Enterostomy
| Classification according to ICD-10 | |
|---|---|
| Z93.- | Presence of an artificial orifice (excl .: artificial orifices that require observation or care → Z43.-) |
| Z93.2 | Presence of an ileostomy |
| Z93.3 | Presence of a colostomy |
| Z93.4 | Presence of other artificial orifices in the gastrointestinal tract |
| ICD-10 online (WHO version 2019) | |
The enterostomy ( ancient Greek ἕντερον ENTERON , "gut" στὁμα stoma "mouth" or "opening" even colostomy , Art After , abdomen after , artificial anus , short colostomy (abbreviation AP ) = "except natural After", colloquially side exit ) is a surgically created opening of a part of the intestine through the abdominal wall, which is used to drain the excretions.
Depending on the section of intestine used, doctors speak of ileostomy (discharge from the ileum ), coecostoma (discharge from the appendix , cecum ), colostoma (discharge from the colon ) or transversostoma (discharge from the transverse colon ). Colostomy, colostomy and transverse ostomy are often grouped under the term colostomy , as the colon makes up a large part of the large intestine (intestineum crassum).
A urostoma , on the other hand, is a surgically created outlet for draining urine.
Possible underlying diseases or disorders for the creation of an enterostoma are carcinomas of the abdomen (72%); Inflammatory bowel diseases such as Crohn's disease , ulcerative colitis or diverticulitis (21%), familial adenomatous polyposis (FAP) and complications during abdominal operations, organ malformations in newborns, accidents and others (7%).
The corresponding operation is called an enterostomy, in the special cases ileostomy or colostomy. All age groups are affected - not, as is often assumed, only older people. It is estimated that there are around 100,000 ostomists in Germany.
Surgical procedure
The operation to create and relocate an enterostomy is performed under anesthesia . The care of the patient by an ostomy specialist before the operation is an important part of a competent enterostomy, as is the preoperative marking of an optimal stoma position while sitting, lying and standing (exception: emergency surgery). By preoperative marking, incorrect placements, for example in body folds, can be avoided, which can lead to poor adhesion of the stoma supply and subsequently reduced quality of life.
Most stoma applications are performed using an abdominal incision ( laparotomy ). In some cases, in which no major surgery is necessary regardless of the stoma, a minimally invasive surgical procedure during a laparoscopy is increasingly being used. With the exception of the coecostoma, an enterostoma can be created either end-to-end or double-barreled ( see below ), depending on the surgical background . Since the cecostomy is equivalent to the formation of a fistula between the caecum and the abdominal wall, it must be considered separately.
A colostoma (note: colloquial colon stoma) is created in a slightly raised manner (prominently) and free of tension through the straight abdominal muscle ( rectus abdominis muscle ). Inward kinks on the abdominal wall must be avoided. To avoid internal hernias , the mesentery ( mesocolon descendens ) is fixed to the lateral abdominal wall. The colostoma primarily promotes mushy to firm stools at longer intervals. All types of enterostomies are surgically applied by a specialist in visceral surgery .
In an ileostomy, as much of the small intestine as possible should be preserved in order to avoid high electrolyte and water loss (functional short bowel syndrome ). The supplying leg is directed downwards ( caudally ) and should protrude 1 to 2 cm (other authors say up to 6 cm) above the skin level by the small intestine bulging outwards in order to avoid contact of the aggressive small intestinal secretion with the skin . The ileostomy stimulates permanently and the excretions are pasty to liquid.
Terminal (entero-) stoma
After complete or extensive removal of the large intestine ( total / subtotal colectomy ), after removal of the rectum and / or the anus ( anus ), an artificial opening is created in the abdominal wall, the remaining healthy intestine is brought out and sewn to the abdominal wall . Terminal does not necessarily mean that a stoma has been created permanently, but rather refers to the way in which the two ends of the intestine are handled after the operation. In the case of a terminal stoma, the feeding, oral loop is sewn into the abdominal wall. This creates only a single visible opening. The laxative, distal leg of the intestine is completely closed in its opening. A terminal stoma is often created permanently and is usually not moved back, but this is certainly possible when a stoma is created using a Hartmann operation .
