Small Bowel Stomas : State of the Art - ESHGID

Review article: 

Small Bowel Stomas : State of the Art 

Ahmed Shawky 

Department of Surgery,Alexandria University Egypt 

Small bowel stomas 

The word ‘stoma’ has its origins in the ancient 

Greek language, meaning mouth. (1) Although 

the word stoma is sometimes used to describe 

an anastomosis, a stoma by definition is an artificial 

mouth like opening ,done by a surgeon , to 

create an opening to an internal organ (usually 

the intestinal or urinary tract) to the surface of 

the body to allow a convenient and practical means 

of emptying the bowels or voiding urine. (3) 

Historical bakground 

The understanding of the evolution of stomas 

is essential to appreciate the recent advances 

encountered in the last years. The first planned 

colostomy procedure was performed in 1776 by 

a French surgeon, M Pilore (4) . While the first recorded 

operative ileostomy was in 1879 by Baum, 

a German surgeon (5) . From these days Ileostomy 

continued to be performed with often devastating 

results. Perhaps the most dreaded complication 

of early ileostomies, however, was ileostomy 

“dysfunction.” This was a massive efflux from the 

stoma, 

sometime high as 10 liters per day. In the early 

1950s, Crile and Turnbull finally correctly 

attributed ileostomy “dysfunction” to a serositis 

caused by the then routine bringing of the end 

of the ileum through the abdominal wall and 

leaving it exposed. The ileum became severely 

inflamed and edematous, causing a partial 

obstruction. They excised the seromuscular 

layer of the exposed portion of the bowel and 

everted the bowel on itself to cover and protect 

the serosal surface. Coincidentally, Bryan 

Brooke described a technique that also solved 

the problem of “dysfunction.” It was to evert 

full-thickness bowel upon itself and suture the 

bowel to the abdominal skin (6) . (Fig 1) In an 

attempt to eliminate the need for wearing an 

appliance, a Swedish surgeon named Nils Kock 

developed a continent ileostomy in the 1960’s 

by making an internal pouch or reservoir but 

leak remained a problem. In 1972 he overcame 

this problem by designing an intussuscepted 

valve in the ileal outlet to provide a leak-proof 

mechanism (7) . Successful urinary diversions 

were not achieved until 1950 when an American 

surgeon, Eugene Bricker, described the ileal 

Volume VII (II) August 2008 

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conduit. Since the fifties, Bricker’s ileal conduit procedure has remained the most commonly used 

technique for urinary diversion (7) .(Table 1) 

Classification of Stomas: (Table I) 

Input stomas 

(temporary) 

Diversion stomas 

(temporary) 

Output stomas 

(permanent) 


Gastrostomy 

Jejunostomy(fine tube enterostomy) 

Pharyngostomy, Oesophagostomy 

lleostomy (‘loop’ or ‘split’) 

Colostomy (‘loop’, ‘transverse’ or ‘sigmoid’) 

Temporary end-colostomy with primary excision of colonic lesion 

lleostomy (‘terminal’) 

Colostomy(‘terminal’) 

Ileostomy: 

Basic Types and present indications of ileostomies (Table II) 

Despite the recent advance in ileal pouch- anal 

anastomosis in the treatment of UC and familial 

polyposis. Ileostomy continues to play a role 

in surgery. It is the backup for pouch surgery 

when it fails. No ostomate would elect to have a 

stoma if it could be avoided in any way. (8) 

Diverting ileostomies 

are usually loop stomas and temporary. They are 

used to rest distal disease processes or to allow a 

distal anastomosis site to heal especially ultra low 

ones, as well as to relieve obstruction. These are 

used to divert contents temporarily. (9) 

Loop Ileostomies 

Two types are known; Loop in continuity and 

loop end stoma, with their concept considered as 

surgical advance. (Fig2&3) Since inflammatory 

bowel disease activity is maintained by the flow 

of intestinal contents, ileostomy per¬mits resolution 

of distal diseases such as anal abscesses 

and fistulas.The continuity of the bowel could 

be restored once the distal bowel had healed. 

The loop in-continuity ileostomy can replace 

a potentially hazardous colectomy, as in cases 

of toxic megacolon (it must be combined with 

«blowhole» colostomy if the colon is massively 

dilated and cannot be safely mobilized). (Fig 4) 

The procedure acts as a bridge to definitive operation 

for toxic patients with benign disease and 

palliates those with advanced malignancies.A 

properly constructed in-continuity loop ileostomy 

can be easily converted into a permanent 

loop-end ileostomy.The loop-end ileostomy 

is a variation of the loop ileostomy, the end is 

closed, and the mesentery and its vasculature 

are left intact making it especially useful in the 

obese patient. 

An output ileostomy 

Is usually permanent and terminal. It is required 

when distal bowel is resected, and when reconstruction 

is impossible or inadvisable. It is

usually an end stoma.Recently, the use of Octreotide 

with low resections has been studied. 

It has an important role in controlling intestinal 

output, so that it is an available method of «hormonal» 

protective ileostomy in very low rectal 

or anal anastomosis, avoiding a second operation 

for stoma closure. (10) Recently volunteer patients 

who had ileostomy had contributed to the comprehension 

of many of the nutritional and metabolic 

aspects of certain compounds by analyzing and 

studying their stomal effluent. (11,12,13,14,16,17,18) 

The Kock pouch 

(Fig 5) should be constructed only for very 

limited indications namely mucosal ulcerative 

colitis and familial polyposis. It should not be 

used in the management of Crohn’s disease. 

