Overview of Intestinal Stoma
The term ‘stoma’ or ‘ostomy’, which comes from a Latin word meaning ‘opening’ or ‘mouth’, is used to refer to a surgical procedure where part of the intestine (the small bowel or large bowel) is brought out through a hole in the stomach. This was first done by a German surgeon named Baum in 1879 as a way to bypass a blockage in the large intestine caused by cancer.
Nowadays, creating an intestinal stoma is a common life-saving surgery done all over the world. It can be done as an emergency procedure or planned ahead of time to treat many different conditions of the intestine that are non-cancerous or cancerous. In fact, over 130,000 of these surgeries are done every year in the United States alone to treat conditions like colon cancer, inflammatory bowel diseases, injuries from radiation treatment, a condition called diverticulitis which affects the large intestine, and inability to control bowel movements.
Intestinal stoma can be temporary, where it’s reversed after some time, or permanent. Even though it’s a life-saving surgery, it might have some complications.
Anatomy and Physiology of Intestinal Stoma
The small intestine is a part of your digestive system that extends from your stomach to a region known as the ileocecal valve. It’s made up of three parts: the duodenum, the jejunum, and the ileum, and usually measures around 4 to 6 meters long. The small intestine develops from something called the primitive gut when you’re an embryo. The duodenum, which comes first, grows from the foregut. The other two parts, the jejunum and the ileum, grow from the midgut.
The duodenum gets its blood supply from arteries called the superior and inferior pancreaticoduodenal arteries. It helps combine secretions from the pancreas and liver. The second part of the small intestine is the jejunum, where a lot of digestion and absorption happens. The final part is the ileum. Both the jejunum and ileum’s blood supply is provided by the superior mesenteric artery, while they get rid of venous blood through the superior mesenteric vein. This vein meets the splenic vein behind the pancreas to form the portal vein.
The large intestine stretches from the ileocecal valve (where the small intestine ends) to the anus. The large intestine is split into the colon, rectum, and anal canal, each with their own roles and blood supply. The colon is mainly responsible for absorbing water, exchanging electrolytes and helping provide essential vitamins like K and B12, which are produced by bacteria in the colon.
An ileostomy makes use of a part of the ileum. Its function is linked to the location of the stoma, or the hole created in the body for the medical procedure. The closer to the start of the ileum the stoma is, the less effectively it can absorb water and electrolytes. On average, the output from an ileostomy is around 600mL per day. More than 1.5L can be excessive and might make the patient prone to dehydration.
A colostomy involves creating an opening to the outside of the body (a stoma) from parts of the colon. Different types exist, such as a double-barrel colostomy, loop colostomy, and end colostomy. The exact texture of the output from a colostomy depends on where the stoma is located. The closer to the start of the colon, the more liquid the output.
Why do People Need Intestinal Stoma
Intestinal stomas are medical procedures that help manage many gut-related diseases. There are several types of intestinal stoma surgeries, including Hartman’s end colostomy, loop colostomy, and ileostomy. These procedures can help in different situations, depending on your age. For instance, in adults, it’s usually used to manage colorectal cancer. In contrast, in children, it can be used to deal with birth defects like Hirschsprung’s disease and anorectal malformation – conditions that affect the structure of the intestines.
But, the use of intestinal stoma isn’t limited to just cancer and birth defects. It can also be applied in a range of other health issues like inflammatory bowel disease, bowel interruption due to a disease like diverticulitis, bowel injuries, stool leakage, protection of a connecting part of the gut, gangrenous sigmoid volvulus (a condition where a part of the intestines twists on itself), Fournier gangrene (a rapidly spreading infection of the groin or genital area), and leakage following a connection of cut bowel ends.
More specific uses for these different types of intestinal stomas are:
The end colostomy is utilized for certain situations like rectal cancer surgery where the bowel path isn’t restored, in-the-gut infections from a disease like diverticulitis, and lower rectum removal surgeries.
Loop colostomy is used in conditions like unremovable rectal tumors, protection of lower rectum surgeries, proctitis (inflammation of the rectum lining), fecal incontinence (inability to control bowel movements), complex rectal cancer causing bowel blockage, and severe anal fistulas in inflammatory diseases.
End or loop-end ileostomy (a type of stoma that brings a part of the small intestine to the surface of the abdomen) is used when the formation of a small intestine pouch fails, in emergency removal of the large intestine or the entire intestine, in massive intestine removal due to blood supply shortage, in total removal of large intestine for familial adenomatous polyposis (a condition leading to thousands of polyps in the lining of the colon and rectum), in inherited nonpolyposis colon cancer with low rectal cancer, in full intestine removal for hard-to-treat ulcerative colitis, and in entire gut removal for Crohn disease.
