Colostomy

Colostomy surgery is often a frightening prospect for most people. But it can dramatically improve a person's quality-of-life, especially in cases of serious disease.

Types of Colostomies

There are several different types of colostomies including ascending, transverse, and descending.

Ascending. This colostomy has an opening created from the ascending colon, and is found on the right abdomen. Because the stoma is created from the first section of the colon, stool is more liquid and contains digestive enzymes that irritate the skin. This type of colostomy surgery is the least common.

Transverse. This surgery may have one or two openings in the upper abdomen, middle, or right side that are created from the transverse colon. If there are two openings in the stoma, (called a double–barrel colostomy) one is used to pass stool and the other, mucus. The stool has passed through the ascending colon, so it tends to be liquid to semi-formed.

Descending or sigmoid. In this surgery, the descending or sigmoid colon is used to create a stoma, typically on the left lower abdomen. This is the most common type of colostomy surgery and generally produces stool that is semi-formed to well-formed because it has passed through the ascending and transverse colon.

 

Types of products are used for colostomies

Pouch: There are a variety of sizes and styles of colostomy pouches. Pouches are lightweight and odor-proof. Pouches have a special covering that prevents the pouch from sticking to the body. Some pouches also have charcoal filters which release gas slowly and help to decrease gas odor. The following is general information about types of colostomy pouches:

Open-ended pouch: This type of pouch allows you to open the bottom of the pouch to drain the output. The open end is usually closed with a clamp. The open-ended pouch is usually used by people with ascending or transverse colostomies. The output from these colostomies is looser and is unpredictable (does not drain at regular times).
Close-ended pouch: This type of pouch is removed and thrown away when the pouch is filled. Close-ended pouches are usually used by people with a descending or sigmoid colostomy. The output from these types of colostomies is firm and does not need to be drained .
One-piece: A one-piece pouch contains the pouch and adhesive skin barrier together as one unit. The adhesive skin barrier is the part of the pouch system that is placed around the stoma and attached to skin. When the pouch is removed and replaced with a new one, the new pouch must be reattached to the skin.
Two-piece: The two-piece pouch has two parts: an adhesive flange and pouch. The adhesive flange stays in place while the pouch is removed and new pouch is attached to the flange. The pouch does not need to be reattached to the skin each time. The two-piece system can be helpful for patients with sensitive skin.
Pre-cut or cut-to-fit pouches: Some pouches have pre-cut holes so you do not have to cut the opening yourself. Other pouches can be cut to fit the size and shape of your stoma. Cut-to-fit pouches are especially useful right after your surgery because your stoma decreases in size for about eight weeks.

Stoma covers and caps: Stoma caps or covers can be placed on the stoma when the stoma is not active (draining). People with descending or sigmoid colostomies who irrigate may use stoma covers or caps. The cover or cap is attached to the skin in the same way as a pouch.

Before Colostomy Surgery

A patient before colostomy surgery may have lots of fears and concerns. Thus, it is useful to inform and educate the patient as well as the significant others about the expectations, necessary preparations and resources during the pre colostomy phase.  

 

Physical Preparation
        Physical preparation for surgery may involve building the patient's stamina several days before the surgery and cleansing the colon the day prior to the procedure.

 

Pre-Colostomy Diet

        If the client's condition permits, the nurse may recommend a diet high in calories, protein, carbohydrates and in low residue to provide adequate nutrition and minimize cramping by increasing peristatsis. Some good sources of these essential nutrients are fats, meats and pasta or rice.

 

Bowel Preparation before Colostomy

         A day or two before the surgery, the surgeon usually orders a bowel prep to cleanse the colon. You can expect enemas and 8-hour (or more) fasting to be advised. Usually, the nurse will walk the patient through this and it is very important to follow the instructions very carefully so as not to postpone the surgical procedure.

 Colostomy care

How to empty the pouch

• Empty the pouch when it is one-third to one-half full. Do not wait until the pouch is completely full because this could put pressure on the seal, causing a leak. The pouch may also detach, causing all of the pouch contents to spill.
• Place toilet paper into the toilet to reduce splash back and noise.
• Take the end of the pouch and hold it up. Remove the clamp (if the pouch has a clamp system).
• You may need to make a cuff at the end of the pouch to keep it from getting soiled.
• Drain the pouch by squeezing the pouch contents into the toilet.
• Clean the cuffed end of the pouch with toilet paper or a moist paper towel. You may also rinse the pouch but it is not necessary. Make sure and keep the end of the pouch clean.
• Undo the cuff at the end of the pouch. Replace the clamp or close the end of the pouch according to your caregiver's instructions.
  

 

What is irrigation?

People with descending or sigmoid colostomies may be able to irrigate their colostomies on a regular basis. Irrigating the stoma means putting a fluid into the stoma to empty the bowel. This may also be called an enema. Irrigation allows a person to have timed bowel movements. Irrigation can allow a person to be free from stool output for about 24 to 48 hours. Once stool output is regular, a stoma cap can be used between irrigations instead of using a drainable pouch. The stoma cap will absorb mucus and deodorize and vent gas.
Talk to your caregiver about whether irrigation is right for you. Irrigation may be right for you if you had regular bowel movements before the colostomy. You should also be physically able to perform the irrigation procedure. It is also important to have a lifestyle that will allow regular irrigation. For example, you should have a daily schedule in which you can schedule enough time to regularly irrigate. You should also be free from certain colostomy problems. People with problems such as a prolapse or a hernia should not irrigate. Irrigation could make a prolapse worse or create a hole in the bowel. Irrigation could also cause leakage of stools between irrigations or make it hard to control bowel movements.

 

How do I irrigate my colostomy?

Ask a specially trained caregiver such as an ostomy nurse how to properly irrigate your colostomy. Below are some general steps for irrigation:

• You will need a plastic irrigating container with a long tube and a cone to introduce water into the colostomy. You will also need an irrigation sleeve that will direct the output into the toilet. You will need an adjustable belt to attach the irrigation sleeve and a tail closure for the end of the sleeve.
• Choose the same time each day when you will not be interrupted to irrigate your colostomy.
• Fill the irrigating container with about 16 to 50 ounces (500 to 1500 mL) of lukewarm water. The water should not be cold or hot. The amount of water each person needs to put in the irrigating container varies. Ask your caregiver how much water you will need to irrigate. Hang the irrigation container at a height in which the bottom of the container is level with your shoulder. Sit up straight on the toilet or on a chair next to the toilet.
• Take the adjustable belt and attach it to the irrigation sleeve. Place the belt around your waist and place the sleeve over your stoma. Place the end of the irrigation sleeve into the toilet bowel.
• Release air bubbles from the tubing on the plastic irrigating container by releasing the clamp. Allow a small amount of water to be released into the sleeve. Clamp the tubing again.
• Moisten the end of the cone with water or lubricate it with water-soluble lubricant.
• Place the tip of the cone about three inches deep into the stoma. Make sure there is a snug fit but do not place the cone too deeply or forcefully into the stoma. Release the clamp on the tubing again and allow the water to flow into the stoma. The water must go in slowly and takes about five to ten minutes. Keep the cone in place for another 10 seconds.
• Remove the cone from the stoma. Allow the output to drain into the irrigation sleeve for about 10 to 15 minutes. Dry the end of the irrigation sleeve. Clip the bottom of the sleeve to the top with a clasp or close the end of the sleeve with the tail closure. You may move around for about 30 to 45 minutes until all the water and stool has drained. Drain the output from the sleeve into the toilet. Clean the area around the stoma with mild soap and water and pat dry.