Recurrence of the disease in the pouch can necessitate 

removal of the pouch and subsequent 

symptoms of the short bowel syndrome. (19) The 

occurrence of Crohn’s disease in a patient with 

an ileal-pouch anastomosis often results in severe 

morbidity and significant chance of reservoir 

loss after constructing a pouch. Changing 

the original ulcerative colitis diagnosis to 

Table II : Present Indications for ileostomy. (Nugent 1999). 

End 

•After proctocolectomy for Crohn’s disease. 

•Rarely, if patients have synchronous colorectal 

cancers including a low rectal cancer. 

•Rarely in familial polyposis, with rectal cancer 

in whom a pouch may not be advisable. 

Crohn’s disease occurs when complex perianal 

or pouch fistulizing disease, prepouch ileitis 

and complex fistula occur. In these patients Infliximab 

was found beneficial, in the treatment 

of these patients. Good pouch function requires 

long term treatment with Infliximab in most patients. 

However the treatment of Crohn’s disease 

in patients with Kock pouch with the recent 

drug Infliximab has not been evaluated. (20) 

A recent study was done to determine the cumulative 

success rate of Kock continent ileostomy 

and the reasons leading to its excision and to 

compare the results with ileal pouch-anal anastomosis. 

Overall, the continent ileostomy was 

converted to conventional stoma in 24% of patients. 

The cumulative success rate was 96 % at 

1 year, 86 % at 10 years, 77 % at 15 years, and 

71 % at 29 years. The most common reason for 

pouch excision was partial or total nipple-valve 

sliding. The success rate of continent ileostomy 

was significantly lower than that of ileoanal 

anastomosis. The durability of continent ileostomy 

was mainly related to the mechanism of 

the nipple valve. Kock continent ileostomy can 

offer satisfactory long-term function in more 

than two-thirds of patients up to 30 years. (21) 

Loop 

•Protect an ileoanal or Kock’s pouch 

•Protect an ileorectal anastomosis in inflammatory 

bowel disease 

•Proximal to a colorectal or coloanal anastomosis 

or sphincter repair 

•Above an enterocutaneous fistula or severe perianal 

Crohn’s disease 


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A urinary conduit is constructed to compen¬sate 

for the loss of or severe malfunction of the urinary 

bladder. The ureters are implanted in the 

ileal conduit, which is only a conduit, and does 

not serve as a reservoir.In addition to traditional 

indications, the ileal conduit procedure, in a 

recent study, was found to be safe and welltolerated 

procedure in neurologically impaired 

patients. (22) 

Decreasing Morbidity 

Proper construction of a stoma is the only way 

to reduce complications. 

Proper Location of the Stoma 

An ileostomy stoma must be placed in smooth 

skin, away from irregular contours such as bony 

prominences, scars, and skin and fat folds which 

will interfere with secure seal of the appliance 

faceplate. The opening for the stoma should be 

separate from the abdominal inci¬sion. The location 

chosen for the stoma must be a site which 

the patient can see and manage. (1) The best way 

to choose the stoma site is to tape a disk, representing 

the stoma appliance, to the patient 

and observe what happens to the disk when 

the patient assumes different positions. Ideally 

the patient should be dressed in street clothing. 

For most patients the stoma will be located in 

the right lower quadrant and through the rectus 

muscle. Particular attention should be given to 

patients with special conditions, especially the 

obese. (23) If the stoma site is not marked preoperatively 

the most sophisticated operation 

can result in a patient with a severe handicap, 

merely because it is impossible to maintain the 

seal of the appliance. 

Protruding Spigot Conformation 

The ideal stoma protrudes 2 cm. This protrusion 

of the ileum creates a conduit to direct stomal 


discharge away from the skin, thereby reducing 

the possibility of skin erosion. (2) 

Preservation of the Peristomal Skin 

The need for protection of the skin in every 

stage of operation cannot be overstated.When 

the skin is shaved at the selected stoma site 

in preparation for surgery, meticu¬lous care 

should be taken not to cut or abrade the area 

because lacerations beneath the appliance are 

an open invitation for skin destruction. During 

construction of the stoma, the surgeon must be 

careful not to place sutures through the epidermis 

of the peristomal skin; if he does, healing 

will occur with formation of a rosette of scars 

that deforms the skin and markedly interferes 

with secure seal of an appliance. Instead, the 

sutures should be placed through the wall of the 

intestine and the dermis. (24) 

Ileostomy in the Obese Patient 

Significant hazards are present when an ileostomy 

must be constructed in the obese patient. 

The likeli¬hood that the stoma will be obscured 

is great. Limitation to mobilization causing undue 

tension on the vasculature leads to a higher 

frequency of retraction and necrosis.The solution 

to many of the problems of stoma construction 

in the obese patient is to construct a 

loop-end stoma in one of the upper abdominal 

quadrants. The loop-end construc-tion is advantageous 

because blood supply to the stoma 

is preserved. (2) Another solution in the obese to 

overcome thickened, foreshortened mesentery 

of the terminal ileum is by performing a subcutaneous 

lipectomy about the stoma and creating 

a thinned neoabdominal wall to facilitate the 

creation of the stoma. (25) 

Recent Surgical techniques 

Several surgical techniques have been advised

ecently to decrease the amount of effluent and 

to minimize surgical trauma in these patients. 

For a temporary diverting ileostomy, which 

may be also applied to diverting colostomies, a 

technical modification was recently introduced. 

