Why Patients End Up With Permanent End Ileostomy
Patients require a permanent end ileostomy primarily due to failed ileal pouch-anal anastomosis (IPAA), inability to undergo pouch reconstruction, or when restoration of intestinal continuity is not feasible or has failed—with approximately 15% of IPAA procedures ultimately failing over a patient's lifetime. 1
Primary Reasons for Permanent Ileostomy
Failed Ileal Pouch-Anal Anastomosis (IPAA)
- Lifetime failure rates of IPAA are approximately 15%, resulting in an ileostomy for an indefinite period with or without pouch excision 1
- Failures occur primarily due to:
Emergency or Acute Severe Colitis Requiring Staged Surgery
- Subtotal colectomy with end ileostomy is the initial procedure for acute severe ulcerative colitis, particularly in patients on >20 mg prednisolone daily for >6 weeks or those treated with anti-TNF agents 1
- Some patients never proceed to pouch reconstruction and retain the permanent ileostomy by choice or medical necessity 1
Patient Factors Precluding IPAA
- Poor anal sphincter function makes patients unsuitable candidates for IPAA 1
- Sphincter injury prevents pouch construction 1
- Advanced age with deteriorating sphincter function, though age alone is not an absolute contraindication 1
- Patient preference after experiencing quality of life with temporary ileostomy 2
Crohn's Disease Complications
- Positive distal microscopic margins after total abdominal colectomy significantly increase risk of anastomotic failure (HR 5.4) requiring permanent ileostomy 3
- Recurrent Crohn's disease affecting the rectum or pouch, preventing restoration of continuity 3
Non-Inflammatory Pouch Dysfunction Leading to Permanent Ileostomy
When IPAA fails due to mechanical rather than inflammatory causes, permanent ileostomy may be required: 1
- Pouch-anal stricture 1
- Pouch fistula 1
- Problems with pouch capacity 1
- Chronic pre-sacral sepsis 1
- Retained rectal stump complications 1
Life-Threatening Complications Necessitating Permanent Diversion
Pelvic sepsis represents the most serious complication, with patients undergoing one-stage IPAA without defunctioning ileostomy experiencing higher rates of life-threatening sepsis requiring emergency reoperation 4. When severe septic complications occur, salvage surgery may fail, necessitating permanent ileostomy 1.
Alternative to Permanent End Ileostomy: Continent Ileostomy
Kock's pouch (continent ileostomy) is an alternative to conventional end ileostomy for patients after failed IPAA, those with sphincter injury, or those experiencing significant problems with conventional ileostomy (leakage, skin problems) 1. However, approximately 50% require reoperation due to nipple valve complications, though 10-year continent pouch survival is around 90% 1. Quality of life with Kock's pouch appears superior to end ileostomy, with end ileostomy patients more than twice as likely to report social, work, and sexual restrictions 1, 5.
Critical Pitfalls to Avoid
Attempting pouch salvage without appropriate expertise leads to poorer outcomes—pouch salvage surgery must be performed in high-volume specialist centers with substantial case volume, as these centers achieve salvage rates above 50% with acceptable functional outcomes 1. Before declaring a pouch failed, salvage surgery options (corrective procedures or pouch reconstruction) must be considered with patient input 1.
Delaying surgery in acute severe colitis increases surgical complications, making early referral to specialist colorectal surgical teams essential 1, 6. Patients who delay often end up with worse outcomes and higher likelihood of permanent ileostomy 6.