Double-barreled (entero-) stoma
The abdominal wall is opened and the functional area of the intestine that is to be preserved is pulled out of the abdominal wall in the form of a loop. In order to prevent the intestine from sliding back into the abdomen, a rider is often used e.g. B. in the form of a flat plastic rod pushed under the noose. The intestine is then incised from above and turned inside out so that two visible intestinal openings are created. The bowel section that promotes stool (coming from the stomach) is referred to as the feeding loop or oral leg, the draining part ( running towards the anus ) is called the draining loop or aboral leg. The reason for creating a double-barreled stoma (ileostomy, colostomy) is usually the relief of a part of the intestine or a critical intestinal suture (deep rectal anastomosis, coloanal anastomosis, pouchanal anastomosis). Such a stoma is known as a protective stoma and can usually be closed (relocated) again after a few weeks.
Permanent (entero-) stoma
Permanent, non-relocatable stoma.
Temporary (entero-) stoma
Temporary, non-permanent stoma.
Relocation
If a relocation is planned, it can take place no earlier than six weeks after the ostomy. If leaks in an intestinal suture were the cause of the ostomy, it can only be moved back when the intestinal suture has completely healed. To do this, the sewn-in ends of the intestine are loosened from the abdominal wall and joined together again with a suture. The connection to a pouch is a special case .
Possible risks and complications
In rare cases, injuries to the intestine, neighboring organs or vessels can occur during the operation. If a seam connection in the intestine leaks, serious consequences such as peritonitis , blood poisoning , intestinal paralysis (intestinal atony), intestinal obstruction and others can develop. In rare cases, fistulas can form, particularly as a result of infections .
Unpredictable circumstances such as extensive adhesions in the abdominal cavity or anatomical peculiarities may require a change or expansion of the planned operation.
The seam connections may shrink postoperatively. These constrictions ( stenoses ) are usually widened by means of stretching ( bougienage ). In some cases, another intervention is necessary. Adhesions in the abdomen can lead to chronic pain years later and rarely to an intestinal obstruction.
Special stoma complications include the retraction of the stoma below the skin level ( retraction ), prolapse of the stoma, abdominal fracture ( hernia ) and stoma blockage. The background of an ostomy blockage is a stenosis caused by adhesions in the abdomen, by scarring, by stuck foods (fibers) that are difficult to digest. a. can be caused. If severe abdominal pain and cramps, possibly combined with vomiting, persist for more than 2 hours, the doctor or a medical outpatient department must be consulted immediately , as there is a risk of intestinal obstruction.
Since the intestine and, accordingly, a stoma do not have pain receptors ( nociceptor ), special care must be taken when handling sharp-edged objects, e.g. B. razors, scissors and. a. in order not to injure the stoma. A stoma is sensitive so it may bleed lightly if you touch it, which is not a concern. Serious bleeding, on the other hand, requires a medical examination. A black discoloration of the stoma can indicate the onset of necrosis that requires immediate treatment.
It is not a concern if the bowel is still working irregularly in the first time after the operation. The excretions can also be more fluid at the beginning and there can be increased flatulence at first .
Regular care by an enterostoma therapist can help prevent complications and clarify important questions. Corresponding contacts can be obtained from the specialist association Stoma, Continenz und Wunde e. V. (formerly DVET Fachverband Stoma und Incontinenz e.V.) or via the Deutsche ILCO e. V. to be found.
The stoma supply
Colostomy and ileostomy patients can no longer control their stool. Special ostomy supplies are therefore used to absorb stool and gases. An ostomy supply usually consists of a base plate to be glued to the abdominal wall and a bag attached to it, which is used to hold the excretions. Bags held by a belt alone and without an adhesive or skin protection surface are generally no longer used today. A distinction is made between one and two-part systems. In the one-piece systems, the base plate and bag are firmly connected to one another and can only be changed together. Two-part systems are characterized in that the base plate and bag are separate units, which means that the plate is glued and the bag is subsequently connected to it by means of a locking ring or adhesive surface. The two-part supply system allows the plate to remain on the stomach when the bag is changed for hygiene reasons. Both supply systems are offered with a bag closed at the bottom as well as with a so-called slip bag, which allows emptying without changing the bag. As a rule, the colostoma is supplied with a closed bag, as the intestine only occasionally promotes stool. The bag is then changed when the bowel has emptied. For an ileostomy, a pouch is used, which can be emptied at any time due to the permanent promotion of excretions without having to remove the entire ostomy supply or the pouch.
