TERMINOLOGY OF STOMA
By Saldy Yusuf
In anatomy, a natural stoma is any opening in the body, such as the mouth. Any hollow organ can be manipulated into an artificial stoma as necessary. This includes the esophagus, stomach, duodenum, ileum, colon, pleural cavity, ureters, and kidney pelves. One well-known form of an artificial stoma is a colostomy, which is a surgically-created opening in the large intestine that allows the removal of feces out of the body, bypassing the rectum, to drain into a pouch or other collection device. The historical practice of trepanation was also a type of stoma1.
In 1710 Dr. Littre (France) described a method of creating a stoma, and then in 1776 Dr. Pillore (France) performed the first ostomy operation. In 1878 Dr. Maydl (Germany) performed 1883 to 1889 the first proctosigmoidectomy, successful recovery of a patient was reported in literature. By 1952 Dr. Brooke (England) everted the intestine – conventional ileostomy. In 1958: R.B. Turnbull, Jr. School of ET (USA) is founded- Norma Gill is trained as the first enterostomal therapist in the world and 1978: WCET (The World Council of Enterostomal Therapists) international stoma therapist organisation is founded 2.
C. ANATOMY AND PHYSIOLOGY REVIEW
1. Digestive System.
Digestion begins in the mouth mechanically by the teeth and chemically by the enzim. Swallowed through oesophagus into the stomach as bolus. In the stomach bolus digested to be small part known as chymus. It possible by the acting of secretion of HCL and ability of the stomoch to expand and contract to produce a wave like movement that urgues cymus onward (peristaltis movement ). Cymus passing into duodenum through spyncter pylorus. During it’s journey through the small intestine most of nutrients in the food are absorbed into the body, leaving a fairly liquid mixture of indigestible matter and water. The main parts of colon are caecum, colon acendens, colon transversum, colon decendens, caecum and rectum. The main function of large intestine or colon are absorbs liquid and electrolyte into the body. In colon transversum the indigestible or waste matter become pasty and it will be faeces form in the colo decendens untill sigmoid. For the moment faeces stored in rectum before defecate through anus 3.
2. Urinary Sistem.
Urinary system has complex functions, such as; ability to maintain body fluid and electrolyte balance, maintain pH by controlling acid-base factors, secretion some hormon in order to controll blood pressure, secretion eriropoietin as the precussor of erytrosit, etc.
Anatomical strucutres of urinary system starts in kidneys (paired organs behind posterior wall of abdomen) and then going to the ureters downward into the bladder or vesica urinaria. Urine collects in the bladder as reservoir and pass out regularly by the contraction of detrussor muscle through urethra to the outside of the body 4.
D. WHAT FOR
Normally someone defecate trough anus, but for some reasons the can not do it as a normally. Congenital disease like Hirscprung, anomaly disorder like anal imperforate, chronis disease like diverticulitis, or uncommon disease like familial polyposis disturbs faeces movement to anus. So surgeon make a “stoma” into abdominal wall as the artificial anus. Hopely it will be functionally like anus but in some case, there are so peristomal skins complications, whatever it give patients a second chance to life, but it’s not about prolonged of life, it’s just about how to improve quality of life.
An urinary diversion/urostomyis needed when the bladder is not functioning properly. The are four major reasons for performing a urinary diversion. The most common reason is for bladder cancer. Others neurologic dysfunction of the bladder, birt defects and chronis inflammation of the bladder 5.
E. STOMA VS OSTOMY
In medicine, a stoma (Greek – pl. stomata) is an opening (a direct translation of the Koine Greek would be “mouth”), either natural or surgically created (artificial), which connects a portion of the body cavity to the outside environment. Surgical procedures in which stomata are created are ended in the suffix ‘-ostomy’ and begin with a prefix denoting the organ or area being operated on 1.
Ostomy is a surgically created opening for excretion of faecal waste (colostomy, ileostomy) or urine (urostomy) that can be temporary or permanent 6.
Ostomy is a word ending (or suffix) that means a surgical opening has been made in a structure to divert the direction of flow of the contents 7.
F. TYPES OF OPERATIONS
1. Anterior Resection (Of the rectum).
The disesased portion is cut out and the bowel is then joined back. The new join is called an anastomosis 8.
2. Abdomino Perineal Resection.
Also referred to as an APR or AP Resection. This operation usually peformed for cancer that is very close to the anus (bottom-opening). Patient will have a wound on abdomen and one where the rectum and anus removed, so the end colostomy wil be permanently 8.
3. Hartmanns Procedure.
This opeartion allows th esurgeon to remove the diseased part of the colon. Insted of joining the colon back is kept separated from the rectum and anus. The new end of the bowel us brought up to the skin surface and made into an end colostomy. The rectum is then made into a pouch which remains inside the pelvis. It continues to produces mucus which will give patient a sensation to urge to go to the toilet 8.
When complete colon and rectum are surgicaly removed, this is called a proctocolectomy. If the spincter is still intact the doctor will be able to create a new storage bay out from small intestine (ileum) 8.
