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48 Taylor and Pemberton
Table 2 Daily Fecal Bile Acid Excretion After Proctocolectomy
Surgical procedure n Acid loss Comments
Brooke ileostomy 16 150–300 Some had ileal resection [19]
Brooke ileostomy 10 235–1070 Some had ileal resection [20]
Brooke ileostomy 5 mean 400 mg/kg/day [32]
Continent ileostomy 5 mean 550 mg/kg/day [32]
Continent ileostomy 5 mean 1400 With ileal resection [32]
Health controls ≤500
Source: From Phillips SF. Biological effects of a reservoir at the end of the small
bowel. World J Surg 11:763, 1987. Modified with permission of the author.
Abnormal and borderline Schilling tests have been reported in patients
with a continent ileostomy [48,49]. However, vitamin B
12
absorption is gen-
erally unimpaired, and any defect in this absorption is often transient. Fur-
thermore, serum plasma levels of vitamin B
12
tend to be normal. Active
absorption of vitamin B
12
and intrinsic factor has been demonstrated by
instillation of the complex into the reservoir of patients with intact ileal
segments [49]. Gadacz et al. [49] postulated that the prolonged contact time
between the intestinal contents and the ileal mucosa may enhance vitamin
B
12
absorption. Thus construction of a Kock pouch does not predispose the
patient to vitamin B
12
malabsorption unless the terminal ileum has been
removed.
Schjonsby et al. [55] found increased concentrations of Bacteroides
in the continent ileostomy effluent, compared to conventional ileostomy, to
be associated with vitamin B
12
malabsorption. These patients with “stagnant
Table 3 Fecal Weight and Excretion of Fat After Proctocolectomy
Fecal weight Fecal fat
Surgical procdures n (g/24 hr) (g/24 hr)
Continent ileostomy [24]
Excellent results 29 616 ± 27 4.6 ± 0.5
Diarrhea/pouchitis 13 1405 ± 57 9.6 ± 2.1
Brooke ileostomy [24] 19 651 ± 44 3.4 ± 0.4
Health <250 <7.0
Source: From Phillips SF. Biological effects of a reservoir at the end of the
small bowel. World J Surg 11:763, 1987. Modified with permission of the
author.
Stoma Physiology 49
loop syndrome” received oral lincomycin and had improvement of vitamin
B
12
absorption, decreased fecal fat excretion, and decreased concentrations
of ileal Bacteroides.
Continent Ileostomy Motility
Kock designed the continent ileal reservoir in such a way that the motor
activity within its different parts might offset themselves [56]. Subse-
quently, patterns of small bowel motility within the pouch have been further
studied [57]. Small intraluminal pressure waves (amplitude < 10 cmH
2
O;
frequency 5–7 min) constituted the basal motor activity; which was similar
to the normal terminal ileal motor pattern. However, with distention of the
pouch to > 60% of its maximum capacity, high-pressure waves (HPW; am-
plitude > 25 cmH
2
O; frequency 1 every 3 min) were superimposed on the
basal motor pattern. These waves were associated with fullness and discom-
fort. The authors concluded that the ileum is able to accommodate large
intraluminal volumes with only small incremental increases in intraluminal
pressure.
COLOSTOMY
General
Approximately 1500–2000 mL of fluid and 120 mEq of sodium are passed
daily from the ileum to the colon. The colon secretes little fluid to add to
this volume; rather, the colon stores the fecal content and slowly propels
the stool in a caudad direction for eventual evacuation. During the passage
of stool from the right to the left colon, absorption is so efficient that less
than 200 mL of water and 25 mEq of sodium are expelled daily in the
feces. To a lesser extent, the colon absorbs bile acids not absorbed in the
terminal ileum. However, ileal resection predisposes the patient to exces-
sive colonic bile acids, which promote secretion of water and electrolytes.
When a colostomy first begins to function, the output is liquid. The
liquid steadily increases in volume and is expelled on an irregular basis.
After 10–14 days the consistency of the effluent becomes quite viscous.
Slowly, a pattern of stool evacuation develops and the stool is expelled on
a more predictable basis.
In general, the diet of a patient with a colostomy should be unrestric-
ted. The patient soon recognizes specific foods that increase stomal output
or flatulence. As in the case of an ileostomy, high-fiber foods increase fecal
weight. If sufficient colonic absorptive surface is preserved proximal to the
colostomy, dehydration and electrolyte disturbances are rarely matters of
concern.
