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The Management of Ileostomy
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The Management of Ileostomy NEIL W. SWINTON JOSEPH R. VAN HORNE
ILEOSTOMY is most commonly performed on patients with chronic nonspecific ulcerative colitis. Ileostomy followed or accompanied by total colectomy is the only known cure for this disease. 12 Many patients with ulcerative colitis are able to lead a relatively normal life under adequate medical supervision with a minimal amount of disability and without surgical intervention. However, the disease process persists in a quiescent phase either as a result of medical treatment or because of the natural tendency of the disease toward periods of remission. The generally quoted frequency of ileostomy and total colectomy in patients with chronic nonspecific ulcerative colitis is 15 to 20 per cent. At the clinic, in part due to the large number of patients referred primarily for surgical treatment who have had excellent medical treatment elsewhere, this figure has been over 40 per cent. It is not the purpose of this presentation to review in detail the indications for ileostomy and colectomy. The necessity of surgical intervention for those patients with an acute fulminating form of the disease who do not respond rapidly to medical measures, those with severe hemorrhage, perforation, obstruction, fistulas, stricture, associated malignancy or arthritis is well recognized. We are increasingly impressed, however, with the necessity of considering an elective ileostomy and colectomy to prevent "chronic invalidism" in these patients. For many the disability and the economic distress to the patients, their families, and frequently their friends may reach such proportions that ileostomy and total colectomy must be considered. At the Westminster Hospital Teaching Group, the Gordon Hospital in London, an appreciable number of patients with chronic nonspecific ulcerative colitis have now undergone colectomy and ileorectal anasto-
837
838
Neil W. Swinton, Joseph R. Van Horne
mosis. These patients have had a careful follow-up since 1952. Aylett2 and Abell reported very encouraging results. There has been little or no experience with the method in this country to date. The experiences at the Gordon Hospital so far are encouraging and it may be that in the future ileorectal anastomosis with preservation of the rectum and the avoidance of a permanent ileostomy may be feasible in selected cases. It must be pointed out, however, that on the basis of our present knowledge of this disease, the pathologic process in the retained rectum will always persist even though in a quiescent phase. In our experience, it has been possible to re-establish intestinal continuity following an ileostomy and partial colectomy in only a small number of patients with chronic ulcerative colitis. There can be no question that in recent years the improvements in the surgical technique and in the management of patients with permanent ileostomies have reached a stage where the majority can be restored to a useful and well-adjusted position in society with a minimal amount of disability resulting from the ileostomy. The most important factor in the successful management of the patient with an ileostomy is a properly constructed ileal stoma. Such a stoma must function adequately with minimal inconvenience to the patient and not become obstructed, develop fistula, retract or prolapse. OPERATIVE PROCEDURE
Three different types of ileostomies have been employed at the clinic: the double-barreled ileostomy, the divided ileostomy and the mucosalgrafted ileostomy. The Double-Barreled neostomy
This type has been used in the past only in patients with the most severe, fulminating phases of the disease, and although rarely employed at present, it has on occasion been a life-saving measure. It has the advantage of ease of performance with a minimum of intra-abdominal manipulation. A 3 to 4 inch right rectus muscle-splitting incision is made in the right lower quadrant with the upper margin of the incision at the level of the umbilicus. The distal ileum is visualized and a loop of ileum some 6 to 8 inches from the ileocecal valve proximal to the disease process is delivered into the wound. The loop is positioned in the lower portion of the incision so that the proximal limb is below the distal segment. Its mesentery is sutured to the free edges of the peritoneum with interrupted gut sutures after the bowel has been divided between clamps. The wound is carefully closed in layers. Tincture of benzoin or Vaseline gauze is applied to the skin for protection around the protruding loops of bowel, and a large, soft, rectal tube is placed in the ileostomy and secured with
The Management of Ileostomy
839
Fig. 218. Double-barreled ileostomy, allowing immediate decompression with rectal tube. Useful as an emergency procedure but requires later revision.
a purse-string suture. This rectal tube may be attached to a bottle for immediate decompression and drainage. It should begin functioning within 24 to 36 hours. The tube may be removed after a few days when the intestinal discharge becomes less profuse (Fig. 218). This is not a suitable permanent type of ileostomy and will require later revision. The Divided Ileostomy
This has been the type of operation most commonly used at the clinic in the past. It was designed primarily for the three-stage operation of ileostomy and total colectomy: stage 1, the divided ileostomy; stage 2, the removal of the colon down to the sigmoid with implantation of the sigmoid, and stage 3, the abdominoperineal resection. At present, with one or two stage procedures being employed in most instances, this operation has been replaced by the so-called mucosal-grafted ileostomy. The divided ileostomy is a permanent type and will not ordinarily require later revision. The abdomen is opened as in the operation for the double-barreled ileostomy, and the ileum delivered into the wound with as little manipulation of the intra-abdominal contents as possible. The mesentery of this loop is divided for about 3 inches with careful and separate ligation of its vessels. The mesenteric edge of the proximal limb is incised for a short distance at its mid portion to allow increased mobility of this segment and to lessen the tension of the proximal mesentery (Fig. 219). The bowel is then divided between clamps and the distal limb brought out through a stab wound above and to the right of the umbilicus (Fig. 220). It may subsequently be incorporated in the transverse incision which is ordinarily used for the later removal of the colon and implantation of the sigmoid. The proximal functioning limb is placed in the lower end of the wound. The divided mesentery is attached to the peritoneum with interrupted catgut sutures, care being taken not
840
Neil W. Swinton, Joseph R. Van Horne Fig. 219
Fig. 220
,,'
. . <:;) .....
