Perioperative management - Ileostomy Reversal

General Note

There are various forms of stomas created for different intentions.

Fundamentally, they are distinguished by the section of the intestine used:

• Colostomy (ascending, transverse, descending, sigmoidostomy)
• Small bowel stoma (ileostomy, jejunostomy)

and by the stoma shape:

• End
• Loop
• Special form: Split-stoma

This article concerns the reversal of a loop ileostomy. Similarly, a loop colostomy is managed.

In end stomas (and also split stomas), it is referred to as 'restoration of continuity,' as typically a laparotomy (laparoscopy) is required to anastomose the bowel ends.

The following information on indications, etc., generally applies to the treatment of stomas and not specifically to the reversal of ileostomies.

Indications are determined exclusively on an individual basis:

• Depending on the age, general condition, and outcome of the patient regarding their underlying disease, the chosen stoma form can be reversed at the earliest after the underlying disease has healed!
• The highest reversal rate (about 90%) is for stomas created for anastomosis protection. In contrast, stomas created in the context of anorectal fistula formations in Crohn's disease are reversed in less than half of the cases!

Stoma Configuration:

• End (only the efferent limb is exteriorized)
• Loop (oral and aboral limbs in the stoma)
• Intestinal section for the stoma form used: Jejunum, Ileum,Colon

Timing of Stoma Reversal

• There is currently no clear recommendation for the optimal timing.
• An early closure of a loop protective ileostomy 10 to 14 days after creation is theoretically possible after quick recovery from the primary operation, with positive effects on quality of life and potential stoma complications. However, due to physiological inflammatory adhesions between the intestine and abdominal wall and between the intestinal loops, reversal at this early stage is significantly more difficult. These adhesions typically resolve within 6-10 weeks, so reversal usually occurs 10-12 weeks after creation.
• A colostomy after discontinuity resection should be dissolved no earlier than 6 months after the primary operation; after severe peritonitis, it is advisable to wait even 9 to 12 months to ensure sufficient patient recovery and to reduce the extent of potential adhesions.

• Acute flare-up of Crohn's disease or ulcerative colitis
• Local recurrence of the underlying disease
• Expected incontinence

• Re-staging (abdominal and thoracic CT) in neoplastic diseases
• Rectoscopy and clinical assessment (digital) of the anastomosis after low anterior rectal resection
• Assessment of the sphincter apparatus
• Abdominal CT with rectal contrast filling for assessment of the anastomosis, possibly also contrast filling of the efferent limb, alternatively endoscopic control (colonoscopy).
• Laboratory with coagulation

For the reversal and restoration of continuity, no special preparations are usually necessary. However, to prevent fecal contamination, especially with a colostomy, an enema into the stoma immediately preoperatively (1 hour) may be useful. Bowel lavage is not required. Perioperative antibiotic prophylaxis to reduce wound infections is advisable.

An informed consent should include the following points:

• General surgical risks (bleeding, postoperative bleeding, risk of thrombosis, risk of embolism, etc.)
• Wound healing disorders (common)
• Intraoperative bowel injury
• Anastomotic insufficiency
• Postoperative stenosis (too tight re-anastomosis)
• Postoperative ileus (paralysis, mechanical (see above))
• Irregular bowel movements
• Possibly revision surgery
• Fistula formation (cutaneous stool fistula)
• Incisional hernia
• Incontinence
• Ureteral injury (in case of descending stoma)
• Adhesions

The procedure is performed under intubation anesthesia.

For the reversal of a loop stoma, a supine position with the left arm positioned outward for a stoma on the right, and the right arm positioned outward for a stoma on the left, is indicated.

For restoration of continuity without anastomosis in the small pelvis, the supine position with the left arm positioned outward is advisable.

For the creation of a descending rectostomy, the lithotomy position with the left arm positioned outward is used.

For laparoscopic procedures, the positioning is as follows for laparoscopic sigmoid resection:

• Lithotomy position
• Positioning of the right arm
• Shoulder supports

Simple Reversal of a loop Stoma:

• Surgeon: on the side of the stoma
• Assistant: opposite
• Instrument Nurse: on the assistant's side at the patient's knee level

Restoration of Continuity in Lithotomy Position via Laparotomy:

• Surgeon: right, possibly switching to the stoma side to mobilize the stoma
• Assistant: opposite or between the legs
• 2nd Assistant (optional): between the legs
• Instrument Nurse: on the surgeon's side at the patient's knee level

Restoration of Continuity via Laparoscopy:

• Surgeon, Assistant, and Instrument Nurse usually on the right, possibly switching the surgeon to the opposite side to mobilize the stoma.
• In the case of Descending Rectostomy using a CEA Stapler, an assistant (or surgeon) between the legs.

During the reversal of a loop ileostomy or colostomy:

• No special retention systems or instruments required.

During continuity restoration via laparotomy:

• Abdominal wall retractor and for the descending rectostomy CEA stapler for transanal anastomosis.

During continuity restoration via laparoscopy:

• Laparoscopy tower, camera, trocars, CEA stapler for the descending rectostomy.

Postoperative Analgesia: Adequate pain management (Metamizole and if needed, a weak opioid such as Tilidine or Tramadol). Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management). Follow this link to the current guideline Treatment of acute perioperative and post-traumatic pain.

Medical Follow-up: Laboratory check on the 3rd and 5th postoperative day.

Thrombosis Prophylaxis: e.g., Clexane 0.4 ml s.c. once daily. In the absence of contraindications, due to the moderate thromboembolic risk (surgical procedure > 30 minutes duration), in addition to physical measures, low molecular weight heparin should be administered in a prophylactic, possibly weight- or disposition risk-adapted dosage until full mobilization is achieved.
Note: Renal function, HIT II (history, platelet control)
Follow this link to the current guideline Prophylaxis of venous thromboembolism (VTE).

Mobilization: immediately

Physical Therapy: Not necessarily required with immediate mobilization and uncomplicated healing process or hospital stay.

Dietary Progression: 3 days of tea-soup-yogurt-Fresubin, then solid food.

Bowel Regulation: as needed (e.g., laxative drops)

Work Incapacity: Depending on intraoperative findings, approximately 2-3 weeks.