PREPARING FOR YOUR STOMA REVERSAL

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1 PREPARING FOR YOUR STOMA REVERSAL Information Leaflet Your Health. Our Priority.

2 Page 2 of 6 Introduction- What you need to know As part of your bowel operation you may have had a temporary stoma formed. Stomas are formed for a variety of medical reasons, but often means the bowel has to be re sited so that it can heal. Surgery to reverse a temporary stoma is basically to reconnect the bowel, once the bowel has had time to heal adequately. For many, this represents a return to normality and a return to normal bowel function. At this point it is important to manage your expectations of the reversal procedure and be aware that it is likely that your bowels will never be the same as they were before the initial operation. It might take a period of a few weeks, months or even a couple of years to settle into a new normal routine and it is important to be patient however difficult this may be. This leaflet aims to identify issues which are important to consider before making the decision to have your stoma reversed. Can the bowel be joined up? The decision to undertake reversal of a stoma is complex and depends on a number of factors. Firstly, any surgery no matter how big or small is never without risk, the most important factor is your overall fitness. Secondly, assessment of your underlying condition and how you recovered following your first surgery. How soon can it be joined up? It is very understandable that you want to return to a normal lifestyle as soon as possible. The timing of reversal varies from person to person and the decision is taken on an individual basis. The time to do this range from a few months to one to two years on average. After any operation scar tissue (adhesions) forms inside the abdomen. This scar tissue can cause the surgeon considerable difficulties and can make it difficult for the surgeon to reach parts of the bowel and operate safely. Adhesions tend to be worse following the initial operation, so it is advised that the reversal surgery is left until an appropriate time to allow scar tissue to settle, healing to take place and for you to recover from the first operation. Tests conducted prior to reversal of stoma Before a stoma reversal is considered you may undergo a number of tests, which may include; CT scan, water soluble enema, examination under anaesthetic and/or colonoscopy. These tests are essential to make sure the internal bowel join (anastomosis) has healed, ensure full visualisation of the bowel and, dependent on your individual situation, to provide evidence that there is no other bowel abnormality or recurrent disease. Problems which may delay or prevent reversal Anastomotic leak (an-as-tom-ot-ic) - is a breakdown along a join in the bowel (anastomosis) which causes fluids to leak. Fistula - is an abnormal connection between an organ, vessel, or bowel and another structure. These can be a result of injury or surgery. Abscess - is a collection of pus that has accumulated in a cavity.

3 Page 3 of 6 Blind end track (sinus) - an abnormal channel leading from the abdominal cavity to skin surface. This can result in chronic sepsis (infection). Recurrent or residual cancer - the return of local or distant cancer, or cancer which may have not been completely removed at the initial operation. Adhesions (scar tissue) - scar tissue that forms after any operation, therefore operating at the wrong time can be technically difficult or simply too dangerous Severe health problems (heart/chest disease) - can impact on your general fitness to operate without risk. Closure of your stoma In 95% of cases only a small incision around the stoma is required during the reversal/closure procedure. However, this will again depend upon your individual situation and the type of stoma you have had formed. Your Consultant and/or Colorectal Nurse Specialist/Stoma Care Nurse Specialist will discuss your situation with you prior to making the decision to have reversal surgery. Length of stay in hospital This will depend on the type of operation you undergo and your overall fitness. Closure of loop ileostomy/colostomy is approximately 5 days and closure of end ileostomy/colostomy is approximately 5 to 10 days. You will be expected to stay in hospital until bowel function takes place. This can take a few days or longer. You need to ensure that you can cope with your bowel movements once again. Complications following surgery In any surgery there are risks, which are associated with general anaesthetic and the procedure itself. Complications specific to stoma reversal include: Ileus - temporary stoppage in bowel movement. Bowel obstruction - blockage of the bowel movement. Anastomotic leak (an-as-to-mot-ic) - is a breakdown along a join in the bowel (anastomosis) which causes fluids or faeces to leak, potentially causing severe infection. Anastomotic stricture (an-as-to-mot-ic) - a narrowing in the diameter of the bowel which can lead to a blockage. After stoma reversal this narrowing can cause symptoms such as a feeling of permanently wanting to open your bowels although only passing a small amount each time, discomfort when having your bowels opened or a bloated feeling in your tummy caused by a hold up of stool. These symptoms will hopefully settle as your bowel starts to work again but in some cases it may be necessary for you to have a minor procedure to stretch the narrowed area.

