Dangerous stoma after surgery. Ileostomy closure operation. Ø Double-barreled split ileostomy
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In this article, we will consider nutrition for ileostomy, diet for colostomy, as well as nutritional features after reconstructive reconstructive surgery (after stoma closure). But before that, a few words about the “quality of life” of patients with stoma.
The presence or colostomy is unpleasant, but patients adapt to this condition over time and, in most cases, lead a normal life.
I always ask my ostomy patients questions about their quality of life, and more than half of my patients consider their lives to be normal and even wonderful! One of my patients had a colostomy for over 35 years and was so used to it that he experienced no sexual or social restrictions, and enjoyed life to the fullest, traveling and leading a very active lifestyle. According to scientists:
- 79% of people feel “very good” some time after bowel surgery;
- 64% experience “no pain”;
- 84% note that the stoma “does not affect their parenting in any way”;
- and 62% “do not experience any problems with the opposite sex”;
- 54% after the operation “have a normal sex life”;
- 36% do not have any (!) social restrictions associated with an artificial anus.
But you have to get used to the stoma and learn to coexist with it. First of all, this concerns an individual approach to nutrition.
So, nutrition with an ileostomy
Ileostomy surgery, as you remember, is performed for various indications (cancer, ulcerative colitis, Crohn's disease, abdominal trauma, diverticula, bleeding, intestinal obstruction, etc.), so here we will consider general nutrition recommendations, and the subtleties regarding your disease, you need to ask your doctor.
In all cases, unless otherwise indicated, certain foods should be avoided for the first 4-6 weeks after a stoma.
Foods that should be excluded from the diet of a patient with an ileostomy
- The diet should not contain meat or poultry with skin (hot dogs, sausages, sausage), meat with spices, shellfish, peanut butter, nuts, fresh fruits (except bananas), juices with pulp, dried fruits (raisins, prunes, etc.) .d.), canned fruit, canned pineapple, frozen or fresh berries, coconut flakes;
- The diet forbids "heavy meals": raw vegetables, boiled or raw corn, mushrooms, tomatoes, including stews, popcorn, jacket potatoes, fried vegetables, sauerkraut, beans, legumes and peas;
- Exclude dairy, mixed with fresh fruits (except bananas), berries, seeds, nuts. Rolls with nuts, poppy seeds, sesame seeds, dry fruits or berries, whole grain cereals, spices in grains, berries, spices such as pepper, cloves, whole anise seeds, celery seeds, rosemary, cumin seeds, and herbs;
- The diet should not contain jams, jellies with seeds, carbonated drinks
After 4-6 weeks, you can gradually introduce these products, but one per day and in small quantities.
If something caused a negative bowel response (diarrhea, pain, bloating), then rule it out for a few more weeks, try after a while, but perhaps in the future this "irritant" will need to be avoided!
How much stool is normal for an ileostomy?
Bowel emptying after an ileostomy operation occurs more frequently and, in most cases, with liquid contents (diarrhea, diarrhea)
The “higher” (closer to the stomach) the ileostomy is placed, the more fluid the patient loses. Normal excretion is 800 - 1200 ml per day (1 liter - 1000 ml) It is normal if the excretion has the consistency of oatmeal or applesauce. Empty the bag 6-8 times a day or if it is half full and record how much fluid comes out, especially in the first 3 weeks. This is to prevent dehydration.
If a jejunostomy is performed, there is a lot of watery stool, and patients with jejunostomy may need intravenous drug solutions to prevent dehydration.
What should be done to better absorb nutrients?
- The main condition for proper nutrition with an ileostomy is good chewing, this will improve digestion and reduce the likelihood of obstruction (blockage) of the digestive tract;
- Small portions are better absorbed than large ones;
- Eat slowly and 5-6 times a day;
- Too dry, dense food is absorbed worse, and too liquid - leaves the stomach and intestines very quickly;
- In general, liquid nutrition increases stool bulk. Drink slowly and little by little.
Can certain foods increase stool volume?
- Yes, simple carbohydrates (sugar, honey, juices increase stools), it is recommended to exclude or limit their consumption in food;
- With an ileostomy, water is not always well absorbed and can also cause diarrhea. The issue of rehydration is decided individually!