..- .
'
Fig. 221
Fig. 222 Fig. 219. Divided ileostomy, showing delivery of loop of terminal ileum, and additional division of mesentery of proximal segment. Fig. 220. Divided ileostomy, showing position of distal limb in a stab wound above and to the right of the umbilicus. Proximal limb is placed in the lower portion of the wound. Fig. 221. Divided ileostomy, showing suture of mesentery of the functioning ileum to the peritoneum on each side. No suture is placed in intestinal wall. Fig. 222. Divided ileostomy, showing insertion of a soft rectal tube in functioning ileum.
to damage or constrict the blood supply of the bowel (Fig. 221). Sutures are never placed in the serosa of the intestine. The segment of ileum should be anchored so that at least 2 inches protrude above the level of the skin; this segment will eventually shrink to about half that length. A 1 inch projection of ileum from the abdominal wall will usually fit into the ileostomy appliance. The wound is carefully closed in layers and a
The Management of Ileostomy
Fig. 223
841
Fig. 224
Fig. 223. Stab-wound ileostomy, showing the functioning ileum b implanted in a lateral stab wound, and the nonfunctioning segment a placed in the upper angle of the wound, where it may later be removed in the transverse incision used for colectomy. (From Lahey, F. H.: Advantages of a stab wound ileostomy. Surg., Gynec. & Obst. 95: 28-32, July 1952.) Fig. 224. Stab-wound ileostomy, showing careful anchorage of mesentery of the functioning ileum by interrupted sutures of silk to parietal peritoneum of lateral wall and gutter. (From Lahey, F. H.: Advantages of a stab wound ileostomy. Surg., Gynec. & Obst. 95: 28-32, July 1952.)
large, soft, rectal catheter is inserted into the functioning limb of the ileostomy. This catheter may be removed in four to five days, and at a later date measurements are made for a permanent appliance (Fig. 222). A modification of this technique-the stab-wound ileostomy-was advocated by Dr. Lahey 6 in 1952. This procedure has the advantage of placing the permanent ileostomy distal to the wound incision and resultant scar. It was noted that the majority of patients gain an appreciable amount of weight following ileostomy and colectomy. This had caused difficulty in fitting a leakproof ileostomy appliance because the resulting scar was depressed by the adjacent bulging subcutaneous fat. By placing the permanent ileostomy in a circular stab lateral to the wound incision, about half way between the iliac spine and the umbilicus, this difficulty was avoided (Fig. 223). This principle has been adopted in the so-called mucosal-grafted technique. The abdominal incision is similar in position to that already described, but carried 1 or 2 inches above the level of the umbilicus. Before closure of the incision, the free edge of the mesentery of the functioning ileum is carefully anchored to the parietal peritoneum of the abdominal wall and lateral gutter by interrupted sutures of silk. This is a most important factor in the prevention of prolapse or retraction (Fig. 224).
842
Neil W. Swinton, Joseph R. Van Horne
The Mucosal-Grafted IleostonlY
This operation has been used almost exclusively over the past two and a half years for the majority of our patients with ulcerative colitis. Patey 7 in 1951 and Brooke3 in 1954 in England apparently were the first to suggest this technique. Crile and Turnbu1l6 have popularized it in this country. Turnbull's9.10 series of 50 consecutive cases reported in detail in 1956 revealed a significant decrease in the frequency of early and late postoperative complications with this method. The distressing occurrence after operation of fluid and electrolyte loss and the late complications of stricture at the skin margin seemed to be largely avoided with this method of performing an ileostomy. Our results have also indicated fewer immediate and late postoperative complications. Turnbull10 pointed out that the two major complications of the conventional type of ileostomy are attributed to a definite pathologic process which occurs in the ileostomy itself. A serositis of the exposed section of the ileum may spread throughout the entire wall of the protruding bowel, resulting in an ileitis with inflammatory rigidity and absence of peristalsis in this segment. This causes local obstruction in the early postoperative period with consequent loss of excessive quantities of fluid and electrolytes, especially sodium, postassium and chloride. The inflammatory process tends to spread to the adjacent skin edges and subcutaneous tissues, resulting in scarring and stricture formation at the junction of the skin and ileum. In the past this has frequently required surgical intervention. Advocates of the mucosal-grafted operation believe that this complication may be prevented by covering and protecting the serosa, exposed at the time of operation, with mucosa, thus obtaining primary healing between the mucosa and skin. A left paramedian incision is made, and the proximal ileal segment brought out through a circular stab wound in its usual position in the right lower quadrant. Colectomy may be performed at the same time but, if for any reason this is not feasible, the distal segment of ileum may be implanted in the primary incision. Between 2 and 3 inches of ileum is allowed to project beyond the skin. The divided edge of the mesentery is anchored securely to the parietal peritoneum up to the point of exit of the ileostomy (Fig. 225, a). If the colectomy is to be performed during this procedure, it is then carried out and the primary abdominal incision closed in layers. N ext the cut edge of the mesentery of the protruding ileum is ligated with a fine catgut suture about 1 inch above the level of the skin. With a finger in the ileostomy and a hemostat on the mesentery for traction, the seromuscular layer is divided both longitudinally and circumferentially by means of blunt scissors from a point about 1 cm. distal to the point of ligation of the mesentery. This seromuscular flap is teased away from the submucosal layer by blunt dissection (Fig. 225, b). After ligation of any bleeding points in the submucosa, the flap is trimmed and pulled
The Management of Ileostomy
b.