Medications introduced through the stoma are readily absorbed. The
exceptions are enteric-coated or time-release formulas, which may be ex-
50 Taylor and Pemberton
pelled before adequate absorption has occurred. This situation is more of a
problem with proximal colostomies, in which excretion is common.
Proximal Colostomy
Ileal content that enters the right colon is predominately liquid. The right
colon is important for mixing the ileal effluent to facilitate water and elec-
trolyte absorption through uniform exposure of the luminal contents to the
mucosal surface. The cecum and the ascending colon store and knead the lu-
minal contents through a series of antiperistaltic annular contractions. The
proximal colon is the origin of giant migrating contractions responsible for
mass movements of luminal contents distally [58]. Constructing an ascend-
ing or proximal transverse colostomy interferes with the storage and mixing
of stool and reduces the absorptive capacity of the colon. Hence the output
from these stomas is a high-volume liquid effluent with a high sodium
concentration. Fecal material is expelled from a right-sided colostomy on a
frequent and irregular basis, which allows little or no planned control of
stomal output. For these and other reasons, right-sided colostomies should
be avoided whenever possible.
Middle Colostomy
The midcolon is responsible for transit and absorption of the luminal con-
tents. The motor activity is characterized by annular contractions that divide
the fecal mass and propel it distally and proximally in a to-and-fro fashion.
The construction of a distal transverse or descending colostomy increases
the length of absorptive surface and allows enhanced colonic mixing of
the fecal material. Sodium is actively absorbed, thereby generating osmotic
gradients that facilitate passive absorption of water. Hence the effluent from
distal transverse and descending colostomies is lower in volume and less
liquid than that from proximal colostomies (Fig. 1).
Distal Colostomy
The distal colon functions primarily as a storage area for fecal material
until willful defecation occurs at an appropriate time. Infrequent strong con-
tractions in the distal colon, which are occasionally sensed by the patient,
facilitate caudal propagation of fecal material [58]. The consistency of the
fecal matter reaching the distal colon is ordinarily semisolid to solid in
nature. After construction of an end-sigmoid colostomy, the colonic contents,
composed of unabsorbed food products and bacteria, are expelled , usually no
more than once or twice a day. Hence regulation of stool elimination from a
distal colostomy through the use of irrigation techniques is often possible.
Irrigation initiates colonic distention, which stimulates colonic peristalsis and
mass contractions and thus facilitates stool evacuation [59].
Stoma Physiology 51
Fecal volumes in a sigmoid colostomy approximate the losses from
an intact colon. Like the small intestine, the colon adapts to increased fluid
losses from the gastrointestinal tract via aldosterone-mediated fluid and so-
dium resorption by the colonic epithelium [60]. Thus fluid and metabolite
homeostasis is facilitated by preservation of the colon proximal to the co-
lostomy, with active participation of the colon in the correction of volume
and salt depletion.
CONCLUSION
The small intestine and colon are critical organs that play a central role in
maintaining fluid and electrolyte homeostasis. Nearly all patients adapt to
the physiological changes caused by the creation of an intestinal stoma
provided that there is sufficient healthy proximal intestine. Metabolic dis-
turbances in patients with stomas are often subtle and develop gradually.
Careful attention to fluid and electrolyte balance is therefore necessary to
preclude complications related to intestinal diversion. Nonetheless, the met-
abolic consequences of creating an intestinal stoma are minor and, by them-
selves, rarely alter the patient’s lifestyle dramatically.
SUGGESTED READINGS
Hill GL. Ileostomy: Surgery, Physiology and Management. New York: Grune and
Stratton, 1976. This comprehensive review of the original physiological stud-
ies of conventional ileostomies is a required reference for stomal physiology.
Pemberton JH. Management of conventional ileostomies. World J Surg 1988; 12:
203–210. Provides a concise review of the normal and abnormal physiologi-
cal effects of a conventional stoma.
Phillips SF. Biological effects of a reservoir at the end of the small bowel. World
J Surg 1987; 11:763–768. Offers an excellent review of normal terminal ileal
physiology and the pathophysiological effects of constructing a reservoir.
REFERENCES
1. Tang CL, Yunos A, Leong APK, Seow-Choen F, Goh HS. Ileostomy output
in the early post-operative period. Br J Surg 1998; 82:607–608.
2. Hill GL. Ileostomy: Surgery, Physiology, and Management. New York:
Grune and Stratton, 1976:65.
3. Brooke BN. Management of ileostomy including its complications. Lancet
1952; 2:102–104.
4. Crile G Jr, Turnbull RB. The mechanism and prevention of ileostomy dys-
function. Ann Surg 1954; 140:459–466.