G. TYPES OF OSTOMY
1. Type of Ostomy Based on Location.
Is an opening into the caecum generally used to decompress the large bowel in cases of obstruction. Very rarely used as a formal stoma. (Dansac). A cecostomy is a catheter that is inserted into the cecum, which is the first part of the large bowel and is usually located within the right lower quadrant of the abdomen 9.
A colostomy is a surgical procedure that involves connecting a part of the colon onto the anterior abdominal wall, leaving the patient with an opening on the abdomen called a stoma. In a colostomy, the stoma is formed from the end of the large intestine, which is drawn out through the incision and sutured to the skin. After a colostomy, feces leave the patient’s body through the abdomen. A colostomy may be permanent or temporary, depending on the reasons for its use 1.
A colostomy generally strarts to function 2-5 days post-operatively. The output, volume and consistency vary in each individual case anf on the locaton of the stoma within the colon. This means that a colostomy in the distal colon will produce stool of thicker consistency and lower volume, than a colostomy in the proximal colon. There is frewuently an “adaptation phase”, wich may last for several weks. The average woth person with a colostomy would/empty the pouch 2 times a day 6.
Indication for colostomy sucah as; Cancer of rectum, Diverticulitis, Congenital Anomalies, Trauma, Obsrtuction 10.
A surgical procedure where a opening is created in the duodenum 11.
Surgical formation of a permanent opening into the duodenum. May be for the purpose of introducing a tube for post-pyloric feeding 12.
An ileostomy (ileal conduit) is a surgically created opening in the small bowel, the ileum. In most cases the surgeon uses part of terminal ileum (last section os small intestine) to form the stoma. The ileum is brought through the abdominal wall, everted to form a spout and sutured to the skin. The output/consistency will cary depending on the location of the stoma within the small bowel. A stoma pouch/bag is applied to allow for the collection of faeces 6.
An ileostomy begins to function within the first 48-72 hours after surgery. The initial effluent is usually viscous, green and shiny. The output doesnot necessarily signal return of peristalsis; it can be fluid that has been collected in the distal small bowel. Once peristalsis returns the patient may experience a period of high volume output from the stoma. This often referred to as the “adaptation phase”. Output during this period can exceed 1000 ml per day. This physiological basis of this high output phase is loss of the colons absorptive surface coupled with the delay factor normally provided by the ileocaecal valve. It is very important to monitor the patient in this period (fluid and electrolyte balance) 6.
Indication of ileostomy such as; Inflammatory Bowel Disease (Ulcerative Colitis, Crohn’s Disease), Congenital anomilies, Trauma, Familial polyposis10.
The surgical operation of making an artificial opening into the jejunum 12.
A jejunostomy is a surgically created opening from the jejunum that is brought through the abdominal wall and sutured to the skin. This type os stoma is relatively uncommon, but may be necessary in extensive Crohn’s disease or ischemia. A high output stoma pouch/bag will be required to manage this stoma6.
A jejunostomy will generally function immediately. The very wafer output and high volume (4-12 litres per 24 haour) necessitates the need for additional parenteral nutrition. This due to the inability for normal digestive absorption to take place in the ileum6.
6). Transverse Colostomy
This type of stoma is formed in the transverse part of the colon. It is usually positioned on the right upper quadrant of the abdomen and can be formed as either a loop or split stoma. Loop transverse colostomies are often raised for symptomatic/palliative reasons. Dua to the position of these stoma, being outside the recuts muscle, herniation and prolapse are common complications6.
7). Sigmoid colostomy
This type of stoma is formed from the sigmoid part of the colon. It is situated on the left hand side of the abdomen and can either be an end or loop stoma. The sigmoid colostomy can take the longest to regain its normal peristalsis, although some flatus and faecal liquid may be seen by the third of fourth day. A normal output is expected to be a soft-formed stool which may take between five days to a few weeks to estabilish after surgery6.
Colostomy function varies, but is normally between twice a day to every other day depending on diet, general condition, medical treatment and/or underlying disease6.
Surgical creation of an opening into the vermiform appendix to irrigate or drain the large bowel14.
Surgical opening into the appendix 6.
b. Gastrostomy (percutaneous endoscopic gastrostomy).
Gastrostomy refers to a surgical opening into the stomach. Creation of an artificial external opening into the stomach for nutritional support or gastrointestinal compression. Typically this would include an incision in the patient’s epigastrium as part of a formal operation. It can be performed through surgical approach or percutaneous endoscopic gastrostomy (PEG). The opening may be used for feeding, such as with a gastrostomy tube7.
c. Urostomy (also see Ileal conduit urinary diversion) / Bricker’s loop.
A diversion of the urinary flow away from the bladder, resulting in output through the abdominal wall. The most common method involves use of a portion of intestine to conduct the urine out through the abdomen and into an external pouch worn for urine collection15.
Surgical construction of an artificial excretory opening from the urinary tract16.
