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198 Gorfine
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11
Ostomy Take-Down
Scott A. Strong
The Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A.
INTRODUCTION
Permanent and temporary ostomies have been historically employed for the
management of acute and chronic intestinal disorders. Over the last several
decades, we have witnessed a succession in the usage of fecal diversion,
with temporary stomas currently created more frequently than permanent
stomas in many surgical practices. This change comes as a result of many
factors, including improved blood transfusion techniques, safer anesthetic
agents, enhanced antimicrobial therapy, greater understanding of oncologi-
cal principles, and the development of revolutionary stapling instruments.
Furthermore, loop stomas have supplanted end ostomies in most instances
where temporary fecal diversion is warranted. Sepsis, radiation enteritis,
and inflammatory bowel disease previously mandated fecal diversion with
an end stoma because of risk introduced by an acute infectious process,
damaged tissue, or compromised immune function. However, most surgeons
have learned that they can safely perform a primary anastomosis in many
of these settings associated with a distinct risk for anastomotic leak and
intra-abdominal or pelvic sepsis if the procedure is accompanied by the
creation of a proximal loop stoma. Take-do wn of a tempo rary ostomy ,
whether it is created from small or large bowel as an end, end-loop, or
loop st oma, is associated with recognized morbidity dictated by myriad
factors, but the operative risk can be typically reduced to an acceptable
level with appropriate preoperative assessment and suitable operative
technique.
Timing of the Procedure
Take-down of a temporary stoma should be generally delayed until the
patient has returned to an acceptable state of health as evidenced by healthy
appetite, appropriate weight gain, relative lack of fatigue, and resumption of
203
204 Strong
preoperative activities. It is imperative that tissues have healed, infectious
processes have resolved, anemia has nearly corrected, and immunosuppres-
sive effects have been minimized.
Surgeons prefer to wait 3–6 months before takedown of an end os-
tomy when the distal limb is located remote from the stoma aperture and
8–12 weeks before closure of a loop stoma. Delay of the procedure is rarely
associated with adverse effects [1]. Furthermore, the ease and safety of the
operation generally correlate with the duration of delay [2–7]. If a patient
develops a condition that requires emergent or urgent laparotomy during
the interval between ostomy construction and planned closure, take-down
may be considered, assuming that the surgeon can adhere to the basic tenets
of anastomosis construction and that the distal bowel is devoid of lesions,
strictures, and perforations. If contamination or sepsis is encountered during
this urgent procedure, stoma closure is deferred until an appropriate length
of additional time has elapsed following the latest procedure.
Many patients with rectal cancer will be candidates for adjuvant che-
motherapy that is initiated 4–6 weeks after their initial procedure. While
most persons can tolerate stoma closure between chemotherapy cycles, the
oncologist may prefer that ostomy take-down be delayed until all therapy
has been completed. Conversely, an occasional patient will implore his or
her surgeon to reverse the stoma prior to achieving the above-mentioned
milestones, and the physician will ignore convention and acquiesce to the
individual’s request. This seemingly kind gesture can lead to disastrous re-
sults, because dense adhesions that mandate tedious and difficult dissection
through extended incisions may yet persist at the time of early stoma take-
down. Moreover, major complications can result that require reoperation
and rediversion for many additional months.
PREOPERATIVE ASSESSMENT
Any patient presenting for ostomy take-down should be diligently ques-
tioned and pertinent records should be reviewed. Specifically, the patient
must be quizzed regarding prior operative complications and complaints
indicative of pre-existing fecal incontinence, stool urgency, chronic diar-
rhea, inflammatory bowel disease, or severe irritable bowel syndrome. The
medical records—including operative notes, pathology reports, and discharge
summaries—will usually indicate the type and configuration of the stoma
as well as the presence of significant underlying diseases. Likewise, previ-
ous roentgenographic studies and endoscopy reports may provide relevant
information dictating the need for further evaluation. Additional preopera-
tive assessment of these individuals ought to be personalized but may in-
clude anorectal physiology testing, ultrasonic and radiographic imaging, as
well as endoscopic scrutiny.
Ostomy Take-Down 205
Anorectal Physiology Testing
During the preoperative assessment, some patients will confess that they
previously experienced incontinence to flatus or stool, while others will
provide a history of prior obstetrical injury, fistulotomy, or sphincterotomy
that may portend continence problems following stoma closure. In these
instances, as well as in the case of persons recovering from ileal pouch–
or coloanal anastomosis, anal manometry might be warranted to quantify
sphincter pressures. Although resting and squeeze pressure values correlate
poorly with function, low measurements can assist in cautionary counseling
and may provide an impetus for sphincteroplasty prior to ostomy takedown.
A competent sphincter is only one factor affecting continence. Normal
anorectal sensation, adequate rectal compliance and capacity, as well as
appropriate motility are also important. In a patient with a diseased rectum
or anal canal, the continence mechanism can be compromised, and stoma
closure will be likely associated with compromised quality of life. This
poor outcome can be predicted by assessing rectal compliance, tone, and
capacity in the anorectal physiology laboratory. Alternatively, if a person
is able to retain a 150-mL saline enema for at least 5 min, adequate conti-
nence without urgency is typically expected [8].
Imaging
Individuals suspected of pre-existing sphincter injury may also benefit from
endoanal ultrasonography to better visualize the internal and external sphinc-
ters over their entire length. Although the affected person may deny prior
problems with incontinence, surgical alterations in pelvic floor musculature,
rectal compliance, and anal canal sampling may complicate the pre-existing
sphincter injury and result in difficulties with fecal incontinence following
ostomy take-down. In these instances, repair of significant sphincter injur-
ies must be considered prior to stoma closure.