5. Hill GL, Millward SF, King RFGJ, Smith RC. Normal ileostomy output:
close relation to body size. Br Med J 1979; 2:831–832.
52 Taylor and Pemberton
6. Ladas SD, Isaacs PE, Murphy GM, Sladen GE. Fasting and post-prandial
ileal function in adapted ileostomates and normal subjects. Gut 1986; 27:
906–912.
7. Hallgren T, Oresland T, Andersson H, Hulten L. Ileostomy output and bile
acid excretion after intraduodenal administration of oleic acid. Scand J Gas-
troenterol 1994; 29:1017–1023.
8. Steinhart AH, Jenkins DJA, Mitchell S, Cuff D, Prokipchuk EJ. Effect of
dietary fiber on total carbohydrate losses in ileostomy effluent. Am J Gas-
troenterol 1992; 87:48–54.
9. MacGregor IL, Wiley ZD, Sleisenger MH. The role of bile acids in determin-
ing ileal flow rates in normal subjects and following ileostomy. Digestion
1978; 18:192–200.
10. Hulten L, Kewenter J, Persson E, Ahren C. Vitamin B
12
absorption in ileos-
tomy patients after operation for ulcerative colitis. Scand J Gastroenterol
1970; 5:113–116.
11. Kramer P. The effect of varying sodium loads on the ileal excreta of human
ileostomized subjects. J Clin Invest 1966; 45;1710–1718.
12. Soybel DI. Adaptation to ileal diversion. Surgery 2001; 129:123–127.
13. Huber F-X, Stern J, Hinz U, Werle E, Haack D, Kienle P, Heuschen U, Aul-
mann M, Decker-Baumann C, Herfarth C. Effects of restorative proctocolec-
tomy on renal and adrenal function . Dis Colo n Rect um 1999; 42:1318–1324.
14. Svaninger G, Nordgren S, Palselius IRN, Fasth S, Hulten L. Sodium and
potassium excretion in patients with ileostomies. Eur J Surg 1992; 157:601–
605.
15. Chrsitie PM, Knight GS, Hill GL. Metabolism of body water and electrolytes
after surgery for ulcerative colitis. Br J Surg 1990; 77:149–151.
16. Moss S, Gordon D, Forsling ML, Peart WS, James VH, Roddis SA. Water
and electrolyte composition or urine and ileal fluid and its relationship to
renin and aldosterone during dietary sodium deprivation in patients with
ileostomies. Clin Sci 1981; 61:407.
17. Unwin RJ, Moss S, Peart WS, Wadsworth J. Renal adaptation and gut hor-
mone release during sodium restriction in ileostomized man. Clin Sci 1985;
69:299–308.
18. Sutters M, Carmichael DJ, Unwin RJ, Sozi C, Hunter M, Calam J, Lightman
SL, Peart WS. “Low sodium” diuresis and ileal loss in patients with ileosto-
mies: effect of desmopressin. Gut 1991; 32:649–653.
19. Gallagher ND, Harrison DD, Skyring AP. Fluid and electrolyte disturbances
in patients with long-established ileostomies. Gut 1962; 3:219–222.
20. Hill GL, Mair WSJ, Goligher JC. Cause and management of high volume
output salt-depleting ileostomy. Br J Surg 1975; 62:720–726.
21. Hill GL, Mair WSJ, Goligher JC. Impairment of “ileostomy” adaptation in
patients after ileal resection. Gut 1974; 15:982–987.
22. Neal DE, Williams NS, Barker MC, King RF. The effect of resection of the
distal ileum on gastric emptying, small bowel transit and absorption after
proctocolectomy. Br J Surg 1984; 71:666–670.
23. Kelly DG, Branon ME, Phillips SF, Kelly KA. Diarrhea after continent ileos-
tomy. Gut 1980; 21:711–716.
Stoma Physiology 53
24. Taylor BM, Cranley B, Kelly KA, Phillips SF, Beart RW, Dozois RR. A
clinicophysiological comparison of ileal pouch-anal and straight ileoanal
anastomosis. Ann Surg 1983; 198:462–468.
25. Cooper JC, Laughland A, Gunning EJ, Burkinshaw L, Williams NS. Body
composition in ileostomy patients with and without ileal resection. Gut 1986;
27:680–685.
26. Soper NJ, Orkin BA, Kelly KA, Phillips SF, Brown ML. Gastrointestinal
transit after proctocolectomy with ileal pouch-anal anastomosis or ileostomy.