Fig. 225. a, Suture of remaining mesenteric border to the free edge of falciform ligament and lateral parietal peritoneum. b, Division of the seromuscular layer both circumferentially and longitudinally, and its separation from the submucosal layer c, Mucosubmucosal layer being folded oyer to be sutured to skin edge. (After R. B Turnbull, Jr., Surgical Clinics of North America, August, 1956.)
down over the serosa of the proximal 1 inch of protruding ileum and sutured with interrupted catgut sutures to the circular skin edge (Fig. 225, c). A protective ointment is applied to the skin, and a temporary plastic adhesive appliance, carefully cut to fit the protruding ileum, is immediately attached. No tube is inserted into the stoma. POSTOPERATIVE COMPLICATIONS
During the first few days following ileostomy certain phases of dysfunction may occur in many cases. The amount of fluid and electrolytes lost as a direct result of this ileus of the stoma may be excessive and serious. During this period which is critical in many cases, particular
844
Neil W. Swinton, Joseph R. Van Horne
care must be taken to maintain adequate replacement of fluid and electolytes. If this is neglected, the most severely ill patients may die, and convalescence may be lengthened for many others. Mechanical intraabdominal obstruction of the small bowel may occur as an early or late complication. Failure to attach the ileal mesentery properly to the parietal peritoneum is the usual cause of kinking of the proximal ileum. If this condition does not respond rapidly to tube decompression, surgical intervention may be necessary. In our experience, several late complications have been common in patients with ileostomies of the conventional type. Periods of excessive fluid loss may occur at any time, even months and years after the initial operation. This loss may result from concurrent illnesses, dietary indiscretion or other causes. Patients should be forewarned of this possibility and advised that immediate medical attention or even hospitalization may be necessary within a few hours after excessive fluid loss. Usually the gentle passage of a well-lubricated gloved finger or soft rectal tube, or irrigation will correct the obstruction and dysfunction. However, hospitalization will be required for many patients, with a Miller-Abbott tube inserted in certain instances, and fluid and electrolytes rapidly replaced. Fistula formation may result from the irritation of an improperly fitted appliance, or from the inclusion of the ileal wall in a suture of any type at the time of operation. Chronic infection at the junction between the ileum and skin, in the underlying subcutaneous tissues, or in a hematoma of the ileal mesentery at this level may lead to fistula formation. Formation of a fistula at the skin level necessitates surgical revision. Prolapse of the protruding ileum is usually a late complication. It ordinarily results from either the inadequate fixation of the mesentery to parietal peritoneum or inadequate abdominal wall support around the ileum. The latter results from infection, excessive scar formation or the failure to close the wound meticulously in layers. The same factors may occasionally cause retraction of the ileostomy beneath the skin level. Both of these procedures require surgical revision, and it is usually best to make an entirely new ileostomy at a different site on the abdominal wall even though it may necessitate moving the stoma to the left lower quadrant. The protruding prolapsed ileum should never be excised; this does not correct the basic cause of the prolapse and further decreases the remaining amount of small intestine. Stricture formation at the skin level has been our most frequent complication. This is caused by the serositis and ileitis previously mentioned, and also by the development of a subacute and chronic infection of the tissues at the junction of the ileum and skin, with resultant contracting scar and stricture. When a stricture has developed, the ileal stoma should not be dilated excessively. This may lead to perforation of the ileum and fistula formation may result. When a fistula is well-developed,
The Management of Ileostomy
845
Fig. 226. An adaptation of Warren and McKittrick's method of dealing with skin stricture. (after Warren and McKittrick, Surgery, Gynecology and Obstetrics, November, 1951.)
excision of the scar with reapproximation of mucosa to skin after the method of Warren and McKittrickll is the procedure of choice (Fig. 226). If the entire colon has not been removed, massive hemorrhage may occur at any time after ileostomy. It must be appreciated that ileostomy eliminates the danger of hemorrhage from the retained portion of colon in only a small number of cases. When hemorrhage occurs, colectomy or abdominoperineal resection may be indicated as an emergency procedure. Skin irritation around the ileal stoma may be a distressing problem. If the ileostomy has been properly performed, and if, from the time of operation, the skin is protected with a properly fitting appliance so that the ileal discharge is not left in contact with the skin, irritation should not occur. It is important that some type of appliance be placed over the ileal stoma at the time of operation and changed as often as necessary to prevent skin irritation. It has been our policy at the time of operation to apply tincture of benzoin, or some other protective medication liberally to the skin surrounding the stoma, and to attach a carefully fitted plastic appliance over the stoma. Our nurses are instructed to see that this is changed as often as necessary to prevent the development of any skin reaction. After six or seven days more permanent appliances may be used. Karaya powder is an excellent skin protection after the ileum is completely healed. It should not be used early in the postoperative phase, as it may result in sloughing of the mucosa. Wound herniation may occur after ileostomy. If this becomes troublesome, complete revision and the construction of an ileal stoma at a different site in the abdominal wall may be required. We cannot overestimate the value of the help given by certain lay groups to our patients in their postoperative period of readjustment to health and resumption of their rightful position in society. In this country and in England groups of patients of both sexes who have had ileostomies have formed Q-T Clubs. This name is derived from the Q and T wards of the Mt. Sinai Hospital in New York where the idea originated. Monthly meetings are usually held by such clubs and these are enthusiastically attended. Based on the principle of group therapy, members discuss freely among themselves the many problems that an ileostomy may
846
Neil W. Swinton, Joseph R. Van Horne
Fig. 228 Fig. 227 Fig. 227. Inexpensive plastic appliance which is applied on the operating table and can be cut to fit. This is changed as required during the immediate postoperative period. Fig. 228. More permanent types of appliances.
