Problems With Ileostomies

Mr Paul Rooney, Consultant Surgeon, Royal Liverpool Hospital

Powerpoint File

Ileostomies were first introduced into the management of ulcerative colitis in 1913 by Brown. It did not really become established until the 1940’s when ablative surgery for managing colitis became more widely accepted.

Then in 1952 Brooke designed the everted ileostomy we know today. The loop ileostomy was developed by Turnbull in 1961 as a satisfactory defunctioning procedure. Both forms of ileostomy have had their own problems and complications. Some of these problems are generic such as skin problems usually related to an inappropriate appliance, incorrect size, poor seal, frequent unnecessary changing, sweat, allergy, eczema, poor hygiene, radiotherapy and drug interactions. These can be usually sorted out by a good entero-stomal therapist. Others require surgical intervention. Stoma retraction, stenosis, parastomal hernia, prolapse and recurrent disease, carcinoma and Crohn’s disease together with fistulation, varices and of course stoma ischaemia may require surgical intervention. Often more difficult to manage are long term complications related to metabolic and haematological problems. These include chronic dehydration, low haemoglobin, low ferritin, abnormal liver function tests, decreased serum B12 particularly for Crohn’s disease patients. Stoma outputs are a significant problem particularly when more than 10cm has been resected from the terminal ileum in the formation of stoma. The normal daily effluent from the ileostomy should be between 300 to 800 mls. If more than 10cm has been resected this may increase the output from 800 to 1500 mls with consequential increase losses of sodium, potassium and water predisposing to both urolithiasis with both calcium and uric acid stones. There would appear to be an increased risk of gall stones in patients with ileostomies, probably related to loss of the bile salt pool which is also related to the length of ileum which has been resected.

ILEOSTOMY FLUX

Flux is the word used to describe profuse ileostomy diarrhoea. It is an extremely important complication as it leads to rapid dehydration, hyponatreamia and hypokalaemia. If the patients have been on steroids then it will precipitate and Addisonian crisis which is life threatening. The underlying cause for the increased flow should also be attended to. These include short bowel, residual disease bowel, radiotherapy, intestinal infection, local or systemic sepsis, bacterial overgrowth, intestinal obstruction. Degrees of instestinal obstruction are often common post operatively and are overlooked as a source of high ileostomy output. Outputs may reach 4 or 5 litres per day with patients seemingly well and able to eat and drink with no obvious abdominal distention. Losses over 1 litre per day should be replaced by normal saline. Patients at home with losses of greater than 1.5 litres per day should be admitted. If the patient has been on steroids within a year and hydrocortisone 100mg qds should be started until the output is back to normal. Reduction output can usually be achieved by Lomotil and Codeine. Somatostatin analogues also have a place together with PPI’s.

COMPLICATIONS OF ILEOSTOMY CLOSURE

Complications of loop ileostomy closure may be as high as 50%. Major complications include leak and fistula, intra-abdominal sepsis and intestinal obstruction. Death would appear to be rare. Closure maybe achieved either by end to end suturing or by side to side stapling. There is only anecdotal data to which is the best method.

References

Hill, GL et al

Impairment of Ileostomy Adaptation in Patients with Ileo-Resection

GUT 15: 982 – 987

Hill, GL et al

Cause and Management of High Volume Output, Salt Depleting Ileostomy

BJS 62: 720 – 726

Hosie et al

Temporary Loop Ileostomy following Restorative Colectomy

BJS 79: 33 – 34

Keighley & Williams

Surgery of the Anus and Colon

Eds. W.B. Saunders 1999