 

What are some problems that can happen with a stoma?

Most stoma problems happen during the first year after surgery.

• Stoma retraction: Retraction happens when the height of the stoma goes down to the skin level or below the skin level. Retraction may happen soon after surgery because the colon does not become active soon enough. Retraction may also happen because of weight gain. The pouching system must be changed to match the change in stoma shape.
• Peristomal hernia: Peristomal hernias occur when part of the bowel (colon) bulges into the area around the stoma. Hernias are most obvious during times when there is pressure on the abdomen. For example, the hernia may be more obvious when sitting, coughing, or straining. Hernias may make it difficult to create a proper pouch seal or to irrigate. The hernia may be managed with a hernia belt. Changes may also need to be made to the pouching system to create a proper seal. Surgery may also be done in some people.
• Prolapse: A prolapse means the bowel becomes longer and protrudes out of the stoma and above the abdomen surface. The stomal prolapse may be caused by increased abdominal pressure. Surgery may be done to fix the prolapse in some people.
• Stenosis: A stenosis is a narrowing or tightening of the stoma at or below the skin level. The stenosis may be mild or severe. A mild stenosis can cause noise as stool and gas is passed. Severe stenosis can cause obstruction (blockage) of stool. If the stoma is mild, a caregiver may enlarge it by stretching it with his finger. If the stenosis is severe, surgery is usually needed.

 

What types of foods can I eat after a colostomy?

• People with colostomies can eat a regular diet. Choose healthy foods from all the food groups. To avoid constipation, eat foods such as oatmeal, whole-grain breads and cereals, fruits and vegetables. There may be some foods that you cannot tolerate very well. If a food gives you cramps or diarrhea, do not include that food in your diet. Try the food again in a few weeks. Eat small portions first and then gradually increase your portion sizes.
• You may want to avoid foods that cause gas and odor. Some foods that may cause gas and odor are vegetables such as broccoli, cabbage, and cauliflower. Other foods include beans, eggs, and fish. You can also reduce gas by eating slowly and not using straws to drink liquids. Foods that may help to control odor and gas in some people are fresh parsley, yogurt and buttermilk.
• Drink at least 8 to 10 (eight ounce) cups of water each day. Follow your caregiver's advice if you must limit the amount of liquids you drink. Healthy liquids for most people to drink are water, juices, and milk. Limit the amount of caffeine you drink, such as coffee, tea, and soda.

 

How can a colostomy fit into my lifestyle?

• Work: You can go back to work when your caregiver says it is OK. You may need special support to prevent a hernia if you work is heavy labor, such as lifting or digging. You may need an ostomy belt over the pouch to keep it in place if you move a lot at your job.
• Exercise: Exercise is very important. Talk to your caregiver about an exercise program once you feel stronger. Together you can plan a program that works for you. It is best to start slowly and do more as you get stronger. Exercising makes the heart stronger, lowers blood pressure, and helps keep you healthy. Your body and mind should feel better after exercising. Walking, jogging, bicycling, and swimming are good exercises. Talk with your caregiver before playing contact sports. You may need to wear a special support or a colostomy cover to protect your stoma. Empty your pouch before playing sports.
• Bathing or swimming: You may take a bath with or without your pouch. You can take a shower or bath with your pouch off. Water will not go into the stoma during a shower or bath. For swimming, you should always wear your pouch. Empty your pouch before getting into the water if you swim. You may want to put waterproof tape strips over the edges of your skin barrier.
• Relationships:
  • You may feel anxious, nervous, or scared when you first start to care for your colostomy. You may not like the way your body looks. You may feel like you are no longer in control of your body. These are normal feelings. Talk to someone close to you or to your caregiver about these feelings.
  • Learning to live with a colostomy may be difficult for both you and your spouse. Together you can find ways to live with this change in your life. It will take time for you to feel better after surgery. If you had an active sex life before colostomy surgery, it can be the same after surgery. You cannot hurt your stoma by having close body contact. Be sure to empty the pouch before having sex.
• Traveling: Always carry extra colostomy supplies and pouches with you when traveling. Take enough supplies for your trip. You may not be able to find what you need while traveling. Contact your local ostomy group or ostomy nurse for help. They may be able to give you a list of ostomy caregivers in the area you are visiting.
  • If you fly, pack your supplies in your carry-on luggage not your checked suitcase because luggage is sometimes lost or delayed.
  • If you drive, do not put your supplies in the trunk or glove compartment. This can cause your supplies to get hot, melt and not stick well. Keep your ostomy supplies in the coolest place in the car.

 
Nursing Considerations
 

Risk for impaired Skin Integrity: risk factors may include absence of sphincter at stoma and chemical irritation from caustic bowel contents, reaction to product/removal of adhesive, and improperly fitting appliance.

Risk for Diarrhea/Constipation: risk factors may include interruption/alteration of normal bowel function (placement of ostomy), changes in dietary/fluid intake, and effects of medication.*

Deficient Knowledge [Learning Need] regarding changes in physiologic function and self care/treatment needs may be related to lack of exposure/recall, information misinterpretation, possibly evidenced by questions, statement of concern, and inaccurate follow-through of instruction/development of preventable complications.

Disturbed Body Image may be related to biophysical changes (presence of stoma; loss of control of bowel elimination) and psychosocial factors (altered body structure, disease process/associated treatment regimen, e.g., cancer, colitis), possibly evidenced by verbalization of change in perception of self, negative feelings about body, fear of rejection/reaction of others, not touching/looking at stoma, and refusal to participate in care.

Impaired Social Interaction may be related to fear of embarrassing situation secondary to altered bowel control with loss of contents, odor, possibly evidenced by reduced participation and verbalized/observed discomfort in social situations.

