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Creation of a Stoma Joshua
A. Katz, M.D.,
via
The New Outlook - The creation of a stoma for an ostomy represents a major, immediate and sometimes permanent change in the life of a human being. This can have profound effects upon lifestyle, intimacy, employment, recreation and travel. Fear, misunderstanding, loss of self-image and social isolation can compound the situation. Colorectal surgeons and nurses who care for patients with a stoma must recognize that to save someone from a life-threatening condition means little if the life the person returns to is made miserable by a poorly functioning stoma. The objective of any operation involving a stoma is to create a stoma that the patient can care for with simple routine using an appliance that fits reliable, comfortably and protects the surrounding skin. Time between ostomy changes should be at least once a day, and never longer than seven days. There should be no leakage of feces around the appliance. Creation and utilization of a stoma is a team approach involving the patient, the ostomy nurse and the colorectal surgeon. Patients must assume responsibility for their own health and well-being. They need to learn about their disease and understand what operation is being performed and why. They need to know whether they have a colostomy or ileostomy, and whether it is permanent or temporary. An important thought to keep in mind is “when you do not know, ask.” It is useful to keep a medical summary of ones medical and surgical history written down. So be sure to list current medications, physicians names, addresses and telephone numbers. If a relative or friend has power of attorney or is a health proxy, or it there is a living will, this should also be recorded. One may also choose to obtain copies of operative notes and discharge summaries from recent or complex procedures and hospitalizations. This record is particularly critical when traveling or relocating. It is important to know that by law a medical facility must make all information about a patient available upon request of the patient. This means that at any time, you can request a copy of your medical record. In particular, patients planning a long journey - - usually more than a week - - or relocation, should notify their doctor, travel with a copy of their medical record, and prior to leaving, seek and obtain the name and number of a physician at their destination. The ostomy nurse also plays a critical role in the preoperative and post operative management. Prior to surgery - in elective or non-emergency cases - the surgeon and nurse sit down to review with the patient what procedure is being done and why. The patient then has his/her body examined while standing, sitting and lying down to determine the best place on the abdominal wall to locate the stoma. One or more sites are then marked so that the surgeon knows where to place the stoma during the procedure. Principles of stoma location and creation include: * Keeping the stoma away from bony landmarks like ribs, hips, scar and creases. * Making sure the patient can see the stoma. * Placing the stoma so it is not in the midline abdominal incision. * Keeping the stoma within the rectus muscle to prevent peristomal hernias. * Preventing stoma tension and assuring an adequate blood supply.* Budding the stoma so that it is inverted to permit proper pouch placement. this is particularly important for ileostomies so that the pouch can be placed right next to the stoma with no exposed underlying skin and thus prevents skin irritation, ulceration and breakdown. An ostomy nurse can help patients adapt post-operatively to living with their stoma by assessing the quality of the ostomy system and its fit, and modifying the pouching method. Particularly in the several months following surgery, patients may gain or lose weight depending upon their disease and may undergo several different pouching methods before developing a regimen with which they are comfortable. The ostomy nurse can facilitate and direct the process. Patients with ostomies should consider a yearly visit with an ostomy nurse to reassess pouching methods and to assess for problems. While these principles of preoperative assessment and operative management are considered standard of care by colorectal surgeons, there is yet no data that prove the validity of these principles. In addition, some patients with optimally constructed flush stomas function well, For this reason, Cleveland Clinic We have developed a “stoma scoring system” and have used this to asses 70 patients in conjunction with validated quality of life estimates as well as appliance wear time and leak rate. Data are currently undergoing statistical analysis and the results will be published. The above taken in part from the New Outlook Newsletter -Chicago------------Dated May 2005 |