The Ostomy Files: An Alternative Solution for Difficult-to-Manage Colostomies in the Descending and Sigmoid Colon

  One of the most challenging issues associated with colostomy management is an improperly cited stoma, which may occur as the result of the absence of preoperative stoma site marking, emergency surgery, postoperative weight gain, or attempts to site the stoma in the operating room. In addition, obesity is epidemic across North American cultures. Each of these two issues is associated with unique obstacles related to ostomy management. A poorly sited colostomy alone or in combination with obesity creates major self-care, quality-of-life, and ostomy management difficulties.

  Improperly sited stomas often are placed in skin creases, fat folds, near previous scars or bony prominences, or in or around other topographical irregularities on the abdomen. What may be an ideal location for one patient can be a disastrous location for another patient. Stomal malplacement disregards the need for a flat peristomal skin surface onto which an ostomy pouching system can be adhered. Self-care may be negatively affected or impossible because the patient is unable to see the stoma. Obstacles to independent care and lack of predictable, reliable wear-time not only reduce the individual’s quality of life, but also may lead to chronic leakage, peristomal skin irritation, and subsequent increased costs of care.

  Even if preoperative stoma siting services are available, creating an adequate site on the abdomen of an obese individual may be problematic. A thick, obese abdominal wall may make it difficult for the surgeon to free up enough healthy bowel to create a protruding stoma, which often results in the creation of a flush or retracted stoma. Consequently, the same problems described above for poorly sited stomas emerge for obese patients and have a similar negative impact on quality of life and costs of care.

  Before a broad array of manufactured ostomy pouching systems was commercially available, colostomy irrigation was recommended as a way to control bowel movements for patients with a descending or sigmoid colostomy. Without this approach, this set of patients faced chronic leakage, odor problems, social isolation, and skin irritation due to the lack of effective ostomy supplies as well as poorly located stomas and/or obesity.

  The descending and sigmoid colon are the only locations in the bowel where stool output regulation via irrigation may be possible. Colostomy irrigation was common 40 or 50 years ago. It involves giving an enema through the stoma at about the same time each day or every few days, depending on the individual’s bowel habits. This is done to control the time of the bowel movement. (Because a significant portion of the bowel remains intact, these patients may continue to experience constipation and/or diarrhea.) Today, for a variety of reasons, colostomy irrigation seems to be recommended less commonly in clinical practice. With the increase in the percentage of obesity in children and adults and the problems this condition creates for individuals with a colostomy, irrigation should be reconsidered as a management alternative for some patients.

  It should be emphasized that management of a poorly sited colostomy via colostomy irrigation is not appropriate for every patient. Most importantly, the colostomy must be located in the descending or sigmoid colon. An extended history of the patient’s bowel habits, lifestyle, medications, diet, cancer treatments, and desire and ability to perform the procedure must be evaluated before teaching can begin.

  The patient may present with a history of persistent leakage, dependence on caregivers for ostomy care, less-than-successful experience with a variety of types and depths of ostomy skin barriers, “pancaking” stool behind the ostomy skin barrier, or other skin and self-care issues.

  Success depends on several criteria. First, a person should have a history of regular bowel movements before ostomy surgery as well as a colostomy located in the descending or sigmoid colon. Second, the patient must have visual and manual dexterity and adequate time in the daily routine. Other issues that are critical but often overlooked by clinicians include whether the individual has access to running water, access to a toilet, a rigid work schedule (eg, swing shifts), and the desire, patience, and motivation essential for success.

  Clinicians should be cautioned about reassuring these patients they will “never have to wear a colostomy pouch again.” Remaining stool-free for 24 hours or more may take time to achieve; hence, an ostomy pouch still may be necessary until a reliable schedule has been reached. Patients also should be taught how to evaluate the cause-and-effect relationship certain foods and fluids have on their body’s fecal output – eg, constipation, diarrhea, or gas. Again, it should be emphasized that each person’s digestive system is unique and will react differently to different foods. Dietary counseling should be individualized.

  Ideally, teaching a patient how to perform colostomy irrigation should be conducted on an outpatient basis or in the patient’s own home. It may take several visits before the individual is able to duplicate the demonstration and feel confident with self-care.

  As surgical technologies and ostomy supplies continue to evolve and improve, clinicians should be open to a variety of ways to solve ostomy management problems. Sometimes we have to look back to help our patients move forward.

The Ostomy Files is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ. This article was not subject to the Ostomy Wound Management peer-review process.