Deciding whether to have a reversal of your temporary ileostomy or to live with it long term, can feel like a huge decision. Your recent ileostomy formation surgery may be fresh on your mind, and you may have lots more questions to ask before making the decision to have further surgery. Not everyone with a temporary stoma goes on to have surgery to reverse it, many ostomates decide to keep their stoma for their own reasons. It is a very personal decision and here is everything you need to know about having an ileostomy reversal, which hopefully will help you decide what feels right for you.
Types of temporary ileostomies:
There are usually two different types of ileostomy surgery; a loop ileostomy and an end ileostomy.
A loop ileostomy is typically temporary. It is created when a loop of the small bowel is lifted above skin level during surgery and may be held in place with a stoma rod. A cut is then made on the exposed bowel loop and the ends are then rolled down and sewn onto the skin. The loop ileostomy consists of two stomas which are joined together.
An end ileostomy is created when part of your large bowel (colon) is removed or needs to rest, and the end of your small bowel (ileum) is brought to the surface of your abdomen to form a stoma (ileostomy). An end ileostomy can be either temporary or permanent. If the diseased part of the bowel has been removed, the remaining part needs to rest before the ends can be joined back together. If the surgeon deems it too risky, or not possible to join these two parts back together, then a permanent solution is chosen and reversal will not be an option.
Why are temporary ileostomies formed?
An ileostomy is formed to treat several conditions. Some of these conditions involve surgery which requires a temporary ileostomy that can be reversed when you are fully recovered from the initial operation and any subsequent follow up treatments.
Conditions that might require surgery involving a temporary ileostomy:
- Colorectal cancer
- Diverticular disease
- Ulcerative Colitis
- Crohn’s disease
- Familial adenomatous polyposis surgery
- Congenital abnormalities
- Colo-vaginal/colo-vesicle fistula
Conditions that might require a permanent ileostomy:
- Crohn’s disease
- Colonic motility dysfunction
- Blocked, damaged, or ruptured large intestines
When would ileostomy reversal surgery be offered?
After your initial stoma surgery, your surgeon will explain to you the type of stoma surgery you have had and discuss whether a reversal at a later date, is an option for you, depending on the nature of your surgery and the reason it was performed. For those with a permanent ileostomy, there is no option for reversal.
The timing of your reversal is important. The optimum time is usually between 3-12months following your initial surgery. This is to ensure you have good muscle tone and that your bowel is in a healthy state for surgery. If your surgery was for bowel cancer, a reversal is not usually offered until chemotherapy has been completed and the bowel has had chance to recover afterwards (usually about 6 weeks after the end of treatment).
Reversal of your stoma will only be offered if your surgeon is confident that you will regain enough bowel control following surgery. Depending on the type of stoma surgery you have had, the surgeon may need to perform a rectal exam and possibly arrange some further tests before making this decision. This is to check that your bowel has healed enough and that your anal sphincter muscles are in good working order. The tests may vary depending on your surgeon and hospital procedures.
Test which may be used:
- Rectal examination to check the strength of your sphincter muscles and the strength of your bowel control
- CT Scan to confirm there is no active disease that could compromise your reversal
- A contrast enema to check there are no leaks with the join in your bowel
- Flexible sigmoidoscopy or for patients with an ileoanal pouch, a pouchoscopy to see how well your bowel/pouch has healed.
What is involved in ileostomy reversal surgery?
Reversing a loop ileostomy is a relatively straight forward procedure which is carried out under general anaesthetic, whilst you are an in-patient. A cut is made around the stoma and the section of small intestine is pulled out of the abdomen. The area that had been divided to form the stoma is stitched back together and placed back inside the abdomen.
It is sometimes possible to reverse an end ileostomy if most of the large intestine (colon) has been sealed and left inside the abdomen, or if an ileo-anal pouch is planned. But the surgeon will need to make a larger incision to locate and re-attach the small intestines. It therefore takes longer to recover from this type of surgery and there are greater risks of complications.
Surgery still comes with risks and your surgeon will discuss your reversal surgery and any possible risks with you. You will also see your Stoma Care Nurse who will support you with more information about any potential complications following surgery.
What to expect following an ileostomy reversal surgery?
Expectations can differ depending on each hospital protocol for reversals. Following ileostomy reversal surgery, you may be advised to stick to liquids only, so that your bowel can rest and then start a soft diet, low in fibre for the following 1-2 days. Moving around as much as possible will help your bowel to be active and helps your general recovery. After 3-5 days depending on your recovery and whether you have had your bowels opened or passed flatus (wind), you will be allowed home. With an enhanced recovery programme, the length of stay in hospital could be less and you may be sent home much sooner if all is well.
Your bowel habits maybe a bit erratic for some time after the surgery. You may experience loose motions or even constipation, a feeling of urgency, some discomfort/pain when passing motions, sore skin from the back passage, incomplete emptying, and even some degree of incontinence for up to a few months following surgery. It could take a few months for these problems to settle down and can take up to twelve months to reach your ‘new normal’. You may find that you bowel activity never quite returns to the way it was before original ileostomy surgery. If these symptoms persist it is important to speak to your surgeon or nurse, as there are things that can be done to help.
It may take some time to get back to a normal, healthy diet. Whilst your bowel is feeling fragile it is a good idea to limit any foods which could irritate the stomach and bowel. These are food such as:
- Acidic fruits eg: citrus fruits like oranges, lemons, grapefruit, strawberries
- Wind inducing vegetables eg: broccoli, beans, cabbage, sprouts or onions
- Spicy foods
- Fizzy drinks, especially beer or larger
If you are struggling with diarrhoea, speak with your GP or Stoma Care nurse as there are medications available to help.
After a loose bowel movement, it is important to keep your skin free from irritation and soreness. Washing the area with warm water and patting dry afterwards, will help keep it clean. Application of a good barrier cream will help protect your skin and minimise any skin problems. As the anus starts to become used to having stools pass through it again, things should improve.
How you may feel about reversal surgery:
It may be of benefit to ask important questions about stoma reversal surgery to both your surgeon and stoma care nurse before you go ahead with reversal surgery. Be realistic about how you will feel going through another surgery and the possibility of experiencing a period of disrupted bowel dysfunction. Talk to people who have been on this journey to get a real feeling of how it could be for you. Your stoma nurse could arrange this for you. There is also plenty of online literature to help support you.
Some ostomates may well be eagerly awaiting the date for their reversal surgery, but for others they may find that having an ileostomy has improved their quality of life and so may not want to go ahead with a reversal for many reasons. It is a very personal decision, and it must feel right for you.