What should I know about colon resection and ostomy placement as a medical student?

Understanding Colon Resection and Ostomy Placement for Medical Students

Medical students should understand that proper ostomy care is essential for preventing complications like skin breakdown, leakage, and dehydration, which significantly impact patient morbidity, mortality, and quality of life. 1

Types of Ostomies

Colostomy

• Most common type of enteral stoma, created from a portion of the colon 2
• Common indications: colorectal cancer, diverticulitis with perforation, trauma, Crohn's disease, fecal diversion 2
• Typically constructed from sigmoid, descending, or transverse colon (right side avoided due to liquid effluent and leakage risk) 2
• Output characteristics: formed stool, typically once daily 2
• Appliance change frequency: every 6-7 days 2

Ileostomy

• Constructed from terminal ileum close to ileocecal valve to maximize nutrient absorption 2
• Common indications: colorectal cancer, inflammatory bowel disease, colonic dysmotility 2
• Characteristics: easier to construct and reverse but associated with more dehydration and skin excoriation 2
• Output characteristics: liquid effluent requiring emptying 3-4 times daily 2
• Appliance change frequency: approximately every 4 days 2

Ostomy Configurations

End Ostomy

• Created when intestine is divided with proximal end brought out as stoma 2
• Distal end remains in abdomen or rarely brought out as mucus fistula 2
• Easiest for patients to pouch 2
• Used for permanent stomas or intestinal perforation requiring resection 2

Loop Ostomy

• Created by bringing continuous intestine through abdominal wall and opening anterior wall 2
• Results in two intestinal openings side by side within same skin aperture 2
• Proximal end (draining stool) is made dominant 2
• Indications: distal obstruction, temporary diversion to protect anastomosis 2
• Easier to create and reverse than end stoma 2

Continent Ileostomy

• Uses internal pouch with nipple valve in efferent limb 2
• No appliance needed in most cases 2
• Uncommon due to high complication rate requiring revision surgery 2

Common Complications and Management

Early High Ostomy Output (HOO)

• Definition: output >1.5 L/day occurring within 3 weeks of stoma formation 2
• Common with ileostomy, rare with colostomy 2
• Management:
  • Hydration (IV if necessary) to prevent renal failure 2
  • Antimotility medications (Loperamide 2-4mg before meals) 1
  • Bulking agents (Psyllium fiber) 1
  • Consider early reversal if persistent (though reversal before 6 weeks increases complication risk) 2

Ostomy Leakage

• Risk factors: obesity, placement in skin crease, loop configuration, liquid effluent, flush stoma 2
• Prevention: preoperative marking by stomatherapist 2
• Management:
  • Convex barriers, barrier rings, ostomy belt 1
  • Ensure proper sizing with measuring guide 1

Skin Complications

• For irritated skin: barrier powder + skin sealant 1
• For persistent dermatitis: consider corticosteroid spray 1

Ostomy Supply Guidelines

Initial Prescription

• 10-20 pouches/month
• 10-20 skin barriers/month
• 1 box barrier rings/strips
• Adhesive remover and skin sealant 1

Maintenance Prescription

• Ileostomy: 15-20 pouches/month, 7-10 barriers/month
• Colostomy: 15-30 pouches/month, 4-5 barriers/month 1

Patient Education and Support

Critical Education Points

• Basic skills: emptying and changing pouch
• Supply management: how to order supplies, available manufacturers
• Dietary/fluid guidelines
• Potential complications
• Medication management
• Managing gas and odor 3

Patient Challenges

• Practical ostomy management (peristomal skin issues, leaks, supply ordering)
• Emotional distress (embarrassment from leaks, odors, noise)
• Adaptation to daily life (anxiety affecting self-care, social isolation)
• Provider relationships (lack of anticipatory guidance) 4

Surgical Considerations

Colonic Resection in Trauma

• For right-sided colon injuries, ileocolonic anastomosis has lower leak rate (4%) than colocolonic anastomosis (14%) 5
• Risk factors for anastomotic leakage: Abdominal Trauma Index Score ≥25, hypotension in ED 5
• Consider colostomy for high-risk patients with left colon injuries 5

Best Practices for Medical Students

1. Understand the anatomical and physiological differences between colostomy and ileostomy
2. Learn to identify common complications and their management strategies
3. Recognize the importance of preoperative stoma site marking
4. Appreciate the psychosocial impact of ostomies on patients
5. Ensure comprehensive discharge planning including education on basic skills and supply management

Remember that adequate stomal care significantly improves clinical outcomes and reduces hospitalizations, directly impacting patient morbidity, mortality, and quality of life 2, 1.