Ileostomy Is an Intestinal Stoma Fashioned from the Distal Small Intestine

Home , Bowel resection, Enterostomy, Ileostomy

CHAPTER Ileostomy Vikram B. Reddy | Walter E. Longo 84

leostomy is an intestinal stoma fashioned from the losses were noted by Cattell and Sachs18 and Cave and distal small intestine. Although the creation of an ileos- Nickel,19 with the latter reporting a 33% mortality following Itomy can be the smallest part of a larger surgery, the an ileostomy. Despite the initial success, ileostomy creation stoma can have the most significant physical and psycho- was associated with significant morbidity due to the social effect on a patient.1–6 Despite an eventual return peristomal skin irritation from the small bowel effluent. to a prior quality of life and activity level, body image and Lahey later described the morbidity and the mortality sexual function do not change over time. A well-constructed associated with ileostomies.13 ileostomy can be lifesaving with minimal adverse effect Warren and McKittrick of Massachusetts General on the quality of life, when constructed after careful Hospital reported in 1951 on the outcome of 210 patients counseling of the patient, preoperative planning, excellent with ulcerative colitis managed by an ileostomy between technique, and valuable postoperative enterostomal 1930 and 1949.20 They coined ileostomy dysfunction and therapy. Even after a well-constructed ileostomy, recogni- characterized it as “cramp-like pain and, paradoxically, tion and prevention of postoperative dehydration due to increase in the volume of ileostomy discharge,” which in the liquid output is imperative to prevent pouching severe cases can lead to emesis and watery diarrhea with problems, electrolyte abnormalities, and even renal failure. significant loss of fluids and electrolytes leading to a shocklike state. Unfortunately, these symptoms were noted HISTORY in 62% of the patients. They also observed that early dysfunction was due to the peristaltic activity against the Stoma is derived from the Greek word stomat, meaning rigid abdominal wall, whereas late dysfunction was due mouth or opening. Spontaneous small bowel stomas to cicatrizing granulation tissue on the serosa of exterior- from abdominal trauma or incarcerated hernias with ized ileostomy. Symptomatic relief was achieved with subsequent survival ensured the possibility of stomas as catheter decompression, which was required in a third lifesaving procedures. Although reports of colostomies of all ileostomy patients and in more than half of all existed throughout the 18th century with the first report patients with ileostomy dysfunction. by Littre in 1710,7 small intestinal stomas were successfully Crile and Turnbull summarized ileostomy dysfunction applied more commonly in the 20th century. Baum in as the sequelae of peritonitis of the protruding ileostomy Germany recorded the first ileostomy in 1879 in a patient that causes a functional obstruction.21 They noted spontane- with an obstructing right colon cancer. In 1888 Maydl from ous maturation over 4 to 6 weeks by eversion of the mucosa Vienna reported on the successful use of exteriorization to the abdominal wall. Several procedures to combat the of a loop of small or large bowel and suspension over serositis, and thus ameliorate ileostomy dysfunction, were the abdominal wall by a rubber rod through a defect in proposed: skin grafting the ileostomy as described by the mesentery.8 Dragstedt et al.,22 fasciocutaneous grafting by Monroe Both in Europe and the United States the successful and Olwin,23 and mucosal grafting by Turnbull and Crile.24 role of enterostomy to relieve abdominal distention gained However, the most technically facile procedure was acceptance. Initially, ileostomies, as described by Brown described by chance by Brooke of the University of Bir- in 1913,9 were primarily associated with surgical relief mingham in 1952 and involved the evagination of the from ulcerative colitis, dysentery, tuberculosis, and large ileal end and suturing of the mucosa to the skin.15 To this bowel obstruction. However, the use of an ileostomy, even day, the so-called Brooke ileostomy remains the standard for ulcerative colitis, was met with disdain, whereas other technique for constructing an ileostomy. procedures, even those involving ileosigmoid anastomoses, were favored.10 It was not until the 1940s that the justified INDICATIONS and inevitable role of an ileostomy in the management of ulcerative colitis was accepted at major institutions.11–15 Although ileostomies were initially used after proctocolec- In 1931 Rankin described staged proctocolectomy with tomy (for ulcerative colitis and polyposis) or the relief of ileostomy for the management of ulcerative colitis and obstruction, their use has evolved over the years in numer- polyposis.16 The initial staged ileostomy was created ous disease processes. Etiologies include functional, through a McBurney incision, division of the ileum close hemorrhagic, infectious, inflammatory, ischemic, malig- to the ileocecal valve, and exteriorization of the proximal nant, or mechanical. Their indications are better described end with a clamp on the end for 2 days. Bargen et al.,17 by their permanence: permanent, temporary, or protecting, working on Rankin’s technique, replaced the clamp with as shown in Table 84.1. a small drainage catheter in the exteriorized ileostomy. Although he noted immediate convalescence, significant PERMANENT fluid losses from the ileostomy requiring drastic fluid An end ileostomy is usually indicated in situations in resuscitation were required. Similar fluid and electrolyte which the disease process affects the entire colon and 991 Ileostomy CHAPTER 84 991.e1

