S4E5 Transverse Colostomy
Intro - Welcome to Stoma and Continence Conversations from Coloplast Professional. I'm Hannah, Ostomy Care Associate Education Manager at Coloplast. Working in specialist care, I know that stoma, bowel and bladder issues impact the lives of those you care for. This podcast is here to support your educational needs and help you in supporting your patients. You'll hear from fellow healthcare professionals and experts by experience discuss the latest hot topics in the world of stoma, continence care and specialist practice.
This time…
These stomas are normally really quite large stomas and they stay quite large and they can increase in size.
When I was taught how to site transverse colostomies, I was always taught, it's if you can, site in three places..
Why, why could this actually be happening?
Hannah - Hello and welcome to this podcast where this time we'll be discussing transverse colostomies and covering some of the primary complications of this less common stoma type. So today I will be asking Paul about some of the key characteristics of this stoma type and how we can best support this particular patient group. Paul. Hi firstly, how are you?
Paul - I'm not bad. Hi Hannah. Thank you so much. Oh, I quite like this. It's like roles reversed, isn't it? It's brilliant.
Hannah - It is! I feel like I'm now the master! So like I said, today we're gonna be having a little bit of a chat about transverse colostomies. Which as we both know fill nurses with dread. You hear the words transverse colostomy, and I used to get a bit of a twitch, I think when I heard that particular two words together.
Paul – Yes! Soon as you hear transverse colostomy it’s almost a rocking motion, isn't it? When as soon as you hear those words, that's it, as you said, fills you with dread.
Hannah - So hopefully by going through a few things here, we can help alleviate some of those worries and able people to get that patient group a little bit better looked after and maybe alleviate some twitches, hopefully!
Paul - Exactly. Exactly. Hopefully, hopefully!
Hannah - So firstly, bit of a back to basic sort of question really. So what is a transverse colostomy and why are they normally performed?
Paul - As the name may imply a transverse colostomy is created anywhere along the transverse colon. Even though it is classed as a temporary stoma, as we both know, it's typically performed for such things as obstructing cancers, and it is created proximally one to the obstruction and they're generated for symptom control. So because many of these individuals undergoing transverse colostomy formation, they're too clinically unwell or unstable to undergo that full resection. And as I say, it is predominantly for palliative reasons, hence why it is a temporary stoma. But for majority of these individuals, it is a permanent.
Hannah - So given, as you've just said that the majority of these individuals with a transverse colostomy are generally unwell, potentially palliative, is there anything that we as CNS’s should be considering when both counseling and siting them preoperatively?
Paul - That's a really, really good question to ask because, and again, what I'm gonna do is I wanna split that into two kind of paths. So I'm gonna split that into the siting and the counseling. So first of all, the siting. It's not always possible to site somebody for a transverse colostomy, this can be for a number of different reasons, such as, you know, their general health, pain, distension, time of day that they're performed. Cause I can guarantee most of these are gonna be performed as an emergency out of hours. And we know, you know, there's not always somebody there who is actually able to site preoperatively. If you are able to site these individuals preoperatively, there are a couple of differences between what I'd call a standard siting and siting for a transverse colostomy. Obviously it's gonna be in the transverse so these individuals are gonna be sited high. They're gonna be in the upper quadrants rather than the lower quadrants. And when I was taught how to site transverse colostomies, I was always taught, it's if you can, site in three places. So that right upper quadrant, central, and left upper quadrant, if at all possible. It just gives the surgeon that extra little bit of ability to site that stoma. And because the actual siting process and actual creation of the transverse colostomy is incredibly quick. As I say, these individuals undergoing this type of stoma formation are normally quite unstable and quite unwell. So site high, upper quadrants, and if you can give the surgeon a couple of options, even if the individual has pain and all those sorts of things, what I would always say is the same rules apply then to when, say the standard siting is your best ‘guesstimate’ as a nurse is gonna be better than a surgeon's assessment. So even if the patient can't stand up, they can't bend or anything like that. Please, please, please use your expertise, use your applied assessment of that individual's abdomen and try just to avoid any noticeable skin folds, creases, etc. Going into the other branch of that, the counseling. Now we all know that every single individual we counsel preoperatively has their own needs, their own wants, etc. And to get the most out of any counseling session, the patient agenda and your agenda have to match. Now, the added potential complication, or consideration I should say for counseling for a transverse, is if they are palliative… again, you've gotta take that into consideration. And if it is palliative in respect of them going home or to hospice, again is that thing of ensuring that we are proactive in the discharge planning and just talking the patient through the actual process. Because again, the best way, and the only real way to do really, really good counseling is making sure that the patient's agenda is met as much as yours. And it might even be a case of, do you know what, I’m gonna see you postoperatively and we'll sort you out then. So, you know, I've had that a number of times where the patient just doesn't wanna know anything. It's just a case of - yep. And it's, yep, fine, we'll deal with everything afterwards. So both siting and counseling very, very much on a individual basis.
