Sunday August 12, 2012
Straight into a bag
By TAN SHIOW CHIN
Patients face a difficult transition when going to the toilet is replaced by collecting their faeces or urine in a bag.
AS we all know, what goes in the body, must come out of the body. Everything that we eat, drink or breathe in, is processed, converted, utilised, and eventually, expelled from the body in one way or the other.
The food we eat and the fluids we drink exit our bodies via defecation and urination.
In fact, learning how to control our sphincters, ie being potty-trained, as toddlers, is considered so important to our psychological development that it has a prominent place in the well-known human development theories of psychoanalysts Sigmund Freud and Erik Erikson.
Hence, when the ability to control when and where we urinate or defecate is taken away from us, it can cause significant distress.
This is especially so when the reason it is taken away is because of cancer.
Says Asia South Pacific Ostomy Association vice-president Dr Harikesh Buch: “Human beings acquire sphincter control within the first two years of life.
“When you have a stoma, you lose it, so you are back to childhood; so that is what they are fighting.
“Secondly, is the fight with the big C — cancer. When they can accept the stoma, then they can accept the cancer as well.”
The treatment for certain cancers and bowel conditions require the removal of certain diseased organs that are essential to passing out urine or faeces.
Dr Buch, a consultant surgeon from Mumbai, India, shares that conditions such as colorectal cancer, Crohn’s disease, and ulcerative colitis, which might require the removal of parts of the intestines as treatment, often need the creation of a colostomy or ileostomy.
A colostomy can be located anywhere along the path of the large intestine or colon, but is most commonly located on the lower left section of the abdomen, near the end of the colon.
Colostomies are required when the rectum and anus cannot be used for defecation, usually because they are cancerous and have to be removed.
Meanwhile, ileostomies are needed when all, or most of the large intestine, is unable to process what remains of our food from the small intestine. This can be due to removal or blockage of the large intestine.
As such, an ileostomy is typically located on the right side of the abdomen, at the end of the final section of the small intestine known as the ileum.
Dr Buch adds that another kind of ostomy is an urostomy for draining urine, normally created in patients who have been surgically treated for bladder cancer.
He says that ostomies can be permanent or temporary, depending on their purpose. For example, a temporary colostomy might be indicated when an inflamed bowel needs to “rest” in patients with inflammatory bowel disease, and will be reversed when the bowel is well again.
Stomas and bags
In all ostomies, a stoma has to be created first.
“Stoma in Latin means ‘mouth’,” says Dr Buch. “We are creating an artificial outlet in the body to allow faeces or urine to exit.”
In a colostomy, one end of the colon is surgically attached to the abdomen wall, while in an ileostomy, it is the end of the ileum. In an urostomy, the two ureters are connected to the abdomen wall via a short tube made out of a piece of the patient’s small intestine.
Attached to this stoma on the outside is an ostomy collection system to catch what comes out of the stoma.
According to Dr Buch, there are generally two kinds of ostomy or stoma collection systems: a closed pouch and a two-piece system.
A closed pouch, also known as a one-piece system, is essentially a collection bag attached to the skin via a flange ring.
A two-piece system consists of a base plate or wafer, which attaches to the skin, and a collection bag, which attaches to the base plate.
The bags themselves can be divided into drainable bags and disposable bags.
The choice of which type of collection system to use depends on a number of factors, including financial and psychological.
Dr Buch says that it is advisable to use the two-piece system for ileostomies and urostomies, as what comes out is in liquid form. This increases the chances of the stoma and surrounding skin becoming wet every time you need to change the entire collection system, which would be more frequent with a closed pouch.
“You can get skin complications like inflammation and ulceration, then it becomes very difficult to fix the bag because the surface is sore and wet,” he says.
The need for counselling
Having a permanent ostomy is a life-changing experience.
Getting used to losing control over when you pass motion or pee, and accepting the reality of passing out your faeces or urine into a bag attached to your abdomen is a difficult transition to make, and for some patients, almost impossible.
Couple that to having to frequently change or empty the bags and dealing with gas and odours, and it is not surprising that patients usually need someone to guide them and answer their questions long after they start using an ostomy collection system.
“Usually patients say ‘yes, yes, yes’ during pre- and post-op counselling, but usually they will forget everything by the time they go home.
“So they need support and continual counselling for around six months to a year after they are discharged,” Dr Buch says.
As someone who has had a colostomy himself for several years, he says that it is often the small things that bother people the most.
For example, learning what foods to take and avoid, how to manage having sex or getting pregnant, when to tell the person you are dating that you have an ostomy, and managing yourself while travelling, as well as cultural issues, like being clean for prayers for Muslims.
That is why he believes that it is very important to have community care programmes or telephone helplines that patients can turn to for help with such issues.
“The whole idea is to make them independent, to get them back to the same life they had pre-stoma.”
In Malaysia, one of the main distributors of ostomy collections systems is planning to set up such a community care programme and a telephone helpline next month for the benefit of patients nationwide.