Do I Have To Live With Stoma Forever ?

Do I Have To Live With Stoma Forever ?

Live With Stoma Forever ? – In the first blog about stoma before, I mentioned about stoma-forming surgery that could be permanent or temporary.

The formation of an intestinal stoma (usually ileostomy or colostomy) is an integral part of the surgical management of several pathologies of the gastrointestinal tract, in both emergency and elective patients.  A stoma may be created in a temporary or permanent role to reduce morbidity and mortality associated with several conditions of the gastrointestinal including perforation, inflammatory bowel disease, bowel obstruction and elective cancer operations.

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A. History of Intestinal Stomas

In the pre-anaesthetic era the formation of intestinal stomas was uncommon. The names of the first few patients whose treatment comprised the forced creation of an intestinal fistula are known. The first among them was George Deppу, who had sustained an abdominal wound during the Battle of  Ramilles on 23 May 1706, after which he had a colostomy formed, which functioned for the remaining 14 years of his life. In 1737, the Queen of Great Britain, Caroline of Brandenburg-Ansbach, the wife of George II, had a spontaneous intestinal stoma (“Royal stoma”) after rupturing the membrane of strangulated umbilical hernia. Because the strangulation led not only to obstruction, but bowel gangrene as well, she died three days later. In 1750, William Cheselden operated on 73-year old Margaret White for strangulated umbilical hernia related to incoercible vomiting  and cut out 55 cm of the intestine, which was fixed at the level of the hernial orifice. Despite the horrible hygiene conditions, she survived and for a long time cared for the peristomal skin with a towel and a rag (Wu 2012, Cromar 1968 Kingsnorth 2006, Cheselden 1750). live with stoma forever

B. Types of Intestinal Stoma

Intestinal stomas can be temporary, diverting stomas designed to rest distal bowel, protect distal anastomoses (e.g. following low anterior resection) or to relieve obstruction.

Permanent stomas are indicated when primary anastomosis is not safe or possible due to the disease process (e.g. gross faecal contamination, poor blood supply or distal bowel resection precluding anastomosis as seen in abdominoperineal resection [APER] when the anus is removed).

Figure I. Different Types of Stoma

Indications for Intestinal Stomas

Table I
Table II

1. Colostomy. How it’s performed

The main surgical techniques are:

  • Open surgery (laparotomy), where the surgeon makes a long incision in the abdomen to access the colon
  • Laparoscopic (or keyhole) surgery, where the surgeon makes several smaller incisions and uses a miniature video camera and special surgical instruments to access the colon

Where possible, keyhole surgery is the preferred choice. This is because research has shown that patients recover quicker and have reduced risk of complications. However, in emergency situations, such as a bowel obstruction, the staff and equipment needed for a keyhole operation may not be available, so an open operation needs to be performed. live with stoma forever

There are 2 main ways a colostomy can be formed, a loop colostomy and an end colostomy.

1.1 Loop Colostomy

To form a loop colostomy, a loop of colon is pulled out through an incision in your abdomen. This section of colon is opened up and stitched to the skin to form an opening called a stoma. The stoma will have 2 openings, but they will be close together and you may not be able to see both.

One of the openings is connected to the functioning part of your bowel. This is where waste products leave your body after the operation. The other opening is connected to the “inactive” part of your bowel, leading to your rectum. This opening only produces small amounts of mucus.

The position of the stoma depends on which section of the colon is diverted, although it’s usually on the left-hand side of your abdomen, below your belt line. If the operation is planned in advance, you’ll meet a specialist and stoma nurse before the operation to discuss possible locations for the stoma. This may not be possible if the operation is performed as an emergency.

The stoma will appear large at first, as the effects of surgery cause it to swell. It usually shrinks during the weeks after surgery, reaching its final size after about 8 weeks. The stoma will be red and moist. It has no nerve endings, so it isn’t painful to touch. It may bleed when touched, but this is entirely normal and no cause for concern. In some cases, a support device (called a rod or bridge) may be used to hold the loop of colon in place while it heals. This will usually be removed after a few days.

