That is the question.

In this issue I shall be focusing on the question of colostomy – the question – “to have or not to have” will be investigated. Spinal cord injury is one of the most devastating injuries that a human can suffer. The injury and its effects on the body are far reaching and the life of the spinal injured person changes in many ways. Just one aspect is that of altered bladder and bowel function. It has been documented in many studies across the world, that the dysfunction of the bladder and bowel causes greater morbidity than the effects of spinal cord injury on sexuality. It is important therefore to look at all options available when dealing with the question of bowel continence. One option for spinal cord injured victims is that of colostomy.

So firstly, let’s look at what a colostomy is. Essentially this is a procedure that is carried out whereby the stool is diverted to a site on the abdomen via a fistula – this allows the bowel to empty into a bag via a stoma and therefore is effectively diverted away from the anus. In patients other than the spinal cord injured person, colostomies are mostly done for bowel cancer or other inflammatory bowel problems. In spinal cord injured persons it’s done mainly for convenience – we shall look later into this aspect.

Secondly, a quick look at how this is done. The procedure these days should not involve a long and possibly complicated hospital stay. Before the routine use of “key hole surgery” or laparoscopic surgery techniques, colostomy used to involve a large abdominal cut with very invasive surgery to fashion the colostomy. This would lead to long periods in hospital, with complications possible such as wound infection and non-healing as well as prolonged periods of an ileus – a condition where the bowel does not function. Today colostomies can be done via key-hole surgery. There are no large wounds and the operation is minimally invasive with a quick recovery expected. Hospital stay is minimized (1 week to 10 days maximum), complications related to ileus and wound infection are virtually not seen, and a return to a normal diet is normally seen after day 3. If a colostomy is contemplated then an end colostomy rather than a loop colostomy should be done. End colostomies involve bringing a stoma out and leaving a very small blind ending rectum. A loop colostomy merely involves brining a loop of bowel being brought out as a stoma and leaving the bowel to the rectum intact – this often leads to stool bypassing the loop and still being expelled via the rectum and anus.

So why should one have a colostomy? There may be several reasons for this. However it should be emphasized that this is not something that all spinal cord injured patients require – this is a choice that is individually made. Usually, persons elect to have a colostomy to ease the burden of care, especially for tetraplegic patients. The “bowel routine” can be time consuming sometimes taking three to four hours every alternate day and the need to remain almost regimented in the routine becomes all consuming. Tetraplegics, especially those who have suffered a high lesion, are unable to transfer and initiate the routine on their own and are therefore reliant on caregivers to do this task.

A colostomy often frees these persons from this time consuming and burdensome routine. In addition to this a colostomy allows greater freedom of diet, greater degrees of confidence in that embarrassing “bowel accidents” are avoided and therefore allows greater freedom in one’s social and/or work life. There is no correct time to elect to have a colostomy should you want one and to have the procedure is therefore a personal choice. Many patients are prepared to try the conventional bowel routine and will never have a colostomy remaining happy with the conventional bowel routine. Others elect to have the procedure done whilst still in acute rehab. However, if the bowel routine proves to be too time consuming, with frequent accidents and burdensome on the caregivers, a colostomy is a good option.

Finally, there are many patients who elect to have colostomies after being wheelchair bound for 15 years or more. At this point it is not uncommon that these patients start to struggle with the bowel routine. It is true to say that with time, more and more laxatives are required to achieve a satisfactory bowel evacuation. The time it takes to complete the evacuation also increases. The lower segments of the colon become long, dilated and redundant leading to hold up of the stool. The bowel too becomes less responsive to chronic laxative use. All these factors mean more time and effort spent on the bowel routine – in these cases colostomy is a good option.

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