Risk for Sexual Dysfunction: risk factors may include altered body structure/function, radical resection/treatment procedures, vulnerability/psychologic concern about response of SO(s), and disruption of sexual response pattern (e.g., erection difficulty)

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Hemi-colectomy

A hemicolectomy is an operation to remove part of the large bowel (colon/intestine) because
either it is not working properly or it is diseased.
Either side of your colon can be removed depending upon the location of the disease ie. a right
or left hemi colectomy, you will be advised where your disease is located.

The two ends of the bowel are joined together by sutures or clips. There is a risk of a temporary stoma if the left side of the colon is removed. Your surgeon will discuss this with you before surgery.
Occasionally, the transverse part of the bowel may be removed (the middle section of your large bowel which lies across the abdomen). This is also known as an extended hemicolectomy.

The Operation

You will have a general anaesthetic, and will be asleep for the whole operation. A cut is made in the skin in the middle lower part of your abdomen 25cm (10 inches) long. The right side of the colon and the lowest part of the small bowel are freed. The diseased bowel is taken out. The cut ends of the small bowel and of the middle of the colon are joined together. The cut is then closed up.
You will not end up with a colostomy or need to wear a bag to collect the bowel waste. You should plan to leave hospital about 10 days after the operation.

Before The Operation

Stop smoking and get your weight down if you are overweight. If you know that you have problems with your blood pressure, your heart or your lungs, ask your family doctor to check that these are under control. Check the hospital’s advice about taking the pill or hormone replacement therapy (HRT).
You may be required to take bowel preparation to clear the bowel prior to your admission. Please follow the instructions carefully. If you come into hospital the day of your surgery, you must fast for 6 hours prior to your operation.
Check that you have a relative or friend who can come with you to hospital, take you home and look after you for the first week after the operation. Bring all your tablets and medicines with you to hospital. On the ward you may be checked for past illnesses and may have special tests ready for the operation. You will be asked to fill in an operation consent form. Many hospitals now run special pre-admission clinics, where you visit for an hour or two, a week or so before the operation, for these checks.

After - In Hospital

You may have a fine plastic tube coming out of your nose and connected to another plastic bag to drain your stomach. Swallowing may be a little uncomfortable. You will have a dressing on your wound and perhaps a drainage tube nearby, connected to another plastic bag. The wound is painful and you will be given injections, and later tablets, to control this. Ask for more if the pain is still unpleasant. A general anaesthetic will make you slow, clumsy and forgetful for about 24 hours. Do not make important decisions during that time. You will probably have a fine drainage tube in the penis or front passage to drain the urine from the bladder until you are able to get out of bed easily.
You should be eating and drinking normally after about 4 days. The wound has a dressing which may show some staining with old blood in the first 24 hours. There may be stitches or clips in the skin. Sometimes 7 or 8 stitches are put across the wound to add strength. Stitches and clips are removed after about 8 days. The drain tube is removed after 4 days or so. You can wash the area as soon as the dressing has been removed. Soap and tap water are entirely adequate. Salted water is not necessary. You can shower or bath as often as you want.
You will be given an appointment to visit the Outpatient Department for a check up about one month after leaving hospital. The results from the laboratory about your colon will be ready by then. The nurses will advise about sick notes, certificates, etc.

 

After - At Home

You are likely to feel very tired and need rests 2-3 times a day for a month or more. You will gradually improve so that by the time 3 months has passed you will be able to return completely to your usual level of activity. You can drive as soon as you can make an emergency stop without discomfort in the wound, ie. after about 3 weeks.
You can restart sexual relations within 2-3 weeks when the wound is comfortable enough. You should be able to return to a light job after about 6 weeks and any heavy job within 12 weeks.

Possible Complications

Complications are unusual but are rapidly recognised by the nursing and surgical staff. If you think that all is not well, ask the nurses or doctors. You will be given injectable medication and stockings to avoid blood clots occurring in the leg. If pain or swelling occurs in either leg please alert nursing and medical staff immediately.
Chest infections may arise, particularly in smokers. Co-operation with the physiotherapists to clear the air passages is important in preventing the condition. Do not smoke. Occasionally the bowel is slow to start working again. This may take a week or more. Your food and water intake will continue through your vein tubing.
Sometimes there is some discharge from the drain near the wound. This stops given time. Sometimes the join in the bowel may leak. The doctor will talk to you about this. Wound infection is sometimes seen. This settles down with antibiotics in a week or two. Aches and twinges may be felt in the wound for up to 6 months. Occasionally there are numb patches in the skin around the wound which get better after 2-3 months. Because of loss of some of the bowel you may need vitamin replacement. This will be discussed with you.

Nursing Considerations

Nursing Priorities

1. Promote healing and adequate nutritional intake.
2. Prevent complications.
3. Provide information about surgical procedure/prognosis, treatment needs, and concerns.

Discharge Goals

1. Nutritional intake adequate for individual needs.
2. Complications prevented/minimized.
3. Surgical procedure/prognosis, therapeutic regimen, and long-term needs understood.
4. Plan in place to meet needs after discharge.

1.NURSING DIAGNOSIS: risk for imbalanced Nutrition: less than body requirements
Risk factors may include

Restriction of fluids and food
Change in digestive process/absorption of nutrients

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Nutritional Status (NOC)

Maintain stable weight/demonstrate progressive weight gain toward goal with normalization of laboratory values.
Be free of signs of malnutrition.

2. NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding procedure, prognosis, treatment, self-care, and discharge needs
May be related to

Lack of exposure/recall
Information misinterpretation
Unfamiliarity with information resources

Possibly evidenced by

Questions, statement of misconception
Inaccurate follow-through of instruction
Development of preventable complications

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
Knowledge: Disease Process (NOC)

Verbalize understanding of procedure, disease process/prognosis.
Verbalize understanding of functional changes.

Knowledge: Treatment Regimen (NOC)

Identify necessary interventions/behaviors to maintain appropriate weight.
Correctly perform necessary procedures, explaining reasons for actions.

POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition/presence of complications, personal resources, and life responsibilities)

risk for Imbalanced Nutrition—less than body requirements—change in digestive process/absorption of nutrients, early satiety, gastric irritation.
Fatigue—decreased energy production, states of discomfort, increased energy requirements to perform activities of daily living (ADLs).

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Gastrojejunostomy

A gastrojejunostomy is the surgical creation of an opening in the stomach to connect it to the upper portion of the small bowel, or small intestine, so that the surgeon can place a tube into the opening. The tube allows medications and nutritional liquids to be given through the tube directly into the stomach.

 

Indication

Gastrojejunostomies are performed on patients who cannot eat normally or take medicine orally due to a blockage or cancer of the stomach or pancreas. Some patients who have a condition that causes an obstructed bowel may undergo a gastrojejunostomy if they are unable to have a nasogastric tube, a tube that runs from the nose into the stomach.