A totally diverting ileostomy is performed with 

the help of a Foley catheter secured in the subcutaneous 

tissue, and pulled upward and to the 

right like a sling around the ileum. This simple 

modification allows for better protection of 

distal anastomosis and an optimal diversion of 

enteric transit. (26) Whether reversed terminal ileal 

segments can be used to decrease ileostomy 

output in patients who have undergone total 

proctocolectomy and ileostomy, was studied. 

An approximately 25-cm length of terminal ileum 

was reversed in an antiperistaltic manner, 

and the new terminal ileal end was used for the 

ileostomy constructed in the usual manner. This 

was compared to a conventional ileostomy. The 

antiperistaltic ileostomy was found to be effective 

in reducing the daily amount of ileostomy 

effluent and facilitates stoma care, owing to its 

diminished liquid component. (27) 

A novel ileocecal valve-preserving ileostomy 

Procedure was devised to reduce high output 

liquid loss. After total colectomy, the terminal 

ileum and ileocecal valve were isolated from 

the cecum by dissection. The ileum was then 

brought out through the abdominal wall. The 

stool became solid within 1 week after the start 

of solid food. This novel procedure may result in 

an improvement in the quality of life of patients 

who undergo total proctocolectomy. (28) Another 

recent study, describing a technique for laparoscopy-assisted 

creation of a loop ileostomy was 

done. The average duration of operation was 47 

(range, 28-75) minutes, with no conversions to 

laparotomy. All patients were able to tolerate a 

regular diet on the first postoperative day. This 

study concluded that Laparoscopy-assisted creation 

of a loop ileostomy is an effective method 

for temporary fecal diversion in patients undergoing 

anorectal surgery. (29) Restoration of intestinal 

continuity in patients with ileostomy after 

total colectomy or with colostomy after Hartmann’s 

procedure is a major operation. Gasless 

laparoscopically assisted reversal, using 

abdominal wall lifting has been evaluated. The 

laparoscopic reversal was completed in 80% of 

patients; the rest were converted to an open procedure. 

Reduced trauma, reduced postoperative 

pain, and fewer cutaneous tissues exposed to 

bacterial contamination were among the advantages 

of the procedure. Moreover, the use of 

a laparotenser makes it possible to operate on 

elderly patients with cardiovascular diseases. 

(30) After proctocolectomy most patients will be 

offered a pull-through procedure, the continent 

ileostomy is a valuable alternative in patients 

who are either, not candidates for or have failed 

an ileal pouch-anal anastomosis. The traditional 

continent reservoirs with an intussuscepted 

bowel segment as valve mechanism have an unsatisfactorily 

high incidence of dysfunction and 

frequent reoperations. The T-pouch valve concept, 

previously used for urinary reservoirs, was 

evaluated as a continent stool reservoir. Construction 

of a valve mechanism that omits intussusception 

of the bowel was done. The technique 

consists of isolating the terminal segment 

of the small bowel with its blood supply. The 

valve mechanism is created by embedding this 

segment in a serosa-lined tunnel of two apposed 

limbs of bowel that will form the pouch reservoir. 

Preliminary results indicate complete continence 

of the pouch and promise a significant 

improvement as compared with the traditional 

Kock pouch. (31) A temporary loop ileostomy is 

usually closed after 6 to 12 weeks when the 

intestinal edema is reduced and the peristomal 

adhesions are less dense. This period is three to 

four times longer than necessary for assurance 

of anastomotic healing. With the use of a bioresorbable 

membrane to minimize the formation 

of peristomal adhesions, early closure is hypo- 


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thetically possible at three weeks. Patients undergoing 

creation of a defunctioning ileostomy 

were randomized in either to have an adhesion 

barrier membrane wrapped around the limbs 

of the ileostomy, with closure at three weeks, 

or to the control group, with no barrier membrane 

and closure after more than six weeks. 

The adhesion barrier membrane was found to 

reduce peristomal adhesion and facilitates early 

closure at three weeks with minimal complications. 

(32) Even without the adhesion barrier 

membrane, early closure of bowel stoma can be 

performed without major complications in elective 

patients. This procedure shortens hospital 

stay. (33,34) Subsequent closure of a loop ileostomy 

may be associated with early complications, 

particularly bowel obstruction. This stimulated 

investigators to test stapled ileostomy closure 

the results of a preliminary nonrandomized 

study suggested that there was no significant 

difference in the rate of complications between 

sutured and stapled closure of loop ileostomy; 

however a stapled anastomosis was easier to 

perform. (35) Other investigators found loop ileostomy 

easy to create and close by staplers. Sideto-side 

stoma closure was achieved using a GIA 

linear stapler through a parastomal incision. It 

was associated with a low morbidity. (36) 

Postoperative Course,Compli-cation Their 

Recent Management: 

The placement of a small intestinal stoma is 

still a common procedure despite the recent 

advances in pouch surgery. Intestinal stomas 

are envisioned with a high morbidity which is 

mostly caused by surgical inadequacy. This can 

lead to considerable problems in management 

of the stoma in the long term and ultimately will 

affect quality of life of the patient. The cumulative 

morbidity can be given by 50% with prolapse, 

hernia, stenosis and necrosis as well as 

stoma retraction being the most relevant. (1) An 

adequate intestinal stoma will positively affect 


the quality of life of the patient. The availability 

of devices developed by the industry and the inauguration 

of a professional service simplified 

the management of patients with a stoma. Thus, 

most patients are able to maintain an active and 

socially integrated life with minimal physical 

and psychical limitations. (37) 

