Generality
The ileostomy is a delicate and complex surgical procedure, which consists in the deviation of the ileum (or, more rarely, of a section of intestine that precedes it) towards an opening made specifically on the abdomen.
To make the ileostomy necessary some diseases of the large intestine can be, such as colorectal cancer, Crohn's disease, ulcerative colitis and so on.
There are three different ways to perform an ileostomy; the choice of a specific surgical approach is up to the doctor and depends on the severity of the intestinal pathology, which makes the operation indispensable.
Short reference to intestinal anatomy
The intestine is the portion of the digestive system between the pylorus and the anal orifice. From the anatomical point of view, the doctors divide it into two main sectors: the small intestine, also called small intestine, and the large intestine, also called large intestine .
The large intestine is the terminal tract of the intestine and of the digestive system. It starts from the ileocecal valve and ends at the anus; it develops in 6 sections (cecum, ascending colon, transverse colon, descending colon, sigma and rectum), is about 2 meters long and has an average diameter of about 7 centimeters (hence the name of large intestine).
What is the ileostomy
The ileostomy is a delicate surgical procedure that involves the deviation of the small intestine - generally of the ileum - towards an opening made on the abdomen.
This opening, defined with the name of stoma, serves for the early exit of the stool, that is, without their normal transit through the large intestine and the anus.
For obvious reasons, surgeons make the stoma in such a way that it can be connected to a special waterproof bag, capable of receiving fecal material.
In other words, the ileostomy is the operation with which the surgeons shorten the normal intestinal path and create an orifice on the abdomen, which effectively replaces the functions of the anus.
Statistical data
The ileostomy is a fairly common intervention. For example, according to an Anglo-Saxon survey, in England, the number of ileostomies practiced annually is around 9, 900.
IS IT A TEMPORARY OR PERMANENT REMEDY?
The ileostomy can be a modification to the normal transit of the stools either temporary ( reversible ileostomy) or permanent ( definitive ileostomy ).
Bags for ileostomy
If it is a temporary solution, a further surgical operation is scheduled some time later, during which the operating doctor puts the ileum into communication with the large intestine.
When you run
Doctors practice an ileostomy when the large intestine - particularly the section known as the colon - is damaged, inflamed or does not function properly.
To cause this series of alterations are some particular intestinal pathologies / conditions, including:
- Colorectal cancer (or colorectal cancer) . Colorectal cancer is the most common malignant neoplasm of the gastrointestinal tract and represents a major cause of death from cancer, both in men and women.
From the therapeutic point of view, the main treatment is the colectomy operation, during which the operating surgeon removes the diseased section of the intestine.
The choice to resort also to the ileostomy depends on the size and position of the removed section. The execution of the opening can be temporary or permanent, depending on whether the conditions exist for a recovery of the functionality of the remaining colorectal tract.
- Crohn's disease . It is an autoimmune disease, belonging to the category of so-called inflammatory bowel diseases. The symptoms that characterize it are diarrhea, abdominal pain and a sense of recurrent fatigue.
The ileostomy is not the first choice treatment for Crohn's disease. However, it can become so in all those cases in which, according to doctors, the temporary isolation from the faeces of the inflamed intestine is of benefit to the latter.
- Ulcerative colitis . It is another chronic intestinal inflammatory disease, which specifically affects the large intestine (primarily the rectum and then the colon). Its typical symptoms are diarrhea mixed with blood, abdominal pain and mucous losses.
The intended treatment is usually pharmacological. In fact, doctors resort to ileostomy only when the medicines do not produce the desired results.
The ileostomy can be temporary or permanent, depending on the severity of the inflammation and the more or less concrete possibilities of a reduction in the inflammatory state.
- Intestinal occlusion . Doctors talk about bowel obstruction when the intestine is blocked and does not allow what is flowing inside to progress regularly. Intestinal obstruction is a medical emergency, when, where the blockage occurs, bleeding, infections and intestinal perforation may occur.
The treatment generally involves a colectomy, followed by a colostomy (ie the deviation of the colon towards an opening made on the abdomen) or by an ileostomy. The choice falls on ileostomy when intestinal obstruction affects the entire colon.
The solution may have a temporary or permanent duration, depending on the gravity of the situation.
- Familial adenomatous polyposis (FAP) . It is a rare intestinal pathology, characterized by the formation of particular benign precancerous lesions, within the colon and rectum. Such benign precancerous lesions are called polyps and have a high tendency to become malignant. Consider, in fact, that 99% of patients with FAP sooner or later develop a colorectal cancer over the course of their lives.
Generally, the treatment consists of a preventive colectomy operation, followed by a permanent ileostomy.
- Intestinal injury from abdominal trauma . The traumas to the abdomen that can provoke an intestinal injury are: a stabbing, a gunshot wound, an accident in the workplace, a car accident, etc.
Wounds resulting from such traumatic events may require a partial colectomy, followed by a temporary ileostomy or, in particularly serious cases, permanent.