Description

This procedure is typically performed with surgery, where an incision is made in the stomach. Precutaneous gastrojejunostomies are performed through a very small incision, much smaller than that usually required for a normal gastrojejunostomy. Interventional radiologists perform precutaneous gastrojejunostomies, and these procedures usually result in fewer complications and quicker recovery times.

 

Procedure

Patients preparing for a gastrojejunostomy should not eat or drink for at least six hours prior to surgery so that there is no fresh food or liquid in the stomach. Patients should advise their doctors and surgeons of any medications they are currently taking prior to surgery. Some medications, such as blood thinners, may need to be reduced or stopped several weeks prior to surgery to minimize the risk of excessive bleeding and other potential complications. Patients should also advise their doctors of any allergies, previous reactions to anesthesia, and any chronic health conditions.

Gastrojejunostomies are performed under general anesthesia, usually given intravenously through an IV line. Precutaneous gastrojejunostomy procedures are usually done with a local anesthetic and sleeping medication. Patients who have precutaneous gastrojejunostomies still require an IV line so that the surgeon can administer fluids, painkillers, antibiotics, and other medications as necessary.

An ultrasound is usually used to help the surgeon or interventional radiologist determine where to place the gastrojejunostomy tube. The tube is usually placed right before the rib cage. The patient's stomach is inflated with air through a tube that runs through the nose into the stomach so that the surgeon can place the tube properly.

Precutaneous gastrojejunostomies involve the stomach being fastened to the inside of the abdomen with small clips that are inserted through the skin. The clips are removed once the procedure is complete.

 

 

Procedure: Laparoscopic Gastrojejunostomy (stomach-small bowel connection)

 

A. The Condition. You may have a condition in which food cannot pass out of your stomach. In this situation, your surgeon will bypass the blockage by connecting your intestine directly to your stomach. Dr. Frantzides was the first in the world to perform and publish a laparoscopic gastroduodenostomy for gastric outlet obstruction in 1996.

 

B. Symptoms

• Nausea, vomiting
• Crampy abdominal pain
• Weight loss, weakness

 

C. Laparoscopic Gastrojejunostomy.

The surgeon will make about 3-4 small incisions in your abdomen. A port (nozzle) is inserted into one of the slits, and carbon dioxide gas inflates the abdomen. This process allows the surgeon to see inside of your abdomen more easily. A laparoscope is inserted through another port. The laparoscope looks like a telescope with a light and camera on the end so the surgeon can see inside the abdomen. Surgical instruments are placed in the other small openings and used to connect the small intestine (jejunum) to the stomach. This is done with surgical staplers. After this has been accomplished, the carbon dioxide is released out of the abdomen through the slits, and then these sites are closed with sutures or staples, or covered with glue-like bandage and steri-strips.

 

D. Nonsurgical Treatment.

Sometimes your problem may be treated with suctioning out the stomach, withholding food for several days, and giving IV fluids. Your doctor will discuss with you what your best option is.

 

E. Risks. The primary risks of laparoscopic gastrojejunostomy are:

• Infection of the skin at one of the small ports sites
• Leakage of the connection between the stomach and small bowel
• Collection of pus inside your abdomen (intraabdominal abscess)
• Postoperative ileus (the intestines slow down/stop working for several days)
• Small bowel obstruction (kinking of the small bowel, causing blockage)

 

F. Expectations

1. Before Your Operation. Laparoscopic gastrojejunostomy usually is an elective procedure. The preoperative evaluation might include blood work, urinalysis, a barium swallow x-ray, endoscopy (looking down your throat with a scope), and perhaps an abdominal CT scan. If you smoke, then you should stop immediately. If you are taking blood thinners (for example, aspirin, coumadin, Lovenox, or Plavix), then you will need to stop these one week prior to your procedure. Your surgeon and anesthesia provider will review your health history, medications (including blood thinners), and options for pain control.

 

2. Your Recovery. You usually can go home in 2-4 days after a laparoscopic gastrojejunostomy. You may need to wait until your bowels start working. You will be given medication for pain. You should limit your activity to light lifting (no more than 15 lb) for one month.

 

3. Inform Surgeon if you have one or more of the following:

• High fever
• Severe abdominal pain
• Odor or increased drainage from your incision
• No bowel movements for three days

 

Nursing considerations

Client Assessment Database

Data depend on the underlying condition necessitating surgery.

 

Teaching/Learning

Discharge plan

considerations: Assistance with administration of enteral feedings/total parenteral nutrition (TPN) if required, and acquisition of supplies

Refer to section at end of plan for postdischarge considerations.

 

Nursing Priorities

1. Promote healing and adequate nutritional intake.

2. Prevent complications.

3. Provide information about surgical procedure/prognosis, treatment needs, and concerns.

Discharge Goals

1. Nutritional intake adequate for individual needs.

2. Complications prevented/minimized.

3. Surgical procedure/prognosis, therapeutic regimen, and long-term needs understood.

4. Plan in place to meet needs after discharge.

• 1. NURSING DIAGNOSIS: risk for imbalanced Nutrition: less than body requirements
• 2. NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding
•         procedure, prognosis, treatment, self-care, and discharge needs

 

POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition/presence of complications, personal resources, and life responsibilities)

risk for Imbalanced Nutrition—less than body requirements—change in digestive process/absorption of nutrients, early satiety, gastric irritation.

Fatigue—decreased energy production, states of discomfort, increased energy requirements to perform activities of daily living (ADLs).

 

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Gastroenterostomy

Gastroenterostomy is a general term that describes two types of surgical procedures in which the stomach is surgically reconnected to the small intestine after removal of all or part of the stomach or part of the small intestine. Once the gastrectomy is performed, the surgeon must join (anastomosis) the remaining part of the stomach to the small intestine to allow for movement of digested food and fluids. If the remaining part of the stomach is joined to the first part of the small intestine (duodenum), the procedure is called a gastroduodenostomy. When joined to the middle section of the small intestine (jejunum), the procedure is called a gastrojejunostomy.

Indications

A gastroenterostomy may be indicated for those with benign or cancerous tumors of the stomach, peptic ulcer disease that is unresponsive to medical therapy, and slowed gastric motility (gastroparesis).
Peptic ulcer disease (PUD) is a collective term to describe ulcers that arise in the stomach or first part of the small intestine (duodenum) as a result of an overproduction of acid and pepsin (an enzyme). Frequently, Helicobacter pylori bacteria are found in the stomachs of individuals with PUD.

The exact cause of gastroparesis is not known. However, a disruption of the nerve stimulation in the intestine seems to be a factor. It is a common complication of diabetes or visceral nerve disease such as seen with systemic sclerosis. It may also be a complication following surgical cutting of the vagus nerve (vagotomy).