Parastomal hernia is a common complication 

after stoma formation. It affects 2-28 % of end 

ileostomies, and 0-6 % of loop ileostomies. Site 

of stoma formation (through or lateral to rectus 

abdominis), trephine size, fascial fixation and 

closure of lateral space are not proven to affect 

the incidence of hernia. The role of extraperitoneal 

stoma construction is uncertain. Mesh 

repair gives a lower rate of recurrence (0-33%) 

than direct tissue repair (46-100 %) or stoma 

relocation (0-76%). (38) Although not all hernias 

require surgical repair, a variety of surgical 

techniques exist. Fascial repair, relocation of 

the stoma, and the local use of a nonabsorbable 

mesh are the three major approaches. Despite 

this variety of techniques, recurrence rate and 

complications are high. A recent laparoscopic 

technique was invented where the hernia is 

closed and reinforced with a hand-made “funnel-shaped” 

Gore-Tex dual mesh. This technique 

has all advantages of laparoscopy, combined 

with the advantages of local mesh repair. 

The shape of the Gore-Tex mesh reduces hernia 

recurrence even more, prevents prolapse. (39,40) 

Peristomal irritation is a common, unwanted 

side effect and may be secondary to a multitude 

of factors, with the most common peristomal 

skin conditions being minor to moderate skin 

irritation, fungal infections (Candida albicans), 

and/or bacterial infections, allergic contact dermatitis 

up to rarely pyoderma gangrenosum. 

Unfortunately, there is little published data 

about the nature and management of peristomal 

dermatoses. (50) Allergic contact dermatitis is occasionally 

seen. Various allergens implicated as

a cause of peristomal allergic contact dermatitis 

include neomycin, epoxy resins, rubber, 

lanolin, citronella oil in ostomy bag deodorant, 

and adhesive remover wipes. (51) Inflammatory 

peristomal skin reactions may be responsive to 

corticosteroids. Unfortunately, the lubricating 

nature of various topical corticosteroid formulations 

may prohibit proper attachment of the 

stomal appliance. Recently described method 

of treatment is the use of topical corticosteroid 

spray, triamcinolone acetonide, delivered via a 

metered dose inhaler provided effective treatment 

for a patient, while still allowing proper 

adhesion of ostomy appliances. This technique 

may be applied also to dermatoses associated 

with surgical dressings when discontinuation of 

the irritant or allergen may be impossible. (52) 

Peristomal ulcers and abscesses 

May occur for reasons that are not entirely 

clear. Abscesses should be drained immediately, 

before they cause extensive undermining and 

damage to the peristomal skin. Recently, the effectiveness 

of topical sucralfate in the management 

of peristomal dermatoses was evaluated in 

adults using an open study design. Apart from 

forming a physical barrier to further irritation, 

sucralfate binds to basic fibroblast growth factor 

preventing its degradation and thereby promotes 

healing. Daily, topical sucralfate treatment was 

associated with healing within 4 weeks. There 

was limited response to treatment in patients 

with traumatic ulcers, excoriated dermatitis or 

pyoderma gangrenosum. (53) 

Peristomal fistula 

Is usually caused by recurrence of Crohn’s disease. 

It is an indication for contrast studies and 

recon-struction of ileostomy with resection of 

the diseased segment. Recently administration 

of oral adsorbent to a patient with Crohn’s who 

had a complicated peristomal fistula that did not 

improve with conventional therapy. Six grams 

of oral adsorbent (AST-120) were added daily 

to a regimen of elemental diet therapy and prednisolone. 

The fistula gradually decreased in size 

after the administration of the oral adsorbent, 

and had healed completely after 40 days’ treatment. 

There were no side effects from the oral 

adsorbent. This case report suggests that oral 

adsorbent could be an effective treatment for 

peristomal fistula associated with Crohn’s disease. 

(54) A case of skin affection on the abdomen 

in a 75 year-old woman with an ileostomy. The 

lesion developed during a period of two years 

on a site distant from the patient’s present ostomy. 

However, it was located on the site of a 

former ileostomy removed 25 years ago. The 

lesion was due to proliferation of remaining gut 

mucosa. (55) 

Fluid balance and adequate urine output 

should be maintained by administration of balanced 

electrolyte solutions of intravenous fluids 

if the patient gets behind in fluid intake. (56) A 

study analysed the effect of the topically acting 

glucocorticoid budesonide on ileostomy output 

in patients with Crohn’s disease the absorptive 

capacity of the intestinal mucosa for water may 

be improved by topically acting steroids and 

suggest that this occurs independently of their 

anti-inflammatory effect. (57) Temporary ileostomy 

in patients who underwent proctocolectomy 

is associated with a risk of hypokalemic nephropathy. 

The appropriate and definite therapy is 

a surgical one, i.e. ileostomy closure. Monitoring 

metabolic changes after proctocolectomy 

and ileostomy, is essential. (58) Mild diarrhoea 

in patients with an ileostomy can result in rapid 

dehydration and severe electrolyte imbalance. 

Longer episodes of high output from the 

ileostomy may be secondary to recurrence of 

Crohn’s disease, short bowel syndrome, or partial 

obstruction. (1) An unusual cause of bleeding 

occurs in the patient who has portal hyperten- 


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sion and an ostomy. When the intestine heals 

to the abdominal wall skin, a portal-systemic 

shunt is created. The vessels around the stoma 

may form varices and bleed massively. Several 

treatment options have been reported for 

this entity to control bleeding, by making a 

circumferential incision around the stoma, obtaining 

hemostasis, and resuturing the stoma to 

the skin. This pro¬vides only temporary relief. 