ABSTRACT Ileostomy is an intestinal stoma fashioned from the distal small intestine. Although the creation of an ileostomy can be the smallest part of a larger surgery, the stoma can have the most significant physical and psychosocial effect on a patient. Despite an eventual return to a prior quality of life and activity level, body image and sexual function do not change over time. A well-constructed ileostomy can be lifesaving with minimal adverse effect on the quality of life, when constructed after careful counseling of the patient, preoperative planning, excellent technique, and valuable postoperative enterostomal therapy. Even after a well-constructed ileostomy, recogni- tion and prevention of postoperative dehydration due to the liquid output is imperative to prevent pouching problems, electrolyte abnormalities, and even renal failure. KEYWORDS Ileostomy, Ileostomy indications, Ileostomy techniques, Ileostomy complications 992 SECTION II Stomach and Small Intestine

in the pelvis or in high-risk patients. In immuno- TABLE 84.1 Indications for Ileostomy compromised or malnourished patients, anastomoses that can otherwise be safely performed may also need fecal Type Surgical Procedure and Disease Process diversion. Although fecal diversion with an ileostomy may Permanent Proctocolectomy with end ileostomy not diminish the risk of an anastomotic leak, the septic complications are significantly diminished and may avoid • Crohn disease 37 • Ulcerative colitis reoperation. • Polyposis (familial adenomatous Loop transverse colostomies were traditionally used polyposis, Lynch syndrome, etc.) for fecal diversion. This trend changed when Williams Total colectomy or proctocolectomy et al. performed a randomized controlled trial to compare with end ileostomy the outcomes of a loop colostomy with a loop ileostomy • Colonic dysmotility with poor and demonstrated that the incidence of prolapse, leakage, anorectal function skin irritation, odor, and surgical site infection at the time • Neurogenic bowel of the ostomy closure were significantly lower with a loop Temporary Colectomy with ileostomy ileostomy.38 Multiple other meta-analyses have confirmed • Crohn disease with subsequent the significantly lower incidence of prolapse with a loop ileorectal anastomosis ileostomy and lower chance of wound infection and hernia • Ulcerative colitis as the first stage of formation after closure of a loop ileostomy as opposed ileal pouch anal anastomosis to a loop colostomy.39–43 • Clostridium difficile colitis • Gastrointestinal hemorrhage Partial colectomy with ileostomy PHYSIOLOGY • Right colon perforation/obstruction in In the absence of any intestinal disorders or resection, the immunocompromised or morbidly ill small intestine is able to absorb most of the fluid that it is • Ileocolonic ischemia exposed to. Ninety percent of the nutrients and nearly 6 L Diverting Colorectal anastomosis • Low anastomosis of fluid are absorbed in the jejunum while the ileum can • Radiation absorb the remaining 2.5 L, leading to a concentrated efflu- • High-risk patient ent into the colon, where an additional 1.5 L are absorbed. Ileal pouch anal anastomosis The transport of water is passive and requires movement of solutes. The rate of water absorption in different portions of the intestine is a function of the solute absorption in that segment of the bowel. Sodium absorption is more rectum or the functional status of a patient precludes an complex and involves both active and passive transport. anastomosis. Currently, a permanent ileostomy is used in In the jejunum, sodium is transferred out of the lumen by the management of severe proctocolitis due to ulcerative cotransport with active uptake of both carbohydrates and colitis25,26 or Crohn disease (especially with significant amino acids, whereas it is actively transported against an perianal disease),27 familial adenomatous polyposis (FAP), electrochemical gradient in the ileum. Bicarbonate ions and functional disorders, such as colonic dysmotility (with facilitate the active transport of sodium out of the lumen poor anorectal function)28,29 and neurogenic bowel.30 against the electrochemical gradient. Bicarbonate uptake in the jejunum is by active transport, whereas its trafficking TEMPORARY in the ileum depends on the intraluminal concentration. A functional end ileostomy is fashioned after a segmental The majority of chloride ions follow sodium transport or total colectomy for a disease process that spares the passively down the electrochemical gradient. Potassium distal colon or rectum and allows for a delayed reestablish- ion movement into the lumen is also passive down the ment of intestinal continuity. This is encountered in electrochemical gradient. patients with fulminant or toxic Crohn colitis or ulcerative Vitamin B12 and bile salts are absorbed in the terminal colitis, Clostridium difficile colitis,31 uncontrolled lower ileum. Without ileal reabsorption, hepatic synthesis of gastrointestinal bleeding without a clear source, ischemia bile salts would not be sufficient for fat digestion. Lack involving the ileocolic pedicle, or malignant obstruction of absorption of bile salts can lead to profound diarrhea involving the ascending colon or small bowel in the setting by causing fluid and electrolyte secretion into the lumen of immunosuppression where an anastomosis may not be and impairing colonic absorption of water and sodium. prudent. Serum vitamin B12 levels remain normal unless more than 100 cm of terminal ileum has been removed. DIVERTING Interestingly, the ileum aids in slowing the transit and In some disease processes, a proximal diversion with a allows for absorption proximally. The transit time of the loop ileostomy may be necessary as the first of a series of first 50% is one-third of the ileum.44 Consequently ileal staged interventions or for protection of a distal anasto- resection can lead to shortened transit time and increased mosis. The role of diverting loop ileostomies have been output, whereas resection of an equivalent segment of extensively studied with low anastomoses in rectal cancer32 jejunum may not have an effect on transit time. and with ileal pouch anal anastomoses.33–36 Ileostomy volume in the absence of proximal bowel Diverting loop ileostomies have been used to diminish loss can vary among individuals with output greater than the complications of a distal anastomotic leak, especially 1.5 L, concerning for diarrhea and possibly fluid and Ileostomy CHAPTER 84 993 electrolyte derangement. Ileostomies empty in small volumes constantly, with increase in output after meals. Different foods have different transit times, and this may vary even among individuals, even for the same food. Normal ileostomy output is almost isotonic with normal saline, and sodium loss is significantly more than with normal stool. Fluctuations in sodium resorption with food intake are also noted. With intake of hypotonic solutions, fluid output in the ileostomy decreases to allow for sodium reabsorption, whereas excessive salt intake causes watery effluent.45 Water intake has no effect on output, with increased intake increasing urine output only. In addition, normal ileostomy effluent carries a significantly higher quantity of bacteria, mainly coliform organ- isms.46 The effluent also contains a significant quantity of proteolytic enzymes that can damage exposed skin. The incidence of cholelithiasis increases from 5% at 5 years after ileostomy formation to approximately 50% after 15 years. This worsens in the presence of ileal resection and by decreased solubility of cholesterol with a reduction in the bile salt pool.47 The situation is further worsened in patients with ileal Crohn disease.48 Renal conservation of sodium and water in the setting of an ileostomy leads to acidic urine, which may contribute to a high incidence of uric acid and calcium stones.49 PREOPERATIVE CONSIDERATIONS An ileostomy can be a very effective method of fecal FIGURE 84.1 Siting of an ileostomy. diversion and is compatible with an excellent quality of life. However, the placement of the ileostomy is paramount. The ileostomy should be placed in a location that is and a number next to it indicating the preference of the convenient for the patient to see and manage with minimal site. This should be covered with a translucent occlusive hindrance of movement and difficulty in disguising it with dressing. Alternatively, subcutaneous injection of methylene clothing (Fig. 84.1). Counseling and consultation with blue can be used to achieve a more permanent marking an enterostomal therapist or an ostomate of similar age, of the abdominal wall, although this is seldom needed. gender, and disease process may need to be arranged. After the patient has been anesthetized for the surgery, a The United Ostomy Association (www.ostomy.org) has 27-gauge needle can be used to mark the skin at the site extensive material that may be a helpful resource. of the “X” after removing the occlusive dressing. There are several factors to consider when marking a stoma site preoperatively: the patient’s occupation, clothing SURGICAL TECHNIQUE style, belt line, flexibility, abdominal wall contour in different positions, any physical disabilities, location of previous Creation of an ileostomy (Fig. 84.2), irrespective of the abdominal scars, bony prominences, and abdominal girth. nature of the stoma, begins with mobilization of the The ideal location for most ileostomies is in the right lower selected segment of bowel to reach beyond the abdominal quadrant away from any skin creases, bony prominences, wall at the site of the stoma marking. Corresponding to or the midline incision. It is particularly important to the size of the bowel to be used for the stoma, a 1.5- to avoid any location that will disrupt the skin-appliance 2-cm circumferential incision is placed in the skin and seal with change in body position. Most often, the ideal extended through the subcutaneous tissues, down to the location is in the infraumbilical fat mound overlying the anterior rectus fascia. During open surgery, Kocher clamps rectus sheath. The ostomy site should be marked with are placed on the edge of the fascia to allow alignment the patient standing or supine, bending, and sitting.50 of the layers of the abdominal wall during stoma creation. Location of the stoma at the belt line should be avoided. A vertical incision is then placed; the underlying rectus Although desirable, creation of an ileostomy below the belt muscle fibers are visualized and split along the length of line to facilitate hiding of the stoma may not be feasible the fibers to expose the posterior rectus sheath. Care is in the obese or those with a history of prior ostomies. In taken to avoid any injury to the epigastric vessels, which, the obese patient, a stoma in the upper quadrants where if unintentionally injured, can be ligated. A transverse there will be less abdominal wall fat may be a more suitable incision is placed on the anterior rectus sheath to create location. In patients with a history of prior abdominal a cruciate opening. The posterior rectus sheath and the procedures, several stoma sites should be marked with underlying peritoneum are divided as one while avoiding notation made of the most to least preferred sites. The any injury to the underlying bowel. In open surgery, a sites should be noted with a marking pen, making an “X” laparotomy pad can be placed underneath the peritoneum 994 SECTION II Stomach and Small Intestine