- Some foods and medicines contain the substances sorbitol, mannitol (in particular in chewing gum), they also contribute to diarrhea. Pay attention to their content on the packages;
- Alcohol and caffeine stimulate stools, they are also diuretic and can increase dehydration.
What foods will help reduce the frequency of bowel movements?
- Complex carbohydrates - pasta, rice, cereals, potatoes, bread provide the volume of denser feces and slightly slow down the passage of the food bolus through the intestines.
- Sodium loss is common with an ileostomy, to make up for this loss you need to eat salty foods (6-9 g of salt per day), eat salty foods and snacks, especially cheeses, if you lose a lot of fluid.
- Foods such as bananas, boiled white rice, baked potatoes, baked apples and oatmeal help thicken stools. Try to include them in every meal.
- If the doctor has prescribed psyllium (plantain), then you should carefully add it little by little first to one serving of food and see how the intestines react. If the result is satisfactory, then psyllium can be added to each serving of food.
- There are foods that are either very unpleasant gases: all types of cabbage, garlic, beans and other legumes, asparagus, fish, meat - simply avoid them.
- Avoid beets if you are afraid that the stool will turn red (bloody) in color.
What to do if you have lost weight and the food is not digested? Can I take nutritional supplements to increase protein and calories in my diet?
- If “malabsorption syndrome” has developed, then you can try special protein supplements, sports supplements, such as Resource Beneprotein, BUT avoid carbohydrate supplements, such as Boost or Ensure.
- You can only try carbohydrate supplements that have less than 10 grams of sugar per serving (Carnation).
- If you don't like supplements, try snacks like salty crackers, cheddar cheese.
What is the best drink if the stool is too frequent?
- The best absorbed liquid is similar to the composition of blood, which has sodium, potassium and a small amount of glucose in its composition. There are special oral solutions for rehydration, they can be bought at the pharmacy. For example, Regidron, but, unfortunately, they have an unpleasant taste and you can’t drink a lot of them.
- You can make your own drink: 1 liter of water + 2/3 tablespoons of salt + 2 tablespoons of sugar + a little lemon juice to taste.
- Drink this solution between meals.
- Do not add ice or dilute this solution.
- Avoid sugary, carbonated, caffeinated or alcohol-containing drinks.
- Try to drink liquid 20-30 minutes before meals or 20-30 minutes after meals. This separate consumption of food and liquid allows you to reduce the frequency of stools.
How much water should you drink a day to prevent dehydration?
- The need for fluid is individual and depends on the type of stoma. In any case, you need to drink enough to avoid dehydration.
- Usually up to 2 liters per day if there are signs of dehydration and at least 1 liter if there are no signs of dehydration.
Signs of dehydration:
increased thirst
Weight loss over 900 g in the last 24 hours
Dry mouth
By chapped lips
Low pressure
Dark urine, little urine
Headache or dizziness
arrhythmia attacks
Leg cramps or muscle spasms.
If you have any of these signs, you need to see a doctor!
Are there medications that can make stools less frequent and reduce dehydration?
- Yes, there is, most often they use imodium or lomotil (by prescription only).
- The doctor prescribes doses of antidiarrheal drugs individually! Pain medications are sometimes added, which can also reduce stool frequency (by prescription).
These drugs are taken not only with meals, but also at bedtime. - If you experience nausea or vomiting after taking these drugs, you should immediately consult a doctor.
Intestinal paresis while taking imodium is a common complication! Intestinal paresis with stoma is a direct threat to life, especially in the first weeks after surgery, until the stomach and intestines have adapted to the new functioning conditions, and the patient's body is weak.
Symptoms of paresis of the stomach, intestines: bloating, nausea, belching with the smell of feces, vomiting of feces, green fetid contents, gases and feces from the stoma cease to flow. Paresis is not treated at home! With paresis, a probe is inserted into the stomach, medications are prescribed that stimulate intestinal motility, sometimes the condition of the patient's body is so severe that the treatment is carried out in intensive care. Never take Imodium without your doctor's prescription!
Diet for colostomy
With no such problems with digestion as with an ileostomy. In general, there should be "a normal, normal balanced diet, with a liquid volume of about 1.5 liters." With a colostomy, the stool is thicker and usually does not require a special diet or medical manipulation.