present in the process of day-to-day living. These discussions may concern adhesive cements, deodorants, methods of cleaning and proper care of appliances, nighttime problems and domestic readjustments. Some of these clubs issue monthly bulletins as well as a complete manual, which contains invaluable detailed information for any patient with an ileostomy. The number of ileostomy appliances that have been developed or suggested almost equals the number of patients who have undergone the operation. During the first postoperative week we routinely use an inexpensive plastic appliance with a two-faced adhesive layer at one end which may be cut out to fit the individual protruding ileum (Fig. 227). After the first week the more permanent types of appliances may be considered (Figs. 228, 229 and 230). In general, an adequate appliance is one that will adhere to the abdominal wall for at least 24 hours without leaking or becoming loose; it should be accident-proof day and night. It should be comfortable to the wearer and allow complete freedom of motion for all activities. It should also be inconspicuous under the patient's clothing, easy to clean, odor-proof, and reasonably economical. We have had extensive experience with cases of chronic nonspecific ulcerative colitis. 8 In 1956 we reported 4 a series of 871 patients, of whom 413, or 47 per cent, had required one or more surgical procedures. The immediate operative mortality in this group was 3.8 per cent. The postoperative complications were as follows: immediate or late obstruction of the small bowel in 43.6 per cent of cases; excessive fluid and electrolyte imbalance, both early and late, 12 per cent; skin irritation 15 per
The Management of Ileostomy
847
Fig. 230 Fig. 229 Fig. 229. Position of a permanent type of appliance on the patient. Fig. 230. A properly placed ileostomy, over which a permanent type of appliance fits correctly.
cent; fistula formation 22 per cent; postoperative hernia 4.2 per cent, and prolapse and ileal retraction in 3.5 per cent. It has been encouraging, however, that almost every year the number of patients with postoperative complications has decreased and during the past two years, with the use of the mucosal-grafted ileostomy, we have almost entirely eliminated any troublesome postoperative complication. In the light of our experience, there can be no question that the majority of patients with chronic nonspecific ulcerative colitis who require removal of the colon and establishment of an ileostomy can be returned to a useful and acceptable place in society. We can only hope that further study and experience with this disease will, at some future date, make it entirely a medical problem. The early reports from England on ileorectal anastomoses should be studied carefully. Our limited experience with this procedure to date does not permit us to express any opinion on its ultimate value in the treatment of this disease. Our past experience makes us extremely cautious at this time to adopt it as a general policy. REFERENCES 1. Abel, L.: Personal communication. 2. Aylett, S.: The avoidance of an ileostomy by ileo-rectal anastomosis. Proc. Roy. Soc. Med. 49: 952-956 (Nov.) 1956. 3. Brooke, B. N.: Management of patient with colostomy or ileostomy. Postgrad. Med. 30: 237-241 (May) 1954. 4. Colcock, B. P. and Mathiesen, W. L.: Complications of the surgical treatment of ulcerative colitis. A.M.A. Arch. Surg. 72: 399-404 (March) 1956. 5. Crile, G. Jr. and Turnbull, R. B. Jr.: Mechanism and prevention of ileostomy dysfunction. Ann. Surg. 140: 459-466 (Oct.) 1954 6. Lahey, F. H.: Advantages of a stab wound ileostomy. Surg., Gynec. & Obst. 95: 28-32 (July) 1952. 7. Patey, D. H.: Primary epithelial apposition in colostomy. Proc. Roy. Soc. Med. 44: 423-424 (June) 1951. 8. Swinton, N. W.: Management of ileostomies. Proc. Roy. Soc. Med. 49: 945-949 (Nov.) 1956. 9. Turnbull. R. B. Jr.: Mucosal grafted ileostomy. S. CLIN. NORTH AMERICA 36: 841-847 (Aug.) 1956.
Neil W. Swinton, Joseph R. Van Horne 10. Turnbull, R. B. Jr.: Colectomy with simultaneous ileostomy as the surgical treatment of diffuse ulcerative colitis. Surgery 41: 843-856 (May) 1957. 11. Warren, R. and McKittrick, L. S.: Ileostomy for ulcerative colitis: technique, complications and management. Surg., Gynec. & Obst. 93: 555-568 (Nov.) 1951. 12. Zetzel, L.: Medical progress: ulcerative colitis. New England J. Med. 251: 610615 (Oct. 7) 1954 and 653-658 (Oct. 14) 1954.
