*Fabian Kamiński1, 2, Jacek Dadan1, Grażyna Majewska2
Inappropriate stoma location – consequence of operation or first surgical complication?
Źle umiejscowiona stomia – konsekwencja operacji czy pierwsze powikłanie chirurgiczne?
1I Department of General and Endocrine Surgery, University Clinical Hospital in Białystok
Head of Department: Professor Jacek Dadan, MD, PhD
2Stoma Care Outpatient Clinic, University Clinical Hospital in Białystok
Head of Clinic: Fabian Kamiński, MD
Według danych NFZ z roku 2014 w Polsce żyje 35 377 osób z kolostomią i 6270 osób z ileostomią. Większość chorych stanowią pacjenci onkologiczni, znaczną część chorzy paliatywni z krótkim okresem przeżycia. Wiek stomików powoli obniża się ze względu na wzrost zapadalności ludzi młodych na choroby zapalne jelit i nowotwory jelita grubego. Stomia więc dotyczy w znacznej części ludzi młodych, aktywnych zawodowo i jest zagadnieniem społecznym. Autorzy w artykule skupiają się na jednym z podstawowych powikłań stomii – złym jej umiejscowieniu. Wyznaczenie miejsca stomii przed operacją jest elementem kluczowym. Powinno być ono przeprowadzane przed każdym zabiegiem operacyjnym mogącym zakończyć się wyłonieniem stomii. Powyższa ocena powinna być przeprowadzona w trzech pozycjach: leżącej, siedzącej i stojącej. Następnie uśredniając pomiary, wybiera się optymalne miejsce stomii. Ostatecznego oznaczenia dokonuje się u pacjenta w pozycji siedzącej, z wyprostowanymi plecami i stopami płasko postawionymi na podłodze, w takiej pozycji, w której pacjent będzie samodzielnie wymieniał sprzęt stomijny. Autorzy konkludują, że jeżeli stomia jest wyłoniona prawidłowo w czasie radykalnej operacji, nie ma powikłań miejscowych, pacjent jest wyedukowany w kwestii pielęgnacji i zaopatrzenia w sprzęt stomijny, akceptuje swoją sytuację i jest aktywny zawodowo, to w świetle definicji WHO jest zdrowy.
According to the National Health Fund data of 2014, there are 35 377 people with colostomy and 6270 people with ileostomy currently living in Poland. Most of them are oncological patients, a great deal of them are palliative patients with short-term survival. The age of stoma patients is slowly decreasing due to the increase in the incidence of inflammatory bowel diseases and colon cancer in young people. Thus, stoma affects mostly young, professionally active people and constitutes a social issue. In the article, the author focuses on one of the basic complications of stoma – its inappropriate location. The selection of an appropriate stoma site prior to the surgery is a fundamental part of the procedure. It should be conducted before every surgical treatment that may result in stoma formation. The above-mentioned evaluation ought to be carried out in three positions: lying, sitting and standing. Following this, an optimal stoma site is selected by way of averaging the measurements. The final marking is performed with a seated patient, their back straight and feet flat on the floor, that is in the position that allows the patient to replace ostomy appliances on their own. The author concludes that if stoma is properly formed during a radical surgery, no local complications are observed, the patient is taught how to care for their stoma and equip themselves with ostomy appliances, they accept their situation and are professionally active, then in view of the WHO definition, they are indeed healthy.
According to the National Health Fund data of 2014, there are 35 377 people with colostomy, 6270 with ileostomy and 7589 with urostomy in Poland, which makes a total of 49 236 stoma patients. Simultaneously, more than 7000 stoma formation surgeries are performed – 5705 colostomy procedures, 1021 ileostomy procedures and 1031 urostomy procedures, respectively. In England and Wales there are approximately 100 000 stoma patients with an annual increase of 20 000, whereas in the U.S. and Canada there are about 800 000 stoma patients, with an annual increase of 120 000 (1). These numbers are indeed huge. Changes in the population of patients are quite considerable, most of them are oncological ones, a great deal of them are palliative patients with short-term survival. In highly developed countries, the number of patients with neoplasms of rectum is constantly increasing, yet it should be noted that the shift in surgical technique towards progressively lower anastomoses oftentimes makes it possible to avoid a permanent colostomy. On the other hand, this new shift causes the number of protective stomas to increase. The age of stoma patients is slowly decreasing due to the increase in the incidence of inflammatory bowel diseases and colon cancer in young people caused by civilisation progress (2).
