What is a ileostomy, and what is a colostomy?

Indications and Procedures

Despite great advances in drugs and nonsurgical procedures, doctors can cure some disabling or life-threatening diseases of the
intestines only on the operating table. Common procedures of this type are the colostomy and ileostomy, both of which replace the
anus with a stoma on the abdominal wall.

Colostomy and ileostomy are medical terms compounding stoma (from the Greek word for “mouth”) and a prefix identifying the section of gut that ends in the newly created “mouth.” If a portion of the colon is retained and ends in a stoma, the operation constructing it is called a colostomy. If the entire colon is removed and the lower section of the small bowel, or ileum, ends in a stoma, the operation constructing it is called an ileostomy. Nonmedical support groups for patients commonly use the back-formation “ostomy” to refer to any operation that creates a stoma (including a urostomy, in which a stoma is created for the excretion of urine) and to such patients as “ostomates,” although neither term belongs to medical technical vocabulary.

Physicians determine that an ileostomy or a colostomy is necessary after inspecting the damaged intestinal segments by endoscopy, by imaging, or during surgery. In consultation with a surgeon, the patient agrees to undergo the procedure. The patient fasts before the surgery and receives laxatives and enemas (except in the case of obstructions or severe ulcerative colitis) to clean as much feces from the intestines as possible and thus reduce the chance of infection during surgery. The surgeon, often with the advice of an enterostomal therapist (ET), examines the patient’s abdomen carefully, checking where the skin naturally folds and stretches when the patient assumes various common body positions, and a spot for the stoma is selected that is convenient for the patient and free of stress from muscles and skin tension. That place is marked. An area to the right and below the navel is the usual location for an ileostomy. The left side is commonly chosen for a colostomy.

In ileostomy, the surgeon makes the opening incision, starting a few centimeters above the navel and continuing to the pelvic area. After the abdominal cavity is exposed, the tissues connecting the colon to surrounding structures are severed, starting at the cecum; the blood supply is cut and tied off; and clamps are placed over the
ileum and
rectum. Then the colon is cut free of the small intestine
and rectum and is removed. If the operation is a subtotal procedure, the rectum is sutured shut and left in place or the open end is pulled through the abdominal wall as a mucous stoma. (Such a second stoma is sometimes fashioned because the surgeon plans to connect the ileum and rectum in a later operation.) If the surgeon performs a proctocolectomy, the rectum is removed after the stoma is made and the anus is sutured shut.

The stoma is built by cutting a small round opening first in the skin and then in the abdominal wall and pulling the end of the ileum through the hole. The end sticks above the skin, is folded back over itself, and is sutured to the edges of the hole, leaving the stoma protruding two to three centimeters. This basic ileostomy is called a Brooke ileostomy, after the English surgeon Bryan Brooke.

Variations on this basic procedure are employed depending on the wishes and health of the patient. A Kock pouch, named after its inventor, Nils Kock of Sweden, can be fashioned just behind the stoma in the abdominal cavity to act as an artificial rectum, collecting liquid waste until the ostomate wishes to void it; because this arrangement gives the patient control over defecation, it is called a continent ileostomy. The surgeon uses about forty-five centimeters of ileum to form the pouch and adjusts the stoma so that it acts as a valve until a tube is inserted for drainage. In some cases, when the underlying condition necessitating removal of the bowel segment is ultimately determined to be cured, and if there is sufficient remaining bowel, the ostomy can be reversed by closing the stoma and then reconnecting the bowel either to the rectum or to the anus.

If the ileum and rectum are joined, the procedure is called an ileorectal anastomosis. The rectum resumes its old job as a feces reservoir, and the patient defecates normally through the anus. This arrangement is seldom employed for ulcerative colitis patients, however, since the disease usually persists in the rectum. If the ileum is sutured directly to the anus, the procedure is called an ileoanal anastomosis. Because there is no rectum to collect feces, the surgeon must construct one. The pouch is made from loops of ileum that are slit along their length and stitched together. If not enough ileum remains from which to make a pouch, the surgeon pulls the end through the rectum and ties it directly to the anus, a procedure called an endorectal ileal pull-through. The anastomosis procedures require two operations—one for the temporary stoma and construction of the pouch, one to connect the pouch and the rectum, or anus—to give the artificial rectum a chance to heal properly and so prevent leaking.

Colostomies feature somewhat more variety of stoma placement than ileostomies, but since removal of the rectum, sigmoid colon, or both are the most common reasons for the creation of the stoma, it is usually placed on the lower left of the abdomen, near the hipbone. If more of the colon is removed, the stoma may be higher up toward the rib cage. The operation begins much as for an ileostomy, except that only the portion of the colon from the damaged or diseased area to the anus is removed and the initial incision begins near that damaged section. The remaining, healthy colon is pulled through holes in the abdomen and skin, and its end is rolled back and fastened. The stoma protrudes out about two to three centimeters, so that an appliance for storing waste, if needed, can be attached.