Diet involves the active participation of the patient in determining what is right for him and what is not. The patient himself understands which foods cause him discomfort, abdominal pain and gas formation, and avoids them.
The issue of fiber in the diet of patients with colostomy is solved individually, in some patients fiber improves the function of the stoma, while in others, on the contrary, it causes abdominal pain and gas.
Constipation in colostomy is not uncommon. Sometimes the cause of constipation in a colostomy is narcotic analgesics or other medications.
Also, constipation during a colostomy can be caused by a lack of fluid.
For constipation with a colostomy, they first of all resort to diet correction, adding fruits and vegetables with food usually helps to cope with stool retention and does not require laxatives to be supplemented with therapy.
Dear friends! The medical information on our website is for informational purposes only! Please note that self-medication is dangerous for your health! Sincerely, Site Editor
An intestinal stoma is formed in the abdominal wall for the passage of stool and gases, bypassing the existing passage through the intestines. The formation of the hole is carried out strictly according to indications when it is impossible for the intestine to perform the main function - the removal of feces and gases. There are two types of intestinal openings:
- colostomy, when a section of the colon is brought to the surface of the abdomen;
- ileostomy, when a section of the small (ileal) intestine is brought to the surface of the abdomen.
When forming a stoma, surgeons pursue the following goals:
- Restoration of intestinal patency and the function of removing feces and gases.
- Complete cessation of the flow of feces into the rectum. This surgical measure stops the natural defecation, allows you to quickly solve a variety of problems that arise from damage to the organs of the abdominal cavity and pelvis.
Permanent or temporary stoma
Colostomy and ileostomy, as a rule, are superimposed for a short time (3-4 months). The main indications are pelvic injuries, complicated intestinal obstruction, the presence of neoplasms in the intestines, a stoma can be formed after surgical treatment of ulcerative colitis, Crohn's disease, intestinal polyposis.
A colostomy can be temporary or permanent. A temporary artificial opening is formed during the primary surgical intervention, the removal of the colostomy is carried out as planned. Subsequently, bowel function is fully restored. In some cases, in the presence of tumors, anal bleeding, acute obstruction, or resection of the intestine in a complicated course of ulcerative colitis, a permanent colostomy is formed. Surgeons decide on such measures in the presence of serious indications, when reconstructive surgery is impossible for some reason.
Reconstructive Coloplasty
The appearance of an unnatural intestinal opening often causes physical and moral suffering in patients. It is clear that the closure of the colostomy and the restoration of normal bowel function is extremely important for them. On average, a second operation is performed 3-4 months after the formation of a temporary stoma, when the person has fully recovered from the first surgical intervention. This period can be lengthened if there is inflammation in the abdominal cavity, complications and relapses of the disease. Depending on the specific clinical situation, these terms are strictly individual.
There are the following types of operations:
- Laparoscopic (or endoscopic) intervention.
- Open or abdominal surgery.
Less traumatic and more progressive is the laparoscopic method. In the CELT clinic, reconstructive surgery can be performed even in patients who have adhesions in the abdominal cavity, as well as in cases where a small area of the rectum remains.
Operation technique
Epidural anesthesia and/or endotracheal anesthesia are used for pain relief. To close the temporary stoma, surgeons remove the sutures from the surfaces and spread the sections apart. In the presence of a double-barreled colostomy (when the two ends of the intestine are brought out), the usual stitching of the walls is performed.
In the presence of a single-barrel hole, more complex manipulations are carried out. Specialists connect the ends of the walls with special staples or threads using special staplers or manually. Sections of the intestine can be joined "end to end", which is more physiological, or superimposed according to the "side to side" principle.
After connecting the parts of the intestine, before closing the abdominal wall, surgeons evaluate the tightness of the connections. Reconstruction of the colon and restoration of the natural passage of feces depends on the duration of the disconnected area, the presence of adhesions, scarring, inflammation, and other factors.
The surgeons of the CELT clinic have been performing reconstructive operations on the intestines for many years and have gained a lot of experience.
Colostomy closure usually performed 3-6 months after the first operation, although the time interval is ambiguous. While some authors have extrapolated from the literature on non-traumatic cases and insist on such a long interval between colostomy and closure, others argue that a shorter interval of one to two months gives the lowest complication rate.