 

Reason for Procedure

A gastroenterostomy may be done as a surgical intervention for peptic ulcer disease, to remove tumors of the stomach, or to facilitate emptying of the stomach in conditions of slowed gastric motility. A gastroenterostomy usually accompanies a surgical resection of the stomach (gastrectomy). Once the gastrectomy is performed, the surgeon must create a new opening from the stomach to the intestines (enterostomy). This type of procedure is now being performed as one of the surgical procedures in individuals who are severely obese. This type of surgery, called bariatric surgery, encompasses gastroenterostomy, gastroplasty, and jejunal bypass.

 

Procedure

General anesthesia is administered. One tube may be inserted to drain the bladder (urinary catheter) and another to drain the stomach (nasogastric tube) contents. The surgeon creates an incision that runs midline from the ribcage to the lower abdomen. The surgeon uses either surgical stitches or a stapling device to join the stomach to a healthy segment of the small intestine so there is a passageway (enterostomy) between the stomach and the intestine. One or more small drains may be placed at the surgical site to temporarily allow for drainage of blood and fluid. The abdominal wound is closed in layers. The final skin layer will be closed with a small stapling device. This procedure is now being performed laparoscopically, especially in individuals who are having bariatric surgery

 

Prognosis

The outcome depends on the underlying disease, the extent of the disease, and the extent of surgery required. Generally, the procedure is successful in providing an alternative conduit (enterostomy) between the stomach and the small intestine.

 

Complications

The most common complications from the procedure include wound infection, leaking at the site where the stomach is joined to the intestine (anastomosis), lung congestion (atelectasis), and bleeding. Less common complications include shock (from bleeding) or cardiac arrest. Late complications include recurrent ulcers, diarrhea (from sugar and carbohydrate intolerance), and iron deficiency anemia.

 

Nursing considerations

Client Assessment Database

Data depend on the underlying condition necessitating surgery.

Teaching/Learning

Discharge plan

considerations: Assistance with administration of enteral feedings/total parenteral nutrition (TPN) if required, and acquisition of supplies

Refer to section at end of plan for postdischarge considerations.

Nursing Priorities

1. Promote healing and adequate nutritional intake.

2. Prevent complications.

3. Provide information about surgical procedure/prognosis, treatment needs, and concerns.

Discharge Goals

1. Nutritional intake adequate for individual needs.

2. Complications prevented/minimized.

3. Surgical procedure/prognosis, therapeutic regimen, and long-term needs understood.

4. Plan in place to meet needs after discharge.

 

1. NURSING DIAGNOSIS: risk for imbalanced Nutrition: less than body requirements

Risk factors may include

Restriction of fluids and food

Change in digestive process/absorption of nutrients

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Nutritional Status (NOC)

Maintain stable weight/demonstrate progressive weight gain toward goal with normalization of laboratory values.

Be free of signs of malnutrition.

2. NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding

        procedure, prognosis, treatment, self-care, and discharge needs

May be related to

Lack of exposure/recall

Information misinterpretation

Unfamiliarity with information resources

Possibly evidenced by

Questions, statement of misconception

Inaccurate follow-through of instruction

Development of preventable complications

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Knowledge: Disease Process (NOC)

Verbalize understanding of procedure, disease process/prognosis.

Verbalize understanding of functional changes.

Knowledge: Treatment Regimen (NOC)

Identify necessary interventions/behaviors to maintain appropriate weight.

Correctly perform necessary procedures, explaining reasons for actions.

 

POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition/presence of complications, personal resources, and life responsibilities)

risk for Imbalanced Nutrition—less than body requirements—change in digestive process/absorption of nutrients, early satiety, gastric irritation.

Fatigue—decreased energy production, states of discomfort, increased energy requirements to perform activities of daily living (ADLs).

 

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Gastrostomy

Definition

Gastrostomy is a surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube, called a "g-tube," is used for feeding or drainage.

 

Purpose

Gastrostomy is performed because a patient temporarily or permanently needs to be fed directly through a tube in the stomach. Reasons for feeding by gastrostomy include birth defects of the mouth, esophagus, or stomach, and neuromuscular conditions that cause people to eat very slowly due to the shape of their mouths or a weakness affecting their chewing and swallowing muscles.
Gastrostomy is also performed to provide drainage for the stomach when it is necessary to bypass a longstanding obstruction of the stomach outlet into the small intestine. Obstructions may be caused by peptic ulcer scarring or a tumor.

Indications

Gastrostomy feeding tubes are put in for different reasons. They may be needed for a short while or permanently. This procedure may be recommended for:

• Babies with birth defects of the mouth, esophagus, or stomach (for example, esophageal atresia or tracheal esophageal fistula)
• Patients who cannot swallow correctly
• Patients who cannot take enough food by mouth to stay healthy
• Patients who often breathe in food when eating

 

Demographics

In the United States, gastrostomies are more frequently performed on older persons. The procedure occurs most often in African-American populations.

Description

Gastrostomy, also called gastrostomy tube (g-tube) insertion, is surgery performed to give an external opening into the stomach. Surgery is performed either when the patient is under general anesthesia—the patient feels as if he or she is in a deep sleep and has no awareness of what is happening—or under local anesthesia. With local anesthesia, the patient is awake, but the part of the body cut during the operation is numbed.
Fitting the g-tube usually requires a short surgical operation that lasts about 30 minutes. During the surgery, a hole (stoma) about the diameter of a small pencil is cut in the skin and into the stomach; the stomach is then carefully attached to the abdominal wall. The g-tube is then fitted into the stoma. It is a special tube held in place by a disc or a water-filled balloon that has a valve inside allowing food to enter, but nothing to come out. The hole can be made using two different methods. The first uses a tube called an endoscope that has a light at the end, which is inserted into the mouth and fed down

 
For a percutaneous endoscopic gastrostomy procedure, the stomach is inflated with air (A). An incision is made into the abdomen and the stomach, and a plastic cannula is inserted (B). A catheter is inserted into the patient's mouth, pulled down the esophagus, and into the stomach (C). When the catheter is in place, access to the stomach is maintained (D). (Illustration by GGS Inc. )
 
the gullet (esophagus) into the stomach. The light shines through the skin, showing the surgeon where to perform the incision. The other procedure does not use an endoscope. Instead, a small incision is made on the left side of the abdomen; an incision is then made through the stomach. A small flexible hollow tube, usually made of polyvinylchloride or rubber, is inserted into the stomach. The stomach is stitched closely around the tube, and the incision is closed.
The length of time the patient needs to remain in the hospital depends on the age of the patient and the patient's general health. In some cases, the hospital stay can be as short as one day, but often is longer. Normally, the stomach and abdomen heal in five to seven days.
The cost of the surgery varies, depending on the age and health of the patient. Younger patients are usually sicker and require more intensive, and thus more expensive, care.

