Ileostomy

History

Stoma is derived from the Greek word stomat, meaning mouth or opening. Spontaneous small bowel stomas from abdominal trauma or incarcerated hernias with subsequent survival ensured the possibility of stomas as lifesaving procedures. Although reports of colostomies existed throughout the 18th century with the first report by Littre in 1710, small intestinal stomas were successfully applied more commonly in the 20th century. Baum in Germany recorded the first ileostomy in 1879 in a patient with an obstructing right colon cancer. In 1888 Maydl from Vienna reported on the successful use of exteriorization of a loop of small or large bowel and suspension over the abdominal wall by a rubber rod through a defect in the mesentery.

Both in Europe and the United States the successful role of enterostomy to relieve abdominal distention gained acceptance. Initially, ileostomies, as described by Brown in 1913, were primarily associated with surgical relief from ulcerative colitis, dysentery, tuberculosis, and large bowel obstruction. However, the use of an ileostomy, even for ulcerative colitis, was met with disdain, whereas other procedures, even those involving ileosigmoid anastomoses, were favored. It was not until the 1940s that the justified and inevitable role of an ileostomy in the management of ulcerative colitis was accepted at major institutions. In 1931 Rankin described staged proctocolectomy with ileostomy for the management of ulcerative colitis and polyposis. The initial staged ileostomy was created through a McBurney incision, division of the ileum close to the ileocecal valve, and exteriorization of the proximal end with a clamp on the end for 2 days. Bargen et al., working on Rankin's technique, replaced the clamp with a small drainage catheter in the exteriorized ileostomy. Although he noted immediate convalescence, significant fluid losses from the ileostomy requiring drastic fluid resuscitation were required. Similar fluid and electrolyte losses were noted by Cattell and Sachs and Cave and Nickel, with the latter reporting a 33% mortality following an ileostomy. Despite the initial success, ileostomy creation was associated with significant morbidity due to the peristomal skin irritation from the small bowel effluent. Lahey later described the morbidity and the mortality associated with ileostomies.

Warren and McKittrick of Massachusetts General Hospital reported in 1951 on the outcome of 210 patients with ulcerative colitis managed by an ileostomy between 1930 and 1949. They coined ileostomy dysfunction and characterized it as “cramp-like pain and, paradoxically, increase in the volume of ileostomy discharge,” which in severe cases can lead to emesis and watery diarrhea with significant loss of fluids and electrolytes leading to a shocklike state. Unfortunately, these symptoms were noted in 62% of the patients. They also observed that early dysfunction was due to the peristaltic activity against the rigid abdominal wall, whereas late dysfunction was due to cicatrizing granulation tissue on the serosa of exteriorized ileostomy. Symptomatic relief was achieved with catheter decompression, which was required in a third of all ileostomy patients and in more than half of all patients with ileostomy dysfunction.

Crile and Turnbull summarized ileostomy dysfunction as the sequelae of peritonitis of the protruding ileostomy that causes a functional obstruction. They noted spontaneous maturation over 4 to 6 weeks by eversion of the mucosa to the abdominal wall. Several procedures to combat the serositis, and thus ameliorate ileostomy dysfunction, were proposed: skin grafting the ileostomy as described by Dragstedt et al., fasciocutaneous grafting by Monroe and Olwin, and mucosal grafting by Turnbull and Crile. However, the most technically facile procedure was described by chance by Brooke of the University of Birmingham in 1952 and involved the evagination of the ileal end and suturing of the mucosa to the skin. To this day, the so-called Brooke ileostomy remains the standard technique for constructing an ileostomy.

Indications

Although ileostomies were initially used after proctocolectomy (for ulcerative colitis and polyposis) or the relief of obstruction, their use has evolved over the years in numerous disease processes. Etiologies include functional, hemorrhagic, infectious, inflammatory, ischemic, malignant, or mechanical. Their indications are better described by their permanence: permanent, temporary, or protecting, as shown in Table 84.1 .