An enterostomy is an operation in which the surgeon makes a passage into the patient's small intestine through the abdomen with an opening to allow for drainage or to insert a tube for feeding. The opening is called a stoma, from the Greek word for mouth. Enterostomies may be either temporary or permanent. They are classified according to the part of the intestine that is used to create the stoma. If the ileum, which is the lowest of the three sections of the small intestine, is used to make the stoma, the operation is called an ileostomy. If the jejunum, which is the middle section of the small intestine, is used, the operation is called a jejunostomy. Some people use the word ostomy as a word that covers all types of enterostomies.
Enterostomies are performed in order to create a new opening for the passage of fecal matter when normal intestinal functioning is interrupted or when diseases of the intestines cannot be treated by medications or less radical surgery. Some situations that may require enterostomies include:
- Healing of inflamed bowel segments. Enterostomies performed for this reason are usually temporary.
- Emergency treatment of gunshot or other penetrating wounds of the abdomen. An enterostomy is needed to prevent the contents of the intestine from causing a serious inflammation of the inside of the abdominal cavity (peritonitis). These enterostomies are also often temporary.
- Placement of a tube for enteral feeding. Enteral feeding is a method for conveying nutritional solutions directly into the stomach or jejunum through a tube. Tube enterostomies may be long-term but are not permanent.
- Removal of diseased sections of the intestines. Ileostomies performed for this reason are permanent. The most common disorders requiring permanent ileostomy are Crohn's disease, familial polyposis, and ulcerative colitis. Familial polyposis and ulcerative colitis are serious health risks because they can develop into cancer.
- Treatment of advanced cancer or other causes of intestinal obstruction.
Enterostomies are usually performed only as emergency treatments for traumatic injuries in the abdomen or as final measures for serious disorders of the intestines. Most patients do not refuse to have the operation performed when the need for it is explained to them. A small minority, however, refuse enterostomies because of strong psychological reactions to personal disfigurement and the need to relearn bowel habits.
Ileostomies represent about 25% of enterostomies. They are performed after the surgeon removes a diseased colon and sometimes the rectum as well. The most common ileostomy is called a Brooke ileostomy after the English surgeon who developed it. In a Brooke ileostomy, the surgeon makes the stoma in the lower right section of the abdomen. The ileum is pulled through an opening (incision) in the muscle layer. The surgeon then turns the cut end of the intestine inside out and sews it to the edges of the hole. He or she then positions an appliance for collecting the fecal material. The appliance consists of a plastic bag that fits over the stoma and lies flat against the abdomen. The patient is taught to drain the bag from time to time during the day. Ileostomies need to be emptied frequently because the digested food contains large amounts of water. Shortly after the operation, the ileostomy produces 1–2 qt (0.9–1.91) of fluid per day; after a month or two of adjustment, the volume decreases to 1–2 pt (0.5–0.9) per day.
KOCK POUCH (CONTINENT ILEOSTOMY). The Kock pouch is a variation of the basic ileostomy and is named for its Swedish inventor. In the Kock technique, the surgeon forms a pouch inside the abdominal cavity behind the stoma that collects the fecal material. The stoma is shaped into a valve to prevent fluid from leaking onto the patient's abdomen. The patient then empties the pouch several times daily by inserting a tube (catheter) through the valve. The Kock technique is sometimes called a continent ileostomy because the fluid is contained inside the abdomen. It is successful in 70–90% of patients who have it done.
A jejunostomy is similar to an ileostomy except that the stoma is placed in the second section of the small intestine rather than the third. Jejunostomies are performed less frequently than ileostomies. They are almost always temporary procedures.
Tube enterostomies are operations in which the surgeon makes a stoma into the stomach itself or the jejunum in order to insert a tube for liquid nutrients. Tube enterostomies are performed in patients who need tube feeding for longer than six weeks, or who have had recent mouth or nose surgery. As long as the patient's intestinal tract can function, tube feedings are considered preferable to intravenous feeding. Enteral nutrition is safer than intravenous fluids and helps to keep the patient's digestive tract functioning.
Preoperative preparation includes both patient education and physical preparation.
Ileostomy patients must learn to watch their fluid and salt intake. They are at greater risk of becoming dehydrated in hot weather, from exercise, or from diarrhea. In some cases they may need extra bananas or orange juice in the diet to keep up the level of potassium in the blood.
Patient education includes social concerns as well as physical self-care. Many ileostomy patients are worried about the effects of the operation on their close relationships and employment. If the patient has not seen an ET before the operation, the aftercare period is a good time to find out about self-help and support groups. The ET can also evaluate the patient's emotional reactions to the ostomy.
The patient is prepared for surgery with an evaluation of his or her nutritional status, possible need for blood transfusions, and antibiotics if necessary. If the patient does not have an intestinal obstruction or severe inflammation, he or she may be given a large quantity of a polyethylene glycol (PEG) solution to cleanse the intestines before surgery.
Aftercare of an enterostomy is both psychological and medical.
If the enterostomy is temporary, aftercare consists of the usual monitoring of surgical wounds for infection or bleeding. If the patient has had a permanent ileostomy, aftercare includes learning to use the appliance or empty the Kock pouch; learning to keep the stoma clean; and readjusting bathroom habits. Recovery takes a long time because major surgery is a shock to the system and the intestines take several days to resume normal functioning. The patient's fluid intake and output will be checked frequently to minimize the risk of dehydration.
Enterostomies are not considered high-risk operations by themselves. About 40% of ileostomy patients have complications afterward, however; about 15% require minor surgical corrections. Possible complications include:
- skin irritation caused by leakage of digestive fluids onto the skin around the stoma, irritation is the most common complication of ileostomies
- the development of abscesses
- gallstones or stones in the urinary tract
- inflammation of the ileum
- odors (can often be prevented by a change in diet)
- intestinal obstruction
- a section of the bowel pushing out of the body (prolapse)
Normal results include recovery from the surgery with few or no complications. About 95% of people with ostomies recover completely, are able to return to work, and consider themselves to be in good health. Many ileostomy patients enjoy being able to eat a full range of foods rather than living on a restricted diet. Some patients, however, need to be referred to psychotherapists to deal with depression or other emotional problems after the operation.
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United Ostomy Association, Inc. (UOA). 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. <http://www.uoa.org>.
Rebecca J. Frey
Crohn's disease—A disease of the intestines that causes inflammation leading to scarring, thickening of the walls of the intestine, and eventual obstruction.
Duodenum—The first of the three segments of the small intestine. The duodenum connects the stomach and the jejunum.
Enteral nutrition—A technique for feeding patients with liquid formulas conveyed directly into the stomach or jejunum through tubes.
Enterostomal therapist (ET)—A specialized counselor, usually a registered nurse, who provides ostomy patients with education and counseling before the operation. After surgery, the ET helps the patient learn to take care of the stoma and appliance, and offers long-term emotional support.
Ileum—The third segment of the small intestine, connecting the jejunum and the large intestine.
Jejunum—The second of the three segments of the small intestine, connecting the duodenum and the ileum.
Ostomy—A common term for all types of enterostomies.
Stoma—The surgically constructed mouth or passage between the intestine and the outside of the patient's body.
Tube enterostomy—An enterostomy performed to allow the insertion of a feeding tube into the jejunum or stomach.
Ulcerative colitis—A disease of the colon characterized by inflammation of the mucous lining, ulcerated areas of tissue, and bloody diarrhea.