J Surg Res 1989; 46:300–305.
27. Pemberton JH, van Heerden JA, Beart RW Jr, Kelly KA, Phillips SF, Taylor
BM. A continent ileostomy device. Ann Surg 1983; 197:618–626.
28. Bruewer M, Stern J, Herrmann S, Senninger N, Herfarth C. Changes in intes-
tinal transit time after proctocolectomy assessed by the lactulose breath test.
World J Surg 2000; 24:119–124.
29. Mibu R, Itoh H, Nakayama F. Effect of total colectomy and mucosal proctec-
tomy on intestinal absorptive capacity in dogs. Dis Colon Rectum 1987; 30:
47–51.
30. Wright HK, Cleveland JC, Tilson MD, Herskovic T. Morphology and absorp-
tive capacity of the ileum after ileostomy in man. Am J Surg 1969; 117:
242–245.
31. Holgate AM, Read NW. Relationship between small bowel transit time and
absorption of a solid meal: influence of metaclopramide, magnesium sulfate,
and lactulose. Dig Dis Sci 1983; 28:812–819.
32. Gorbach SL, Nahas L, Weinstein L, Levitan R, Patterson JF. Studies of intes-
tinal microflora. IV. The microflora of ileostomy effluent: a unique microbial
ecology. Gastroenterology 1967; 53:874–880.
33. Scott R, Freeland R, Mowat W, Gardiner M, Hawth orn e V, Marshall RM, Ives
JG. The prevalence of calcified upper urinary tract stone disease in a random
population—Cumbernauld Health Survey. Br J Urol 1977; 49:589–595.
34. Smith LH. Application of physical, chemical and metabolic factors to the
management of urolithiasis. In: Fleisch H, Robertson WG, Smith LH, Vahlen-
sleck W, eds. Urolithiasis Research. New York: Premium Press, 1976:199–
211.
35. Christie PM, Knight GS, Hill GL. Comparison of relative risks of urinary
stone formation after surgery for ulcerative colitis: conventional ileostomy
vs. J-pouch. A comparison study. Dis Colon Rectum 1996; 39:50–54.
36. Miettinen TA, Peltokallio P. Bile salt, fat, water, and vitamin B
12
excretion
after ileostomy. Scand J Gastroenterol 1971; 6:543–552.
37. Huibregtse K, Hoek F, Sanders GT, Tytgat GN. Bile acid metabolism in
ileostomy patients. Eur J Clin 1977; 7:137–140.
38. Ritchie JK. Ileostomy and excisional surgery for chronic inflammatory dis-
ease of the colon: a survey of one hospital region. I. Results of complications
of surgery. Gut 1971; 12:528–540.
39. Kurchin A, Ray JE, Bluth EI, Merritt CR, Gathright JB, Pehrsson BF, Ferrari
BT. Cholelithiasis in ileostomy patients. Dis Colon Rectum 1984; 27:585–588.
40. Philips SF. Biological effects of a reservoir at the end of the small bowel.
World J Surg 1987; 11:763–768.
54 Taylor and Pemberton
41. Kelley DG, Branon ME, Phillips SF, Kelly KA. Diarrhoea after continent
ileostomy. Gut 1980; 21:711–716.
42. Kelly DG, Phillips SF, Kelly KA, Weinstein WM, Gilchrist MJ. Dysfunction
of the continent ileostomy: clinical features and bacteriology. Gut 1983; 24:
193–201.
43. Sandborn WJ, Tremaine WJ, Batts KP, Pemberton JH, Rossi SS, Hofmass
AF, Gores GJ, Philips SF. Fecal bile acids, short-chain fatty acids, and bacte-
ria after ileal pouch-anal anastomosis do not differ in patients with pouchitis.
Dig Dis Sci 1995; 40:1474–1483.
44. Go PM, Lens J, Bosman FT. Mucosal alterations in the reservoir of patients
with Kock’s continent ileostomy. Scand J Gastroenterol 1987; 22:1076–1080.
45. Nilsson LO, Kock NG, Lindgren I, Myrvold HE, Philipson BM, Ahren C.
Morphological and histochemical changes in the mucosa of the continent
ileostomy reservoir 6–10 years after its construction. Scand J Gastroenterol
1980; 15:737–747.
46. Cox CL, Butts DR, Roberts MP, Wessels RA, Bailey HR. Development of
invasive adenocarcinoma in a long-standing Kock continent ileostomy. Re-
port of a case. Dis Colon Rectum 1997; 40:500–503.