Hannah - So now looking at the postoperative phase, which we've already, I suppose, alluded to a little bit at the start of the podcast. What are those main complications? As we've said, there are several! But what are the main ones that can occur following that formation, and how do they compare to, say a colostomy in maybe the descending colon?
Paul - Again, I'm kind of gonna split these, these complications and these main complications down into three - prolapse, herniation, and leaks. Now, there was a really, really interesting article released last year, 2021, and the link to that article will be in the podcast description. It looks at the rates of stomal prolapse with transverse colostomies compared to stomas formed in the descending colon. And there are in fact higher rates of stomal prolapse in transverse colostomies over descending colostomies. There's no major difference between complications between laparoscopic or open. According to this study there were no differences in the rate of other postoperative complications, which I found really, really interesting about the article. Cause as you said, you know, I think, you know, prolapse is just one of the complications that can occur. But as I said prolapses are more evident in individuals with a transverse colostomy. So just to confirm again, let's go back to basics when we're talking prolapse. A prolapse occurs when the bowel protrudes through the stomal opening in the skin greater than the extent it was anticipated. So obviously we all know colostomies are shorter than ileostomies, generally speaking. And depending on the individual, when it comes to general stomas, obviously, you know, somebody who's got a stoma, which you know, was five or six millimeters, a colostomy, and it's now three or four. To them that can be a prolapsing stoma. So again, it's that understanding of their needs and that counseling and the support mechanisms that we can put in place. And I think, you know, we've all seen prolapses are 10 centimeters more, and plus. You know, it can, when it first happens, it can be very, very distressing and frightening for the individual. But generally speaking, it's not a life threatening situation. Obviously there are those ones which fall outside of the norm. But generally speaking, it's more distressing than actually being a serious event, life threatening event. Now, when it comes to a prolapsing stoma as well, especially transverse colostomies, it's all about making sure that you don't try to squeeze that stoma and squeeze that prolapse into a base plate that's too small and a cutting that's too small. So please, please, please make sure that when you are measuring, a lot of the time, it can be what I call mushroom. You know what it's like when the top of the stoma is bigger than the actual base of the stoma. So making sure you get that appropriate size base plate. It sounds simple, but, unfortunately I have seen many, many stomas where you've got trauma on the mucosa and that's caused by this dragging and this base plate that's cut too small. So a larger cutting if at all possible. If you've got it, hopefully you have, just to make sure we reduce the risk of trauma to the stoma. And then with a prolapse as well. One of the other things is they can be pretty big, so it's actually making sure you've got the volume within the actual pouch itself to contain the prolapse, but also the output as well. So a lot of the time these prolapses can almost fill the bag, even without any output in there! And that kind of brings me onto output. Because they're in the transverse, rather than the descending. Output from a transverse colostomy, they can go from being quite liquid to this kind of a semi formed. So, I've always erred on the side of caution and used a drainable pouch at the very minimum. Sometimes I've started with a high output, a lot of the time I start with a high output with a larger cutting size, and then come down to a larger cutting size base plate with a drainable. That's kind of looking at the output, that's looking at the actual size, it's looking at that, having the ability to actually, you know, contain that prolapse within the pouch itself. So that's looking at prolapse.
Now the other one is herniation, and there are loads and loads of articles out there on stomal herniation and you can read for hours and hours and hours, all about stomal herniation. But again, it's interesting because that article that I alluded to earlier did talk about that there were no differences in rate of other postoperative complications. But for me, I've personally, I found that transverse colostomies herniate really, really quickly, and I've been kind of, you know, when I was thinking about this podcast, I was kind of thinking to myself, you know, why? Why could this actually be happening? Then I think about the kind of the cohort that undergo transverse colostomies are, lots of the times they are nutritionally suboptimal, things like pain, all of those sorts of things, and I'm thinking, well, yeah actually you know, again, it is those things that we do talk about when we talk about the risk of herniation. Lots of the times they're very, very evident in this patient cohort. So herniation is a really, really, in my opinion, one of the big three when it comes to transverse colostomies. Obviously ensuring that you get a base plate that best suits that individual's peristomal body profile. So don't just think flat. You might need concave for these individuals. And don't just think one piece, these individuals may again, depending on pain and situation, I've had some really, really good results using a two-piece system, so you're not having to constantly take that base plate off and you're able to just change the bag. Now, if you are using the two-piece system with this cohort, what I recommend is not using a ‘click’, doesn't matter what manufacturer it is. I think, you know, it's that mechanical coupling, sometimes you have to press really hard to get those mechanical couplings in place. So if you are using the two-piece, please, please, please, I really do suggest, if at all possible, using a flex or a sticky two-piece option which again, just makes life that much easier and kinder to the patient. And the ASCN does have guidance and guidelines on both managing hernias and managing the prolapsed patient as well. And again, we'll put the ASCN link in the podcast description.