A loop colostomy is usually formed temporarily to treat conditions such as diverticulitisCrohn’s disease and bowel cancer.

1.2 End Colostomy

To form an end colostomy, one end of the colon is pulled out through an incision in your abdomen and stitched to the skin to create a stoma.

Like when a loop colostomy is formed, the position of the stoma depends on which section of the colon is diverted. However, it’s usually on the left-hand side of your abdomen, below your belt line.The stoma will have one opening, through which waste products pass. The other end of the colon, which goes down to your rectum, is sealed and left inside your tummy.

End colostomies are often permanent, although temporary end colostomies are sometimes formed as an emergency to treat bowel obstructions, colon injuries or bowel cancer.

Figure 2: (a)End Colostomy and (b)Loop Colostomy

2. Ileostomy, How it’s performed  

2.1 End Ileostomy

An end ileostomy normally involves removing the whole of the colon (large intestine) through a cut in your abdomen. The end of the small intestine (ileum) is brought out of the tummy through a smaller cut and stitched on to the skin to form a stoma. Over time, the stitches dissolve and the stoma heals on to the skin.

After the operation, waste material comes out of the opening in the tummy into a bag that goes over the stoma. This type of ileostomy is often, but not always, permanent.

2.2 Loop Ileostomy

To form a loop ileostomy, a loop of small intestine is pulled out through a cut in your tummy. This section of intestine is then opened up and stitched to the skin to form a stoma. The colon and rectum are left in place. In these cases, the stoma will have 2 openings, although they’ll be close together and you may not be able to see both.

One of the openings is connected to the functioning part of your bowel. This is where waste products leave your body after the operation.

The other opening is connected to the “inactive” part of your bowel that leads down to your rectum.

The loop ileostomy is usually temporary and may be reversed during a second operation at a later date.

Figure 3 completed J-pouch procedure using two loops from the small intestine

2.3  Ileo-anal Pouch

In some cases, it may be possible to have a permanent internal ileo-anal pouch, also known as a J pouch, formed instead of an ileostomy. An ileo-anal pouch is created from the ileum and joined to the anus, so waste material passes out of your body in the normal way.

The pouch stores the waste material until you have a poo. The area around the pouch usually needs to heal before it’s used, so a temporary loop ileostomy may be created above the pouch.

A second, smaller, operation is usually carried out a few months later to close the loop ileostomy.

C. So, I have a chance to not live with my STOMA forever, right?

Due to the explanation above, we can conclude that not all stoma-formed surgery will end up with having stoma forever. There is a chance for stoma patient to have stoma closure/reversal.

The decision to have a reversal operation depends on how much and which part of the bowel has been removed. If very little of the rectum remains, then it is likely that bowel control will be impaired. Your healthcare professional will advise whether stoma reversal is possible, it is estimated that around 35% of ostomates have a temporary stoma.

The main considerations for the stoma reversal are: Journal Reversal of Stoma

  1. The doctors must be happy that you are fit enough for another operation.  n
  2. The bowel that your temporary stoma was created to protect has healed or improved since the first operation.
  3. The anal sphincters which control the flow from your bowels are working, so that loss of control of your bowels (faecal incontinence) will not develop afterwards.

Depending on what operation you have had, the surgeon may need to perform a rectal examination, and possibly arrange some further test before making this decision.

D. What does the surgery involve?

The closure of your stoma is ‘technically’ not as demanding as your previous surgery when the stoma was created. This operation involves making a cut around the stoma, to free it from the tummy wall and stitching the bowel back together to restore continuity, the stitching may be referred to as an anastomosis. The joined bowel is dropped back inside the tummy. This is followed by the stitching of the tummy wall muscles and skin. It is still considered a significant operation. Very occasionally it is necessary to reopen the original laparotomy wound scar to be able to reverse the stoma.