Modern stoma systems are equipped with a filter made of activated charcoal , which enables gases to escape from the bag without any odor.
Carriers of a colostomy have the option of irrigation . The aim of irrigation is to empty and cleanse the bowel through regular irrigation. After this application, Colostoma carriers are free of excretions for a longer period of time and can supply themselves with an ostomy cap (small cover that adheres to an adhesive or skin protection surface) or an ostomy closure system in the form of a plug connected to an adhesive cover. Irrigation is only possible after consultation with a doctor. Ostomartists can shower or bathe with or without a supply system.
nutrition
There is no special diet for ostomists. Only foods with a high crude fiber content such as citrus fruits , asparagus , mushrooms , pineapples , nuts and hard fruit pods and kernels should be avoided because they clog the stoma and can lead to an "stoma blockage". As with those who are not affected, the effect varies greatly from person to person. In individual cases, after an ostomy has been created, the body may experience previously unknown reactions such as cramp-like abdominal pain to individual foods. It is therefore advantageous to keep a food diary in order to get an overview of the effects of individual foods.
People with an ileostomy have thinner excretions because the absorption of fluids without the large intestine is restricted. The loss of fluids must be compensated for by consuming more drinks. Inadequate fluid intake creates an increased risk of kidney and gallstones , as well as prerenal kidney failure . The minerals sodium and potassium are also washed out with the liquid stool , which should be taken into account in the diet. Nutritionists can recommend special diets for this.
Depending on the remaining length of the remnant of the small intestine, the absorption of various vitamins and minerals may be impaired and, possibly, short intestine syndrome . Basically, the more small intestine that has been removed, the greater the effects. If only the last 20 cm of the small intestine is missing, vitamin B 12 and bile acids can no longer be absorbed, which is the most common complication. If the small intestine is shortened, the vitamin B 12 status must be regularly checked and the vitamin B 12 balance balanced by bypassing the intestine ( parenterally ). The lack of absorption of the bile acids can to a large extent be compensated for by increased liver performance. If the liver fails to balance it out, problems with the digestion of fats and the elimination of fatty stools arise .
Ostomatists should tell their doctor about their condition. Some medications may also no longer be completely absorbed by the remaining intestine and may need to be administered parenterally .
A non-worrying aspect of the ileostomy is the fact that some foods are excreted in their original color. If you see blood red in the bag, you should first consider whether you have eaten beetroot, for example, or whether you have taken an energy drink in the same color.
Sports, work and other activities
A well-designed stoma hardly limits life. Sport, work and sexual activities are quite normal. To prevent a hernia , however, you should not lift significantly more than 10 kg. Sports with physical contact such as martial arts endanger the stoma. Specialist shops have special abdominal ties, protective caps and swimming belts that can provide additional protection for the stoma and stoma supply during sport or at work.
Pregnancy carries the same risks for ostomists as it does for any other woman. There are only restrictions here on the basis of the previous illness or if a double-barreled stoma is created.
On presentation of a severely handicapped ID card or a medical certificate, ostomists can contact the CBF Darmstadt e. V. purchase the so-called Euro key . The key fits on motorway toilets, toilets for the disabled in many cities in Germany, Austria, Switzerland and already in some other European countries. A hygienic plate change in clean sanitary facilities is possible at any time.
The nationwide parking facilities in accordance with Section 46 Paragraph 1 No. 11 of the Road Traffic Act (StVO) (so-called yellow parking permit) can also
- Severely handicapped persons with a recognized degree of disability of at least 60 or due to chronic inflammation of the colon or bowel (ulcerative colitis or Crohn's disease)
- An ostomist with a double ostomy and a recognized degree of disability of at least 70
take advantage of.