'P' .
The Management of Ileostomy NEIL W. SWINTON JOSEPH R. VAN HORNE
ILEOSTOMY is most commonly performed on patients with chronic nonspecific ulcerative colitis. Ileostomy followed or accompanied by total colectomy is the only known cure for this disease. 12 Many patients with ulcerative colitis are able to lead a relatively normal life under adequate medical supervision with a minimal amount of disability and without surgical intervention. However, the disease process persists in a quiescent phase either as a result of medical treatment or because of the natural tendency of the disease toward periods of remission. The generally quoted frequency of ileostomy and total colectomy in patients with chronic nonspecific ulcerative colitis is 15 to 20 per cent. At the clinic, in part due to the large number of patients referred primarily for surgical treatment who have had excellent medical treatment elsewhere, this figure has been over 40 per cent. It is not the purpose of this presentation to review in detail the indications for ileostomy and colectomy. The necessity of surgical intervention for those patients with an acute fulminating form of the disease who do not respond rapidly to medical measures, those with severe hemorrhage, perforation, obstruction, fistulas, stricture, associated malignancy or arthritis is well recognized. We are increasingly impressed, however, with the necessity of considering an elective ileostomy and colectomy to prevent "chronic invalidism" in these patients. For many the disability and the economic distress to the patients, their families, and frequently their friends may reach such proportions that ileostomy and total colectomy must be considered. At the Westminster Hospital Teaching Group, the Gordon Hospital in London, an appreciable number of patients with chronic nonspecific ulcerative colitis have now undergone colectomy and ileorectal anasto-
837
838
Neil W. Swinton, Joseph R. Van Horne
mosis. These patients have had a careful follow-up since 1952. Aylett2 and Abell reported very encouraging results. There has been little or no experience with the method in this country to date. The experiences at the Gordon Hospital so far are encouraging and it may be that in the future ileorectal anastomosis with preservation of the rectum and the avoidance of a permanent ileostomy may be feasible in selected cases. It must be pointed out, however, that on the basis of our present knowledge of this disease, the pathologic process in the retained rectum will always persist even though in a quiescent phase. In our experience, it has been possible to re-establish intestinal continuity following an ileostomy and partial colectomy in only a small number of patients with chronic ulcerative colitis. There can be no question that in recent years the improvements in the surgical technique and in the management of patients with permanent ileostomies have reached a stage where the majority can be restored to a useful and well-adjusted position in society with a minimal amount of disability resulting from the ileostomy. The most important factor in the successful management of the patient with an ileostomy is a properly constructed ileal stoma. Such a stoma must function adequately with minimal inconvenience to the patient and not become obstructed, develop fistula, retract or prolapse. OPERATIVE PROCEDURE
Three different types of ileostomies have been employed at the clinic: the double-barreled ileostomy, the divided ileostomy and the mucosalgrafted ileostomy. The Double-Barreled neostomy
This type has been used in the past only in patients with the most severe, fulminating phases of the disease, and although rarely employed at present, it has on occasion been a life-saving measure. It has the advantage of ease of performance with a minimum of intra-abdominal manipulation. A 3 to 4 inch right rectus muscle-splitting incision is made in the right lower quadrant with the upper margin of the incision at the level of the umbilicus. The distal ileum is visualized and a loop of ileum some 6 to 8 inches from the ileocecal valve proximal to the disease process is delivered into the wound. The loop is positioned in the lower portion of the incision so that the proximal limb is below the distal segment. Its mesentery is sutured to the free edges of the peritoneum with interrupted gut sutures after the bowel has been divided between clamps. The wound is carefully closed in layers. Tincture of benzoin or Vaseline gauze is applied to the skin for protection around the protruding loops of bowel, and a large, soft, rectal tube is placed in the ileostomy and secured with
The Management of Ileostomy
839
Fig. 218. Double-barreled ileostomy, allowing immediate decompression with rectal tube. Useful as an emergency procedure but requires later revision.
a purse-string suture. This rectal tube may be attached to a bottle for immediate decompression and drainage. It should begin functioning within 24 to 36 hours. The tube may be removed after a few days when the intestinal discharge becomes less profuse (Fig. 218). This is not a suitable permanent type of ileostomy and will require later revision. The Divided Ileostomy
This has been the type of operation most commonly used at the clinic in the past. It was designed primarily for the three-stage operation of ileostomy and total colectomy: stage 1, the divided ileostomy; stage 2, the removal of the colon down to the sigmoid with implantation of the sigmoid, and stage 3, the abdominoperineal resection. At present, with one or two stage procedures being employed in most instances, this operation has been replaced by the so-called mucosal-grafted ileostomy. The divided ileostomy is a permanent type and will not ordinarily require later revision. The abdomen is opened as in the operation for the double-barreled ileostomy, and the ileum delivered into the wound with as little manipulation of the intra-abdominal contents as possible. The mesentery of this loop is divided for about 3 inches with careful and separate ligation of its vessels. The mesenteric edge of the proximal limb is incised for a short distance at its mid portion to allow increased mobility of this segment and to lessen the tension of the proximal mesentery (Fig. 219). The bowel is then divided between clamps and the distal limb brought out through a stab wound above and to the right of the umbilicus (Fig. 220). It may subsequently be incorporated in the transverse incision which is ordinarily used for the later removal of the colon and implantation of the sigmoid. The proximal functioning limb is placed in the lower end of the wound. The divided mesentery is attached to the peritoneum with interrupted catgut sutures, care being taken not
840
Neil W. Swinton, Joseph R. Van Horne Fig. 219
Fig. 220
,,'
. . <:;) .....