Next, one prospective uncontrollable and two prospective randomized trials have shown that closure at the same hospitalization, 7-14 days after the first operation, is safe and cost-effective. Although closure for the same duration of hospital stay is not appropriate for all patients, appropriately selected subgroups of patients without other severe trauma or significant postoperative complications may benefit from colostomy closure shortly after colostomy.
Most even unsewn rectal injury heals well in an average of 7-10 days, and therefore the closure of the colostomy at the same hospitalization seems feasible and safe.
Colostomy Closure Technique
Type colostomy determines access through a local incision or a full laparotomy. Loop and double-barrel colostomy can be easily reconstructed through an incision in the area of the colostomy, which allows you to clean the edges of the intestine and sew them in one row. Hartmann's operations with a mucosal fistula near the colostomy also allow for local access.
Although most of these patients will be operated under general anesthesia, the use of local anesthesia has also been described. However, among 14 patients (12 with loop colostomy and two with terminal colostomy and mucosal fistula), the rate of serious postoperative complications was unusually high (43%, three anastomotic leaks, two wound infections, one ileus). It is unclear whether local anesthesia, which creates suboptimal operating conditions, is one of the causes of these complications.
After Hartmann operations without a mucous fistula, a second median laparotomy under general anesthesia is necessary. To minimize the surgical trauma of the second intervention, laparoscopically assisted operations are successfully used, with and without pneumoperitoneum. The advantages of closure after Hartmann's operation are less, as loop colostomies can be closed through a local incision in a short time and with minimal trauma.
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Outcomes of colostomy closure
Colostomy closure is associated with significant risk. In an analysis of 40 trauma patients who had 28 loop and 12 terminal colostomies closed on average eight months after injury, we found that the postoperative complication rate was 30%. Serious postoperative complications included a fecal fistula that was treated nonsurgically, a stricture at the anastomotic site that required reoperation, and two small bowel obstructions, one of which was resolved conservatively and the other required surgical dissection of the adhesions. Interestingly, the closure of the colostomy after a colonic injury causes a greater number of complications than after a rectal injury.
Similar results have been reported in other research which gave complication rates of 24%, 35%, 32%, and 27%. Although most complications were relatively minor and included wound infections and easily treatable extra-abdominal infections, serious complications such as anastomotic leaks or intra-abdominal abscesses are not uncommon and even mortality rates of up to 2% have been reported. The risk of complications is increased by premorbid factors, especially diabetes, heart and kidney disease.
Young and somatically unburdened Patients should have a low risk, but it is not possible to completely eliminate the risk. Complications associated with closure of the colostomy should be considered as an additional argument for performing a primary suture for colon injuries.
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The patient stays in the clinic for several days. Several different devices can be attached to it, they are removed after the patient recovers:
- A dropper that provides fluid to the body.
- A catheter to remove urine.
- Oxygen mask or nasal oxygen cannulas to facilitate breathing.
A colostomy bag, a special sealed bag, is attached to the stoma. It is usually larger than the standard ones. Later it is replaced with smaller ones, before being discharged.
During the hospitalization process, a nurse at the Assuta clinic will teach you how to care for your stoma, how to keep your skin clean and avoid irritation, advise on the process of emptying and changing bags. The bags are waterproof so you can swim with them.
3-10 days after the colostomy surgery, the patient will be able to leave the hospital.
During this period, it is important to avoid tedious activities that will give a load to the abdominal cavity. The medical staff of the Assuta clinic will inform you how to return to such activities.
In the first few weeks after a colostomy, there may be excessive flatulence and unpredictable discharge. However, the condition will improve when the intestines recover from surgery.
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Colostomy closure
If the stoma is temporary, surgery will be needed to close it. It is performed only when the patient's health has been restored, he has recovered from the consequences of the formation of a colostomy. It is usually performed, as a rule, 12 weeks after the initial intervention.
However, the recovery process may be longer if further treatment is required, such as chemotherapy. In this case, there is no exact limit, some people can live with a colostomy for several years before it is closed.
Sometimes surgery to close a colostomy is not recommended. For example, if the muscles that control the anus (sphincter muscles) have been damaged. Then the elimination of the stoma will cause intestinal incontinence.
The operation to close a loop colostomy is relatively simple. The surgeon makes an incision around the stoma. The upper part of the large intestine is connected to the rest of it.
