Ileostomy

Definition

An ileostomy is a surgical procedure in which the small intestine is attached to the abdominal wall in order to bypass the large intestine; digestive waste then exits the body through an artificial opening called a stoma (from the Greek word for "mouth").

Purpose

In general, an ostomy is the surgical creation of an opening from an internal structure to the outside of the body. An ileostomy, therefore, creates a temporary or permanent opening between the ileum (the portion of the small intestine that empties to the large intestine) and the abdominal wall. The colon and/or rectum may be removed or bypassed. A temporary ileostomy may be recommended for patients undergoing bowel surgery (e.g., removal of a segment of bowel), to provide the intestines with sufficient time to heal without the stress of normal digestion.

Chronic ulcerative colitis is an example of a medical condition that is treated with the removal of the large intestine. Ulcerative colitis occurs when the body's immune system attacks the cells in the lining of the large intestine, resulting in inflammation and tissue damage. Patients with ulcerative colitis often experience pain, frequent bowel movements, bloody stools, and loss of appetite. An ileostomy is a treatment option for patients who do not respond to medical or dietary therapies for ulcerative colitis.

Other conditions that may be treated with an ileostomy include:

• bowel obstructions
• cancer of the colon and/or rectum
• Crohn's disease (chronic inflammation of the intestines)
• congenital bowel defects
• uncontrolled bleeding from the large intestine
• injury to the intestinal tract

Demographics

The United Ostomy Association estimates that approximately 75,000 ostomy surgeries are performed each year in the United States, and that 750,000 Americans have an ostomy. Ulcerative colitis and Crohn's disease affect approximately one million Americans. There is a greater incidence of the diseases among Caucasians under the age of 30 or between the ages of 50 and 70.

Description

For some patients, an ileostomy is preceded by removal of the colon (colonectomy) or the colon and rectum (protocolectomy). After the patient is placed under general anesthesia, an incision approximately 8 in (20 cm) long is made down the patient's midline, through the abdominal skin, muscle, and other subcutaneous tissues. Once the abdominal cavity has been opened, the colon and rectum are isolated and removed. The anal canal is stitched closed.

An ileostomy can be placed in different sites on the abdomen (A). Once the incision is made, the ileum is pulled through the incision (B), and a rod is placed under the loop. The loop is cut open, one side is stitched to the abdomen (C). The portion of intestine is flipped open to expose the interior surface (D), and the opposite side is stitched in place (E). (

Illustration by GGS Inc.

)

There are two basic types of permanent ileostomy: conventional and continent. A conventional ileostomy, also called a Brooke ileostomy, involves a separate, smaller incision through the abdominal wall skin (usually on the lower right side) to which the cut end of the ileum is sutured. The ileum may protrude from the skin, often as far as 2 in (5 cm). Patients with this type of stoma are considered fecal-incontinent, meaning they can no longer control the emptying of wastes from the body. After a conventional ileostomy, the patient is fitted with a plastic bag worn over the stoma and attached to the abdominal skin with adhesive. The ileostomy bag collects waste as it exits from the body.

An alternative to conventional ileostomy is the continent ileostomy. Also called a Kock ileostomy, this procedure allows a patient to control when waste exits the stoma. Portions of the small intestine are used to form a pouch and valve; these are directly attached to the abdominal wall skin to form a stoma. Waste collects internally in the pouch and is expelled by insertion of a soft, flexible tube through the stoma several times a day.

Diagnosis/Preparation

The patient meets with the operating physician prior to surgery to discuss the details of the surgery and receive instructions on pre- and post-operative care. Directly preceding surgery, an intravenous (IV) line is placed to administer fluid and medications, and the patient is given a bowel prep to cleanse the bowel and prepare it for surgery. The location where the stoma will be placed is marked, away from bones, abdominal folds, and scars.