4 Page 4 of 6 Diversion colitis - inflammation of the colon which develops in a lower part of the colon after the passage of stool above has been diverted via ileostomy/colostomy. In most cases this inflammation settles soon after the stoma is reversed but it may also cause a period of loose stools and possibly some rectal bleeding before the inflammation subsides. Generally there is no treatment required after the stoma is reversed. Loss of capacity - Normally, the rectum stretches to hold stool until you can get to a toilet. Your original surgery may have included removing part of or your entire rectum. Your capacity for storing stool has been reduced and therefore your bowel will require some time to compensate for this and the ability to compensate varies from person to person. Rectal/pelvic surgery, radiation treatment and inflammatory bowel disease can cause scarring that makes the walls of the rectum stiff and less elastic. The remaining lower bowel has then lost the capacity for storing stool as it can t stretch as much to hold stool. Your bowel will require some time to compensate for this and the ability to compensate varies greatly from person to person, this could also be a permanent result following reversal of stoma. As with any major surgery, it is important to recognise that stoma reversal carries more than 1% risk of death. If concerned please speak freely with your Colorectal Nurse Specialist or Consultant. Your stoma reversal will be performed as a planned operation and therefore aims to minimise the risk of post-operative complications. Your Consultant and associated team such as the anesthetist and nurse specialists will have assessed all possible risks before the operation and put measures in place to prevent problems occurring. It is important to remember that you are having another operation and in general your recovery once home will be similar to that of the initial operation. This will be discussed further in the Recovery after stoma reversal leaflet. Your bowel function following surgery As discussed earlier you will need to remain in hospital until your bowel function returns. This may take a few days or longer. Once the bowel has started working again it is difficult to predict what your individual bowel function may be. Indeed, very few patients return to the same bowel functions as they had prior to the first operation. During the first few weeks bowel function can be erratic and many encounter problems with; Constipation or diarrhoea Increased frequency - needing to go more often. Increased urgency - when you need to go, you ve got to go now. Stool fragmentation - when you to pass a lot of stool but only pass small volumes. Faecal incontinence (soiling) - leakage of faeces or mucous, possibly throughout the day and during sleep. Persistent wind or bloating - losing the ability to distinguish between wind/stools. Sore skin around the back passage (anus) usually due to soiling. It is important to recognise that each symptom may be temporary or become a long term problem. There are a number of factors which affect this erratic bowel function; 1. The amount of colon and/or rectum removed. (The bowel reabsorbs water back into the body. During your first operation part of the bowel has been removed, as a result the consistency of the stools becomes looser).

5 Page 5 of 6 2. Treatments and the health of the remaining colon and/or rectum. (Treatments such as chemotherapy or radiotherapy to the pelvis can delay the return of bowel function. Damage from treatments may make function unpredictable and in some cases painful). 3. Other previous pelvic surgery and/or any previous or co-existing pelvic disease. 4. The distance of the join (anastomosis) in the bowel from the back passage (could affect capacity for storage of stools). 5. Capability of the rectal muscles, whether they are strong or weak. These muscles can be damaged by neurological and muscular conditions. Also including child birth. Although daunting, it is important to establish bowel function following the reversal procedure and assess the symptoms which you experience. There are remedies for the symptoms that you may experience such as diet, exercise and medication, although as previously indicated these symptoms may never fully resolve. We encourage you to be open and discuss your situation with your Consultant or Colorectal Nurse Specialist. Summary This leaflet may seem to provide a negative view of the issues that can arise prior to and following the reversal of a stoma, however this is not the intention. The ultimate aim is to ensure you are aware of the implications of surgery and to provide realistic expectations of the reversal of stoma procedure. Providing you with this information will assist you in making an informed choice to enable you decide to undergo stoma reversal surgery. It is recognised that each situation is different and individuals can have very different outcomes and experiences, therefore it is important to seek guidance, further information and discuss your individual situation in confidence with your Consultant, GP or Colorectal Nurse Specialist. Other leaflets available include recovery after stoma reversal, if you wish to see a copy of this before your surgery please ask your Colorectal Nursing Specialist team.

6 Page 6 of 6 If you would like this leaflet in a different format, for example, in large print, or on audiotape, or for people with learning disabilities, please contact: Patient and Customer Services, Poplar Suite, Stepping Hill Hospital. Tel: Information Leaflet. PCS@stockport.nhs.uk. Our smoke free policy Smoking is not allowed anywhere on our sites. Please read our leaflet 'Policy on Smoke Free NHS Premises' to find out more. Leaflet number SUR80 Publication date November 2014 Review date November 2018 Department Surgical and Critical Care Location Stepping Hill Hospital