during its division, while in a laparoscopy, pneumoperitoneum can be maintained while entry is made into the abdominal cavity. The created hole should allow passage of two fingers. However, this may vary with the habitus of the patient and the edema of the bowel wall. A larger opening may lead to a parastomal hernia but may be preferable with edematous bowel or with hemodynamic instability. A tight opening may cause ischemia and obstruction of the ileostomy. At this point, the mobilized small bowel should be exteriorized and examined for viability and tension. Care should be taken to avoid twisting of A the mesentery. If the mesentery is floppy and appears to twist around the luminal axis, it should be tacked to the anterior abdominal wall with absorbable sutures. Viability of the exteriorized bowel can be entertained by visualizing the pink serosa, palpating the pulsatile flow in the immediate vicinity, examining the viable mucosa of the stoma, or by trimming the ileostomy edge to confirm bleeding. After adequate length to avoid creation of a flat stoma has been ensured, the abdominal wall can be closed and the stoma can be matured depending on the type of ileostomy. Absorbable sutures are commonly used to mature the stoma, and bites should be placed in the subcuticular area rather than the epidermis to prevent ectopic mucosal implants at the suture sites on the dermis, which can lead to mucous production and break in the appliance- skin seal. B END ILEOSTOMY An end ileostomy is technically the easiest small bowel stoma to create due to the mobility of the small bowel mesentery (Fig. 84.3). The mobilized, well-vascularized stapled end of the small bowel is everted through the abdominal wall while avoiding any twisting of the mesentery. Thick or bulky mesentery may need debulking to facilitate eversion. The staple line is completely removed. Three to four full-thickness sutures (depending on the peristomal fat) can be placed through the edge of the stoma, a more proximal seromuscular bite approximately 4 to 6 cm proximal to the edge, and into the subcuticular area of the skin opening (tripartite bites). After the sutures are placed, they can be tied to evert the ileostomy. Multiple other absorbable sutures can then be placed between the full-thickness edge of the ileostomy and the subcuticular layer to complete the mucocutaneous junction. Some surgeons prefer to not place any sutures in the seromuscular layer and are still able to evert the stoma without difficulty. The finished end ileostomy should protrude approximately 2 to 3 cm above the skin surface to increase the distance of the effluent egress from the skin-appliance interface, thereby diminishing leaks and peristomal skin irritation.51 Because most end ileostomies are often permanent or long term, care should be taken to avoid stomas that are flush or barely protrude above the skin because C short ileostomies tend to leak ostomy effluent under the stoma flange and cause severe skin excoriation and weeping FIGURE 84.2 Construction of an ileostomy. (A) Incising the fascia. wounds with resultant pain and difficulty with pouching (B) Splitting the rectus and dividing the posterior sheath and the stoma.52 peritoneum. (C) Exteriorizing the small bowel. DIVERTING LOOP ILEOSTOMY A diverting loop ileostomy (Fig. 84.4) is typically used for fecal diversion after a proctectomy with ileoanal Ileostomy CHAPTER 84 995