When traveling long-distance, it is advisable to have the international travel certificate drawn up by the self-help association of European ostomists signed by the doctor. It educates foreign authorities and airport staff about the stoma and prevents the stoma from being removed for inspection without a doctor being present.
history
The system of the first enterostomata was handed down from antiquity . For example, Praxagoras of Kos in the 4th century BC An artificial anus was created for intestinal injuries. History does not report whether these treatments were successful. Paracelsus (1493–1541) emphatically pointed out that the “art aficionado” should definitely be given preference over other manipulations of the injured intestine.
Finally succeeded Jean Pillore (France 1776), the first planned ostomy against the background of a stenotic Sigma cancer , in which the intestinal wall was sutured to the wound edges. However, due to pre-treatment with mercury, the patient died. In 1793 Duret made a colostomy in the groin region in a three-day-old child . The said Duret patient lived to be 45 years old.
But only van Erckenlens showed the advantages of this access in his study in 1879 and thus helped the ostomy system to achieve a breakthrough, which comes closest to today's. At the time, the death rate from these interventions was 40 percent. In 1888 the Viennese Karl Maydl published his method in which he pulled a loop of intestine in front of the abdominal wall, inserted a hard rubber bolt wrapped with iodoform gauze through a mesenteric slit and sutured the two legs together below the bolt. The transverse opening of the bowel took place no later than six days later. Maydl thus laid the basis for the technique of creating double-barreled colostomies, which is still valid today.
In 1935, König and Rütz developed the first two-part rubber fall arrest device for ostomy care, which was fixed with a belt. But this presented an equally strong odor is as the hitherto more conventional metal beaded or made of rubber, stuffed with cloth shells (pads) which were fixed with steel springs and leather belt. The Danish nurse Elise Sörensen, whose sister was an ostomate, finally had the idea for a new ostomy supply in the form of a self-adhesive bag in 1954. Together with the entrepreneur Louis Hansen, manufacturer of plastic bags , she developed the first self-adhesive ostomy bag with a zinc oxide adhesive surface.
In 1968 the North American Association of Enterostomal Therapists was founded in the USA , which was later renamed the International Association for Enterostomal Therapy and since 1992 has been called the Wound, Ostomy and Continence Nurses Society (WOCN) . In 1972, the ILCO , a self-help group for ostomate wearers , set up in Germany , which led to the establishment of the first German school for enterostomatherapy in 1978 . Since then, the conditions for caring for ostomy patients have improved.
See also
literature
- Hermann Delbrück: Artificial anus after cancer. Advice and help for those affected and their families . 2., revised. Edition. Kohlhammer, 1997, ISBN 3-17-014040-X
- Henriette Feil-Peter, Elisabeth Hornburg, Christel Ravenschlag: Ostomy Care - Enterostomatherapy . 7th edition. Schlütersche Verlagsanstalt, Hanover 2001, ISBN 3-87706-660-7
- Gabriele Gruber, Eberhard Aulbert: Ostomy care. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. (1997) 3rd, updated edition. Schattauer, Stuttgart 2012, ISBN 978-3-7945-2666-6 , pp. 971-988.
Web links
- ILCO e. V. Self-help association of ostomists and colon cancer patients in Germany
- Stoma-Welt eV information platform for ostomists
Individual evidence
- ↑ a b German ILCO eV .
- ↑ a b C. Kelm, E. Urbanek: Enterostomata Indications - Attachment Techniques - Complications ( Memento of the original from September 28, 2007 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF; 753 kB) . After a lecture at the Symposium for Care and Medical Nutrition in Enteroostomata and Tracheostomata, Herne, March 31, 2004.
- ↑ a b Tumor Center Heidelberg / Mannheim: Archived copy ( memento of the original from June 20, 2007 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.
- ↑ FgSKW - Trade Company stoma, incontinence and wound e. V. homepage accessed on September 6, 2016
- ↑ Gabriele Gruber, Eberhard Aulbert: Stomapflege. 2012, p. 980.
- ↑ Gabriele Gruber, Eberhard Aulbert: Stomapflege. 2012, pp. 978-981.
- ↑ CBF Darmstadt e. V.
- ↑ Travel certificate (PDF; 11 kB)
- ↑ Wound, Ostomy and Continence Nurses Society (WOCN) .