Loop ileostomy is utilized in situations like protection of full intestine removal in familial adenomatous polyposis and chronic inflammatory bowel disease, severe fecal incontinence, Fournier gangrene, severe toxic colitis, low rectal or coloanal connection, severe infection of the lower skin, severe Crohn perianal sepsis (infection near the anal area in Crohn disease), rectal trauma or muscle injury, complicated rectovaginal or rectourethral fistula (abnormal connections between rectum and vagina or rectum and urethra), and in the management of anastomotic leak (leak from the connection site of cut bowel ends).
When a Person Should Avoid Intestinal Stoma
There are no solid reasons that completely prevent the creation of a stoma, which is a surgically created opening in the body for waste removal. However, certain conditions may potentially make the procedure more challenging and risky.
One of these conditions could be ‘carcinomatosis,’ which refers to the widespread spread of cancer in the body. Another issue is a ‘short mesentery,’ which is a part of your body that attaches your intestines to the wall of your abdomen. If the mesentery is short, it may not be possible to comfortably pull the intestine through the wall of the abdomen to create the stoma.
Experiencing tension on the stoma, particularly prevalent among overweight patients, is a significant risk factor for complications post-surgery. Tension can happen when the stoma is stretched too tight, which can lead to problems after the operation.
Equipment used for Intestinal Stoma
During surgery, the tools the surgeon uses depend on the specific type and technique of the intestine-related operation. Some doctors may use surgical staplers and staples instead of stitches. These staplers come in a variety of sizes and heights, so the surgeon can choose the most suitable one. The choice of stapler and the height of the staples often depends on the specific characteristics of different bodily tissues.
For instance, the thickness of the tissue is a key factor in surgeries related to the colon. The typical thickness of the colon wall ranges up to 3 millimeters, while the standard thickness of the small intestine wall ranges between 1 and 2 millimeters.
If the surgeon chooses to use a laparoscope to create an artificial opening (stoma) in the body, they will need specific tools. These include a laparoscopic tower (a device used to insert the camera and surgical instruments into the abdomen), trocars (sharp-pointed tools used to puncture the abdomen), a bowel grasper (tool that holds and manipulates the bowel), and the laparoscope itself (a long, thin tube with a high-intensity light and high-resolution camera at the front).
After the surgery, the patient will need a well-fitted bag to collect waste from the stoma. Along with the bag, they’ll need other supplies such as paste and rings, spray, adhesive remover wipes, dry wipes, powder, skin protector wipes, and belts. These materials help to keep the area around the stoma clean and prevent skin damage.
Who is needed to perform Intestinal Stoma?
The process of creating an opening in the intestine, known as a stoma, is typically performed by general doctors who specialize in surgery. Surgeons who focus on the colon and rectum have a lot of experience in creating stomas and might take past procedures into account. When a child needs a stoma, the procedure is done by pediatric surgeons, who are doctors specifically trained to perform operations on children. But after the stoma is working properly, it’s usually taken care of by nurses or specialists in the care of stomas.
Preparing for Intestinal Stoma
Getting the patient ready before surgery is really important because it can decrease the risk of problems that can occur after the operation. In recovery protocols, medical professionals strive to ensure the patient is in the best possible health state just before the surgery to reduce the risk of any complications post-operation. It’s recommended, for instance, that patients reduce or ideally stop drinking alcohol, smoking and using recreational drugs. Doctors will also assess and improve the patient’s metabolic health, or how their body converts food and drink into energy.
Providing patients with information and emotional support is crucial. This can result in better long-term success after the surgery and help avoid issues such as anxiety, depression, and agoraphobia, a type of anxiety disorder. Moreover, these aspects can enhance the individual’s quality of life post-surgery and help them be more independent.
Before the surgical procedure begins, a trained professional (like a nurse or a doctor) will select and mark the appropriate spot for the ostomy, a surgically made hole that allows waste to leave the body. This is important to prevent complications that can arise from a poorly placed ostomy. An ideal spot is often at the top of the belly button fold as it provides easy access to the ostomy and good visibility.
One of the essential steps in preparing for surgery involves clearing the bowel in order to minimize the chance of infections at the surgical site. Typically, this involves taking medication that helps clean out the intestine (known as a mechanical bowel preparation or MBP) along with oral antibiotics meant to decrease the number of bacteria in the bowel. While there are varying opinions on routine use of MBP in patients having colorectal (related to colon and rectum) surgery, recent guidelines recommend using antibiotics combined with MBP to lower the risk of surgical site infections.
Other common preparatory measures might include shaving the belly area, inserting a catheter (a thin tube) into the bladder (known as a Folley catheter insertion) to help with urine collection, placing a thin tube into the stomach via the nose to help with feeding or removal of stomach content (nasogastric tube placement), and ensuring the right balance of fluids and electrolytes in the body.
