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An ileostomy is a surgical opening constructed by bringing the end or loop of small intestine (the ileum) out onto the surface of the skin. Intestinal waste passes out of the ileostomy and is collected in an external pouching system which is adhered to the skin. Ileostomies are usually sited above the groin on the right hand side of the abdomen.
Ileostomies are slowly being replaced by the now preferred alternative Ileo-anal pouch, J-Pouch, or Barnett continent intestinal reservoir. This surgery turns part of the small intestine into an internal reservoir, thus eliminating the need for an external appliance.
In some patients with Crohn's disease, they have a procedure called an ileorectal anastomosis, which is done if Crohn's disease attacks the entire large intestine but stays away from the rectum. In this procedure, the entire large intestine is surgically removed, but the rectum is left intact. The ileum is then stitched to the rectum to allow fecal matter to go through the rectum just as it did when the patient had a large intestine. One disadvantage to this procedure is that bowel movements become more frequent and the faecal matter may appear greenish because they no longer have a large intestine to extract the water. However, with certain adjustments, those who have had this procedure for their Crohn's disease can resume normal bowel movements.
Ileostomies are necessary where injury or a surgical response to disease has rendered the large intestine incapable of safely processing intestinal waste, typically because the colon has been partially or wholly removed.
Diseases of the large intestine which may require surgical removal include Crohn's disease, ulcerative colitis, familial adenomatous polyposis, and total colonic Hirschsprung's disease. An ileostomy may also be necessary in the treatment of colorectal cancer. One example is a situation where the cancer tumor is causing a blockage. In such a case the ileostomy may be temporary, as the common surgical procedure for colorectal cancer is to reconnect the remaining sections of colon or rectum following removal of the tumor provided that enough of the rectum remains intact to preserve sphincter function.
In a temporary ileostomy, a loop of the small intestine is brought through the skin, and the colon and rectum are not removed. Temporary ileostomies are also often made as the first stage in surgical construction of an ileo-anal pouch, so fecal material doesn't enter the newly-made pouch until it heals and has been tested for leaks—usually a period of eight to ten weeks. The temporary ileostomy is then "taken down" (or reversed) by surgically repairing the loop of intestine which made the temporary stoma and closing the skin incision.
People with ileostomies must use an ostomy pouch to collect intestinal waste. People with ileostomies typically use an open-ended (referred to as a "drainable") one- or two-piece pouch that is secured at the lower end with a leakproof clip, or velcro fastener. The alternative is the less-preferred closed-end pouch that must be thrown away when full. Ordinarily the pouch must be emptied several times a day, and changed every 2–5 days for the two-piece pouches. The one piece pouch must be changed every twenty-four hours.
Ostomy pouches fit close to the body and are usually not visible under regular clothing unless the wearer allows the pouch to become too full. It is essential to have the stoma measured regularly as it changes in shape after the initial surgery. The stomal- or colorectal-nurse does this initially for a patient and advises them on the exact size required for the bag (pouch)'s opening.
Some people find they must make adjustments to their diet after having an ileostomy. Tough or high-fiber foods (for example: potato skins, tomato skins, and raw vegetables) are hard to digest in the small intestine and may cause blockages or discomfort when passing through the stoma. Chewing food thoroughly can help to minimize such problems. Some people also find that certain foods cause annoying gas or diarrhea. Many foods can change the color of the intestinal output, causing alarm —Beetroot, for instance, produces a red output that may appear to be blood. This is a discoloration only. Nevertheless, people who have an ileostomy as treatment for inflammatory bowel disease typically find they can enjoy a more "normal" diet than they could before surgery. Correct dietary advice is essential in combination with the patient's gastroenterologist and hospital approved dietician. Supplementary foods may be prescribed and liquid intake and output monitored to correct and control output. If output does contain blood at any time, an ileostomate is advised to visit the emergency department.
Since the late 1970s an increasingly popular alternative to an ileostomy has been the Barnett continent intestinal reservoir (or BCIR), commonly called a J-pouch (and sometimes ileo-anal pouch). The formation of this pouch (made possible through a procedure first pioneered by Dr. Nils Kock in 1969), involves the creation of an internal reservoir which is formed using the ileum and connecting it directly to the anus—after removal of the colon and rectum—avoiding the need for subsequent use of external appliances.
The Barnett continent intestinal reservoir, or J-pouch, is a type of an appliance-free intestinal ostomy. The BCIR was a modified Kock pouch procedure pioneered by Dr. William O. Barnett. It is a surgically created pouch, or reservoir, on the inside of the abdomen, made from the last part of the small intestine (the ileum), and is used for the storage of intestinal waste. The pouch is internal, so the BCIR does not require wearing an appliance or ostomy bag.