Attempts must be made to control the portal 

hypertension. Report of a case that was successfully 

treated by placement of TIPS, which 

offered minimally invasive and definitive treatment. 

(59) Lower gastrointestinal bleeding from 

a perianastomotic ulcer 2 years after ileostomy 

take down was reported. Perianastomotic ulcers 

may be under recognized as delayed complications 

of side-to-side small bowel anastomosis. 

Push enteroscopy via the rectum was valuable 

in making the diagnosis. (60) 

Lymphoma 

Developing in an ileostomy is an extremely rare 

complication. The presentation is similar to the 

commoner, yet still rare, adenocarcinoma but 

the staging and management of the condition 

differs. (61) An unusual case of squamous cell carcinoma 

arising at the ileocutaneous stomal site 

was recently reported. The presenting symptoms 

were peristomal ulceration and bleeding. The 

patient was treated with wide local excision of 

the stoma and the peristomal skin, and relocation 

of the ileostomy. A search of the literature 

for other similar cases subsequently identified 

two additional cases that were reported in the 

literature in 1987 and 2000. (62) 

Feelings of damaged body image because of 

the presence of the ileostomy and the required 

appliance can distress many patients. A variety 

of garments and appliance covers exists to help 

lessen the ostomate’s feelings of self-consciousness. 

(63 The assessment of capability of work 


consists of measuring the patient subjective 

willingness to perform and his efficiency which 

should be objectively examined by functional 

diagnostic tools. Generally persons with stoma 

are nearly not disabled and capable of gainful 

employment. This also pertains to professions 

with specific hygienic requirements, such as a 

production and distribution of foods. Persons 

with well applied and provided stomata should 

avoid severe physical burdens, unsuitable postures 

and periodical forms of labor like piecework. 

(64) Follow up: It is clear that endoscopy 

remains a powerful tool that is important for 

diagnosis and therapy of complications unique 

to these surgical procedures. It seems prudent 

to advocate endoscopic cancer surveillance for 

patients with pouches and ostomies; however, 

it remains to be seen whether these efforts will 

ultimately have an impact on long-term patient 

morbidity and mortality. (65) 

Colostomy or ileostomy ? A controversial issue 

Ileostomy for proximal diversion as a preferred 

option over colostomy has been a recent topic 

of interest. Controversy continues as to whether 

loop ileostomy (LI) or loop transverse colostomy 

(LTC) is the optimal method of defunctioning 

low colorectal or coloanal anastomoses. 

Patients requiring defunctioning following anterior 

resection and total mesorectal excision 

were randomized to receive either LI or LTC. 

Comparison was made between the groups regarding 

the difficulty of stoma formation and 

closure, the recovery after stoma closure and 

stoma-related complications. There were no 

significant differences in the difficulty of formation 

or closure or in the postoperative recovery 

between the groups. However, there were more 

complications related directly to the stoma in 

the LTC group: faecal fistula, prolapse, parastomal 

hernia, and incisional hernia during followup. 

None of these complications occurred in the 

LI group. (66) Another study evaluated the qual-

ity of life (QOL) of patients with a temporary 

ileostomy and compared it with that of patients 

with a temporary colostomy. Both ileostomy 

and colostomy resulted in significant QOL impairment. 

However, with ileostomy, the effluent 

was more tolerable, had less of an impact 

on personal hygiene. There were no differences 

in travel, dress, daily chores, or sexual activity 

between the two groups. (67) Many other recent 

studies suggested that loop ileostomy is the best 

procedure to electively defunctionate colorectal 

anastomosis. (68) 

Enterostomal Therapy 

In 1965 the enterostomal therapists formed an 

organization which eventually evolved into the 

International Association for Entero¬stomal 

Therapy. Through their nursing programs the 

ostomy patient receives specialized care preoperatively, 

during surgery, and during the immediate 

and long-term postoperative course. 

Today, even community hos¬pitals that cannot 

support a full-time enterostomal therapist must 

have an individ¬ual trained to provide specialized 

nursing care and teach the patient how to 

care for his stoma. (69) 

Stoma Equipement 

The design of stoma equipment itself has also 

seen great progress. Karaya (a complex polysaccharide 

hydrocolloid) has traditionally been 

used around stomas as a barrier and sealant. 

Newer hydrocolloid dressings composed of 

plectin and gelatin are now commonly used 

to promote adherence and protect normal surrounding 

skin. (70) To date, appliances are still 

subjected to modification and improvement 

and new appliances (Welland Medical) has introduced 

a new one-piece drainable pouch that 

has a secure integral locking device on the outlet. 

This new pouch also incorporates a unique 

Dual-Carb filter which combines modified and 

unmodified carbon to help fight the various odor 

types that an ileostomy can produce. (71) Recently, 

a toilet-disposable stoma bag has been introduced 

eliminating disposal problems, reducing 

the time taken in the bathroom and also reducing 

the odor (Welland Medical). (1) Even for 

flush high output ileostomies special convex 

drainable appliances have been invented. (72) 

Volunteer Ostomy Organizations 

The ostomy patients to seek help among themselves. 

