleeding, and induration. Carefully document abnormal findings, and report them to health care provider. These indicators may signal presence of infection, irritation, or sensitivity to materials placed on the skin.
Discontinue use of irritating materials, and substitute other materials. This will help heal and protect irritated and/or denuded skin.
Patch-test patient’s abdominal skin. This will determine sensitivity to suspected materials.

Recalibrate skin barrier opening to size of stoma with each change.

Teach patient to report immediately any burning or itching under skin barrier or any fecal odor.
Stomas become less edematous over a period of 6 to 8 wk after surgery, necessitating changes in the size of the skin barrier opening. The skin barrier opening should be the exact circumference of the stoma, or as recommended by the manufacturer, to prevent contact of stool with skin and to prevent constriction of the stoma, which can result in increased edema of and decreased blood flow to the stoma. Commercial templates are available to aid in estimating size of the opening needed for the skin barrier.
< div class='tao-gold-member'>

Related posts:

  1. Psychosocial support
  2. Care of the renal transplant recipient
  3. Pneumothorax/hemothorax
  4. Bronchiolitis

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 18, 2016 | Posted by in NURSING | Comments Off on Fecal diversions: colostomy, ileostomy, and ileal pouch anal anastomoses

Full access? Get Clinical Tree

 Get Clinical Tree app for offline access