Definition
An ileostomy is a surgical procedure in which the small intestine is
attached to the abdominal wall in order to bypass
digestive waste then exits the body through an artificial opening called a
stoma (from the Greek word for "mouth").
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.
Other patients undergoing ileostomy will have only a temporary bypass of
examples are patients undergoing
or the creation of an
. An ileoanal anastomosis is a procedure in which the surgeon forms a
pouch out of tissue from the ileum and connects it directly to the anal
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
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.
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 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% 30% have pro 20–25%
require further surgery 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 hydrocor oral sulfasalazine or
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.
"Inflammatory Bowel Diseases: Ulcerative Colitis." In
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.
United Ostomy Association, Inc. 19772 MacArthur Blvd., Suite 200, Irvine,
CA . (800) 826-0826.
Hurst, Roger D. "Surgical Treatment of Ulcerative Colitis."
[cited May 1, 2003].
Stephanie Dionne Sherk
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Ileostomies are usually performed in a hospital
. 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?
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