What is an ileostomy?
Cancers treated: Colorectal and small bowel cancer; metastatic pelvic cancer, including vaginal, cervical, ovarian, and prostate cancers
Why performed: The ileum may sometimes become diseased and may cause symptoms of bowel obstruction, bleeding, or nutrient malabsorption. Potentially life-threatening or premalignant conditions such as severe inflammatory bowel disease involving the ileum and colon (Crohn's disease, ulcerative colitis) are also managed with the use of ileostomy. Because the ileum absorbs many essential nutrients relative to the rest of the small bowel, preservation of disease-free regions is paramount. An ileostomy is performed primarily in order to divert digested material for excretion in cases where the colon or rectum is diseased or otherwise unusable. It is also done in order to permit healing of the remaining, but usable, colon to be used later in reestablishing continuity between the small and large bowel. This is also done after two bowel ends are newly rejoined (anastomosis) to allow the bowel to rest and expedite healing. The ileostomy is located before the anastomosis to prevent digested material from stimulating the joined ends from unnecessary contractions.
Patient preparation: Surgical risk assessment is conducted through a general physical examination, medication review and revision, electrocardiography (EKG) and chest X ray, and pulmonary function tests as needed. Other considerations include ensuring that the patient is adequately nourished and hydrated beforehand. Bowel preparation by a gradual decrease in food and liquid intake and enemas is carried out at least twenty-four hours prior to the procedure.
The decision to undergo the procedure should be accompanied by active patient participation. The patient must be thoroughly briefed regarding the care of and implications of a permanent ileostomy in the event that reattachment to the distal bowel is not possible. If the procedure is agreeable to the patient, then the position of the stoma is discussed and marked on the patient’s abdomen prior to the procedure.
Steps of the procedure: After the patient is positioned and the surgical site is sterilized, a mid-abdominal incision is made and carried down to the abdominal cavity. The length of the small and large bowel is examined for viable and nonviable regions. Any diseased sections are excised, with the undiseased ends reattached. Any additional abdominal cavity procedure such as lymph node dissection and resection is carried out.
The construction of the ileostomy will depend on the severity of disease (the presence of disease-free colon for reattachment in a separate procedure). A permanent end ileostomy is constructed by dividing the remaining ileum from the colon, preserving as much bowel as possible. Both ends are closed with staples or sutures. The thin membrane containing the bowel’s blood vessels (mesentery) at the proximal ileal end is cut to allow manipulation; the vessels directly supplying it are preserved. Another abdominal incision is made over the previously marked area, through which 6 centimeters of ileum is pulled. The stapled end is cut, and a spigot is fashioned by suturing the ileum onto the skin at three points. This prevents the fluid and electrolyte imbalance of ileostomy dysfunction caused by partial stoma obstruction.
A temporary loop ileostomy is constructed in a similar manner as an end ileostomy except that both ends of the ileum are used, with the distal end nonfunctional in excretion. In addition, interruption of the mesentery is minimal because of the need for both ends to be supplied adequately with blood.
After the procedure: The patient is allowed to recover consciousness in a postanesthesia care unit before going to the surgical ward. Recovery time can reach ten to twelve days, with resumption of normal activity by four to eight weeks. Maintenance of the ileostomy involves becoming familiar with frequent changing of the different parts of the ileostomy appliance, such as the skin barrier and the ileostomy bag. With the absence of the colon as a water-reabsorbing and storage apparatus for digested food, the patient must empty the collection bag frequently and be more aware of the amount and type of food and drink consumed, especially during exercise and hot weather.
Risks: The risks of bleeding, impaired healing, and infections are always present. Meticulous adherence to surgical technique prevents most of these complications. Long-term risks for the duration of the ileostomy include obstruction from food particles or bowel adhesions, fistulas, infection, and dehydration from increased ileostomy fluid output.
Results: An ileostomy is not directly curative for cancer, but it is a helpful procedure in restoring the patient’s continence and a semblance of normal bowel function at a later time through anastomosis of ileum to colon or rectum. While the position of an ileostomy allows for easy cleaning and draining of the ileostomy appliance and does not interfere greatly with daily routines and activities, one of the most important patient considerations to be made is that of self-image after ileostomy.
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