 

 

Patient education concerning use and care of the gastrostomy tube is very important. Patients and their families are taught how to recognize and prevent infection around the tube; how to insert food through the tube; how to handle tube blockage; what to do if the tube pulls out; and what normal activities can be resumed.

After the Procedure

This is most often a simple surgery with a good outlook.

Outlook (Prognosis)

The stomach and abdomen will heal in 5 to 7 days. Moderate pain can be treated with medications. Feedings will start slowly with clear liquids, and increase slowly.
The patient/family will be taught:

How to care for the skin around the tube
Signs and symptoms of infection
What to do if the tube is pulled out
Signs and symptoms of tube blockage
How to empty the stomach through the tube
How and what to feed through the tube
How to hide the tube under clothing
What normal activities can be continued

NURSING DIAGNOSES

Based on the assessment data, the major nursing diagnoses in the postoperative period may include the following:

Imbalanced nutrition, less than body requirements, related to enteral feeding problems
Risk for infection related to presence of wound and tube
Risk for impaired skin integrity at tube site
Ineffective coping related to inability to eat normally
Disturbed body image related to presence of tube
Risk for ineffective therapeutic regimen management related to knowledge deficit about home care and the feeding procedure

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Cancer of the Oesophagus

Cancer of the oesophagus or gullet develops as a result of cell changes in the lining of the oesophagus.

 

There are two main types of cancer of the oesophagus: squamous carcinoma, which is more common at the upper end of the gullet, and adenocarcinoma, which is more common at the lower end, particularly around the junction between the gullet and the stomach.
There has been a recent increase in the proportion of tumours arising close to the junction of the stomach and gullet, but the reasons for this are not yet known.

Causes

Smoking and drinking alcohol: Smoking tobacco and drinking a lot of alcohol are some of the main risk factors for oesophageal cancer in the Western parts of the world. Cigarettes contain nitrosamines and other chemicals that increase the risk of cancer. Cigar and pipe smoking also increase the risk. When you smoke, you always swallow some of the smoke as well as breathing it into your lungs.

Obesity: Obesity roughly doubles the risk of adenocarcinoma of the oesophagus. This may be because obese people are more likely to suffer from acid reflux and this is a risk factor for oesophageal cancer in itself.

Diet: A poor diet may increase your risk of oesophageal cancer. This may be due to lack of zinc, or other vitamins and minerals. If you eat a well balanced diet, with plenty of high protein foods, such as meat, fish, eggs and dairy products, you are unlikely to be short of zinc.

Other medical conditions

1. Barrett's oesophagus or acid reflux
2. Tylosis - a rare skin condition
3. Achalasia - a condition causing problems with the valve between the oesophagus and stomach
4. Plummer-Vinson syndrome - a condition causing difficulty swallowing
5. Some pollutants and chemicals
6. Helicobacter pylori infection
7. Drugs and other medical treatments

Symptoms of oesophageal cancer

The symptoms of cancer of the oesophagus (food pipe or gullet) include the following

Difficulty in swallowing
Weight loss
Pain or discomfort in the throat or back
Acid indigestion
Hoarseness, or chronic cough
Vomiting
Coughing up blood

Diagnosis

It can be diagnosed by using X-rays using special dye.
Endoscopy
CT scan
for definitive diagnosis Biopsy can be performed

Treatment

Treatment types

Cancer of the oesophagus can be treated using surgery, chemotherapy or radiotherapy. The choice of treatment will depend upon the exact type of oesophageal cancer, its stage, position and size, as well as your age and general health. The treatments can be used alone or in combination. When diagnosing and treating cancer doctors consider the oesophagus in three sections: upper, middle and lower.
Other treatments may be used to ease any swallowing difficulties you may have. These include: intubation or stenting (inserting a tube into the oesophagus to keep it open), dilatationlaser treatment and photodynamic therapy. You may be offered one or more of these treatments, which are described in greater detail on the difficulty in swallowing section. (stretching the oesophagus),

Treatment planning

In most hospitals a team of specialists will discuss with you the treatment that they feel is best for your situation. This multidisciplinary team (MDT) will include a surgeon who specialises in oesophageal cancers, a medical oncologist (chemotherapy specialist), a clinical oncologist (radiotherapy specialist and chemotherapy specialist) and may include a number of other healthcare professionals such as a:

• nurse specialist
• dietitian
• physiotherapist
• occupational therapist
• psychologist or counsellor.

Treatment choices

If two treatments are equally effective for your type and stage of cancer, your doctors may offer you a choice of treatments. Sometimes people find it very hard to make a decision. If you are asked to make a choice, make sure that you have enough information about the different treatment options, what is involved and the side effects you might have, so that you can decide which is the right treatment for you.

Talking about treatment

Remember to ask questions about any aspects that you don’t understand or feel worried about. You may find it helpful to discuss the benefits and disadvantages of each option with your cancer specialist, nurse specialist or with the nurses at Cancerbackup.
If you have any questions about your treatment, don't be afraid to ask your doctor or nurse. It often helps to make a list of questions and to take a close friend or relative with you.

Giving your consent

Before you have any treatment your doctor will explain the aims of the treatment to you and you will usually be asked to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form you should have been given full information about:

• the type and extent of the treatment you are advised to have
• the advantages and disadvantages of the treatment
• any other treatments that may be available
• any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it is not unusual for people to need their treatment to be explained more than once.
It is often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go for your appointment.
People often feel that the hospital staff are too busy to answer their questions, but it is important for you to be aware of how the treatment is likely to affect you and the staff should be willing to make time for you to ask questions.
If you feel unable to make a decision about the treatment when it is first explained to you, you can always ask for more time. You are also free to choose not to have the treatment, and the staff can explain what may happen if you do not have it.

Benefits and disadvantages of treatment

Many people are frightened at the thought of having cancer treatments, particularly because of the potential side effects that can occur.
Although many of the treatments can cause side effects, knowledge about how treatments affect people – and improved ways of reducing or avoiding many of these problems – have made most of the treatments easier to cope with.
Treatment can be given for different reasons and the potential benefits will vary depending upon the individual situation.

Early-stage oesophageal cancer

In people with early-stage cancer of the oesophagus, treatment may be given with the aim of curing the cancer. Occasionally additional treatments are given to reduce the risk of it coming back.

Advanced-stage oesophageal cancer

If the cancer is at a more advanced stage, treatment may only be able to control it, leading to an improvement in symptoms and a better quality of life. Unfortunately, for some people the treatment will have little effect upon the cancer and they will get the side effects without many of the benefits.