AB C

FIGURE 84.3 End ileostomy. (A) Configuration of the end ileostomy. (B) Eversion with tripartite sutures. (C) Completed end Brooke ileostomy. pouch or a low anterior resection with a low colorectal END-LOOP ILEOSTOMY or coloanal anastomosis. Compared with a loop colostomy, Indications for a loop-end ileostomy include obese patient a loop ileostomy has a higher risk of dehydration and with a short mesentery or a thick abdominal wall, or obstruction after takedown but a lower risk of prolapse conversion of a loop ileostomy to an end ileostomy (Fig. or wound infection at the time of takedown.42 The take- 84.6). The bowel is mobilized to the maximal extent down of a loop ileostomy is also technically much easier possible, and the bowel is transected with a stapler. While (Fig. 84.5). the vascularity of the mobilized loop is maintained, a The loop stoma is created by mobilizing a loop of segment of bowel on the mobilized loop attaining the ileum, making an opening in the abdominal wall slightly maximal elevation above the skin is selected. The orienta- larger than would be anticipated for an end ileostomy, tion of the bowel and the mesentery is maintained similar and subsequently exteriorizing the mobilized loop with to the technique of a loop ileostomy. The stoma is matured knowledge of the direction of luminal flow (this can be in a similar fashion to the loop ileostomy with the func- marked with sutures or with ink on the antimesenteric tional limb occupying most of the abdominal wall circum- border). A mesenteric defect is made, and a stoma rod ference. A support rod can also be placed under the is then placed. This defect can also be made prior to the bowel, and this can alleviate the tension at the mucocutane- mobilization, and a Penrose drain or umbilical tape can ous junction, which would otherwise be noted with an be placed to aid in the externalization of the loop for end ileostomy. maturation as a stoma. The remaining fascial openings and skin are closed prior to proceeding with the maturation LAPAROSCOPY of the ileostomy. Cautery is used to divide the antimes- Laparoscopic loop ileostomy was first described by Khoo enteric wall of the ileum close to the efferent limb at the et al. in 1993.55 The technique is similar to open surgery. level of the stoma bridge. This opening is created from After pneumoperitoneum has been attained and the one mesenteric edge to the other. The defunctional limb resection, if needed, has been carried out, an abdominal is matured first with interrupted sutures between the edge wall opening is created at a preselected site. Often, a port of the ileostomy and less than a third of the circumference can be placed at the preselected site, and this can be of the subcuticular layer of the abdominal opening. The enlarged. A wound retractor is placed, and with the aid proximal limb is matured by taking a full-thickness bite of a laparoscopic locking atraumatic bowel grasper, the through the edge of the stoma and attaching it to the selected loop of bowel is directed to the opening. A subcuticular layer (with or without a proximal seromuscular Babcock clamp is used to externalize the selected bowel bite) to create an everted bud. The functional limb should while maintaining orientation and avoiding any twisting occupy the majority (75%) of the skin opening, and a of the mesentery. The stoma is matured as previously well-constructed loop ileostomy can completely divert the described. Single-port surgery is also feasible and will fecal stream while allowing reflux of the downstream avoid additional incisions.56,57 secretions via the defunctionalized limb. Interrupted absorbable sutures can be placed in between the tripartite DIFFICULT ILEOSTOMY everting sutures to complete the mucocutaneous junction. Wrapping the ileostomy with a sheet of sodium hyaluronate Patient characteristics that predict a difficult ileostomy can decrease the adhesions at the time of the ileostomy include obesity, emergency surgery, inflammatory bowel takedown.53,54 disease, or a history of multiple abdominal surgeries. 996 SECTION II Stomach and Small Intestine

A B

C D

FIGURE 84.4 Loop ileostomy. (A) Exteriorization of a loop. (B) Placement of a bridge in the mesentery. (C) Incising the bowel. (D) Maturation of the limbs (simple for the defunctionalized limb, and tripartite for the functional Brooke ileostomy). (E) Completed loop ileostomy.