..- .
'
Fig. 221
Fig. 222 Fig. 219. Divided ileostomy, showing delivery of loop of terminal ileum, and additional division of mesentery of proximal segment. Fig. 220. Divided ileostomy, showing position of distal limb in a stab wound above and to the right of the umbilicus. Proximal limb is placed in the lower portion of the wound. Fig. 221. Divided ileostomy, showing suture of mesentery of the functioning ileum to the peritoneum on each side. No suture is placed in intestinal wall. Fig. 222. Divided ileostomy, showing insertion of a soft rectal tube in functioning ileum.
to damage or constrict the blood supply of the bowel (Fig. 221). Sutures are never placed in the serosa of the intestine. The segment of ileum should be anchored so that at least 2 inches protrude above the level of the skin; this segment will eventually shrink to about half that length. A 1 inch projection of ileum from the abdominal wall will usually fit into the ileostomy appliance. The wound is carefully closed in layers and a
The Management of Ileostomy
Fig. 223
841
Fig. 224
Fig. 223. Stab-wound ileostomy, showing the functioning ileum b implanted in a lateral stab wound, and the nonfunctioning segment a placed in the upper angle of the wound, where it may later be removed in the transverse incision used for colectomy. (From Lahey, F. H.: Advantages of a stab wound ileostomy. Surg., Gynec. & Obst. 95: 28-32, July 1952.) Fig. 224. Stab-wound ileostomy, showing careful anchorage of mesentery of the functioning ileum by interrupted sutures of silk to parietal peritoneum of lateral wall and gutter. (From Lahey, F. H.: Advantages of a stab wound ileostomy. Surg., Gynec. & Obst. 95: 28-32, July 1952.)
large, soft, rectal catheter is inserted into the functioning limb of the ileostomy. This catheter may be removed in four to five days, and at a later date measurements are made for a permanent appliance (Fig. 222). A modification of this technique-the stab-wound ileostomy-was advocated by Dr. Lahey 6 in 1952. This procedure has the advantage of placing the permanent ileostomy distal to the wound incision and resultant scar. It was noted that the majority of patients gain an appreciable amount of weight following ileostomy and colectomy. This had caused difficulty in fitting a leakproof ileostomy appliance because the resulting scar was depressed by the adjacent bulging subcutaneous fat. By placing the permanent ileostomy in a circular stab lateral to the wound incision, about half way between the iliac spine and the umbilicus, this difficulty was avoided (Fig. 223). This principle has been adopted in the so-called mucosal-grafted technique. The abdominal incision is similar in position to that already described, but carried 1 or 2 inches above the level of the umbilicus. Before closure of the incision, the free edge of the mesentery of the functioning ileum is carefully anchored to the parietal peritoneum of the abdominal wall and lateral gutter by interrupted sutures of silk. This is a most important factor in the prevention of prolapse or retraction (Fig. 224).
842
Neil W. Swinton, Joseph R. Van Horne
The Mucosal-Grafted IleostonlY
This operation has been used almost exclusively over the past two and a half years for the majority of our patients with ulcerative colitis. Patey 7 in 1951 and Brooke3 in 1954 in England apparently were the first to suggest this technique. Crile and Turnbu1l6 have popularized it in this country. Turnbull's9.10 series of 50 consecutive cases reported in detail in 1956 revealed a significant decrease in the frequency of early and late postoperative complications with this method. The distressing occurrence after operation of fluid and electrolyte loss and the late complications of stricture at the skin margin seemed to be largely avoided with this method of performing an ileostomy. Our results have also indicated fewer immediate and late postoperative complications. Turnbull10 pointed out that the two major complications of the conventional type of ileostomy are attributed to a definite pathologic process which occurs in the ileostomy itself. A serositis of the exposed section of the ileum may spread throughout the entire wall of the protruding bowel, resulting in an ileitis with inflammatory rigidity and absence of peristalsis in this segment. This causes local obstruction in the early postoperative period with consequent loss of excessive quantities of fluid and electrolytes, especially sodium, postassium and chloride. The inflammatory process tends to spread to the adjacent skin edges and subcutaneous tissues, resulting in scarring and stricture formation at the junction of the skin and ileum. In the past this has frequently required surgical intervention. Advocates of the mucosal-grafted operation believe that this complication may be prevented by covering and protecting the serosa, exposed at the time of operation, with mucosa, thus obtaining primary healing between the mucosa and skin. A left paramedian incision is made, and the proximal ileal segment brought out through a circular stab wound in its usual position in the right lower quadrant. Colectomy may be performed at the same time but, if for any reason this is not feasible, the distal segment of ileum may be implanted in the primary incision. Between 2 and 3 inches of ileum is allowed to project beyond the skin. The divided edge of the mesentery is anchored securely to the parietal peritoneum up to the point of exit of the ileostomy (Fig. 225, a). If the colectomy is to be performed during this procedure, it is then carried out and the primary abdominal incision closed in layers. N ext the cut edge of the mesentery of the protruding ileum is ligated with a fine catgut suture about 1 inch above the level of the skin. With a finger in the ileostomy and a hemostat on the mesentery for traction, the seromuscular layer is divided both longitudinally and circumferentially by means of blunt scissors from a point about 1 cm. distal to the point of ligation of the mesentery. This seromuscular flap is teased away from the submucosal layer by blunt dissection (Fig. 225, b). After ligation of any bleeding points in the submucosa, the flap is trimmed and pulled
The Management of Ileostomy
b.
