Perioperative management - Ileostomy closure

General note

The various types of stoma are indicated by the problem at hand.
The principle distinction is based on the bowel section employed:

• Colostomy (ascendostomy; transversostomy; descendostomy; sigmoidostomy)
• Small bowel ostomy (ileostomy, jejunostomy)

and the shape of the stoma :

• End
• Loop
• Special type: Split stoma

This article details the closure of a loop ileostomy. The procedure would be similar in a loop colostomy.

In closure of an end stoma (and also in split stoma) the procedure reverses the original operation by ‘restoring intestinal continuity, with the anastomosis of the intestinal limbs usually necessitating a laparotomy (laparoscopy).

The information below on indications etc. generally refers to the stoma treatment and not per se to ileostomy closure.

The indications are always determined by the individual situation of the patient:

• Depending on the age, general condition and outcome of the patient with regard to the underlying disease, the earliest osteotomy closure could be performed would be after healing of the underlying disease!
• The highest closure rate (about 90%) is found in ostomies constructed for anastomotic protection. On the other hand, ostomies constructed for anorectal fistula formation in Crohn disease, for example, are closed in less than half of the cases!

Stoma types:

• End (only proximal limb delivered through abdominal wall)
• Loop (both proximal and distal limb in stoma)Intestinal section employed for the stoma type used:Ileum, jejunum
  Colon

• Acute episode in Crohn disease, ulcerative colitis
• Local recurrence of underlying disease
• Expected incontinence

• Once indicated, clinical examination and lab tests.
• Restaging ruling out recurrence of the underlying disease (e.g., rectal cancer/ liver metastases, etc.) usually by chest and abdominal CT, ultrasonography, possibly PET-CT.
• Contrast enema assessing the patency and integrity of the intestinal anastomosis and above all ruling out stenosis proximal to the planned intestinal suture.
• Rectoscopy assessing patency and integrity of the anastomosis in status post LAR (low anterior resection) and ruling out polyps or tumor recurrence.
• If necessary, functional manometry of the sphincter.

As a rule, no special preparations are necessary for closure and restoration of continuity. However, to prevent fecal contamination, especially in a colostomy, an enema into the stoma immediately before surgery (1h) may be useful. Intestinal lavage is not required. A perioperative antibiotic protocol reducing wound infection is recommended.

Informed consent should touch on the following aspects:

• General surgical risks (bleeding, secondary bleeding, risk of thrombosis and embolism, etc.)
• Wound healing disorders (frequent)
• Intraoperative intestinal injury
• Anastomotic failure
• Postoperative stricture (reanastomosis too tight)
• Postoperative ileus (paralysis, mechanical (see above))
• Irregular bowel movement
• Revision surgery, if necessary
• Fistula formation (cutaneous fecal fistula)
• Incisional hernia
• Incontinence
• Ureteral injury (in descendostomy)
• Adhesions