47. Heuschen UA, Heuschen G, Autschbach F, Allemeyer EH, Herfarth C. Ade-
nocarcinoma in the ileal pouch: late risk of cancer after restorative proctoco-
lectomy. Int J Colorectal Dis 2001; 16:126–130.
48. Jagenburg R, Dotevall G, Kewenter J, Kock NG, Philipson B. Absorption
studies in patients with “intra-abdominal ileostomy reservoirs” and in patients
with conventional ileostomies. Gut 1971; 12:437–441.
49. Gadacz TR, Kelly KA, Phillips SF. The continent ileal pouch: absorptive and
motor features. Gastroenterology 1977; 72:1287–1291.
50. Ojerskog B, Andersson H, Bosaeus I, Brevinge H, Nilsson LO. Total body
water and total body potassium in ileostomy patients before and after conver-
sion to the continent ileostomy. Gut 1988; 29:1198–1201.
51. Kay RM, Cohen Z, Siu KP, Petrunka CN, Strasberg SM. Ileal excretion and
bacterial modification of bile acids and cholesterol in patients with continent
ileostomy. Gut 1980; 21:128–132.
52. Nilsson LO, Andersson H, Hulten L, Jagenburg R, Kock NG, Myrvold HE,
Philipson B. Absorption studies in patients six to 10 years after construction
of ileostomy reservoirs. Gut 1979; 20:499–503.
53. Hylander E, Ladefoged K, Nielsen ML, Nielsen OV, Thale M, Jarnum S.
Excretion, deconjugation, and absorption of bile acids after colectomy for
ulcerative colitis. Comparative studies in patients with conventional ileos-
tomy and patients with Kock’s reservoir. Scand J Gastroenterol 1986; 21:
1137–1143.
54. Ojerskog B, Kock NG, Nilsson LO, Philipson BM, Ahren C. Long-term fol-
low-up of patients with continent ileostomies. Dis Colon Rectum 1990; 33:
184–189.
55. Schjonsby H, Halvorsen JF, Hofstad T, Hovdenak N. Stagnant loop syndrome
in patients with continent ileostomy (intra-abdominal ileal reservoir). Gut
1977; 18:795–799.
56. Kock NG. Continent ileostomy. Prog Surg 1973; 12:180–201.
Stoma Physiology 55
57. Akwari OE, Kelly KA, Phillips SF. Myoelectric and motor patterns of conti-
nent pouch and conventional ileostomy. Surg Gynecol Obstet 1980; 150:363–
371.
58. Sarna SK. Physiology and pathophysiology of colonic motor activity. Dig
Dis Sci 1991; 36:827–862.
59. Macleod JH. Colostomy irrigation—A transatlantic controversy. Dis Colon
Rectum 1972; 15:357–360.
60. Elmslie RG, Mulholland AT, Shields R. Blocking by spironolactone [SC
9420] of the action of aldosterone upon intestinal transport of potassium,
sodium and water. Gut 1966; 7:697–699.
3
Preoperative Considerations
Alan G. Thorson
Creighton University School of Medicine and University of Nebraska
College of Medicine, Omaha, Nebraska, U.S.A.
INTRODUCTION
One goal of any surgical procedure is to improve the patient’s quality of
life. In cases where the operation will include the creation of an ostomy,
the resultant quality of life will depend not only on successful treatment of
the underlying disease but also on the patient’s adaptation to the stoma.
Such success will be determined in part by the patient’s ability to manage
a stoma in a way that will allow a return to the lifestyle the patient enjoyed
prior to his or her illness. Factors that will influence this ability include a
stoma that is free from leakage and skin problems and can easily be visual-
ized and cared for in an independent manner. The time spent by the surgeon
with such a patient in the preoperative period can have a significant impact
on the ability to achieve these results and on the ultimate success or failure
of the quality-of-life goal.
There are a number of issues that must be recognized as determinants
of success or failure. These include an understanding of the patient’s atti-
tude toward an ostomy—including fears, misunderstandings, and actual
misinformation; anatomic considerations; and special considerations related
to other health problems or physical disabilities.
PATIENT ATTITUDES
It is not inappropriate to assume that most patients have the attitude that “it
is better to be dead than to live with a stoma.” Therefore, education and
counseling become critical first steps in the process, beginning with listen-
ing to the patient to learn what his or her fears and questions may be.
Most patients, unless they have a family member or close friend with
a stoma, do not even know what one looks like. Having literature or educa-
tional videos available that can demonstrate the appearance of a stoma can
57