End colostomy closure surgery is a more invasive surgery because the doctor needs more access to the abdomen. Therefore, the risk of complications will be higher, the recovery period will be longer.
Most patients feel well enough to leave the clinic 3-10 days after such surgery. It will take some time to restore normal bowel function. Some people have diarrhea, but it goes away with time. There are pains in the anus. The use of protective creams such as sudocrem is suggested.
The operation to close the colostomy is less extensive compared to its creation. However, it will take several weeks to recover and return to normal life.
Potential complications of a colostomy
After creating a stoma, there is a possibility of some complications. Let's consider some of them.
Allocations
After a colostomy that did not involve the rectum or anus, there may be discharge of mucus from the rectum. It is produced by the intestinal mucosa and acts as a lubricant to help the stool pass. Its consistency varies from clear "egg white" to sticky and gooey. If there is blood or pus, it is a sign of infection or tissue damage.
One option for managing this symptom is the use of glycerin suppositories. The capsules dissolve, making the mucus watery, making it easier to get rid of.
Sometimes the mucus causes irritation around the anus, and protective creams can help here.
Paracolostomy hernia
A hernia is a condition in which an organ protrudes from the cavity it normally occupies, such as muscle or surrounding tissue due to weakness. In this particular case, there is a protrusion of the intestine through the muscle tissue of the abdominal cavity, near the site of the colostomy, a noticeable bulge forms under the skin. People with an ostomy have an increased risk of this complication because the abdominal muscles were weakened during the operation.
As effective ways to prevent hernia, are considered:
- Wearing a support belt or underwear.
- Maintain a healthy weight, as being overweight or obese puts extra stress on the abdominal muscles.
- Avoid heavy lifting.
Most hernias are managed conservatively, but sometimes surgery is required after colostomy surgery. However, there is a possibility that the hernia will then reappear.
Colostomy blockage
This complication occurs due to food sticking. Possible signs of blockage:
- Decreased stool volume or watery stools.
- Flatulence.
- Swollen stoma.
- Nausea and/or vomiting.
If there is a suspicion of the occurrence of this complication after colostomy surgery, one should:
- For the time being, avoid solid foods.
- Drink plenty of fluids.
- Massage the abdomen and the area around the stoma.
- Lie on your back, pull your knees to your chest and roll over from side to side for a few minutes.
- Take a hot bath (15 - 20 minutes), which will help relax the abdominal muscles.
However, if there is no improvement, you should immediately contact your doctor, as there is a risk of colon rupture.
You can reduce the chance of this complication of a colostomy by chewing your food slowly and thoroughly, without eating too much at a time.
Foods that promote blockage should be avoided, such as corn, celery, popcorn, nuts, cabbage, coconut macaroons, grapefruit, raisins, dried fruits, apple peels.
Other complications of colostomy after surgery
There are a number of other complications that can occur after a colostomy is formed:
- Skin problems when there is inflammation and irritation on the skin around the stoma. Doctors in Assuta will give recommendations on how to solve it.
- Fistula (fistula) - a fistula develops next to the colostomy, a pathological small canal.
- Stoma retraction - retraction of the colostomy into the abdominal wall. The reason can be both a sharp loss and an increase in weight. As a result, intestinal contents can leak and cause skin irritation. Various types of colostomy bags can alleviate this problem, although in some cases further surgery is required.
- Stoma prolapse - prolapse of the intestinal mucosa due to a wide stoma. Other contributing factors may be intestinal flatulence, increased intra-abdominal pressure, wearing a belt bag. If the prolapse is small, the use of a different bag may improve the situation, although later surgery may be required. It is also recommended not to lift weights, use a bandage.
- Leakage of digestive waste from the colon onto the skin or into the abdomen. With external problems, the use of various colostomy bags and techniques can help, with internal problems, further surgery will be required.
- Ischemia of the stoma due to a decrease in blood flow to it. There will be a need for an additional operation.
- Stenosis or narrowing of the stoma. In most cases, it appears six to eight weeks after the colostomy. An operative approach that widens the mouth can be used. The procedure of "finger bougienage", a special massage, will bring benefits.
The high level of professionalism of doctors in the Assuta clinic, modern medical capabilities will ensure the best treatment result with minimal complications.
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