Preparation
The ileostomy is a very complex operation, therefore it requires a particular preparation.
First of all, the medical team - usually made up of a surgeon, qualified nurses and an anesthesiologist - must determine whether the candidate patient is able to perform a surgical operation or not. Therefore, it prescribes a series of clinical tests - including blood tests, urine tests, electrocardiograms, blood pressure measurements, clinical history analyzes, etc. - to be carried out several days before the supposed date of intervention.
If the outcome of these assessments is positive (therefore the conditions necessary for a surgical procedure to be carried out), the surgeon and assistants move on to the second phase of preparation, the one in which they illustrate the patient's pre-operative recommendations, the methods of intervention, possible risks, post-operative indications and canonical recovery times.
PRE-OPERATIVE RECOMMENDATIONS
The main pre-operative recommendations are:
- A few days before the ileostomy, suspend any treatment based on antiplatelet agents (aspirin), anticoagulants (warfarin) and anti-inflammatory drugs (NSAIDs), because these drugs, by reducing the coagulation capacity of the blood, predispose to serious bleeding.
- On the day of the procedure, appear at full fast from at least the previous evening and with the intestine empty and possibly "clean".
Such a prolonged fast is explained by the fact that ileostomy requires general anesthesia.
With regard to the emptying and "cleaning" of the intestine, for the first, the doctors advise taking a laxative solution several hours before the operation; for the second, they prescribe antibiotics.
- Ask a relative or a close friend in time to keep themselves free on the day of the intervention to offer their assistance, especially when they leave.
Procedure
The first phase of the procedure consists in the implementation of general anesthesia, the second in the realization of intestinal deviation and opening on the abdomen ( abdominal stoma ).
There are three different types of ileostomy: the terminal leostomy (in English, end ileostomy ), the ileostomy with loop (in English, loop ileostomy ) and the ileo-anal anastomosis (in English, ileo-anal pouch ).
To distinguish one type of ileostomy from another is the mode of realization of the ileostomy itself.
The choice relative to the type of ileostomy to be adopted depends, fundamentally, on the reasons that make the intervention necessary.
IMPLICATIONS OF GENERAL ANESTHESIA
General anesthesia means that the patient sleeps and is completely unconscious during the entire procedure.
To administer anesthetic drugs by venous or inhalation (NB: the administration of these drugs lasts until the conclusion of the operation), is a doctor specialized in anesthesia practices (ie an anesthesiologist).
Generally, the anesthetic works within 10-15 minutes. Only after falling asleep, the treating doctor has the go-ahead to start the treatment.
Shortly before anesthesia and throughout its duration, the patient remains connected to a series of instruments that measure his heart rate, his blood pressure, his body temperature and his oxygen level in the blood. In this way, there is a continuous monitoring of its vital parameters and an immediate and real-time feedback of any minimum variation.
TERMINAL ILEOSTOMY: WHAT DOES IT WORK?
The surgeon begins the terminal ileostomy by making a first incision on the abdomen, through which he separates the ileum from the remaining tract of intestine (ie the large intestine).
Then, it performs a second incision, smaller than the previous one, on the right abdominal region, at the point of union between the ileum and the blind. This small incision serves to make the abdominal stoma; in fact, using various surgical instruments, it draws the small intestine tract, separated shortly before, towards the future stoma.
At the level of the stoma, it shapes the edges of the intestinal tract with the contours of the opening on the abdomen and applies the sutures that serve to block the deviation.
The large intestine stump, isolated because it is not sick, can undergo two different fates:
- If there is no possibility of its recovery (for example in case of cancer), the surgeon removes it (colectomy).
- If an improvement in his condition is possible, the surgeon leaves him in place for a possible future restoration of a normal gastro-intestinal canal.
Terminal ileostomy usually has a permanent purpose and is particularly appropriate in case of intestinal obstruction, colorectal cancer, severe traumatic injury and familial adenomatous polyposis.
ILEOSTOMY TO ANSA: WHAT IS IT?
The surgeon starts the ileostomy-like interventions with an incision made on the right side of the abdomen, where the small intestine generally ends.
Then, through this incision, it "takes" a loop of the ileum, drags it to the surface (that is, outside the abdominal cavity), joins it with stitches at the edges of the incision itself and, finally, cuts it into its highest part so as to form two distinct openings. An opening represents the terminal part of the overlying gastrointestinal tract and the point from which the patient will excrete the feces (proximal canal); the other opening is the initial part of the large intestine stump to be isolated, ending with the anus and from which only mucus (distal canal) emerges.
Practiced mainly in the presence of Crohn's disease and ulcerative colitis, the loop ileostomy is generally a temporary solution. Not surprisingly, after all, surgeons sever the loop of the ileum, so that it is easier to restore normal intestinal anatomy.
ILEO-ANAL ANASTOMOSIS ( ILEO-ANAL POUCH ): WHAT IS IT?
