Managing the risk of complications following stoma reversal surgery

The closure of a temporary stoma, whether a colostomy or ileostomy, may be eagerly awaited by the stoma patient and encouraged by the surgeon. However, the procedure is not without risk, complications of stoma reversal may include disruptive bowel changes, wound infection, sepsis and death. The decision to restore intestinal continuity is often underestimated, and the reversal of a colostomy after a Hartmann's procedure implies a high mortality and low percentage of restoration of intestinal continuity. In this article, Pat Black assesses the effects of colostomy and ileostomy reversal on patient outcome.

The implications of stoma reversal on patient outcome

Black

2011

Reversal of Ileostomy following elective anterior resection for rectal cancer: a review of current practice

Jackson

Barnwell

2014

Anterior resection for rectal cancer is typically performed with a covering temporary loop ileostomy. The authors carried out a review of practice to assess the timing of ileostomy reversal following anterior resection to determine if the patient information was accurate. Although the review was small, the findings correlated to those of previous larger studies. The median length of time for reversal was 5 months, which was longer than expected, and 9 months if patients required chemotherapy However, 11% of patients were found not to have their temporary ileostomy reversed. Fewer patients—28.6%—had an ileostomy than previously thought following anterior resection. This review has resulted in a change of practice, with patients being offered reversal in 3–4 months following anterior resection or on completion of chemotherapy. Patients are now contacted by their clinical nurse specialist before their reversal and provided with pre- and postoperative information, advice, and support to manage the effects of bowel dysfunction.

Temporary loop ileostomy or permanent end colostomy for low rectal cancer: making the right choice

Skipper

2019

Low rectal cancer is treated by surgical removal of part of the colon via abdominoperineal resection (APR), ultra-low Hartmann's (ULH) or low anterior resection (LAR), followed by stoma formation. APR and ULH always result in a permanent end colostomy. LAR usually results in anastomosis with a defunctioning loop ileostomy, which can be reversed to restore mostly normal bowel function, making it the procedure of choice. A stoma can be difficult to manage, getting more so with age or infirmity, and complications are frequent, so a temporary stoma is generally preferable for a patient's wellbeing. However, a loop ileostomy is usually more problematic than a permanent colostomy, with greater chance of high output. Meanwhile, reversal surgery is not guaranteed, carries some risk and often results in reduced bowel function. The colorectal multidisciplinary team (MDT) and, in elective surgery, the patient, must decide which is the most appropriate option. The stoma care nurse (SCN) has a vital role in providing pre-operative assessment, supporting informed decision making and siting the stoma, as well as postoperative follow up and support up to and following stoma reversal.