Ileostomy

An ileostomy is a surgically created opening (stoma) on the abdominal surface that allows stools to be excreted into a pouch outside the body. 

Ileostomy is needed when a portion of the intestine is removed for diseases such as cancer. In this procedure, the ileum, which is the last part of the small intestine, is attached to the wall of the abdomen after creating a stoma for it. Stools pass through the stoma into a bag attached outside. 

You can have a permanent or temporary ileostomy depending on the type of surgery you undergo. A permanent ileostomy may be performed after a surgery in which the large intestine (colon), rectum, and anus are removed. If only a portion of the colon is removed and the rectum is intact, a temporary ileostomy may be performed.

Some conditions in which ileostomy may be recommended are:

• Bowel infections
• Inflammatory bowel diseases such as Crohn's disease and ulcerative colitis
• Intestinal cancer
• Blockage in the bowel 
• Diverticulitis: A condition in which diverticula (small pouches in the colon) are inflamed and infected
• Bowel injury 
• Familial adenomatous polyposis (a precancerous condition)

The relative contraindications (where the procedure can be performed, but with caution) include:

• Obesity: A short mesentery (the tissue that is responsible for holding the intestines in place) creates tension in the ileum when the ileum is brought out through the abdominal wall to the skin to form a stoma. This is more common in people who are obese. So extra care is needed to prevent this.
• When cancer has spread and prevents the movement of the ileum

The following preparations are required before the surgery:

• Your doctor may ask you to get certain tests, including blood tests and an electrocardiogram to ensure that your health is otherwise good enough for the surgery.
• Tell your doctor about all the medicines you take, including non-prescription medicines, supplements, and herbs. You may be asked to stop taking blood-thinning medications like aspirin, ibuprofen, and naproxen two weeks before the surgery. 
• Avoid smoking before the surgery to reduce chances of developing complications.
• You should drink clear liquids like clear juice, broth, or water the day before the procedure.
• You may need to use laxatives or enemas to clear your bowels the day before the surgery.
• Avoid drinking or eating anything after midnight the night before the surgery.
• You would be asked to sign a consent form before the surgery allowing the doctor to perform the procedure.

After admission to the hospital, you will be asked to change into a hospital gown and wear compression stockings (to reduce the chances of blood clots in your legs).

An ileostomy is performed under general anaesthesia, and you will not feel anything and will be asleep during the entire procedure. An IV line will be attached to a vein in your arm to give you fluids.

The surgery can be performed in the following ways:

• Open surgery: A large incision is made in the abdomen, which allows the surgeon to view inside and perform the operation.
• Laparoscopic surgery: Small incisions are made in the abdomen through which surgical instruments are passed.

Depending on the specific reason for surgery, the exact steps will differ, but the general steps of ileostomy are as follows:

• A surgeon will mark the spot for the stoma, commonly in the lower right side of the abdomen.
• He/she will make an opening on your skin and abdominal muscles.
• After the affected portion of the intestine is removed, the surgeon will pull the remaining portion (the ileum) through the opening to the outside and form the stoma.
• A pouch will then be attached to this opening to remove waste and the stoma will be fixed using stitches.

The duration of the ileostomy depends on the reason for the surgery. You can expect the following after surgery: 

• You will be shifted to a recovery room, and your pulse, breathing, and blood pressure will be monitored.
• When you wake up, you will still have an intravenous (IV) line attached to your arm.
• You will be provided with pain medicines if you feel any pain at the incision site. Antibiotics will also be given to prevent any infection.
• The healthcare team may encourage you to walk often after surgery. This will help prevent blood clot formation in your legs.
• You will initially be given clear fluids and will gradually be moved to a regular diet.
• You may have a small tube going into your stomach to suck out the contents of your stomach. Once the tube is removed, you may start having a light diet.
• Soon, you may begin to pass stools through the stoma. A light-weight bag covering the stoma will collect the stools. Initially, a nurse will change the bag for you and show you how you can change the bag yourself.
• Your healthcare provider will remove the sutures five to six days after the surgery.
• You may need to stay in the hospital for a week.

You may get tired very quickly for the initial two weeks after surgery. Rest properly, and your strength will gradually improve. 

You may need to take the following care at home: 

Ileostomy care:

• You will need to change the drain, and attach the ileostomy pouch and care for the skin around the stoma. Some pouches can be worn for three days to a week while some can be worn only for a day.
• Empty the bag before it gets filled. Frequently emptying it prevents any chance of leakage and bulge formation under your clothes.
• When you change the pouch, you should first wipe off any mucus in the stoma. After that, wipe the skin around it with a cloth and warm water. Rinse the skin well and then let it dry before you attach the barrier. You may use a mild soap to clean the skin. When you are changing the pouch, notice the stoma for any changes to it. Also check for any irritation or blood around the stoma as you may be allergic to the adhesives, tape, skin barriers or pouch material. Use only those ileostomy products that your doctor has suggested.

Showering: If your wound has healed, you can have a bath without covering your stoma, but if it is still recovering, cover it with a bag and have a bath.

Activity: 

• You may resume your normal activities after you have healed completely and have regained your strength.
• Avoid doing activities such as driving and lifting weights for the first two to three weeks after surgery. You may be able to perform most activities like swimming after your recovery. Still contact sports such as football should be avoided. 
• Do not perform any extreme exercises for three months. However, if you do perform activities such as walking or swimming, do not push yourself.
• You can have a normal sexual relationship after ileostomy as soon as your doctor approves.

Diet:

• Reduce your fibre intake for a few months after the surgery to lower the strain on the stoma and bowels.
• You may have extra stomach gas after the surgery. The ways to reduce gas and excessive odours include:
  • Eat small meals frequently. 
  • Limit certain foods such as onions, fish, beans, eggs, cheese, cabbage, and fizzy drinks.
  • You can have anti-flatulence medicine or charcoal tablets to reduce the odour.
• Try to avoid foods such as popcorn or celery seeds.
• There may be no diet restrictions after three months when you have recovered.
• It is advised to irrigate the stoma using water to prevent constipation.

Work: You may resume work about six to eight weeks after the surgery.

For some people, coping with an ileostomy may be difficult. Talk to your partner, family member, and healthcare provider if you are facing any emotional, social, or practical issues. You may also join a support group to help you cope.

When to see the doctor?

Visit or call your doctor immediately if you notice any of the following:

• A deep cut in the stoma
• Severe diarrhoea with a chance of dehydration
• Continuous nausea and vomiting
• Profuse bleeding from the stoma
• Any changes in the physical appearance of the stoma
• Obstruction, narrowing, or collapse of the stoma
• No output of stools for four to six hours from the stoma with nausea and cramps
• Constant bleeding at the join between the skin and stoma even after applying pressure

Complications associated with ileostomy include:

• Infection
• Skin problems around the stoma due to contact with stools
• Incisional hernia (a part of the intestine protruding through the stoma)
• Blockage of the stoma due to scar tissue
• Diarrhoea
• Allergic reaction to anaesthesia
• Dehydration
• Haemorrhage
• Narrowing of the stoma
• Kidney stones
• Difficulty in passing stools through the stoma and into the bag
• Gallstones

A follow-up is scheduled about three weeks later where the doctor will check if the stoma is at the appropriate size. For a temporary stoma, once the intestines have healed, a separate surgery is performed to reconnect the bowel so that stools can pass through the anus again.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.