OSTOMY CARE AND MANAGEMENT

Gastrointestinal genitourinary surgery have become increasingly complex, many procedures have been developed to achieve faecal and urinary diversion, following resection for both benign and malignant disease. With these procedures, the role of stomas - both temporary and permanent, continent and incontinent has expanded. The diagnosis at an early stage, location of stomas, techniques of constriction, the rate of complications, duration of hospitalization and good post-operative management by enterostomal therapist and other health care professionals has vastly improved the quality of life of an ostomate.

Ostomy care was an isolated field until 1950s even in developed countries. It was only in 1975, ostomy care was inaugurated in India at Mumbai by formation of ostomy association of India. The association was started at Tata Memorial Hospital under the aegis of Indian cancer society. Dr. DJ Jussawalla was the Chairman, with Dr. Praful Desai, Mr. Hiralal Narang, and Dr. LJ D'esouza as the Vice-Chairmen. Mr. Ramakant Shah was elected as Hon. Secretary.

The first stoma clinic came into existence in 1978 at Tata Memorial Hospital, Mumbai, after successful return of Mrs. Anjali Patwardhan as Asia's first trained enterostomal therapist at Cleveland Clinic Foundation Hospital Ohio, USA by Mrs. Norma Gill the Mother of Enterostomal Therapy. Now there are many Ostomy Associations and Stoma Clinics established all over the country to guide an ostomate towards comprehensive rehabilitation.

Life is with full of adjustments and well-adjusted life can give a lot of happiness to self and others. Every year there are many people who undergo ostomy surgery that alters their normal passage of elimination. Ostomies are created for variety of reasons and can be either temporary or permanent, depending on the disease and the problems involved. Abdominal stomas are being constructed with increasing frequency in the treatment of various malignant, congenital, inflammatory and traumatic conditions.

The deprivation of normal control and alteration in physical appearance can have profound psychological impact. The fear of offending others because of malodorous secretions and physical disfigurement can make ostomates avoid social contacts even with family and friends.

The enterostomal therapist provides direct patient care to person with abdominal stomas, fistula, draining wounds, drains, and incontinence as an educator, consultant and researcher with additional knowledge, specific skills and desirable attitudes. An ET can be the turning point in the life of an ostomate especially when he is under severe strain and depression. With compassionate understanding and guidance from an ET a patient can not only regain his self-esteem but resumes his normal social and business activities.

The role of ET includes, pre-operative education and counseling, stoma site selection pre and postoperative technical advice, emotional support discharge planning, outpatient follow up and ongoing rehabilitation care to patient and family.

The life of the ostomate has been vastly improved by technical advancement in surgery techniques, prosthetic devices combined with the development in specialized stoma-care with the five phases of ostomy rehabilitation.

1.Pre-operative phase

Fig 1 : Types of Ostomies

Stoma in lying, sitting and standing position

Fig : 2 Stoma in lying, sitting and standing positions.

Fig : 3 one-piece drainable ostomy pouch.

Fig :4 two-piece drainable ostomy pouch.

Fig : 5 one-piece urinary pouching system and two piece urinary pouch system.

2.Crisis phase

3.Recuperative phase

4.Transition phase

5.Post hospital phase

ABDOMINAL STOMAS

The malignancies that most commonly require construction of stoma include colorectal, bladder, and cervical cancer. A permanent stoma is required when the distal bowel and anal sphincter are removed or when the bladder is removed. A temporary stoma also may be constructed on a temporary basis to protect a bowel anastomosis lower in the colon or to provide decompression of a bowel partially or completely obstructed, by tumour. If tumour is not removed, the stoma provides palliation and relief from obstruction for the duration of the patient's life.

There are different types of stomas i.e. sigmoid or transverse colostomy, ileostomy, urinary diversion, may be end, loop, or double, barell, which require different management.

Pre-operative assessment must be carefully done identifying some specific factors.

Ostomates are very much concerned because of changes in lifestyle like toilet habits (urinary/bowel) sexual and economical issues, social acceptance because of odour noise and appearance of the appliance / pouch under the clothing.

The selection of the stoma-site is of paramount importance. The site varies for different people. The major concern is, that the patient should be able to see and to take care of the stoma. Furthermore, skinfolds, surgical scars and bony prominence should not interfere with the stoma because in order to prevent leakage, the collection device must be fixed flatly to normal skin. Improperly placed stomas will cause much distress to the patient. The day before the operation, the stoma-site should be determined after observation of the patient in lying, sitting and standing positions. Special considerations should be taken while marking the stoma-site for children, patients wearing orthopaedic braces or who are in wheelchair or for a handicapped person.