Intraoperatively, length and quality of the bowel and the small bowel will have an impact on the ease of stoma associated mesentery dictates the ease of construction of creation. an ileostomy. Elevated body mass index (BMI), large The most common problem encountered in a difficult pannus, foreshortened or thickened mesentery (inflam- stoma is the reach of the terminal portion of the small matory bowel disease), mesenteric fibrosis, intraabdominal bowel to and beyond the abdominal wall. The following adhesions, or inflammation, and extent of the residual maneuvers may be attempted to allow for reach: Ileostomy CHAPTER 84 997

FIGURE 84.5 End-loop ileostomy. FIGURE 84.7 Pedicled ileostomy.

• Exteriorization of the mobilized bowel through a lubricated wound retractor (Alexis wound retractor, Applied Medical, Rancho Santa Margarita, California) to avoid any traction injury on the vasculature of the bowel or accidental trauma to the bowel wall. • Incising the peritoneal lining of the mesentery per- pendicular to the mesenteric vessels on both sides of the mesentery (Fig. 84.7). In a bulky mesentery, clearing the mesenteric fat while avoiding the vascular pedicles may provide a little more length. • The stoma can be pedicalized (Fig. 84.8) by dividing the arcade off the superior mesenteric artery while maintaining the collateral flow and the branches close to the wall of the bowel. • Creation of an end-loop ileostomy as described before. • A loop-end ileostomy may be advisable rather than a loop ileostomy.58 The mobilized bowel loop is delivered through the abdominal wall trephine, and the bowel is divided at the most mobile ileal site. The afferent limb is then matured in the usual fashion after dividing the mesentery. The efferent limb can be brought out through the same opening or through another smaller opening on the skin, and the antimesenteric portion FIGURE 84.6 Mesenteric lengthening. of the staple line is removed, and this is sutured to the subcuticular area. If this is not feasible, the afferent • Division of the terminal ileum close to the ileocecal limb can be left stapled off below the fascia as long as valve. there is no risk of a distal obstruction.59 • Division of the ileocolic pedicle at its origin while • Use of mesenteric support rods at the fascia. Usually carefully avoiding damage to the ileal branches. support rods are placed in the mesenteric defect above • Mobilization of the ileal mesentery to and over the the skin but, with a difficult ileostomy, may not prevent duodenum. Further length can be obtained by kocher- retraction or splitting the ileostomy. A mesenteric izing the duodenum. support rod can be placed below the subcutaneous • Placement of the ileostomy in the upper abdominal tissues at the level of the anterior rectus sheath while wall where the subcutaneous adiposity is generally lower maintaining the support rod exit sites lateral to the and may also facilitate better visualization of the stoma. stoma appliance interface on the skin. 998 SECTION II Stomach and Small Intestine

C D

FIGURE 84.8 Loop ileostomy closure. (A) Taking down the mucocutaneous junction. (B) Handsewn closure. (C) Stapled side-to-side anastomosis. (D) Closure of the common channel. (E) Fascial closure. Ileostomy CHAPTER 84 999