It was in this setting that volunteer ostomy 

groups were formed and recently are 

increasing in number. The chief service of the 

ostomy organiza¬tion is to furnish the local 

medical community with trained ostomates to 

assist preoperative and postoperative patients at 

home or in the hospital. All these sources help 

reassure the new ostomate that he can still enjoy 

a full life, including marriage, childbearing, 

travel, par¬ticipation in sports, and all aspects 

of normal existence. (73) 

The Internet and stoma patients 

With the widespread use of the internet numerous 

stoma sites have been created, they help to 

reassure the new ostomate. In a recent study 

all of the Internet-using patients surveyed felt 

the medical information they found was “some 

what” or “very helpful.” Understanding which 

patients “go online” to search for medical information 

is essential for surgeons who wish 

to use the Internet for marketing their practices 

and educating their patients. (74) 

Jejunostomy 

A) Feeding Jejunostomy 

Enteral feeding by jejunostomy is one of the 

main surgical procedures used to supply the proteins 

and calories necessary in the early postoperative 

period after major surgery of the upper 


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digestive tract. Moreover a feeding jejunostomy 

may be required for cancer patients who have 

obstructed upper gastrointestinal tract, when 

gastrointestinal function is adversely affected 

in critically ill mechanically ventilated patients, 

severe burns, head trauma, where the most common 

abnormality is delayed gastric emptying. It 

is also indicated for uncontrollable gastric vomiting, 

anorexia nervosa, gastroparesis, biliary 

tract disease, and for patients at increased risk 

for aspirating secondary to decreased mentation, 

prolonged recumbency, or an unprotected 

airway. Patients with pancreatic disease are often 

malnourished because of biliary and gastric 

outlet obstruction or the catabolic response to 

sepsis or cancer. (75,75,77,78) 

Techniques 

Postgastric feeding may be implemented via 

the placement of a jejunal feeding tube. These 

tubes can be placed surgically or with fluoroscopic 

or endoscopic guidance. (79) Jejunostomy 

tubes can be placed endoscopically percutaneously 

through the jejunum (PEG) or by means 

of percutaneous gastrostomy with jejunal extension 

(PEG-J) (80) . Also tubes can be placed 

laparoscopically. 

Direct percutaneous Endoscopic techniques 

In direct percutaneous endoscopic jejunostomy 

(DPEJ) one study showed that all patients tolerated 

jejunal feedings. All patients progressed 

to their established nutritional goals. Total parenteral 

nutrition (TPN) was not required once 

DPEJ tubes were placed. (81) Another study 

showed that DPEJ placement was successful 

in (72%) of patients. Two patients developed a 

persistent enterocutaneous fistula following the 

removal of the DPEJ tube. DPEJ was found 

effective and safe method for providing jejunal 

tube feeding. A low reintervention rate along 

with high patient satisfaction makes DPEJ an 

attractive alternative to the more commonly 


placed jejunostomy feeding tubes. (82) One randomized 

study compared jejunostomy tubes 

placed endoscopically by means of percutaneous 

gastrostomy with jejunal extension (PEG-J) 

or by direct percutaneous jejunostomy. It concluded 

that for patients who require long-term 

jejunal feeding, a direct percutaneous jejunostomy 

provides more stable jejunal access compared 

with a percutaneous gastrostomy with jejunal 

extension and has a lower associated rate 

of endoscopic reintervention. (83) 

Direct fluoroscopically guided percutaneous 

techniques 

Direct fluoroscopically guided percutaneous 

jejunostomy was performed in a group of patients, 

most of whom had undergone major abdominal 

surgery. The distended jejunum was 

accessed with a 21-gauge needle. The technical 

success rate was (95%) for new feeding 

jejunostomy and (81%) for replacement feeding 

jejunostomy. Two patients who underwent 

replacement jejunostomy required laparotomy 

for possible leakage; there was no important 

procedure-related morbidity and no procedurerelated 

mortality. The technical success and 

complication rates of feeding percutaneous 

jejunostomy compare favorably with those of 

surgery or endoscopy. (84) 

Ultrasound guided assisted DPEJ placement 

Failure rates with DPEG remain high due to 

various technical problems. One study described 

modifications in the technique and ultrasound 

guidance assisted in a difficult DPEJ 

placement. This technique has the potential to 

improve the success rate of this procedure in 

selected cases .(85) 

Laparoscopic techniques (fig6-10) 

Percutaneous endoscopic tube placement can 

be problematic under certain circumstances:

absence of transillumination of the abdominal 

wall, after gastrectomy or obstruction of the 

upper GI tract. As an alternative in these problematic 

situations, several techniques were developed 

for placing feeding tubes under visual 

control by using mini-laparoscopy. The umbilical 

port houses the camera and a second port 

placed at the proposed jejunostomy site are used 

to identify the appropriate segment of jejunum 

and exteriorize through the port opening. After 

jejunostomy a catheter is placed in the usual 

fashion, intestine segment is returned to the abdomen, 

and then the jejunostomy site is secured 

to fascia edges by several non-absorbable sutures. 

(86) Another laparoscopic method using a 

T tube was recently described. Each limb of the 

T-tube was passed into the lumen of the bowel, 

and a purse-string suture was placed around 

the enterotomy and tied intracorporeally. After 

insertion, the serosa surrounding the insertion 

site is tacked to the anterior abdominal wall in 

four places. To test whether the tube was watertight, 

methylene blue was injected solution 

into the tube. (65) Another laparoscopic technique 

was also suggested. The proximal jejunal loop 

was fixed to the parietal peritoneum. The jejunum 

was then punctured with a split needle, and 

the catheter (9F) was pushed into the jejunum. 

Finally, the catheter was secured with an additional 

purse-string suture. (75) 

In patients who require a surgical jejunostomy, 

laparoscopic approach is preferred. Minimally 

invasive techniques have several advantages 

over the standard open surgery (Nagle & Murayama 

2004).Laproscopic placement may not 

be possible if adhesions or peritoneal carcinomatosis 

prevents laparoscopic visualization of 

the bowel (Denzer et al 2003). 

