A colostomy is a surgical procedure that involves connect part of the large intestine (the colon) to the abdominal wall by creating a small opening in the skin (stoma) which allows stool to be evacuated when it can no longer be evacuated by natural means. Colon CancerCrohn’s disease, ulcerative colitis… What are the indications for this intervention? How is it going? What are the daily precautions? Answers from Pr Michel Ducreux, head of the digestive oncology department at the Gustave Roussy Institute.
Definition: what is a colostomy?
As stated above, colostomy refers to the connection of the large intestine to the skin of the stomach. In other words, surgeons cut a passage through the muscles of the abdominal strap and the abdominal wall to sew the colon to the skin of the belly, explains Professor Ducreux. The stools are therefore evacuated at the level of the round opening (the stoma) created a few centimeters from the navel and nicknamed “artificial anus”. Their flow cannot be controlled and they are received in a colostomy “bag” which must be regularly emptied or changed depending on the location of the colostomy and the consistency of the stool.
Temporary or permanent, terminal or lateral colostomy?
The colostomie can be temporary (colostomie discharge) if the surgeon intends to restore digestive continuity during a future operation. It is considered in particular when part of the colon must be rested, for example to allow the drying of fistulas or an abscess. In the case of a colostomie definitive, the surgeon will not restore digestive continuity. It is considered, for example, when the rectum and the anus had to be removed and the sphincter function could not therefore be preserved.
Furthermore, the main difference between a lateral and an end colostomy is which section of the colon is used to create the stoma:
- The lateral colostomy (also called a Hartmann colostomy) is created by taking a loop of intestine from the sigmoid colon and pulling it through an incision made in the abdominal wall. The lower part of the intestine is directed outside the body to allow feces to pass out. The upper part of the intestine is left in place and closed to prevent the exit of faeces.
- The terminal colostomy, it is created by taking one end of the colon and pulling it through an incision made in the abdominal wall. The lower part of the intestine is directed outside the body to allow feces to pass out. The upper part of the intestine is removed or disconnected, which means that feces can no longer pass through the anus
Ascending, transverse, descending or sigmoid colostomy?
As a reminder, the colon is made up of four segments: the right colon (also called ascending colon), located on the right side of the body; the transverse colonwhich connects the right colon to the left colon; the left colon (also called descending colon), located on the left side of the body and the sigmoid colonwhich connects the left colon to the rectum.
Depending on the site of the colostomy, we therefore distinguish:
- ascending colostomy (the rarest type of colostomy);
- transverse colostomy ;
- descending colostomy ;
- et sigmoid colostomy (the most common type of colostomy).
Note: depending on the colon segment concerned, the stool collected in the pocket will not have the same consistency. Since the colon absorbs water from the stool, it is normal for it to be very liquid in the ascending colon and more solid in the sigmoid colon.
© Institut national de Cancer (source 1)
Indications: when and why perform a colostomy?
- A colostomy can be performed as part of the treatment of colon cancer, rectal cancer or anal cancer, when a significant portion of the colon needs to be surgically removed. It can also be performed if part of the colon has been invaded by metastases from another focus (in the case of prostate cancer or ovarian cancer, for example).
- It can also be done in case of inflammatory bowel diseasesuch as Crohn’s disease, ulcerative colitis or ulcerative colitis, when medical treatments are not effective enough.
- Some intestinal trauma (accident, assault, etc.) may require a colostomy, especially in the event of perforation or occlusion.
- In some cases of severe infectionor if certain wounds need a healing timea colostomy may be needed to allow the bowel to rest and heal.
- Infants born with birth defects of the gastrointestinal tract may need a colostomy to divert their stools and avoid complications.
- Finally, some cases offaecal incontinence may justify the creation of an artificial anus.
What precautions should be taken before the operation?
Before a colostomy, it is important to take certain precautions to minimize the risks and facilitate recovery. To begin with, you will be seen by the surgeon who is to operate on you. Objective ? Read the details of the intervention and ask all the questions that concern you. At the end of the appointment, you must be informed of the precautions to take and the risks of the procedure before giving your informed consent. follows a consultation with the anesthesiologist, which makes it possible to rule out possible risk factors. Before the operation, certain medical examinations may also be prescribed for you: blood tests, coagulation test, electrocardiogram, etc.