• Modified abdominoplasty or abdominal wall contouring diarrhea despite a perfectly constructed ileostomy is often may be used in the morbidly obese.60,61 prevalent (20%) in the early postoperative period. Prolapse, Another difficulty that could be encountered is with stenosis, and parastomal hernia are late complications, the eversion and maturation of the stoma. The following which often require operative revision. solutions may be applicable: The primary determinant of output is the length and • Suture the seromuscular wall to the subcuticular area quality of the bowel proximal to the stoma, rather than the without exerting the ileal mucosa. The resulting serositis amount of bowel resected. Clinically significant diarrhea is will eventually constrict the stoma, but this can be noted in up to 20% of patients.65 The highest risk is seen eventually revised. in the first week when the patients are still not able to • Crile and Turnbull technique for construction of the match the stoma output with fluid intake and small bowel ileostomy.24 The serosa and the muscularis of the distal adaption has not completed. Removal of smaller segments portion of the ileostomy are dissected off, and the of bowel over a long period of time has less impact on resulting mucosal cuff is everted and sutured to the output rather than resection of an equivalent length at subcuticular layer of the opening. one sitting. Diarrhea associated with limited ileal resection, even up to 100 cm, is secretory with minimal nutritional POSTOPERATIVE CARE losses rather than the osmotic diarrhea noted with greater resection (and resultant decreased fat reabsorption due to A newly created ileostomy is often edematous and will disruption of the enterohepatic circulation).66 Increased shrink over the next 4 to 6 weeks. Initially, the stoma gastric acid secretion may contribute to increased ileostomy output is serosanguinous, lacks any particulate matter, output, and proton pump inhibitors can play a role in and has been traditionally called bowel sweat. As the stoma decreasing the volume output in patients with extensive starts to function, dark green bilious output is noted, and small bowel resection.67 This effect is mediated by the lack as the diet is advanced, particulate matter appears in the of peptide YY, which acts as an intestinal brake, especially effluent. The exodus of the retained bowel contents from in patients with extensive bowel resection.68 the postoperative ileus can lead to initial voluminous Antimotility agents, fiber supplements, bile acid–binding output, which slowly tapers over time. Dehydration is of agents, and intravenous hydration with appropriate concern in the early postoperative period and studies electrolytes may be needed to counter the fluid losses have shown readmission rates of 17% to 20%,62,63 with and to decrease transit times (Table 84.2).69–71 one study showing renal failure in 8.9%62 of those with Peristomal skin irritation, especially in the immediate ileostomies. Patient education, visiting nurse care, stoma postoperative period, is the most common complaint.72 output logs, and early follow-up have shown to decrease Up to 70% of new ileostomates have unrecognized peri- the incidence of readmissions for dehydration.51 stomal skin irritation.73,74 Most of the peristomal complica- Patient and caregiver education to manage the stoma tions are due to ill-fitting appliances or a large aperture and troubleshoot the appliance should be undertaken as on the flange that allows the ileal effluent to contact the soon as possible in the postoperative period. However, skin. This irritated peristomal skin then weeps exudative most ostomates are only able to empty their appliances fluid, which in turn weakens the seal with ostomy appliance at the time of discharge and will require education and and causes more skin irritation. To compound this further, troubleshooting with assistance from visiting nurse care. leakage also causes more frequent appliance changes, Postoperative education is crucial to care for the stoma, which further disrupts the already damaged skin, setting troubleshoot problems with the stoma and the appliance, up a vicious cycle. Consultation with an enterostomal and improve quality of life with the stoma. Enlisting a therapist for appraisal of the type of appliance and aperture Wound, Ostomy and Continence Nurses (WOCN)-certified on the flange is necessary. nurse to assist in the perioperative care of the patient will Care should be taken to fit the stoma flange aperture decrease ostomy-related distress and improve quality of to the mucocutaneous junction. The peristomal skin life.51 Over the long term, periodic consultation with an should be protected with skin barrier wipes. If weeping enterostomal therapist and attendance at support groups skin is encountered, stoma powder or nystatin powder will improve the quality of life of the patients. COMPLICATIONS TABLE 84.2 Causes of High Output Complications from the construction of an ileostomy can be numerous, as was described by numerous authors in Extensive resection the surgical evolution of stoma formation. Complications 64 Discontinuation of steroids, narcotics, and antimotility agents in ileostomy patients can be noted in more than 70%. Crohn disease Stoma height (<2 cm), female gender, advanced BMI, Stricture young age, loop ileostomy, malignancy, and emergent Intestinal ischemia surgery have been associated with increase in postoperative Infectious enteritis 52 complications. They can be classified as early (within 30 Radiation enteritis days) or late. Most early complications are due to technical Bacterial overgrowth issues with the construction of the ileostomy that can Food intolerance result in peristomal skin irritation, ischemia, retraction, Dietary indiscretion or mucocutaneous separation. Unfortunately, significant Anxiety 1000 SECTION II Stomach and Small Intestine should be used. If a retracted or flat stoma is noted, a on top. The separation heals by secondary intention and convex pouching system may be indicated. Peristomal will eventually lead to stenosis. Stoma retraction has been contour abnormalities should be caulked with stoma paste previously defined as a stoma that is 0.5 cm or more below to prevent any leakage underneath the flange. If peristomal the skin surface, usually due to tension.77 Late retraction satellite lesions are noted under the area of the appliance is usually due to an ischemic insult. Retraction in the flange, fungal infections should be suspected. Topical early postoperative phase, even in a well-constructed ileos- nystatin powder is applied, excess powder is brushed off, tomy, can be noted in obese patients due to an inadequately and an adhesive barrier is applied followed by placement mobilized stoma with a large hanging pannus. of the stoma appliance. Obstruction can be mechanical or functional. Mechani- Ischemia of the ileostomy is suspected when the mucosa cal causes include obstruction due to a tight abdominal of the newly matured ileostomy appears dusky. Its incidence aperture, twisting around the mesenteric axis, or a mis- ranges from 1% to 21%.64,75–77 Causes include poor vascular placed stitch during maturation. Postoperative ileus is the supply or a small abdominal wall opening that can lead most common cause of early functional obstruction. In to congestion and compression of the vasculature supplying the presence of an ileus, the stoma output