  • Colostomy and Ileostomy Reversal

Basically, both colostomy or Ileostomy have the same procedure during closure/reversal surgery.

If your colostomy/ileostomy is intended to be temporary, further surgery will be needed to reverse it at a later date.

The reversal operation will only be carried out when you’re in good health and fully recovered from the effects of the colostomy formation operation. This will usually be at least 12 weeks or more after the initial surgery.

However, the reversal may need to be delayed for longer if you require further treatment such as chemotherapy, or haven’t recovered from the original operation when the colostomy was formed. There’s no time limit for having the stoma reversed and some people may live with their colostomy for several years before it’s reversed.

In some cases, reversing a colostomy may not be recommended. For example, if the muscles that control your anus (sphincter muscles) were damaged after surgery, reversing the colostomy may cause bowel incontinence.

Reversing a loop colostomy is a relatively straightforward process. An incision is made around the stoma to allow the surgeon to gain access to the inside of your abdomen. The upper section of your colon is reattached to the remaining section of your colon.

Reversing ileostomy A cut is made around the stoma (like colostomy reversal surgery) and the section of small intestine is pulled out of the tummy. The area that had been divided to form the stoma is then stitched back together and placed back inside the abdomen. But the surgeon will need to make a larger incision to locate and reattach the small and large intestines.

It’s also possible to reverse an end colostomy. However, the surgeon needs to make a larger incision to locate and reattach the 2 sections of the colon. Therefore, it takes longer to recover from this type of surgery and there’s a greater risk of complications.

E. What to expect after surgery

You may have a drip in your arm to give you fluids until you are drinking.  Once you are awake you can eat and drink normally, you may find small, light, low fiber meals are better tolerated. Most people are moderately sore at the reversal site afterwards, but this can be managed with pain killers. You may feel distended following the procedure, some patients describe this as a  feeling of being “bruised and bloated” but as the swelling decreases this discomfort will ease.

Possible side effects after stoma closure:

  • Diarrhea – After the reversal it is common to experience liquid bowel motions for the first few days up to a few weeks before it settles down. In a small percentage of patients it can take up to 6 months before the bowel motions become more firm. It is fairly common to pass looser and more frequent stools than you may have been used to previously. Adjusting the food you eat and taking bowel slowing medication can help with this.
  • Frequency and urgency – It is normal to have erratic bowel movements for several weeks after this operation. You may find that you need to go to the toilet more urgently and also more often. This can be more of a problem for those who have had a low join or anastomosis in the bowel and for those who have had pelvic radiotherapy and/ or were already suffering from a weak sphincter muscle. The patients who have weak pelvic floor and anal sphincter muscles may leak gas, liquid or solid stools.  Performing pelvic floor exercises may help to regain continence but need to be practiced at least five times a day and over a few months to be of benefit. When done correctly, these exercises can build up and strengthen the muscles to help you to hold both gas and stool in the back passage. Good hygiene and a light barrier cream may be useful to prevent the skin becoming sore if you are experiencing loose and frequent stools.
Figure 4 Representative abdominal images. (a)before ileostomy reversal, (b)before and (c)after application of NPWT(Negative-Pressure Wound Therapy), and (d)3 days, (e)30 days, and (f)90 days after ileostomy reversal. (Journal: 10.1007 Evaluation of negative‑pressure wound therapy for surgical site infections after ileostomy closure in colorectal cancer patients: a prospective multicenter study)

REFERENCES :

  1. https://www.surgeryjournal.co.uk/article/S0263-9319(19)30226-1/fulltext
  2. https://www.researchgate.net/publication/334832709_History_of_surgery_the_evolution_of_views_on_the_formation_of_intestinal_stoma . History of Medicine 6(2): 111-117
  3. https://www.nhs.uk/conditions/ileostomy/what-happens/. Ileostomy how it’s performed. January 20th  2020
  4. https://www.colostomyuk.org/9-myths-stoma/ . Ostomy Day: 9 myths about having stoma. January 20th 2020

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