Can a patient with a total abdominal colectomy (removal of the entire colon) have their ileostomy replaced?

Ileostomy Reversal After Total Abdominal Colectomy

Yes, a patient with a total abdominal colectomy can have their ileostomy reversed, but this depends on the specific clinical scenario, underlying disease, and presence of a rectal stump or pouch construction. The decision should be based on the patient's original indication for surgery, current clinical status, and anatomical considerations.

Anatomical Considerations for Ileostomy Reversal

The feasibility of ileostomy reversal depends on what remains of the lower gastrointestinal tract:

1. With intact rectum/rectal stump:

   • Ileorectal anastomosis can be performed
   • Requires adequate rectal function and absence of disease in remaining rectum

2. With J-pouch construction:

   • Ileostomy reversal connects ileum to the previously created pouch
   • Common in ulcerative colitis patients who had staged procedures

3. Without rectal stump:

   • Permanent end ileostomy is typically required
   • No reversal possible without remaining distal bowel

Disease-Specific Considerations

Ulcerative Colitis

• In staged procedures, temporary ileostomies are often created with plans for future reversal 1
• Subtotal colectomy with ileostomy is the surgical treatment of choice for acute severe ulcerative colitis 1
• J-pouch construction with temporary ileostomy allows for later reconnection 2

Emergency Colectomy Scenarios

• Patients who underwent damage control surgery with temporary ileostomy may be candidates for reversal 3
• Secondary anastomosis is recommended after patient stabilization, typically within 24-72 hours after initial surgery 3

Patient Selection Criteria

Favorable candidates for ileostomy reversal include:

• Hemodynamically stable patients 3
• No significant peritoneal contamination
• Healthy and well-vascularized bowel ends
• No significant comorbidities that would impair healing
• Adequate nutritional status
• No ongoing sepsis or need for inotropic support

Timing of Reversal

• For emergency cases with damage control approach: 24-72 hours after initial surgery 3
• For elective cases: typically 8-12 weeks after initial surgery to allow for:
  • Resolution of inflammation
  • Stabilization of nutritional status
  • Reduction of adhesions

Surgical Approaches

1. Ileorectal Anastomosis:

   • Option when rectum is preserved and healthy
   • Can be performed open or laparoscopically

2. Ileoanal Pouch Anastomosis:

   • For ulcerative colitis patients with total colectomy and rectal mucosectomy
   • J-pouch construction provides reservoir function 2

3. Loop Ileostomy Closure:

   • Simpler procedure for temporary diverting ileostomies
   • Lower morbidity than end ileostomy reversal

Potential Complications

• Anastomotic leak (0.5-4.6% for right colon, 3.5-30% for left colon) 3
• Increased bowel frequency (average 6.85 daily bowel movements reported) 4
• Potential incontinence in some patients 4
• Surgical site infections
• Small bowel obstruction due to adhesions
• Anastomotic stricture

Special Considerations

• In Clostridium difficile colitis, loop ileostomy with colonic lavage has shown to be an alternative to total colectomy with 93% colon preservation rate 5
• Single-incision laparoscopic approaches have demonstrated safety with prompt return of bowel function 6

Conclusion

Ileostomy reversal after total abdominal colectomy is feasible in selected patients with appropriate anatomy and clinical status. The decision should be based on the original indication for surgery, presence of a rectal stump or pouch, and the patient's overall health status.