Contrast roentgenographic studies may provide useful information in
selected patients prior to stoma takedown. A small bowel series might be
warranted if a patient has suffered more than one episode of partial small
bowel obstruction during the period following stoma creation. In this sce-
nario, a formal laparotomy with enterolysis may be necessary at the time
of stoma closure to decrease the likelihood of subsequent obstructive epi-
sodes after reconstitution of the intestinal tract. A preoperative contrast
study may assist the surgeon in identifying potential transitional points. In
the instance where a loop jejunostomy has been created at the time of sur-
gery for enterocutaneous fistula or postoperative sepsis, a preoperative con-
trast study of the small bowel is imperative. Water-soluble contrast is in-
stilled through the stoma’s efferent limb and followed into the large bowel
to exclude any persistent bowel leaks or areas of distal obstruction.
206 Strong
Before closing a stoma designed to protect an anastomosis or perfora-
ted site, some surgeons routinely obtain contrast enemas, while others ques-
tion their utility. Following ileal pouch–anal anastomosis, routine contrast
enemas will detect a clinically occult leak in 8% of patients [9]. Moreover,
Tsao and colleagues from the Mayo Clinic found that abnormal findings in
a pouchogram prior to ostomy takedown signaled those persons at higher
risk for long-term pouch complications [10]. However, the same surgical
group subsequently reported that patients with asymptomatic pouch sinuses
can safely undergo stoma closure and experience long-term function as well
as a quality of life comparable to that of the person whose restorative proc-
tocolectomy was not complicated by a pouch sinus [11]. Therefore it would
appear that contrast enemas are indicated when the clinical history and
physical examination suggest a pouch complication, but their routine use
following ileal pouch–anal anastomosis may not be necessary. The role of
routine contrast enemas in patients with a stoma protecting colorectal or colo-
anal anastomoses is less clear, but similar principles can be likely applied.
Swenson and associates reported that contrast enemas in trauma pa-
tients failed to reveal unsuspected yet pertinent diagnoses, added unneces-
sary expenses and delays, and did not alter operative management [12]. Oth-
ers have reported similar findings, and the role of the contrast enema to assess
persistent rectal injury and confirm suspected fistulas remains controversial
[13–15].
Endoscopy
Endoscopy can be used prior to stoma take-down to assure lumen patency,
assess rectal compliance and capacity, exclude anastomotic defects, and
identify inflammatory changes. Diverted anastomoses below the peritoneal
reflection are commonly strictured by a web-like membrane that can easily
be disrupted with an examining digit or rigid endoscope. Once the proximal
stoma is closed, these strictures will usually remain dilated by the passage
of stool and rarely introduce long-term difficulties. Longer strictures often
herald anastomotic sepsis, radiation injury, and persistent or recurrent tu-
mor. These narrowings rarely respond to simple measures. Instead, associ-
ated complications must be sought and treated, with stoma closure post-
poned until an adequate lumen persists through a healed anastomosis.
Preoperative endoscopy will often identify diversion proctocolitis,
which typically accompanies fecal diversion when the large bowel mucosa
is deprived of its principal nutrients, short-chain fatty acids, contained within
the stool. Nearly 70% of diverted persons will develop diversion proctocolitis,
the presence of which is unrelated to pre-existing conditions, stoma configura-
tion, or duration of diversion [16,17]. This chronic inflammatory condition
fortunately introduces no additional morbidity to stoma take-down and re-
solves soon after the fecal stream is reintroduced to the colonocytes.
Ostomy Take-Down 207
PREPARATION
Because American Society of Anesthesiologists (ASA) classification, dia-
betes, and steroid usage are independent predictors of operative morbidity
in stoma patients, comorbid conditions must be considered and treated ap-
propriately prior to ostomy take-down [5,18–20]. Similarly, physiological
deficits such as anemia, dehydration, electrolyte abnormalities and malnu-
trition ought to be corrected [18]. Antiplatelet medications must be with-
drawn more than 10 days preoperatively, and anticoagulants should be
managed as allowed by the underlying disorder.
Stress-dose steroids are indicated for anyone treated with steroids dur-
ing the past 9 months, and prophylaxis against deep venous thrombosis is
generally warranted [21]. Moderate-risk individuals ought to be prophylaxed
against deep venous thrombosis with intermittent pneumatic compression
boots or low-dose unfractionated heparin. For high-risk surgery patients,
recognized guidelines recommend thrombosis prophylaxis with low-dose
unfractionated heparin, low-molecular-weight heparin, or intermittent pneu-
matic compression. High-risk patients with a greater than usual risk of
bleeding should be initially prescribed intermittent pneumatic compression
boots, with heparin therapy considered during the postoperative period. In
highest-risk patients with multiple risk factors, low-dose unfractionated
heparin or low-molecular-weight heparin is usually combined with inter-
mittent pneumatic compression boots.
Patients scheduled for ileostomy closure rarely require mechanical
cleansing of the intestine, whereas mechanical colonic preparation is war-
ranted for colostomy take-down. Accordingly, a clear liquid diet and poly-
ethylene glycol (4 L) or Fleet phospho-soda (90 mL) is prescribed the day
before surgery with no oral intake allowed after midnight. In persons in
whom the distal bowel is to be used for an anastomosis, a saline washout
of the rectum through a large rectal catheter is employed after the patient
has been anesthetized. Although opinions vary on the optimal antibiotic
prophylactic regimen, most pundits would agree that coverage directed
against enteric pathogens ought to be provided parenterally prior to skin
incision [22,23].
OPERATIVE TECHNIQUE
End Stoma
End stomas can be created from small or large bowel, and the distal limb
may be located adjacent to or remote from the ostomy site. In instances
where the distal limb is located near the ostomy site, the operation is con-
ducted similarly to that described further on for take-down of a loop stoma.
Otherwise, a formal laparotomy is required and the patient is positioned in