Aftercare

Following surgery, the patient is instructed in the care of the stoma, placement of the ileostomy bag, and necessary changes to diet and lifestyle. Because the large intestine (a site of fluid absorption) is no longer a part of the patient's digestive system, fecal matter exiting the stoma has a high water content. The patient must therefore be diligent about his or her fluid intake to minimize the risk of dehydration. Visits with an enterostomal therapist (ET) or a support group for individuals with ostomies may be recommended to help the patient adjust to living with a stoma. Once the ileostomy has healed, a normal diet can usually be resumed, and the patient can return to normal activities.

Risks

Risks associated with the ileostomy procedure include excessive bleeding, infection, and complications due to general anesthesia. After surgery, some patients experience stomal obstruction (blockage), inflammation of the ileum, stomal prolapse (protrusion of the ileum through the stoma), or irritation of the skin around the stoma.

Normal results

The physical quality of life of most patients is not affected by an ileostomy, and with proper care most patients can avoid major medical complications. Patients with a permanent ileostomy, however, may suffer emotional aftereffects and benefit from psychotherapy.

Morbidity and mortality rates

Among patients who have undergone a Brooke ileostomy, medical literature reports a 19–70% risk of complications. Small bowel obstruction occurs in 15% of patients; 30% have problems with the stoma; 20–25% require further surgery to repair the stoma; and 30% experience postsurgical infections. The rate of complications is also high among patients who have had a continent ileostomy (15–60%). The most common complications associated with this procedure are small bowel obstruction (7%), wound complications (35%), and failure to restore continence (50%). The mortality rate of both procedures is less than 1%.

Alternatives

Patients with mild to moderate ulcerative colitis may be able to manage their disease with medications. Medications that are given to treat ulcerative colitis include enemas containing hydrocortisone or mesalamine; oral sulfasalazine or olsalazine; oral corticosteroids ; or cyclosporine and other drugs that affect the immune system.

A surgical alternative to ileostomy is the ileal pouch-anal anastomosis, or ileoanal anastomosis. This procedure, used more frequently than permanent ileostomy in the treatment of ulcerative colitis, is similar to a continent ileostomy in that an ileal pouch is formed. The pouch, however, is not attached to a stoma but to the anal canal. This procedure allows the patient to retain fecal continence. An ileoanal anastomosis usually requires the placement of a temporary ileostomy for two to three months to give the connected tissues time to heal.

Resources

BOOKS

"Inflammatory Bowel Diseases: Ulcerative Colitis." In The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Pemberton, John H., and Sidney F. Phillips. "Ileostomy and Its Alternatives" (Chapter 105). In Sleisenger and Fordtran's Gastrointestinal and Liver Disease , 7th ed. Philadelphia: Elsevier Science, 2002.

Rolandelli, Rolando H., and Joel J. Roslyn. "Colon and Rectum," (Chapter 46), In Sabiston Textbook of Surgery . Philadelphia: W. B. Saunders Company, 2001.

PERIODICALS

Allison, Stephen, and Marvin L. Corman. "Intestinal Stomas in Crohn's Disease." Surgical Clinics of North America 81, no. 1 (February 1, 2001): 185-95.

ORGANIZATIONS

Crohn's and Colitis Foundation of America. 386 Park Ave. S., 17th Floor, New York, NY 10016. (800) 932-2423. http://www.ccfa.org .

United Ostomy Association, Inc. 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. http://www.uoa.org .

OTHER

Hurst, Roger D. "Surgical Treatment of Ulcerative Colitis." [cited May 1, 2003]. http://www.ccfa.org/medcentral/library/surgery/ucsurg.htm .

Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Ileostomies are usually performed in a hospital operating room . The surgery may be performed by a general surgeon, a colorectal surgeon (a medical doctor who focuses on diseases of the colon, rectum, and anus), or gastrointestinal surgeon (a medical doctor who focuses on diseases of the gastrointestinal system).

QUESTIONS TO ASK THE DOCTOR

• Why is an ileostomy being recommended?
• What type of ileostomy would work best for me?
• What are the risks and complications associated with the recommended procedure?
• Are any nonsurgical treatment alternatives available?
• How soon after surgery may I resume my normal diet and activities?