More often than not, stoma formation is a part of surgical treatment of serious diseases of the abdominal cavity: the urinary system and the digestive tract. The word ”stoma” is derived from Greek and stands for ”opening”. Previously used names, i.e. artificial anus or faecal fistulas should not be employed since stoma features no artificial element and these terms do not explain the mechanism of stoma development being a conscious and pre-planned surgical procedure of connecting the intestinal lumen to the skin on the patient’s abdomen. It is intended to be a part of surgical treatment as opposed to a spontaneous development of such connection, namely a fistula which results from inflammation in the course of various diseases, injury or complications of medical procedures (3). For these reasons, it seems that ”stoma” is the most adequate name as it stands for an abdominal anus that differs from the primary one in two ways: firstly, it has a different localization for it is located in the abdomen instead of the crotch and, secondly, there is no sphincter. Excretion or defecation is in most cultures an intimate and embarrassing activity, therefore the circumstance in which the anus is exposed in the abdomen has far-reaching socio-cultural implications for the patient (4).
Despite the fact that stoma is first and foremost associated with the abdominal anus, it is indeed a universal term. Many different types of stoma can be distinguished: gastrostomy concerns the stomach and is formed to enable enteral nutrition, cholecystostomy – drainage of bile through the gallbladder, ureterostomy – connection of ureters to the skin, nephrostomy – drainage of urine directly from the kidney, cystostomy – from the gallbladder, cecostomy – decompression of caecum, or tracheostomy – connection of the trachea to the neck surface. Abdominal stomas include colostomy – bringing out one end of the large intestine, ileostomy – of the small intestine as well as urostomy or, more specifically, ureterocutaneoileostomy, standing for supra-bladder urinary diversion with intestinal interposition using Bricker’s or Wallace’s technique. Intestinal stomas, both colostomy and ileostomy, are divided into end or single-barrel stomas and loop or double-barrel stomas. One may have a temporary or a permanent stoma. An example of a permanent stoma with which the patient has to live for the rest of their life is an end colostomy following abdominoperineal resection of the rectum due to cancer. The most common example of a temporary stoma is a loop ileostomy when after a certain period of time following the creation of stoma, stoma closure procedure is performed followed by the reconstruction of the digestive tract. This type of stoma is also formed as a so-called protective stoma decompressing low anastomosis of the large intestine (5). The most crucial thing that we as surgeons should understand is the fact that stoma is for the patient, not for the surgeon. Oftentimes, the patient has to live with stoma for the rest of their life, whereas the surgeon only deals with it for a few or several days.
Conversation with the patient prior to surgery
Talking to the patient and explaining to them the essence of the disease and the need for stoma formation is an extremely important aspect of the entire therapeutic process. The necessity for stoma formation should not be presented as a necessary evil, handicap or disability, but rather as a positive element of a complex treatment which provides the patient with the chance to recover except that now the anus will be located in the abdomen and not in the crotch. What may prove of help is presenting the examples of other people of similar age who do well with stoma and have accepted their new situation (6). The role of the surgeon is to accurately inform the patient on the type of surgery, its course and potential complications and the necessity for stoma formation as well as on the consequences should the patient refuse to undergo a surgery in order to make sure that the patient understands and accepts our course of action. It should be stressed that the decision to create stoma is due to the realities of the disease and the radical character of the treatment. The surgeon ought to explain to the patient whether they will have an end stoma, a permanent stoma or a temporary one that may be removed at a later date (7). The role of the stoma care nurse is to inform the patient on the types of ostomy appliances and the need for education in self-care activities as well as to assure them that they will not be left alone after the surgery, but will remain under care of the Stoma Care Clinic which will provide them with a sense of security (8, 9). A clinical psychologist’s involvement in the conversation may prove of help, yet they are available only in a few centres (10).
Selecting a stoma site
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