This type or urinary diversion involves disconnecting the ureters from the bladder and attaching them to an isolated segments of ileum (or colon for a colonic conduit). The distal end of the ileum is brought out at a pre-determined site usually on the right side of the abdomen, as a urinary stoma. A urostomy pouch/bag is then applied to allow for the collection of urine. At the time of surgery urethral stents/catheter (through the ureters and out into the stoma pouch/bag) are placed to stabilise the anastomosis, prevent stenosis and obstruction during the initial post operative period. After 7-14 days these urethral stents are removed or may fall out themselves. The kidneys will be constantly producing urine, therefore function from the ileal conduit will be immediate6.
Discarge from a urostomy is normal urine and output depends on intake. The urostomate is recommended to drink about 1800-2500 ml of liquid everyday. Enough and adewuate fluid intake is the single most important factor in prevention of complications such as urinary tract infections and stone formation.
Indication for urostomy such as; Bladder cancer, Trauma, Upper tract deterioration, Congenital anomalies, and Incontinence10.
Creation of a permanent fistula leading into the renal pelvis17. Creation of a permanent opening into the renal pelvis18. Intorduicing a self-retaining catheter or tube into kidney to divert urine from the kidney7.
2). Ureterostomy (Cutaneuos Uretostomy).
Creation of a new outlet for a ureter17.Surgical establishment of an external opening into the ureter16. Creation of a new outlet for a ureter18. The ureters are brought directly onto the skin surface to drain the urine. This type of diversion in mainly performed in babies or children as a temporary intervention untul extensive surgery can be performed. It can also be used as a palliative measure in terminally ill patients with obstructed ureters. E.g. Tumours and when the insertion of nephrostomy tubes are not feasible6.
3). Vesicostomy (cystostomy)
Cutaneous vesicostomy surgical anastomosis of the bladder mucosa to an opening in the skin below the umbilicus, creating a stoma for bladder drainage17.Surgical creation of a stoma between the anterior bladder wall and the skin of the lower abdomen, for temporary or permanent lower urinary tract diversion16. A urinary diversion directly from the bladder to the skin, more common in infants and young children as the baldder is located more abdominallu than in adults. The bladder is mobilised midway between the umbilicus and symphisis pubis. The bladder mucosa is sutured to the skin and a pouch/bag is worn6.
2. Type of colostomy based on stoma
a. Loop Stoma.
A loop of intestine is brought out through a surgical opening made in the abdominal wall. This diverts the faecal flow from diseased, traumatised, obstructed intestine or from the site of an anastomosis. When the stoma is constructed the bowel is not completely divided but is opened along the anterior surface. The opened edges are then everted and sutured to the skin. This stoma has two distinct openings, the proximal functional opening and the distal non-functional opening, that remain connected by the undivided posterior section of the bowel wall.
1). Loop Colostomy
A loop colostomy is formed in the large bowel and common sites are in the transverse colon (right upper quadrant) or sigmoid colon (left iliac fossa).
2). Loop Ileostomy
A loop ileostomy is formed in the small intestine, commonly in terminal ileum (right iliac fossa)6.
b. End Stoma.
The end stoma are sreated by cutting through the bowel completely. Thes stoma is created from part of the bowel which is turned over at the end, just like the cuff of a sleeve. It is the cuffed part that is visible. There is only one in an end stoma8. And end stoma or terminal stoma may be temporary or permanent. A stoma with a single opening is formed when the proximal (functioning) end a surgically divided structure is exteriosed through an opening in the abdominal wall, everted then sutured to the skin. For example in the gastrointestinal tract, the colon forms an end colostomy or the ileum an end ileostomy; or in the urinary tract, the ureter may form an end uretrostomy7.
c. Double Barrel Stoma.
A double barrel stoma is formed when the intestine, inmost instances the colon, is divided. The proximal and distal ends are both brought out through one opening in the abdominal wall then everted and sutured to the skin to forms two stomas lying side by side7.
Altoough some of recent developments in surgical techniques and in construction of inert artificial prosthetic devices have succeded in controlling urinary and fecal flow, their application for patients with cancer appears to be severrely resricted. While we remain concerned about the quality of life, we must keep the eradication and malignancy as our first cocncern; quality of life cannot exist without life! For the present, the morbidity and risks of these procedures, much greater than those of conventional therapy, would place the majority of cancer patients in jeopardy by adversely affecting their therapy.
Standard ostomy surfery remains the simplest, safetst, and most expedient method today for treating patients who have malignant disease. Consequently, good stomal care providers for our patients the best quality of life attainable at the present time19.
2. Coloplast, educational programme 2003.
3. _________Ileostomy, a practical guide to stoma care, Clinimed.
4. Clark Jan, DuBois Helen, Urostomy Guide, United Ostomy Asscociation. 2004.
5. Clark Jent, DuBois Helen, Urostomy Guide, United Ostomy Association, 2004
7. Blackley Patricia. Practical Stoma Wound and Continence Management. 2nd ed. . Victoria: Research Publications; 2004.
8. Hayes Diana. The stomal Care Manual, A practical guide for people with a stoma. 1st.
14. Dorland’s Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc.
15. Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc
16. The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company
17. Dorland’s Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc.
18. Saunders Comprehensive Veterinary Dictionary, 3 ed. © 2007 Elsevier, Inc.
19. Smith Dorothy B, Johnson Douglas E: Ostomy care and the cancer patients, Grune & Straton 165-171, 1986