Finally, when it comes to what I class is the big three in complications and that’s sore skin, and this kind of comes hand in hand with the other two. It really is about not getting into that leakage cycle and breaking that leakage cycle. As I said, lots of these individuals are nutritionally suboptimal, so it really is important that we maintain as a healthier peristomal skin as possible. It sounds like I'm teaching granny to suck eggs here, but it really, really, really, really is important that we get that leakproof seal for these individuals. As you know, Hannah, I am a massive supporter of validated tools, so making sure that you undertake a body profile assessment. If they're being nursed on the wards, making sure that the ward staff are able to undertake a body profile assessment and inform you as the CNS of any changes to that parastomal body profile. And also making sure we get a DET score as well, because again, these individuals and this type of stoma, we have been there, where their skin can deteriorate at a drastic rate. So making sure we've got that baseline, making sure we assess both skin and peristomal body profile.
So, in a nutshell… prolapse - manage that prolapse, trying to reduce the risk of mucosal trauma. Make sure you've got enough room in the bag for both output and the actual prolapse itself. Monitoring for hernia and the potential complications that arise from herniation, and then maintaining healthy peristomal skin.
And I think for me, that is the big three when it comes to parastomal complications to the transverse colostomy. Look at that. Oh, I said that all in one, didn't I?
Hannah - I know, cause you missed me out on my one question. I was meant to say, oooh, and herniation - but you've already done it.
Paul - I've already done it!
Hannah - So I'll skip a question. So lots of really good advice there, Paul, thank you. So as we all know, we love a top tip here at Coloplast Professional. So before we do wrap up this podcast, what would you say your big three top tips are?
Paul - The first one, and almost every time I do a top tip, it always starts with the same one, which is don't panic! Okay, so even if you've never looked after a transverse colostomy before, essential stoma care is the same whether you are looking after an ileostomy, a colostomy, a jejunostomy, a transverse colostomy. The essentials don't change. Okay, so it's all about involving your patient as much as possible in the entire process. Give them the appropriate amount of information to suit them to meet their needs when their needs need meeting. So that's my first one. Don't panic.
Hannah - Always a good one!
Paul - Always a good one. Always a good one. And the second one is assess. So it's one of those ones where, you know, it's assess, assess, assess. So making sure, as I've said, you assess that parastomal body profile. You're assessing the size of the stoma because there are gonna be large stomas, not just large, like we are used to them, you know, stomas being large when they're first created and being oedematous. These stomas are normally really quite large stomas and they stay quite large and they can increase in size. Assessing the peristomal skin for any deterioration.
And my final top tip is MDT. So it really is a multidisciplinary team approach to caring for these individuals, as it is for all individuals. But it really is important to get that care involved, get the people on the ward, the individuals on the ward involved. Making sure they are happy with the care and they know what to do, because again, it's the gut thing of, I think, again, we've all been there when, you know, stomas have been squeezed into a bag. They've tried to go for a smaller bag and all those sorts of things. So it's involvement of the MDT, making sure everybody's singing from the same hymn sheet.
So don't panic, assess and involve the MDT.
Hannah - That's great. So thanks ever so much Paul. Hopefully today's podcast has alleviated a few of those worries regarding transverse colostomies and also answered a few of those questions that maybe weren't so commonly known. And as Paul said, all the links to everything that you mentioned will be in the podcast description. So thank you and thank you for spending some time chatting to me today about the ever elusive transverse colostomy.
Paul - It's an absolute pleasure. As always, there is always more information on the Coloplast Professional website, and again, that link is gonna be in the podcast description. If any of the listeners haven't registered on the website, please, please do so, so you can always be updated on all the new digital education that we do on a weekly basis.
Hannah - So thanks very much for listening, and we will see you next time.
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