How is Intestinal Stoma performed
Stomas are openings in the body that serve as exit points for waste, they can be broadly categorized into two types based on where they are created in the body: ileostomies, which are made in a portion of the small intestine known as the ileum, and colostomies, which are constructed using a part of the large intestine or colon. Both of these types of stomas can be either end-ostomies – where a portion of the bowel is separated and the upper part forms the stoma while the lower part remains inside the body – or loop ostomies, where a section of the bowel wall is partially separated and brought up to the skin, forming a stoma with two openings.
The procedure to create an end-ostomy is usually similar for ileostomies and colostomies. Initial steps include removing a small circular portion of skin and revealing the muscle below by gently dividing the overlying fat. A cross-shaped cut is made in the tough fibrous tissue (fascia), and the muscle fibers beneath are carefully separated to protect surrounding vessels. The lower muscle layer and the lining of the abdominal cavity are then cut, and that upper part of the divided bowel is brought out through the opening. For colostomies, about 2 cm of bowel should stick out from the skin, while ileostomies should have about 5 cm sticking out. After closing the opening, the raised portion of bowel is fixed to the skin, forming the stoma. For ileostomies, a spout-like structure that sticks out from the skin is made by using a particular stitching technique.
Loop stomas, either ileostomy or colostomy, are done when temporary diversion of waste is needed. The first step is to identify a section of bowel that can easily reach the skin. When creating an ileostomy, the chosen bowel segment should be a specific distance away from the valve separating the small and large intestines to make future reversal of the stoma easier. A small gap is made in the connective tissue that holds the intestines in place, and a tube is placed to control the bowel loop. An opening is then made in the abdominal wall, and the bowel is brought out through it. The stitch in the middle of the abdomen is then closed. A cut is then made in the part of the bowel that does not have connecting tissue and the stoma is secured to the skin.
It’s crucial during these surgeries to ensure that the stoma remains healthy and functional. The section of bowel that is brought to the skin surface should be done so in such a way as to avoid placing too much tension on the stoma. Also, the hole made in the abdominal wall for the stoma should be just the right size – not too small to strangle the bowel, but not too large to make the stoma prone to falling out or retracting. Care should be taken to avoid twisting or kinking of the bowel, which could compromise blood supply to the stoma.
Stoma creation can also be carried out using a laparoscope, a thin tube with a camera at the end that’s inserted into the body through a small cut. This type of procedure has many benefits, including minimizing pain, reducing recovery time, shortening the hospital stay, and significantly reducing the chances of adhesion, which are bands of scar tissue that can cause the intestines to stick together and lead to obstruction.
Possible Complications of Intestinal Stoma
Getting an intestinal stoma, which is an opening created during a surgical operation to help waste leave the body, can save lives during many stomach and intestine diseases. However, there might be complications related to this stoma that some patients can experience. These complications can happen early or late after the surgery.
Early complications, like skin irritation or blood accumulation under the skin (referred to as a hematoma), can usually be managed with non-surgical treatment. On the other hand, late complications such as a protruding stoma (stoma prolapse) or a hernia (bulging of an organ or tissue) around the stoma area (parastomal hernia), can be managed with either non-surgical or surgical treatments. Between 10% and 70% of patients may face complications from their stoma, which greatly impacts their life quality and feelings of wellness.
The most commonly occurring complications of intestinal stoma are:
- Ostomy prolapse: This is when the stoma protrudes out from the skin.
- Ostomy stenosis: This is when the stoma’s opening narrows down.
- Parastomal hernia: This type of hernia happens when an organ or tissue bulges out near the stoma site.
- Cutaneous irritation: This refers to skin irritation around the stoma.
- Ostomy retraction: This happens when the stoma sinks below the skin level.
- Obstruction/Ileus: This means there is a blockage in the intestines.
- Ostomy ischemia/necrosis: This is when the tissue around the stoma doesn’t get enough blood, leading to tissue death.
- Fluid and electrolyte imbalance: This refers to disruption in body fluids and essential minerals.
- Hemorrhage/Hematoma: This means there is bleeding or blood accumulation under the skin.
- Fistula: This is an abnormal passage between two organs or between an organ and the outside of the body.
What Else Should I Know About Intestinal Stoma?
The creation of a small hole in the abdomen to connect the intestine to the body’s surface, which can be either an ileostomy or colostomy, is a common surgery often performed by general surgeons. This operation is considered a lifesaving procedure in many instances. However, between 10% to 70% of individuals with this type of opening (also known as an ostomy) might face complications related to their ostomy, significantly impacting their quality of life.
Education before and after the surgery is extremely vital as it helps patients manage their ostomy and adapt to life with an ostomy comfortably and efficiently. An ileostomy connects the small intestine to the abdomen’s surface, whereas a colostomy connects the large intestine.