Fig. 225. a, Suture of remaining mesenteric border to the free edge of falciform ligament and lateral parietal peritoneum. b, Division of the seromuscular layer both circumferentially and longitudinally, and its separation from the submucosal layer c, Mucosubmucosal layer being folded oyer to be sutured to skin edge. (After R. B Turnbull, Jr., Surgical Clinics of North America, August, 1956.)
down over the serosa of the proximal 1 inch of protruding ileum and sutured with interrupted catgut sutures to the circular skin edge (Fig. 225, c). A protective ointment is applied to the skin, and a temporary plastic adhesive appliance, carefully cut to fit the protruding ileum, is immediately attached. No tube is inserted into the stoma. POSTOPERATIVE COMPLICATIONS
During the first few days following ileostomy certain phases of dysfunction may occur in many cases. The amount of fluid and electrolytes lost as a direct result of this ileus of the stoma may be excessive and serious. During this period which is critical in many cases, particular
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Neil W. Swinton, Joseph R. Van Horne
care must be taken to maintain adequate replacement of fluid and electolytes. If this is neglected, the most severely ill patients may die, and convalescence may be lengthened for many others. Mechanical intraabdominal obstruction of the small bowel may occur as an early or late complication. Failure to attach the ileal mesentery properly to the parietal peritoneum is the usual cause of kinking of the proximal ileum. If this condition does not respond rapidly to tube decompression, surgical intervention may be necessary. In our experience, several late complications have been common in patients with ileostomies of the conventional type. Periods of excessive fluid loss may occur at any time, even months and years after the initial operation. This loss may result from concurrent illnesses, dietary indiscretion or other causes. Patients should be forewarned of this possibility and advised that immediate medical attention or even hospitalization may be necessary within a few hours after excessive fluid loss. Usually the gentle passage of a well-lubricated gloved finger or soft rectal tube, or irrigation will correct the obstruction and dysfunction. However, hospitalization will be required for many patients, with a Miller-Abbott tube inserted in certain instances, and fluid and electrolytes rapidly replaced. Fistula formation may result from the irritation of an improperly fitted appliance, or from the inclusion of the ileal wall in a suture of any type at the time of operation. Chronic infection at the junction between the ileum and skin, in the underlying subcutaneous tissues, or in a hematoma of the ileal mesentery at this level may lead to fistula formation. Formation of a fistula at the skin level necessitates surgical revision. Prolapse of the protruding ileum is usually a late complication. It ordinarily results from either the inadequate fixation of the mesentery to parietal peritoneum or inadequate abdominal wall support around the ileum. The latter results from infection, excessive scar formation or the failure to close the wound meticulously in layers. The same factors may occasionally cause retraction of the ileostomy beneath the skin level. Both of these procedures require surgical revision, and it is usually best to make an entirely new ileostomy at a different site on the abdominal wall even though it may necessitate moving the stoma to the left lower quadrant. The protruding prolapsed ileum should never be excised; this does not correct the basic cause of the prolapse and further decreases the remaining amount of small intestine. Stricture formation at the skin level has been our most frequent complication. This is caused by the serositis and ileitis previously mentioned, and also by the development of a subacute and chronic infection of the tissues at the junction of the ileum and skin, with resultant contracting scar and stricture. When a stricture has developed, the ileal stoma should not be dilated excessively. This may lead to perforation of the ileum and fistula formation may result. When a fistula is well-developed,
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845
Fig. 226. An adaptation of Warren and McKittrick's method of dealing with skin stricture. (after Warren and McKittrick, Surgery, Gynecology and Obstetrics, November, 1951.)
excision of the scar with reapproximation of mucosa to skin after the method of Warren and McKittrickll is the procedure of choice (Fig. 226). If the entire colon has not been removed, massive hemorrhage may occur at any time after ileostomy. It must be appreciated that ileostomy eliminates the danger of hemorrhage from the retained portion of colon in only a small number of cases. When hemorrhage occurs, colectomy or abdominoperineal resection may be indicated as an emergency procedure. Skin irritation around the ileal stoma may be a distressing problem. If the ileostomy has been properly performed, and if, from the time of operation, the skin is protected with a properly fitting appliance so that the ileal discharge is not left in contact with the skin, irritation should not occur. It is important that some type of appliance be placed over the ileal stoma at the time of operation and changed as often as necessary to prevent skin irritation. It has been our policy at the time of operation to apply tincture of benzoin, or some other protective medication liberally to the skin surrounding the stoma, and to attach a carefully fitted plastic appliance over the stoma. Our nurses are instructed to see that this is changed as often as necessary to prevent the development of any skin reaction. After six or seven days more permanent appliances may be used. Karaya powder is an excellent skin protection after the ileum is completely healed. It should not be used early in the postoperative phase, as it may result in sloughing of the mucosa. Wound herniation may occur after ileostomy. If this becomes troublesome, complete revision and the construction of an ileal stoma at a different site in the abdominal wall may be required. We cannot overestimate the value of the help given by certain lay groups to our patients in their postoperative period of readjustment to health and resumption of their rightful position in society. In this country and in England groups of patients of both sexes who have had ileostomies have formed Q-T Clubs. This name is derived from the Q and T wards of the Mt. Sinai Hospital in New York where the idea originated. Monthly meetings are usually held by such clubs and these are enthusiastically attended. Based on the principle of group therapy, members discuss freely among themselves the many problems that an ileostomy may
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Neil W. Swinton, Joseph R. Van Horne
Fig. 228 Fig. 227 Fig. 227. Inexpensive plastic appliance which is applied on the operating table and can be cut to fit. This is changed as required during the immediate postoperative period. Fig. 228. More permanent types of appliances.