Surgery

The surgery performed on the oesophagus to remove cancer cells is called an esophagogastrectomy. The doctor performing the surgery reforms the portion of the oesophagus that contains cancer cells, as well as the nearby lymph nodes and the top of the stomach. The oesophagus and remaining stomach area are then reattached, using, in some cases, a piece of the colon. This allows food to continue to pass from the throat to the stomach using the oesophagus.

Prognosis

Overall, the outlook is very poor. The five-year survival rate for cancer of the oesophagus is less than 10 per cent. Survival rates are higher in younger patients who are fit enough for intensive treatment, with cure rates of 20 per cent or more.

Nursing care plan

Assessment and physical examination
Obtain an accurate history of risk factors, including race, cultural background, use of cigarettes and alcohol, or any esophageal problems.

Nursing Considerations

Acute pain related to the clinical conditions associated  with Ca Oesophagus
Altered nutrition: Less than body requirements related to dysphagia.
Fatigue related to less nutritional intake.

Nursing care plan discharge and home health care guidelines

The patient should be able to state the name, purpose, dosage, schedule, common side effects, and importance of taking her or his medications.
Teach the patient to report any dysphagia or odynophagia, which may indicate a regrowth of the tumor.
Teach the patient to inspect the wound daily for redness, swelling, discharge, or odor, which indicates the presence of infection.
Teach family members to assist the patient with ambulation, splinting the incision, and chest physiotherapy.
Educate caregivers on nutritional guidelines, food preparation, tube feedings, and parenteral nutrition, as appropriate.
Inform the patient and family about the availability of high-caloric, high-protein, liquid supplements to maintain his or her weight.

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Radical neck dissection

Definition

Radical neck dissection is a surgical operation used to remove cancerous tissue in the head and neck.

  Types of neck dissection

Radical neck dissection

Refers to the removal of all lymph node groups extending from the inferior border of the mandible superiorly to the clavicle inferiorly, from the lateral border of the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the digastric muscle medially, to the anterior border of the trapezius muscle laterally. Included are all lymph nodes from levels I-V with sacrifice of internal jugular vein, sternocleidomastoid muscle, and spinal accessory nerve.

Extended Radical Neck Dissection

Refers to the removal of one or more additional lymph node groups or non-lymphatic structures or both, not encompassed by the radical neck dissection.

Modified radical neck dissection

Refers to the removal of all lymph nodes by radical neck dissection with preservation of one or more of the non-lymphatic structures: i.e., the spinal accessory nerve, internal jugular vein and the sternocleidomastoid muscle.

 

Purpose

The purpose of radical neck dissection is to remove lymph nodes and other structures in the head and neck that are likely or known to be malignant. Variations on neck dissections exist, depending on the extent of the cancer. A radical neck dissection removes the most tissue. It is performed when the cancer has spread widely in the neck. A modified neck dissection removes less tissue, and a selective neck dissection even less.

 

Demographics

Experts estimate that there are approximately 5,000–10,000 radical neck dissections in the United States each year. Men and women undergo radical neck dissections at about the same rate.

 

Description

Cancers of the head and neck (sometimes inaccurately called throat cancer) often spread to nearby tissues and into the lymph nodes. Removing these structures is one way of controlling the cancer.
Of the 600 lymph nodes in the body, approximately 200 are in the neck. Only a small number of these are removed during a neck dissection. In addition, other structures such as muscles, veins, and nerves may be removed during a radical neck dissection. These include the sternocleidomastoid muscle (one of the muscles that functions to flex the head), internal jugular (neck) vein, submandibular gland (one of the salivary glands), and the spinal accessory nerve (a nerve that helps control speech, swallowing, and certain movements of the head and neck). The goal is always to remove all the cancer, but to save as many components surrounding the nodes as possible.
An incision is made in the neck, and the skin is pulled back (retracted) to reveal the muscles and lymph nodes. The surgeon is guided in what to remove by tests performed prior to surgery and by examination of the size and texture of the lymph nodes.

 

Diagnosis/Preparation

This operation should not be performed if cancer has metastasized (spread) beyond the head and neck, or if the cancer has invaded the bones of the cervical vertebrae (the first seven bones of the spinal column) or the skull. In these cases, the surgery will not effectively contain the cancer.
Radical neck dissection is a major operation. Extensive tests are performed before the operation to try to determine where and how far the cancer has spread. These may include lymph node biopsies, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and barium swallows. In addition, standard preoperative blood and liver function tests are performed, and the candidate will meet with an anesthesiologist before the operation. The candidate should tell the anesthesiologist about all drug allergies and all medication (prescription, nonprescription, or herbal) that are presently being taken.

 

Aftercare

A person who has had a radical neck dissection will stay in the hospital several days after the operation, and sometimes longer if surgery to remove the primary tumor was performed at the same time. Drains are inserted under the skin to remove the fluid that accumulates in the neck area. Once the drains are removed and the incision appears to be healing well, people are usually discharged from the hospital, but will require follow-up doctor visits. Depending on how many structures are removed, a person who has had a radical neck dissection may require physical therapy to regain use of the arm and shoulder.

 

Risks

The greatest risk in a radical neck dissection is damage to the nerves, muscles, and veins in the neck. Nerve damage can result in numbness (either temporary or permanent) to different regions on the neck and loss of function (temporary or permanent) to parts of the neck, throat, and shoulder. The more extensive the neck dissection, the more function a person is likely to lose. As a result, it is common following radical neck dissection for people to have stooped shoulders, limited ability to lift one or both arms, and limited head and neck rotation and flexion due to the removal of nerves and muscles. Other risks are the same as for all major surgery: potential bleeding, infection, and allergic reaction to anesthesia.

 

Normal results

Normal lymph nodes are small and show no cancerous cells under a microscope. Abnormal lymph nodes may be enlarged and show malignant cells when examined under a microscope.

 

Morbidity and mortality rates

The mortality rate for radical neck dissection can be as high as 14%.
Morbidity rates are somewhat higher and are due to bleeding, post-surgery infection, and medicine errors.
 
Procedure
This operation involves the removal of a tumor, surrounding structures, and lymph nodes en mass, through a Y-shaped or trifurcate incision in the affected side of the neck. It is done to remove the tumor and metastatic cervical nodes present in malignant lesions and all nonvital structures of the neck. Metastasis occurs through the lymphatic channels via the bloodstream. Disease of the oral cavity, lips,


and thyroid gland may spread slowly to the neck. Radical neck surgery is done in the presence of cervical node metastasis from a cancer of the head and neck, which has a reasonable chance of being controlled. It may also be done in a slightly less radical form when there is cancer of the tongue and no firm evidence of metastasis.
 