The ileo-anal anastomosis consists of the intervention of union of the ileum with the anus. At the assemblage point, the surgeon folds the terminal part of the ileum in two (forming a sort of elbow), connects the two adjacent areas (so as to double the internal space) and makes them a sort of pocket ( pouch ).
After its creation, the pocket needs to remain isolated for several weeks, so that the small surgical wounds and the various sutures, present on it, heal and take care of everything.
All this implies that, at the same time as the ileo-anal anastomosis, the surgeon also performs a temporary loop ileostomy, to allow the patient to expel the faeces while the healing process takes place.
Surgical meaning of anastomosis
The surgical anastomosis is the bite (ie the union), after resection, of two parts of the same viscera or of two different viscera.
After the procedure
At the end of the ileostomy, there is a hospitalization that can last from a minimum of 3 to a maximum of 10 days. The duration of hospitalization generally depends on the severity of the intestinal problem that made ileostomy necessary.
During admission, the medical staff scrupulously provides the patient:
- Periodically monitors its vital parameters (blood pressure, cardiac activity, etc.), especially in the initial phase.
- It supplies all the nutrients it needs, intravenously.
- It subjects him to catheterization (for the elimination of feces), at least for the first few days.
- It illustrates the various stages of recovery and the most important post-operative recommendations.
IT STOMES AFTER THE OPERATION AND IN THE FOLLOWING WEEKS
Immediately after the operation, the region occupied by the stoma has clear signs of inflammation and is swollen .
However, as the weeks go by, both the inflammation and the swelling gradually diminish, until they finally disappear. In general, the situation normalizes after about 8 weeks.
Finally, it is important to remember that until the surgical wounds have completely healed, an unpleasant odor may come from the stoma.
MANAGEMENT OF THE BAG AND HYGIENE OF THE STOMA
During hospitalization, a member of the medical staff (usually a nurse) teaches the patient how to take care of the bag for stool collection (when to change it, when to understand that it is full, etc.) and how to keep the stoma and the surrounding area clean .
Scrupulous management of the bag and careful cleaning of the stoma reduce the risk of infection.
AFTER THE RESIGNATION
After discharge, the patient should lead a quiet life, without excessive effort, for at least 2-3 months . Neglecting this indication can strongly affect the healing process and the success of the operation.
Flatulence and a strange sensation of pain in the stomach very often characterize the first few weeks following discharge.
Risks and Complications
As with any surgical procedure, even during the execution of an ileostomy there is a risk of:
- Internal bleeding
- Infections
- Formation of blood clots in the veins ( deep vein thrombosis )
- Stroke or heart attack during the operation
- Allergic reaction to anesthetic drugs or sedatives used during surgery
Furthermore, once the operation is completed, due to the extreme delicacy that characterizes the operation, various complications can occur, including:
- Stoma occlusion . The stoma may become blocked due to a build-up of food inside the intestine. In the presence of an occlusion, the typical symptoms are: nausea, abdominal cramps and reduced stool production.
If these disorders last for several hours, it is advisable to contact your doctor or go to the nearest hospital.
- Dehydration . The large intestine is the intestinal tract that absorbs most of the water contained in the stool. In those who are subjected to ileostomy, the passage of feces through the large intestine no longer occurs and this favors the loss of useful liquids and dehydration. To avoid such a drawback, doctors recommend drinking plenty of water.
- Loss of mucus from the rectum (when it is not removed) . If rectum and sigma are still present, it is likely that, despite being isolated, they still produce mucus and disperse it through the anus. It is a very annoying inconvenience, because it requires the patient to go to the toilet from time to time to clean the various leaks.
- Vitamin B12 deficiency . Often, after an ileostomy operation, the section of intestine that absorbs most of the vitamin B12 is isolated or in any case no longer performs this function. This can lead to a deficiency of this organic substance.
Serious deficiencies of vitamin B12 (or cobalamin) can lead to nervous problems such as memory impairment or spinal cord damage.
- Various stoma problems . The main ones are: stenosis (or narrowing) stomal, stomal prolapse (or stoma protrusion), stoma irritation / inflammation, parastomal hernia and stomal retraction.
- Straight phantom . It is a particular condition that causes, in the ileostomy patient, the need to go to the toilet, as before the operation. However, it is a non-real necessity, because the large intestine and, in particular, the rectum are excluded from the passage of feces.
- Pouchite . It is the inflammation of the pocket, created during the intervention of an ileum-anal anastomosis.
- Lethargy and unexplainable tiredness
- breathlessness
- Sense of recurrent fainting
- Headache
- Palpitations
- Tinnitus
- Loss of appetite
Results and daily life
Although it imposes some limitations and some rigid behaviors, the ileostomy allows however to lead an active and satisfying social life.
Patients must pay maximum attention to the diet - especially in the first phase of post-operative recovery - and to the management of the stool collection bag.
As far as physical activity, physical exercise and sexual intercourse are concerned, it is good to follow the instructions given by the surgeon who performed the ileostomy to the letter. Moreover, each procedure represents a case in itself.