Complications 

Feeding jejunostomy is not without complications. 

Several have been recorded however its 

advantages overweigh its disadvantages. One 

study reported only onetube blockade in a series 

of 80 patients with no major complication. (77) Dislodgement, 

pericatheter leakage and peritonitis 

have also been reported. (66) The complications 

associated with early postoperative enteral 

feeding may vary from signs of gastrointestinal 

intolerance such as nausea, emesis, diarrhoea 

and cramp-like abdominal pain to hypotension 

and hypovolaemic shock, and also to the development 

of small bowel ischaemia and necrosis. 

Ischaemic intestinal involvement with progression 

towards necrosis is fortunately a rare event. 

The cause is not well known. A multifactorial 

pathogenesis of the mucosal damage has been proposed, 

where hyperosmolarity of feeding and bacterial 

overgrowth, due to excessive fermentation 

of carbohydrates, a decreased mesenteric blood 

flow and a lowering of peristalsis have been adduced 

as causes of mucosal injury. (78) In an animal 

rat study, water or normal saline were infused 

into the mid small bowel, and sections of bowel 

were taken 5 minutes later for histologic study. 

It revealed disruption of intestinal epithelium. 

It is suggested that disruption of epithelium by 

electrolyte-free water may permit digestion of 

the bowel wall and result in perforation. Tap or 

distilled water may injure intestinal epithelium 

and should not be infused directly into the small 

bowel as jejunal feeding. (79) Intraluminal antegrade 

migration of a jejunostomy tube’s distal 

end with concomitant retrograde movement 

of the small bowel over the tube was first discovered 

at autopsy and was reported as a case 

report. This ultimately resulted in the jejunostomy 

feedings entering the distal ileum, therefore 

bypassing most of the small intestine and causing 

malnutrition and severe diarrhea. (80) Severe 

jejunoileitis is another complication occurring 

in children. This is a potentially fatal complication. 

(87) An unusual postoperative complication 

reported is pneumatosis intestinalis which can 

be life-threatening. Diagnosis was made by CTscan. 

Removal of the catheter seems necessary, 

although controversy remains. (82) Migration of 


13

14 

Fig 1: Brooke ‘s ileostomy Fig 2: Loop ileostomy opened 

Fig 3: Ileostomy completed Fig 4: Blowhole colostomy 

( Kodner 1978) 

Fig 5: Kock continent Ileostomy Fig 6: Lap feeding jejunostomy. Testing 

(Devlin 1994) The site of trocar introduction 

(www.laparoscopy.net) 

Volume VII (II) August 2008

Fig 7: Lap feeding jejunostomy Fig 8: Lap feeding jejunostomy 

Trocar introduced Jejunostomy tube 

(www.laparoscopy.net) (www.laparoscopy.net) 

Fig 9: Lap feeding jejunostomy Fig 10: Lap feeding jejunostomy 

Tube introduced (www.laparoscopy.net) Tube fixed(www.laparoscopy.net) 

Fig 11: Acess jejunostomy Fig 12: Venting jejunostomy. Renal 

(Cuschieri A; Bouchier IAD 1988) pancreatic transplant 

( www.harperhospital.org) 


15

16 

a feeding jejunostomy tube through the entire 

intestine after surgical jejunostomy using a de 

Pezzer catheter was reported. The catheter was 

suture-fixed to the skin. Two months later, patient 

presented because of the “disappearance” of the 

tube. A clinical examination revealed a mature 

jejunostomy tract and absence of the tube. There 

were no signs of intestinal obstruction or peritonitis. 

Abdominal X-ray examination showed 

the catheter inside the jejunum. The patient was 

treated conservatively with serial radiographs 

showing rapid tube migration through the intestine, 

and the tube was eliminated spontaneously 

5 days later. (83) Gastrografin studies through the 

tube detected complications in 40 (14%) of 280 

cases studied. Small-bowel obstruction in (6%) 

cases, nonobstructive small-bowel narrowing 

in (2%), extraluminal tracks or collections in 

(2%), extravasation of contrast material to the 

skin in (4%), jejunal hematomas in (2%), and 

intussusceptions in (1%). Mechanical problems 

related to the tube were detected in (19%)of 

cases, including coiling, kinking, or knotting of 

the tube in (14%), malpositioning in (2%), retrograde 

flow in (1%), occlusion in (1%).Focal 

thickening of small-bowel folds was detected in 

(9%) cases. (84) 

B) Venting jejunostomy and Access jejunostomy 

(Fig 11-12 ) Venting jejunostomy 

The majority of simultaneous kidney-pancreas 

(SPK) transplants are being performed with 

portal venous delivery of insulin and enteric 

drainage of the exocrine secretion, which does 

not allow easy access to the donor pancreas. 

The diagnosis of acute rejection in pancreatic 

transplant requires a percutaneous biopsy. 

Temporary venting jejunostomy (TVJ) in such 

patients offers a novel approach to monitor rejection, 

bleeding, prevent and diagnose anastomotic 

leaks. Endoscopic donor duodenal biopsy 

can be done through the jejunostomy to rule out 

clinically suspected acute rejection. In patients 


with clinical rejection, endoscopy through the 

venting jejunostomy showed inflamed, friable 

duodenal mucosa and duodenal biopsy findings 

were compatible with acute rejection. (85) In a 

more recent study The TVJ allowed access to 

diagnose and prevent anastomotic leak, cauterize 

bleeding mucosa, perform ERCP and biopsy 

the pancreas allograft to diagnose rejection. 