present in the process of day-to-day living. These discussions may concern adhesive cements, deodorants, methods of cleaning and proper care of appliances, nighttime problems and domestic readjustments. Some of these clubs issue monthly bulletins as well as a complete manual, which contains invaluable detailed information for any patient with an ileostomy. The number of ileostomy appliances that have been developed or suggested almost equals the number of patients who have undergone the operation. During the first postoperative week we routinely use an inexpensive plastic appliance with a two-faced adhesive layer at one end which may be cut out to fit the individual protruding ileum (Fig. 227). After the first week the more permanent types of appliances may be considered (Figs. 228, 229 and 230). In general, an adequate appliance is one that will adhere to the abdominal wall for at least 24 hours without leaking or becoming loose; it should be accident-proof day and night. It should be comfortable to the wearer and allow complete freedom of motion for all activities. It should also be inconspicuous under the patient's clothing, easy to clean, odor-proof, and reasonably economical. We have had extensive experience with cases of chronic nonspecific ulcerative colitis. 8 In 1956 we reported 4 a series of 871 patients, of whom 413, or 47 per cent, had required one or more surgical procedures. The immediate operative mortality in this group was 3.8 per cent. The postoperative complications were as follows: immediate or late obstruction of the small bowel in 43.6 per cent of cases; excessive fluid and electrolyte imbalance, both early and late, 12 per cent; skin irritation 15 per
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847
Fig. 230 Fig. 229 Fig. 229. Position of a permanent type of appliance on the patient. Fig. 230. A properly placed ileostomy, over which a permanent type of appliance fits correctly.
cent; fistula formation 22 per cent; postoperative hernia 4.2 per cent, and prolapse and ileal retraction in 3.5 per cent. It has been encouraging, however, that almost every year the number of patients with postoperative complications has decreased and during the past two years, with the use of the mucosal-grafted ileostomy, we have almost entirely eliminated any troublesome postoperative complication. In the light of our experience, there can be no question that the majority of patients with chronic nonspecific ulcerative colitis who require removal of the colon and establishment of an ileostomy can be returned to a useful and acceptable place in society. We can only hope that further study and experience with this disease will, at some future date, make it entirely a medical problem. The early reports from England on ileorectal anastomoses should be studied carefully. Our limited experience with this procedure to date does not permit us to express any opinion on its ultimate value in the treatment of this disease. Our past experience makes us extremely cautious at this time to adopt it as a general policy. REFERENCES 1. Abel, L.: Personal communication. 2. Aylett, S.: The avoidance of an ileostomy by ileo-rectal anastomosis. Proc. Roy. Soc. Med. 49: 952-956 (Nov.) 1956. 3. Brooke, B. N.: Management of patient with colostomy or ileostomy. Postgrad. Med. 30: 237-241 (May) 1954. 4. Colcock, B. P. and Mathiesen, W. L.: Complications of the surgical treatment of ulcerative colitis. A.M.A. Arch. Surg. 72: 399-404 (March) 1956. 5. Crile, G. Jr. and Turnbull, R. B. Jr.: Mechanism and prevention of ileostomy dysfunction. Ann. Surg. 140: 459-466 (Oct.) 1954 6. Lahey, F. H.: Advantages of a stab wound ileostomy. Surg., Gynec. & Obst. 95: 28-32 (July) 1952. 7. Patey, D. H.: Primary epithelial apposition in colostomy. Proc. Roy. Soc. Med. 44: 423-424 (June) 1951. 8. Swinton, N. W.: Management of ileostomies. Proc. Roy. Soc. Med. 49: 945-949 (Nov.) 1956. 9. Turnbull. R. B. Jr.: Mucosal grafted ileostomy. S. CLIN. NORTH AMERICA 36: 841-847 (Aug.) 1956.
Neil W. Swinton, Joseph R. Van Horne 10. Turnbull, R. B. Jr.: Colectomy with simultaneous ileostomy as the surgical treatment of diffuse ulcerative colitis. Surgery 41: 843-856 (May) 1957. 11. Warren, R. and McKittrick, L. S.: Ileostomy for ulcerative colitis: technique, complications and management. Surg., Gynec. & Obst. 93: 555-568 (Nov.) 1951. 12. Zetzel, L.: Medical progress: ulcerative colitis. New England J. Med. 251: 610615 (Oct. 7) 1954 and 653-658 (Oct. 14) 1954.
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