Ileostomy creation and care was revolutionized with the description of the eversion technique by Brooke in 1952. Eversion eliminates the serositis reaction commonly observed from the proteolytic ileal effluent. Another advance has occurred with the widespread employment of trained nurse enterostomal therapists to educate and care for patients with ostomies.
Physiology. The small intestine adapts to ileostomy formation within 10 days postoperatively, with ileostomy output typically reaching a plateau between 200 and 700 mL/day. Because the effluent is highly caustic, it is crucial to maintain a stoma appliance that protects the surrounding skin and seals to the base of the ileostomy.
Stoma construction of either a loop ileostomy or end-ileostomy should include eversion of the functioning end to create a 2.5-cm spigot configuration. Stoma creation lateral to the rectus abdominis increases the risk of peristomal herniation. Precise apposition of mucosa and skin prevents serositis and obstruction. Preoperative marking of the planned stoma prevents improper placement near bony prominences, belt/pant lines, abdominal creases, and scars.
Ileostomy care requires special attention to avoid dehydration and obstruction. The patient is encouraged to drink plenty of fluids and to use antidiarrheal agents as needed to decrease output volume. Patients should be warned to avoid fibrous foods, such as whole vegetables and citrus fruits, because these may form a bolus of indigestible solid matter that can obstruct the stoma. Irrigating the ostomy with 50 mL of warm saline from a Foley catheter inserted beneath the fascia, in combination with intravenous fluids and nasogastric decompression, may relieve obstruction and dehydration. Alternatively, water-soluble contrast enema may be diagnostic as well as therapeutic.
Reversal of a loop ileostomy is relatively straightforward and rarely requires laparotomy. A double-stapled technique with a GIA stapler is utilized if enough intestinal length can be obtained; otherwise, the enterostomy is closed with sutures in two layers.