This technique will be even more useful to visualize 

transplanted duodenal mucosa and collect 

pancreatic secretions (amylase). The venting 

jejunostomy is taken down 9-12 months posttransplantation 

after allograft function is stable. 

The TVJ is well tolerated, and has an acceptable 

complication rate. (86) 

Access jejunostomy 

Extrahepatic bile duct cancers are rare tumors 

with a dismal prognosis. Even after a resection, 

obstructive cholestasis and other biliary complications 

are the rule. To facilitate retrograde 

access to the biliary tree for treatment of such 

biliary complications, a modified Roux-en-Y 

hepaticojejunostomy is constructed such that 

the afferent limb is brought up as a subcutaneous 

or subfascial access jejunostomy (SAJ). 

The safety and utility of construction of an SAJ 

was evaluated in patients with extrahepatic 

cholangiocarcinoma. The SAJ was found to be 

technically simple and safe addition to the management 

of resectable and unresectable extrahepatic 

bile duct cancers, particularly proximal 

lesions. The procedure facilitates brachytherapy 

if indicated, and it allows convenient management 

of postoperative biliary complications, 

frequent dilatations of biliary strictures, insertion 

of an internal biliary stent. (87). A commercially 

available feeding jejunostomy kit, 

Intestofix, can be used to stent the biliary tree 

under adverse local conditions. The stent splinted 

the anastomosis to reduce biliary leaks and 

may help to prevent subsequent stricture formation. 

(88).Direct fluoroscopically guided percu-

taneous jejunostomy was done in another study 

to access the biliary tree. It facilitated drainage, 

dilation, stone extraction, and recanalization in 

the bile ducts or intestine in all studied patients. 

Also Retrograde jejunoesophagogastrostomy 

suction effectively replaced painful nasogastric 

suction in the studied patients. Percutaneous jejunostomy 

is a useful and underused approach 

to managing bowel and biliary obstruction. (72) 

C) Output jejunostomy 

In rare situations the surgeon may be forced to 

construct an ouput jejunostomy when the ileum 

is resected, with congenital anomalies, perforations 

or others. (35) The association of apple peel 

bowel with multiple intestinal atresias is a rare 

event. The interruptions of small bowel continuity 

may be treated successfully with multiple 

end-to-end anastomoses and with the construction 

of a jejunostomy).Total intestinal aganglionosis 

is another condition characterized 

by the absence of intramural ganglion cells, in 

which the disease’s involvement extends from 

the stomach to the anorectum. This disease was 

suggested previously to be incompatible with 

life, but recently an extended small bowel myotomy 

has achieved some prolonged survivors. 

Surgery is performed as a simple jejunostomy 

with myotomy 30 to 35 cm below the ligament 

of Treitz. Some children have survived beyond 

2 years of age without any liver dysfunction, receiving 

a combination of enteral and parenteral 

nutrition. (88,89,90,91) With distal jejunostomy an 

extremely high and problematic output is usually 

present, the principles of stoma care with 

special attention to fluid, electrolytes and short 

bowel is mandatory. (92) 

Duodenostomy 

Following gastrectomy it may be impossible 

to close the duodenal stump safely because of 

surrounding fibrosis and scarring. Controlled 

lateral wall duodenostomy or formal duodenos- 

tomy is performed as an attempt to lower the 

intraluminal pressure of the afferent loop. Good 

results had been observed in many patients (93). 

Nausea and vomiting in patients with advanced 

gastric malignancy and mechanical obstruction 

are distressing and difficult to manage. In 

one patient with linitis plastica and gastric stasis 

treatement with a percutaneous endoscopic 

duodenostomy into the second part of the duodenum 

as the stomach could not be used for 

percutaneous endoscopic gastrostomy (PEG) 

formation was done. The patient experienced 

excellent symptomatic relief and tolerated enteral 

nutrition extremely well, regaining some 

weight. This manoeuvre can produce effective 

symptom palliation allowing the patients to be 

managed at home during the terminal phase of 

their illness. (94,95) 

References 

1-Nugent KP. Intestinal Stomas in Recent advances 

in surgery. eds.Taylor I& Johnson CD. Churchill 

Livingstone 1999;22(11):135-46. 

2-Kodner IJ. Colostomy and ileostomy. Ciba clinic 

sympos 1978; 30(5):2-37. 

3- Sheil WC, Hecht FM. Ed. Webster’s New World 

Medical Dictionary. 2nd 

ed. 2003 Wiley, John & Sons, Incorporated. 

4-Cromar CD. The Evolution of Colostomy. Dis 

Colon Rectum 1968;11(4):256-80 

5-McGarity W. Salute to ET Nurses, Journal of Enterostomal 

therapy 1992; 19(2): 40-41 

6-Kock N. Present Status of the Continent Ileostomy: 

Surgical Revision of the Malfunctioning Ileostomy. 

Diseases Of Colon And Rectum, 

1976;19(3): 200-6 

7-Turnbull G. Guest editiorial. Journal of World 

Council of Enterostomal Therapists. 1994; 14(2): 

6-9 

8-Behrens DT; Paris M; Luttrell JN. Conversion of 

failed ileal pouch-anal anastomosis to continent 

ileostomy. Dis Colon Rectum 1999;42(4):490-5; 

discussion 495-6 


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Small Bowel Stomas : State of the Art - ESHGID

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