There are three varieties of colostomy. The first, a single-barreled end colostomy, is the classical configuration. The rectum and anus are removed, and a single circular stoma, about twenty-five millimeters (one inch) in diameter, is the permanent exit for stool. If, however, the surgeon believes that the colon and rectum can be rejoined, the rectum is left intact and closed. Either of two procedures can be used to give the colon a rest period between the removal of the diseased section and reconnection to the rectum. A double-barreled colostomy involves slicing through the colon and making side-by-side stomas from the ends. In a loop colostomy, the colon is not cut through; instead, a slit is made in one side, which is pulled through the skin and made into an oval stoma, usually larger than other stomas. In both cases, the upper colon discharges stool, and the lower length passes mucus.

Uses and Complications

Both colostomy and ileostomy are last-resort or emergency treatments. When a wound, such as one caused by a knife or gunshot, punctures the intestines, waste matter, full of bacteria, spills into the abdominal cavity. The severe infection that is sure to follow can kill a patient in days; thus, an emergency operation is required. The surgeon pulls healthy bowel through the abdominal wall and forms a temporary stoma (so that no more waste can leak out of the intestines), cleans out the spillage, and repairs the damaged bowel. In many cases, it is possible to reconnect the healthy bowel to the damaged portion after the wound has healed; at the same time, the stoma is closed, and the patient resumes defecation through the anus.

Emergency operations, however, account for only a small percentage of colostomies and ileostomies. About two-thirds of surgeries to form stomas are colostomies, most of which follow operations removing

cancer (usually in the lower colon or rectum) or an obstruction.
Diverticulitis, the inflammation of little pouches in the colon wall, may also require a colostomy; the diversion of wastes allows the inflammation to subside and the colon wall to heal, after which the stoma may be removed and the colon reconnected. Additionally, repair of some rare birth defects may entail a colostomy.

Ileostomies account for about one-quarter of stoma-creating procedures. Most are performed to eradicate ulcerative colitis, a chronic inflammation of the colon that begins in the rectum and may spread upward until the whole colon is involved. No drug or dietary treatment cures ulcerative colitis; when the condition becomes too unbearable for a patient to endure, the colon is removed and an ileostomy is performed. Long-standing ulcerative colitis is particularly likely to become cancerous, and the colon may be removed for that reason alone. Likewise, familial polyposis, a hereditary disease that dots the colon with toadstool-shaped lumps that are likely to become cancerous, may require removal of the colon and ileostomy.

Wounds, diverticulitis, familial polyposis, and birth defects, while not particularly rare, are the reasons for relatively few stomas. Stoma surgery is more commonly performed to treat colorectal cancer (particularly in the elderly) and ulcerative colitis (commonly disabling patients in their twenties). As the average age of the population increases, so does the incidence of
colon cancer and the need for ostomies.

Recovery from stoma surgery is prolonged. Surgery shocks the intestines, and several days pass before the gut resumes the wavelike contractions (called
peristalsis) that enable digestion and push wastes toward the stoma. In the meantime, patients live on intravenous fluid nourishment. When bowel motion restarts and wastes begin coming through the stoma, the ileostomate must develop new habits to cope with the flow of wastes (which are always fluid because the ileum does not remove sufficient water to solidify the waste matter) by learning to attach and empty appliances and to keep the stoma clean. Colostomates, especially those who have lost only their sigmoid colon, can look forward to passing firm stools and may eventually be able to live without an appliance, but months of diarrhea occur before the bowel regains full operation.

Many complications can plague the new anatomy, some of which require surgical correction. The most serious include intestinal obstruction, scar adhesions that distort the shape of the bowel, retraction of the stoma, abscesses, prolapse (more of the bowel pushing out of the body), and kidney stones (which form because persistent diarrhea can dehydrate ostomates). Less threatening, but demanding attention, are offensive odors, diarrhea, skin irritation, and bowel inflammation. Steady advances in surgical technique have lowered the complication rates, and few patients die because of the surgery.

Ostomates often must live with the stoma for the rest of their lives. Feces exit through the stoma, rather than the anus, forcing patients to “toilet train” themselves all over again. Some stomas, known as continent stomas, hold back wastes until the patient is ready to defecate by draining them with a tube. Many, however, are not, and stool and gas steadily seep through the opening, where the waste matter is collected in an appliance, usually a plastic bag that seals over the stoma.

Having a plastic bag of stool on the abdomen and needing to empty it periodically to prevent it from leaking, instead of defecating by sitting down on a toilet, proves a difficult adjustment for some patients, both physically and psychologically. Several aid resources help new ostomates adjust. Specially trained registered nurses called enterostomal therapists teach patients how to manage their new stomas and how to attach appliances or insert catheters to drain continent stomas; they also help care for the stomas after the operation and periodically review their patients’ progress. Gastroenterologists, physicians who specialize in the intestinal tract, can provide medical guidance and directly inspect the bowel wall behind the stoma through an endoscope, a flexible fiber-optic tube, should trouble develop. Support groups offer various resources to those ostomates who feel isolated and depressed because of the stoma.