can be green the ileostomy. Loop ileostomies, with their preserved or yellow, watery fluid with no odor or gas. The other arcades and collateral flow across an intact and undivided symptoms of ileus may also be present. Distinguishing mesentery, are less prone to arterial insufficiency. Palpation between the two etiologies of obstruction will need an of the arterial flow in the mesentery, bleeding from the ileoscopy or a retrograde contrast study via the stoma. edge of small bowel, and mucosal evaluation are paramount Although mechanical causes will need operative interven- to prevent stomal ischemia. Frequently the distal edge of tion, ileus can be managed expectantly and should the stoma, which is the segment most susceptible to eventually resolve. ischemia, will show mucosal changes and, with time, can Peristomal abscess, which presents due to contamination even show demarcation where the vascular supply is at the time of the ostomy formation or due to a fistula, tenuous. Usually the mesentery can be trimmed to the presents with surrounding erythema, warmth, and increas- bowel edge for 2 to 5 cm without any decreased perfusion ing tenderness in the vicinity of the peristomal skin. of the mucosa.78 Trimming the bowel to the area of the Management involves drainage of the collection at a site demarcation can minimize the need for a future stoma that will not interfere with the pouching or at the muco- revision. If an adequately vascularized segment of bowel cutaneous junction. Common causes of a fistula include is exteriorized, and the stoma becomes ischemic, venous Crohn disease, unrecognized suprafascial enterotomy engorgement should be suspected. The opening in the during stoma formation, or accidental incorporation of wall may need to be enlarged, and, if this is not feasible, the dermis when placing the tripartite sutures during the the mesenteric fat may need debulking to allow venous eversion of the ileostomy. Rarely, an intraabdominal process dilation. can present as a fistula or peristomal abscess, and these The extent of ischemia can be variable, and scoring will need operative management. Late peristomal abscess the mucosa with a needle to assess for perfusion facilitates should raise the suspicion of underlying Crohn disease. assessment or preferably by shining light through a lubricated test tube placed in the os of the stoma. Stomal LATE COMPLICATIONS ischemia is suspected when changes are noted in the Late complications are more prone to occur after the mucosa: they can vary from pallor to petechiae to dusky patient has recovered from the initial surgery and has and almost gray necrosis. With mild ischemia, the mucosal become quite familiar with the everyday life of their ileos- surface can slough, but the deeper layers will be viable, tomy. Involving these patients with an enterostomal and this can be observed without the need for reinterven- therapist in a dedicated enterostomal therapy clinic with tion. If the ischemia extends below the fascia, exploration regularly scheduled visits can be very rewarding for the and revision of the ileostomy is needed to prevent progres- patient and ameliorate some of these patients’ anxiety sion to intraperitoneal perforation.79 If the ischemia is when complications occur and thereby improve the confined to the bowel above the fascia and a permanent outcome and quality of life. These late complications ileostomy was fashioned, revision should be entertained generally bother patients with permanent ileostomies depending on the patient’s clinical condition because because most temporary stomas are reversed within 3 to distal ischemia can lead to necrosis and a flat stoma that 6 months. Late complications include bleeding, stoma may be difficult to pouch. Oftentimes, as the edema prolapse and retraction, stenosis, small bowel obstruction, decreases and the abdominal wall opening stretches, mild and parastomal hernia. ischemia can resolve. In conservatively managed mucosal Lower gastrointestinal bleeding manifested by blood ischemia, a fibrotic ring of the mucocutaneous junction in the ileostomy bag is rarely a complication unless it is can develop with eventual stenosis that will need a result of preexisting inflammatory bowel disease or revision. bleeding from the foregut. Such entities as bleeding from Retraction of the stoma is another late consequence small bowel diverticulosis, arteriovenous malformations, of ischemia. This can occur with separation of the mucosa or small bowel tumors must always be considered. That from the skin surface. Most common etiologies include being said, major bleeding from the stoma exclusive of tension at the anastomosis or use of diseased bowel for the aforementioned causes remains uncommon. There the maturation of the stoma. Operative intervention is is a subset of patients with advanced liver disease and not needed, and it can be managed by covering the separa- portal hypertension who are prone to develop stomal tion with stoma adhesive powder and placing the appliance varices.80 This may specifically be seen in patients with Ileostomy CHAPTER 84 1001 ulcerative colitis in the setting of primary sclerosing low threshold to involve plastic surgery when recurrent cholangitis and in alcoholic cirrhosis. These stomal varices or complex parastomal hernias are present. One must be remain a challenge to manage. Local treatment using quite frank with patients and their families that recurrence mucocutaneous separation or ligation may be effective; rates approach 50%. An open or laparoscopic approach however, transjugular intrahepatic portosystemic shunting when feasible should be entertained. Mesh complications at times is often required.81–83 Not uncommonly encoun- occur in a variable rate. tered is bleeding secondary to excoriation from the Small bowel obstruction in the setting of an ileostomy mucocutaneous junction secondary to inadequate pouch- will occur just as in any patient who has had previous ing. This presents as bright red blood per os. This is easily abdominal or pelvic surgery. The etiologies of intestinal diagnosed and treated in conjunction with the enterostomal obstruction include adhesions, volvulus, internal hernia, therapist. recurrent Crohn disease, food bolus obstruction, and Ileostomy prolapse occurs in approximately 5% to 10% stomal stenosis. Patients will classically describe minimal of patients when reported but in reality is most likely to absent ileostomy output, distention, anorexia, and underestimated. This can be an annoying complication vomiting. Pain may be a presenting symptom and, when that may be difficult to resolve. Complications from the present, should alert the clinician to the possibility of prolapse, such as incarceration or strangulation, may threatened bowel and impending ischemia. The aperture occur in less than 10% of prolapsed stomas. Uncomplicated lends to advantages in diagnosis and therapeutics, such ileostomy prolapse can be managed conservatively with as ileoscopy and retrograde contrast enema. It is often manual reduction or the use of osmotic agent facilitated advantageous to involve the enterostomal therapist in by table sugar or even honey.84 In the setting of complicated treatment because food impaction will respond to enemas prolapse with ischemia or incarceration that is unable to and irrigations and dietary modifications, especially if be reduced, the ileostomy requires surgery. This involves recurrent. Intestinal