The pouch works by storing the liquid waste, which is drained several times a day using a small silicone tube called a catheter. The catheter is inserted through the surgically created opening on the abdomen into the pouch called a stoma. The capacity of the internal pouch increases steadily after surgery: from 50ccs, when first constructed, to 600–1000ccs (about one quart) over a period of months, when the pouch fully matures.
The opening through which the catheter is introduced into the pouch is called the stoma. It is a small, flat, button-hole opening on the abdomen. Most patients cover the stoma site with a small pad or bandage to absorb the mucus that accumulates at the opening.[Note 1] This mucus formation is natural, and makes insertion of the catheter easier. The BCIR requires no external appliance and it can be drained whenever it is convenient. Most people report draining the pouch 2–4 times a day, and most times they sleep through the night. This can vary depending on what kinds and quantities of food eaten. The process of draining the pouch is simple and quickly mastered. The stoma has no nerve endings, and inserting the catheter is not painful. The process of inserting the catheter and draining the pouch is called intubation and takes just a few minutes.
Finnish surgeon Dr. Nils Kock developed the first intra-abdominal continent ileostomy in 1969. This was the first continent intestinal reservoir. By the early 1970s, several major medical centers in the United States were performing Kock pouch ileostomies on patients with ulcerative colitis and familial polyposis. One problem with these early Kock pouches was valve slippage, which often resulted in difficulty intubating and an incontinent pouch. As a result, many of these pouches had to be revised or removed to allow a better quality of life.
The late Dr. William O. Barnett began modifying the Kock pouch in 1979. He believed in the concept of the continent reservoir, but was disappointed with the valve's relatively high failure rate. Barnett was intent on solving the problem.[Note 2] His first change was in the construction of the nipple valve. He changed the direction of flow within this segment of intestine to keep the valve in place. This greatly improved the success rate.[Note 3] In addition, he used a plastic material called Marlex to form a collar around the valve. This further stabilized and supported the valve, decreasing valve slippage. This technique worked well, but after several years, the intestine reacted to the Marlex by forming fistulae (abnormal connections) into the valve. Dr. Barnett continued his investigation in an effort to improve these results. After much effort, the idea came to him—a "living collar" constructed from the small intestine itself. This technique made the valve more stable and eliminated the problems the Marlex collars had presented.
After a test series of over 300 patients, Dr. Barnett moved to St. Petersburg, Florida where he joined the staff of Palms of Pasadena Hospital, where he trained other surgeons to perform his continent intestinal reservoir procedure. With the assistance of Dr. James Pollack, the first BCIR Program was established. Both surgeons further enhanced the procedure to bring it to where it is today. These modifications included reconfiguring the pouch to decrease the number of suture lines from three to one (this allowed the pouch to heal faster and reduced the chance of developing fistulae); and creating a serosal patch over the suture lines which prevented leakage.[Note 4] The end result of these developments has been a continent intestinal reservoir with minimal complications and satisfactory function.
Ulcerative colitis and familial adenomatous polyposis are the two main health conditions that lead to removal of the entire colon (large intestine) and rectum, which leads to the need for an ileostomy.[Note 5]
Candidates for BCIR include: people who are dissatisfied with the results of an alternate procedure (whether a conventional Brooke ileostomy or another procedure); patients with a malfunctioning/failed Kock pouch or IPAA/J-pouch; and individuals with poor anal sphincter control who either elect not to have the J-pouch (IPAA) or are not a good candidate for IPAA.
There are, however, some contraindications for having the BCIR surgery. BCIR is not for: people who have or need a colostomy; people with [active] Crohn's disease, mesenteric desmoids, obesity, advanced age, or poor motivation.
When Crohn's disease only affects the colon, it may, in select cases, be appropriate to perform a BCIR as an alternative to a conventional ileostomy. If the small intestine is affected, however, it is not safe to have the BCIR (because the internal pouch is created out of the small intestine, which must be healthy).
A patient must have an adequate length of small intestine to be considered a potential candidate.
A 1995 study by the American Society of Colon and Rectal Surgeons included 510 patients who received the BCIR procedure between January 1988 and December 1991. All patients were between 1–5 years post-op with an admitting diagnosis of ulcerative colitis or familial polyposis. The study was published in Diseases of the Colon and Rectum in June 1995. The study found that:
In 1999 American Society of Colon and Rectal Surgeons published a unique study on 42 patients with a failed IPAA/J-pouch who converted to the Barnett modification of the Kock pouch (BCIR). The authors noted that their study was significant in the very large number of patients, approximately 6 times more than studied by any previous author. The study was published in Diseases of the Colon and Rectum in April 1999. The study found: