What are the indications and management of a colostomy?

Indications and Management of Colostomy

A colostomy is primarily indicated for colorectal cancer emergencies (obstruction or perforation), gangrenous sigmoid volvulus, diverticulitis with perforation, trauma, Crohn's disease, and fecal diversion in cases of incontinence or sacral wounds. 1, 2, 3

Types of Colostomies

• End Stoma: Created when intestine is divided and proximal end brought out as stoma while distal end remains in abdomen; easiest for patients to manage and most often used for permanent stomas or intestinal perforation requiring resection 1
• Loop Stoma: Created by bringing continuous piece of intestine through abdominal wall and opening anterior wall, resulting in two intestinal openings side by side 1
• Hartmann's Procedure: Most common type (81.7% in some studies), particularly indicated for gangrenous sigmoid volvulus and colorectal cancer emergencies 3
• Loop Colostomy: Comprises about 16% of colostomies, primarily indicated for penetrating abdominal injuries 3

Indications for Colostomy

Emergency Indications

• Colorectal Cancer Obstruction:

  • For left-sided obstruction, Hartmann's procedure is preferred over simple colostomy due to shorter overall hospital stay 1
  • For unresectable right-sided cancer, side-to-side anastomosis between terminal ileum and transverse colon (internal bypass) or loop ileostomy is recommended 1

• Colorectal Cancer Perforation:

  • When diffuse peritonitis occurs, controlling sepsis source is priority 1
  • Oncologic resection should be performed for better outcomes 1
  • For perforation at tumor site: formal resection with/without anastomosis or stoma 1
  • For perforation proximal to tumor: simultaneous tumor resection and management of proximal perforation 1

• Unstable Patients with Perforation/Obstruction:

  • For right-sided obstruction: right colectomy with terminal ileostomy; severely unstable patients should receive loop ileostomy 1
  • For left-sided obstruction: Hartmann's procedure; severely unstable patients should receive loop transverse colostomy 1
  • For right-sided perforation: right colectomy with terminal ileostomy 1
  • For left-sided perforation: Hartmann's procedure 1

• Fournier's Gangrene:

  • Colostomy indicated when there is anal sphincter involvement, fecal incontinence, or continued fecal contamination of wounds 1
  • Decision regarding stoma creation should be made after 48-hour observation period to allow acute inflammation regression 1

Non-Emergency Indications

• Fecal Diversion: For fecal incontinence, sacral wounds, or spinal cord injury 1, 2
• Palliative Care: In facilities with capability for stent placement, self-expanding metallic stents (SEMS) should be preferred to colostomy for palliation of obstructing left colon cancer 1

Management Considerations

Output Management

• Normal Colostomy Output: Typically formed stool occurring once daily 4, 2
• Appliance Management: Colostomy appliances usually require changing every 6-7 days 4, 2
• High Output Concerns: Output >1.5 L/day indicates high ostomy output (HOO), risking dehydration and electrolyte depletion 4

Complications and Their Management

• Common Complications: Surgical site infection (23.3%), hospital-acquired pneumonia (10.5%), and wound dehiscence (7.8%) 3
• Peristomal Skin Irritation: Use appropriate barrier products; refer to wound ostomy and continence specialists if no improvement within 2 weeks 2
• Stomal Prolapse: Without ischemia, gentle reduction techniques can be used; emergency surgical referral needed for painful, obstructed, or discolored stomas 2
• High Output Management: Restrict hypotonic/hypertonic fluids to <1000 mL daily; medications may include bulking agents, antimotility agents, and antisecretory agents 4, 2

Surgical Considerations

• Colostomy Closure: Associated with 17-22% complication rate; should be planned carefully 5, 6
• Primary Repair vs. Colostomy: For penetrating colon injuries, primary repair does not carry increased risk of septic complications and saves patient from risks and extended hospital stay associated with colostomy closure 6
• Elderly and High-Risk Patients: Simple fecal diversion can alleviate obstruction with relatively low morbidity and mortality, improving prospects for subsequent definitive surgery 7

Multidisciplinary Approach

• Team Coordination: Establish communication between surgeons, enterostomal therapists, and IBD specialist nurses for optimal management 2
• Patient Support: Connect patients with community-based and online ostomy support groups to address psychological impacts 2
• Nutritional Guidance: Provide counseling to prevent dehydration, particularly for high-output stomas 4, 2

When to Refer to Specialists

• Surgical Referral: For peristomal skin complications not improving after 2 weeks; emergency referral for acute stoma prolapse with signs of incarceration and ischemia 2
• WOC Specialist Consultation: For ongoing pouching difficulties, persistent skin issues, or significant changes in stoma appearance or function 2