With regard to diet, follow your doctor’s recommendations. Most of the time, it is advisable to follow a digestive sparing diet (diet without residue) before the procedure. Certain eating habits can also prevent constipation or diarrhea.
To facilitate the procedure, you will also need to ingest a laxative preparation aimed at removing feces and residues before the operation. It may possibly be supplemented by cleansing enemas. Additionally, you will need to:
- having taken a shower with an antiseptic product.
- fasting (stop eating at least 6 hours before the procedure and stop drinking at least 3 hours before the procedure);
- have quit smoking in the two months preceding the intervention (or at least have greatly limited your consumption) to promote healing;
- about alcohol, it is better to avoid drinking in the seven days preceding the operation. And obviously ban any alcoholic drink on D-Day.
How is a colostomy performed? How long does it last?
The colostomy can be scheduled or decided urgently. It generally lasts less than an hour, and can be performed in isolation or preceded by the removal of part of the colon.
It is carried out under general anesthesiaafter one laparotomy (the surgeon opens the abdomen) or, ideally, after laparoscopy (the surgeon inserts an endoscope and small surgical instruments through small incisions in the abdomen).
Once the segment of the colon connects to the skin of the belly, it is fixed with absorbable suture. The bag allowing the intestines to be emptied is then positioned around the exit orifice (the stoma). The “free” end of the digestive tract can be cut and closed with staples or stitches: this is called a rectal stump. This no longer works, but it can produce mucus which can be evacuated through the anus.
What are the possible complications after the installation of an artificial anus?
Different local complications can occur after a colostomy. They sometimes require surgical management:
- pains ;
- bleeding;
- an infection ;
- a necrosis stoma;
- a mycosis at the level of the stoma;
- the formation of a hernia near the stoma;
- a stenosis or a stoma retraction (it sinks into the abdomen);
- and stomial prolapse (the colon protrudes and “comes out” of the stoma);
- a disembowelment peristomal (the muscular orifice through which the colon passes widens);
- etc.
On a daily basis, what are the consequences of a colostomy?
After the operation, you will stay in the hospital for several days, convalescing. The opportunity to learn to live with your device. A stoma therapist will help you choose the type of colostomy bag that suits you and will teach you little by little how to maintain it on your own.
He is quite normal for the stoma to be “swollen” in the days following the intervention. It can even bleed slightly because it is very vascularized. It is therefore important to protect it to avoid untimely bleeding.
In theory it is not painful because the lining of the colon does not contain sensory nerves. But in case of pain, the medical team will administer analgesics intravenously, or even an epidural anesthetic.
The artificial anus will take on its final appearance a few weeks after the operation: a bright red circle a few centimeters in diameter that slightly protrudes from the surface of the skin.
When to change an ostomy bag?
The stoma requires daily hygiene care : it must be washed every day with water and mild soap, then dried carefully.
Ostomy pouches should stay in place all day. They must be cleaned or discarded after each bowel movement and put back in place. Logistically, it is best to keep a washcloth, compresses, a new ostomy bag and a garbage bag handy.
Note: given the potential discomfort caused by the evacuation of stool, it is sometimes possible to perform an enema to empty the colon and not have to empty the bag for a whole day.
What about diet, physical and sexual activity?
The resumption of food is very gradual: you will start by ingesting food in liquid form, then you will gradually reconnect with solid foods. In case of diarrhea or constipation, promote antidiarrheal or anti-constipation foods. In addition, to have a good transit, be sure to eat a balanced diet at fixed times, to drink enough and to chew well.
Wearing an ostomy bag on a daily basis does not prevent you from working, driving or carrying out your daily tasks. Dress sidewear what you like, but make sure that your clothes, or your underwear, do not compress the stoma.
Unless otherwise advised by your doctor, you can absolutely resume regular physical activity (including swimming, as the pockets are waterproof). Only contact sports such as boxing, rugby or wrestling are generally discouraged.
Regarding sexuality, again, no contraindications to report! The difficulties encountered are not so much technical, but rather psychological: you may well be bothered by your pocket.
Finally, psychological follow-up is strongly recommended, because the stoma can have a strong psychological impact given the bodily and intimate changes it involves. The help of a specialist can help you gradually regain confidence in yourself and your body to lead the most “normal” life possible, despite the specific arrangements related to the ostomy pouch.