Ileostomy

Overview

An ileostomy is a surgical intervention utilized when the large intestine is unable to effectively manage and transport waste material. This procedure involves creating a stoma, an opening in the abdominal wall, to redirect the digestive process. Certain medical conditions or treatments can disrupt the body’s ability to eliminate intestinal waste, prompting the need for an ileostomy. Depending on the circumstances, patients may undergo either a permanent or temporary ileostomy. Temporary ileostomies are intended to be reversed once the patient has fully recovered from the initial surgery.

Types

Ileostomies are recommended to address various medical conditions, and the type of ileostomy depends on the specific circumstances.

• Permanent Ileostomy: In an end ileostomy, also known as the standard or Brooke ileostomy, the ileum is elevated through an abdominal incision, turned inside out, and attached to the abdomen using sutures, forming a stoma. Waste flows through the stoma into an external pouch. Because the waste flow cannot be regulated, the external pouch must be worn continuously.

The standard or Brooke ileostomy, characterized by the use of external pouches, is the most prevalent type of permanent ileostomy. Generally, permanent ileostomies employ either external or internal pouches known as ileal pouches for the collection and storage of digestive waste.

• The J-Pouch: Creating a J-pouch involves multiple steps. The first step typically involves the same process to the standard or Brooke ileostomy, in which the temporary stoma directs waste to an external ileostomy pouch, and the large bowel is removed. In the next step, the loops of the ileum is utilized to construct a pouch in the pelvic region, connecting it to the anus. Waste moves from the small intestine into the pouch, where it is stored until there’s a need to excrete. This allows waste to pass through the anus.

In certain cases, a temporary loop ileostomy may be done to facilitate healing of the new pouch, and this temporary loop ileostomy is later removed.

The J-pouch, also referred to as the pelvic pouch or ileoanal reservoir, is used when the big bowel has been fully removed and can allow waste to pass through the anus.

• The K-pouch: This procedure is less prevalent than the J-pouch. Similar to a standard ileostomy, the K-pouch procedure involves pulling the ileum through an abdominal incision. Ileum loops are utilized to create an internal pouch and a valve, preventing waste from leaking through the ileostomy. To empty the pouch, individuals insert a catheter through the stoma for drainage. Also known as the continent or Kock ileostomy, the K-pouch necessitates a stoma but eliminates the need for an external ileostomy pouch.
• Temporary Ileostomy: Temporary ileostomies serve as the initial stage in the implementation of a permanent ileostomy known as an ileoanal reservoir or J-pouch. The adoption of internal pouches originated in 1978 with the introduction of the S-pouch, and these pouch types are frequently named based on the shape of the pouch employed. Both J-pouch and K-pouch ileostomies utilize internal pouches.

After colon surgery, temporary ileostomies are reversible operations performed to allow the colon to heal and relax. To allow the new pouch to heal, a temporary loop ileostomy may be done. Later on, the temporary loop ileostomy is taken out.

Reasons for undergoing the procedure

Permanent ileostomies may be required for conditions such as Crohn’s disease, colonic motility dysfunction, or instances involving blockage, damage, or rupture of the large intestines. Conversely, temporary ileostomies are commonly employed in surgeries related to colorectal cancer, diverticulitis, ulcerative colitis, Crohn’s disease, and familial adenomatous polyposis. The intention with temporary ileostomies is for them to be reversed once the patient has recovered from the initial surgical procedure. The decision between temporary and permanent ileostomies is made based on the individual’s specific medical needs and the nature of the underlying conditions.

Risk

Medical procedures like ileostomies come with risk. Risks that may be discussed prior to the procedure include:

• Pouchitis, an infection
• Injury to adjacent organs
• Blockage of the digestive tract due to scar tissue
• Bleeding from the stoma or from within the small intestine
• Not being able to process meal nutrients well enough

Before the procedure

The healthcare provider will discuss the necessary preparations, such as fasting, that one should do before surgery. Ileostomies also require administration of general anesthesia before the procedure.

During the procedure

The initiation of any ileostomy can be accomplished through traditional surgical incision or laparoscopic surgery techniques. It usually involves creating a small incision on the right side of the abdomen to access the terminal portion of the small intestine, known as the ileum.

Laparoscopic surgery generally offers advantages such as minimizing blood loss and postoperative pain. In the case of a standard ileostomy, laparoscope is utilized to establish a small opening, through which a loop of the ileum is drawn. The ileum is then inverted to reveal its inner surface, constituting the stoma.

Laparoscope is a slender tube-like instrument equipped with a light and lens to facilitate the operation. The laparoscope may incorporate a tool for extracting tissue, which can be examined under a microscope for disease indicators.

After the procedure

Full recovery from an ileostomy typically takes around two months as the healing process advances. Hospitalization typically lasts about a week, allowing time for the small intestine to heal. For those with a temporary ileostomy, closure or reversal surgery is usually required. Reversal surgery may take place three to six months after the initial ileostomy.

Undergoing an ileostomy is a major surgical undertaking, and it necessitates a period of recuperation. Once the ileostomy has healed, individuals should be able to resume their regular activities, including driving, working, exercising, playing sports, and engaging in sexual activities.

Outcome

Contact a healthcare provider if certain post-operative condition is experienced, such as continuous nausea and vomiting, and cramps, pain, or nausea if more than four to six hours after the stoma has expelled waste. Other symptoms or circumstances to look out for include:

• Persistent bad odor for more than a week, potentially signifying infection
• Any cut or injury to the stoma
• Presence of ulcers deep sores, and severe skin irritation
• More than two or three hours of cramping

Undergoing an ileostomy, whether temporary or permanent, can significantly impact an individual’s life, and adjusting to the associated routines may pose challenges. It is advisable to avoid consuming hard-to-digest foods such as nuts, popcorn, seeds, or crunchy vegetables.

To minimize potential discomfort or pain around the stoma caused by output from the device, several measures can be taken. These include cleaning the skin around the stoma with water and ensuring thorough drying before applying the skin barrier or pouch. Additionally, unless absolutely necessary, it is best to refrain from removing the pouching system more than once a day.

Other measures include:

• Check the fit of the skin barrier opening and pouch to prevent issues like swelling or leakage
• When removing the pouching system, it is advised to be gentle and avoid pulling the skin barrier away from the skin; instead, push the skin away from the barrier
• Establish a regular schedule for pouch changes helps avoid leaks and skin irritation