It is very important that the surgeon must create a good functioning stoma, which will help post-operatively for eventual rehabilitation of the ostomate. The reactions to surgery resulting from alteration of body image and functions like Denial, anger, grief, anxiety and depression is common and understandable.

Each person's stoma is unique, which usually looks red and moist, but may differ in shape and size. There are no nerve ending in the stoma, so it is not painful.

Post-operative stomal assessment should be done which includes the following factors :

A stoma care is a clean procedure which does not require aseptic technique unless absolutely necessary.

Extra efforts for the effective pouch management should be made because the main advantage of pouching is:

3.Accurate measurement and collection of effluent of discharge with odour control measures.

4.Easier mobilization of patient, which will result in, improved patient comfort and security with odourproof leakproof, drainable or closed end pouch.

5.The stoma should be measured from the base before selection of perfect pouch. The ET is responsible for selecting appropriate appliances and training the ostomy patient in their use so that he can return to normal meaningful life. The patients with ileostomy, urinary diversion and transverse colostomies have to wear a pouch all the time but sigmoid colostomate with AP resection or permanent stoma can be taught how to perform irrigations or self enema through the stoma and only a small dressing is required and not a big pouch.

A meticulous skin care is mandatory, but in case of skin excoriation a skin-barrier wafer, paste, or powder may be very helpful. Home going instruction are given to all the ostomates on discharge like:

10.Possible complications like bleeding, prolapse, hernia or skin excoriation etc. and immediate solutions.

LI : Limited information about disease, prognosis and importance to life or sex.

SS : Specific suggestions, fulfilling sexual needs (creativity, intimacy, closeness, love making by changing positions, lubricants, music and lights)

The management of stomas in children follows the same basic principles as in adults, but indications differ and the techniques need modifications, particularly in early infancy for the management of congenital abnormalities. Most of intended to be temporary stomas. But the psychological and social aspects of care must be tailored to meet the needs of every child.

Children in hospital should be nursed or doctored in an environment, where staff are knowledgeable about their development needs and as well as their stoma care. Many companies now produce appliances in a wide range of sizes, to fit the newborn, larger infants, toddlers and growing children. No diapers should be used for the child with a urinary diversion, since he/she would be wet all the time, which could be resulted in severe skin problem.

The effect of ostomate child on the rest of the family and environment on him are very important. Support will be very much necessary for parents as they face the implications of having a baby who looks different from the perfect infant. Discrepancies between the parent's view of normal body image and elimination methods, and reality for their baby are often difficult for them to accept. The aim of the stoma care in children, must be at all times to increase the confidence of the parents and the child to cope with the situation so the child will be able to live as a normal life as possible.

Protect the proximal incision from stomal drainage and maintain the peristomal skin integrity.

In case of pressure sores the prevention is better than cure. The following measures will help to prevent the sores by minimizing pressure, friction and shearing.

Use of hydrocolloid dressing which is available by the following manufacturers 1. Duoderm-ConvaTec Co., 2. Restore-Hollister Co, and 3. Askina-B. Bruan.

Fistula means a tract connects in one epithelial surface with another epithelial surface. Patients with these alterations may experience extended hospitalization or prolonged recovery. In addition, such complications can also raise feelings of doubt, embarrassment and anger, causing low-esteem. These issues can be addressed and handled with empathetic counselling, for both the individual and the family fistula management is a complex and difficult process. But certain guidelines may be helpful to provide, skin protection. Pouching systems and emotional support.

Incontinence of urine or faeces is probably one of the most distressing experience a person can have. Most people demonstrate uneasiness both physically and emotionally when bladder or bowel or sometimes both the functions are lost. Incontinence is the involuntary expulsion of urine or faeces. External collecting devices can be used since these patients may not be able to practice (kegal) pelvic floor exercise. As these patients suffer physical problems related to altered skin integrity. Large sums of money are expended on possible solutions or containment products. Embarrassment, depression and social isolation often follow. The following points may be helpful -

Unfortunately in India, in most hospitals the comparative rarity of ostomy surgery made like a minor problem. But with the ET training programme. Formation of ostomy associations, inservice education programmes, seminars on ostomy and wound management, the awareness is created throughout the country to provide firsthand knowledge to doctors, nurses, ostomates and their families.

Through a thorough assessment of skin integrity and appropriate planning we can definitely provide comfort and improved care by correct use of supplies which results in patient satisfaction.

The task of stoma care in developing country like India was great because of different religions, culture, languages, professional ET care and availability of modern appliances but a sound beginning has been made and future looks brighter.

STOMA CLINIC

Objective : To provide rehabilitation to patients with ostomy, chronic wounds and incontinence

Management of draining wounds, fistulas and non-healing wounds. (Pressure sores, leg ulcers, post-radiation skin reactions)