Preparation of the Patient.
(1) The patient is placed on the table in a dorsal recumbent position, with the head in moderate extension and the entire affected side of the face and neck facing uppermost. During surgery, the face of the patient is turned away from the surgeon.
(2) The preoperative skin preparation is extensive. The patient is draped with sterile towels and sheets, leaving a wide operative field. Endotracheal anesthesia is used. The anesthetic is administered before the patient is positioned for surgery. During the operation, the anesthesiologist works behind the sterile barrier, away from the surgical team.

NURSING PRIORITIES 1. Maintain patent airway, adequate ventilation.
2. Assist patient in developing alternative communication methods.
3. Restore/maintain skin integrity.
4. Reestablish/maintain adequate nutrition.
5. Provide emotional support for acceptance of altered body image.
6. Provide information about disease process/prognosis and treatment.

DISCHARGE GOALS 1. Ventilation/oxygenation adequate for individual needs.
2. Communicating effectively.
3. Complications prevented/minimized.
4. Beginning to cope with change in body image.
5. Disease process/prognosis and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.

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Glossectomy

Definition

Glossectomy is a surgery for the removal of total or a part of the tongue.
Glossectomy is always performed under general anesthesia.
A glossectomy is performed for the treatment cancer of the tongue. Removing the tongue is indicated if the patient has a cancer that does not respond to other forms of treatment.
Cancer of the tongue is considered very dangerous due to the reality that it can easily spread to nearby lymph glands. Most cancer specialists suggest surgical removal of the cancerous tissue.

 

Types

Partial Glossectomy
A partial glossectomy is rather a simple surgery. The hole is normally repaired by sewing up the tongue immediately after the surgery or by using a small graft of skin, if the "hole" left by the removal of the cancer is small.
Care is taken to repair the tongue so as to maintain its mobility, if the glossectomy is more extensive.

Radial Forearm Free Flap
A general approach is to use a piece of skin taken from the wrist together with the blood vessels that supply it. This type of implant is called a radial forearm free flap. The flap is inserted into the hole in the tongue.
This process requires a highly skilled surgeon who is able to connect very small arteries.

 

Total Glossectomy
Complete removal of the tongue, called a total glossectomy. Complete glossectomy is hardly performed.
Alcohol consumption and smoking are the most important risk factors for cancer of the tongue. The risk is notably higher in patients who use both alcohol and tobacco than in those who use only one.

Purpose

A glossectomy is performed to treat cancer of the tongue. Removing the tongue is indicated if the patient has a cancer that does not respond to other forms of treatment. In most cases, however, only part of the tongue is removed (partial glossectomy). Cancer of the tongue is considered very dangerous due to the fact that it can easily spread to nearby lymph glands. Most cancer specialists recommend surgical removal of the cancerous tissue.

 

Demographics

According to the Oral Cancer Foundation, 30,000 Americans will be diagnosed with oral or pharyngeal cancer in 2003, or about 1.1 persons per 100,000. Of these 30,000 newly diagnosed individuals, only half will be alive in five years. This percentage has shown little improvement for decades. The problem is much greater in the rest of the world, with over 350,000 to 400,000 new cases of oral cancer appearing each year.
The most important risk factors for cancer of the tongue are alcohol consumption and smoking. The risk is significantly higher in patients who use both alcohol and tobacco than in those who consume only one.

 

Description

Glossectomies are always performed under general anesthesia. A partial glossectomy is a relatively simple operation. If the "hole" left by the excision of the cancer is small, it is commonly repaired by sewing up the tongue immediately or by using a small graft of skin. If the glossectomy is more extensive, care is taken to repair the tongue so as to maintain its mobility. A common approach is to use a piece of skin taken from the wrist together with the blood vessels that supply it. This type of graft is called a radial forearm free flap . The flap is inserted into the hole in the tongue. This procedure requires a highly skilled surgeon who is able to connect very small arteries. Complete removal of the tongue, called a total glossectomy, is rarely performed.

 

Possible Complications

Complications are rare, but no procedure is completely free of risk. If you are planning to have glossectomy, your doctor will review a list of possible complications, which may include:

• Tongue bleeding
• Infection
• Airway blockage from swelling and bleeding
• Trouble swallowing and aspiration of liquids
• Difficulty speaking
• Weight loss
• Failure of flap-occurs when transplanted skin or flap does not get enough blood flow
• Recurrence of cancer

Some factors that may increase the risk of complications include:

• Lung disease
• Large tumors
• Malnutrition
• Alcoholism
• Smoking
• Prior radiation
• Prior chemotherapy
• Diabetes

Be sure to discuss these risks with your doctor before the surgery.

Diagnosis/Preparation

If an area of abnormal tissue has been found in the mouth, either by the patient or by a dentist or doctor, a biopsy is the only way to confirm a diagnosis of cancer. A pathologist, who is a physician who specializes in the study of disease, examines the tissue sample under a microscope to check for cancer cells.
If the biopsy indicates that cancer is present, a comprehensive physical examination of the patient's head and neck is performed prior to surgery. The patient will meet with the treatment team before admission to the hospital so that they can answer questions and explain the treatment plan.

 

Post Glossectomy Care

After the performance of the glossectomy, patients usually remain in the hospital for 8 to 10 days. They often need oxygen in the first 24–48 hours after the surgery. Oxygen is administered through a facemask or through two small tubes placed in the nostrils.
Until the patient can accept taking food by mouth, he or she is given fluids through a tube that goes from the nose to the stomach. Radiation treatment is often scheduled after the surgery to demolish any remaining cancer cells. As patients regain the ability to eat and swallow, they also begin speech therapy.

 

 

Risks

Risks associated with a glossectomy include:

• Bleeding from the tongue. This is an early complication of surgery; it can result in severe swelling leading to blockage of the airway.
• Poor speech and difficulty swallowing. This complication depends on how much of the tongue is removed.
• Fistula formation. Incomplete healing may result in the formation of a passage between the skin and the mouth cavity within the first two weeks following a glossectomy. This complication often occurs after feeding has resumed. Patients who have had radiotherapy are at greater risk of developing a fistula.
• Flap failure. This complication is often due to problems with the flap's blood supply.

 

Normal results

A successful glossectomy results in complete removal of the cancer, improved ability to swallow food, and restored speech. The quality of the patient's speech is usually very good if at least one-third of the tongue remains and an experienced surgeon has performed the repair.
Total glossectomy results in severe disability because the "new tongue" (a prosthesis) is incapable of movement. This lack of mobility creates enormous difficulty in eating and talking.

Nursing management after procedure

Gargle several times a day to prevent infection.
Take antibiotics as prescribed.
Take pain medicine to ease discomfort.
Slowly resume your normal diet.
Continue to work with a speech therapist.
Be sure to follow your doctor's instructions.

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