obstruction in the setting of an ileos- full-thickness resection of the prolapsed segment. This is tomy is managed similar to other bowel obstructions. accompanied by construction of the stoma at the original Initial correction of dehydration and electrolyte abnormali- site.65 ties is paramount, followed by a detailed physical examina- Ileostomy stenosis is often due to a technical complication and diagnostic imaging, which currently is often a tion that has occurred early on with subsequent ischemia double-contrast computed tomography scan. In the absence or mucocutaneous separation.85 This results in scarring of writhing pain and/or peritonitis, nonoperative manage- and may pose difficulty in both evacuation and pouching ment is instituted, which may involve nasogastric decom- and narrowing of the stoma sufficient to interfere with pression. After eliminating a bolus obstruction, failure to normal bowel function. Because the effluent from the resolve the obstruction within a short period of time may ileostomy is liquid, intestinal obstruction is uncommon, require surgery. A minimally invasive approach, if possible, unless the stenosis involves a segment of the ileum instead is preferred. of stenosis only at the skin level. The patient should be Other less common complications may also occur. evaluated for other causes of stenosis, such as primary or Dermatitis can result in severely denuded skin due to recurrent Crohn disease or malignancy. Dilation, either the nature of the ileostomy effluent. With chronic irrita- digital or endoscopic, may be entertained; however, care tion and wetness, acanthotic changes develop in the must be taken to avoid perforation. Simple revision is peristome skin. Allergy to pouching products should required in this setting, unless it extends to the fascial or always be suspected and may require a change in the subfascial level where a segmental bowel resection may brand and type of appliance, along with topical steroids. be required. At times, enlargement of the skin opening Treatment, in conjunction with an enterostomal therapist, is required. A local revision involving a Z-plasty can also involves correction of causative factors, skin barriers, and be effective.86 antifungals. Parastomal herniation of an ileostomy is an extremely Peristomal pyoderma gangrenosum (characterized by challenging problem for the patient and physician.87 Often painful ulcers with violaceous undermining borders and your conduct at the initial operation when the stoma is thin bridges of epidermis bridging the ulcer) can be seen created is your best opportunity to make all efforts to at the stoma site in patients with inflammatory bowel prevent this complication. Regardless, patient morbidity, disease. It is often associated with female gender, obesity, such as obesity, diabetes, liver and pulmonary disease, and inflammatory bowel disease.89,90 At times difficult to chronic steroid usage, malnutrition, advanced cancer, diagnose because of inadvertent suspicion of other entities and age, are some of the factors that predispose patients such as contact dermatitis, extension of Crohn disease, to this. Not all parastomal hernias require surgical repair. or stitch abscess, these lesions are best managed by systemic, Asymptomatic patients need assurance, but at the same intralesional or topical antiinflammatory agents, including time, instruction on signs and symptoms of incarceration steroids91 and tacrolimus.92,93 Pyoderma parallels inflam- should be provided. Once again, involving the enterostomal matory bowel disease activity, and use of immunomodula- therapist in their care is paramount. Abdominal binders tors and biologics have been associated with resolution. and stoma belts may be worn to aid in promoting hernia Ultimately, stoma repositioning may be needed for manag- reduction and appliance fitting. Surgical repair will be ing refractory pyoderma, but relocation cannot guarantee required in a small group of patients.88 Choice of surgical against recurrence at the new stoma site. procedure depends on many factors. Procedures include Adenocarcinoma arising in an ileostomy has been repair by direct fascial reapproximation, local repair with described.94–99 Etiology can be chronic irritation or associa- prosthetic mesh, or stoma relocation. There should be a tion with inflammatory bowel disease. Unfortunately, it 1002 SECTION II Stomach and Small Intestine is often diagnosed late. Treatment is similar to other 4. Walsh BA, Grunert BK, Telford GL, Otterson MF. Multidisciplinary instances of adenocarcinoma of the small intestine and management of altered body image in the patient with an ostomy. J Wound Ostomy Continence Nurs. 1995;22(5):227-236. involves resection and preferably resiting of the stoma. 5. Nugent KP, Daniels P, Stewart B, Patankar R, Johnson CD. Quality of life in stoma patients. Dis Colon Rectum. 1999;42(12):1569-1574. 6. Krouse RS, Grant M, Wendel CS, et al. A mixed-methods evaluation ILEOSTOMY CLOSURE of health-related quality of life for male veterans with and without intestinal stomas. Dis Colon Rectum. 2007;50(12):2054-2066. A loop ileostomy is generally closed 2 to 3 months after 7. Littre A. Diverses observations anatomiques. Histoire de l’Académie its creation, provided remission of distal pathology or R Sci Paris. 1710. adequate healing of a distal anastomosis is established. 8. Maydl K. Zur technik der kolotomie. Zentralbl Chir. 1888. Studies have suggested the possibility of closure within 2 9. Brown JY. The value of complete physiological rest of the large weeks of the creation. The initial study showed that two- bowel in the treatment of certain ulcerative and obstructive lesions of this organ. Surg Gynecol Obstet. 1913;16:610-613. thirds of patients could have their ileostomies closed 10. Arn ER. Chronic ulcerative colitis: surgical treatment of refractory during the same admission as their index surgery without cases. Ohio State Med J. 1931;27:121-127. doi:10.1046/j.1440-1622. any increase in complications.100 Since then, other studies 2000.01773.x/abstract. have confirmed the low morbidity of an early closure.101–106 11. Bargen JA, Lindahl WW, Ashburn FS, Pemberton JD. Ileostomy A multicenter randomized controlled trial showed the for chronic ulcerative colitis (end results and complications in 185 107 cases). Ann Intern Med. 1943;18:43-56. safety of closure within 2 weeks as opposed to 12 weeks. 12. Corbett RS. A review of the surgical treatment of chronic ulcerative In the setting of chemotherapy, closure can be under- colitis: president’s address. Proc R Soc Med. 1945;38:277-290. taken a month after completion of therapy. Ileostomy 13. Lahey FH. Indications for surgical intervention in ulcerative colitis. closure is generally not advisable prior to or during Ann Surg. 1951;133(5):726-742. 14. Brooke BN. The surgery of ulcerative colitis. Ann R Coll Surg Eng. chemotherapy to mitigate any delay in therapy should a 108 1951;8(6):440-456. complication arises as a result of the stoma closure. 15. Brooke BN. The management of an ileostomy, including its complica- Prior to the closure of a loop ileostomy, a water-soluble tions. Lancet. 1952;2(6725):102-104. contrast enema study is used to assess the bowel distal to 16. Rankin FW. Total colectomy: its indication and technic. Ann Surg. the ileostomy for any structural abnormalities or anasto- 1931;94(4):677-704. 109 17. 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