Out of the hospital, ostomates face a new and different life. As well as learning to handle appliances or irrigate artificial rectums, they must face the fact that a major organ of their bodies is changed. The need for the stoma may anger or depress them, and this fixation on the change, if unalleviated, can evolve into loss of self-esteem and attendant social withdrawal. Many ostomates experience guilt in the belief that the disease and stoma, as well as the effects of the stoma on their families, are somehow their own fault.

These reactions require social and psychological therapy, extending care well beyond that afforded by the surgeon and the hospital. Support groups and the enterostomal therapist supply the majority of this care, but occasionally professional psychological help is required. The repulsion that patients feel for stomas and the consequent chance of morbid psychological reactions have encouraged surgeons to prefer anastomoses to stomas when possible, even though anastomoses are more difficult, have higher failure rates, and require a longer recovery period.

Fortunately, the great majority of ostomates do adjust to their new lives; they seldom have any other alternative. Providing that the original need for surgery has been eliminated—the cancer has been removed, for example—they can look forward to an undiminished life span and few if any restrictions upon appetite, sexual function, or exercise. The majority of ostomates recover completely and are able to return to their previous occupations after recovery. Without the operations, all of them would have led drastically impaired lives, and many would have died. The high success rate places the ileostomy and colostomy procedures among the ranks of surgical interventions that rescue the seriously ill from otherwise incurable organic diseases.

Perspective and Prospects

Although drastic techniques requiring much skill from surgeons and stamina from patients, ostomies did not originate with modern medicine and its sophisticated technology for sustaining patients during operations. Some colostomies date from the last quarter of the eighteenth century. In the nineteenth century, the number of operations creating a stoma—then called “artificial” or “preternatural” anus—increased, although without antiseptic conditions or anesthesia a patient’s chances for survival were not good. Surgeons sometimes placed the stomas on the back instead of the abdomen. In 1908, William Ernest Miles conducted the first operation to remove a cancerous rectum; since the patient’s intestines were still moving waste matter, which needed an exit, Miles created a stoma, thereby establishing one of the most common surgeries of the twentieth century.

Still, colostomies and ileostomies did not proliferate until after World War II. Since then, refinements in surgical techniques and postoperative care have steadily reduced the chance of complications and the length of the recovery period. At the same time, several variations of permanent and temporary stomas have been developed.

Like many other extreme surgical interventions, the ileostomy and colostomy testify to the limits of biomedical knowledge: most of these surgeries are performed because other remedies fail. Until researchers discover the mechanisms causing cancer, ulcerative colitis, and other deadly lower bowel diseases and develop nonsurgical cures, ileostomies and colostomies will remain common, especially among the elderly.

Bibliography

A.D.A.M. Medical Encyclopedia. "Colostomy." MedlinePlus, May 6, 2011.

A.D.A.M. Medical Encyclopedia. "Ileostomy." MedlinePlus, December 10, 2012.

Adrouny, Richard. Understanding Colon Cancer. Jackson: University Press of Mississippi, 2002.

Brandt, Lawrence J., and Penny Steiner-Grossman, eds. Treating IBD: A Patient’s Guide to the Medical and Surgical Management of Inflammatory Bowel Disease. Reprint. New York: Raven Press, 1996.

Bub, David S., et al. One Hundred Questions and Answers About Colorectal Cancer. Sudbury, Mass.: Jones and Bartlett, 2003.

Doherty, Gerard M., and Lawrence W. Way, eds. Current Surgical Diagnosis and Treatment. 12th ed. New York: Lange Medical Books/McGraw-Hill, 2006.

Fries, Colleen Farley. “Managing an Ostomy.” Nursing 29, no. 8 (August, 1999): 26.

Kalibjian, Cliff. Straight from the Gut: Living with Crohn’s Disease and Ulcerative Colitis. Cambridge, Mass.: O’Reilly, 2003.

Mullen, Barbara Dorr, and Kerry Anne McGinn. The Ostomy Book: Living Comfortably with Colostomies, Ileostomies, and Urostomies. Rev. ed. Palo Alto, Calif.: Bull, 1992.

National Digestive Diseases Information Clearinghouse. "Bowel Diversion Surgeries: Ileostromy, Colostomy, Ileoanal Reservoir, and Continent Ileostomy." National Institutes of Health, April 23, 2012.

Parker, James N., and Philip M. Parker, eds. The 2002 Official Patient’s Sourcebook on Ulcerative Colitis. San Diego, Calif.: Icon Health, 2002.

United Ostomy Associations of America. http://www .uoaa.org.