Stoma closure, or ostomy reversal, is a surgical intervention performed to re-establish the natural continuity of the digestive tract. This operation is relevant for patients who received a temporary stoma, an external opening created from a segment of the small intestine (ileostomy) or the colon (colostomy). The temporary stoma diverted stool away from a newly repaired section of the bowel, allowing it time to heal without contamination. Once the underlying condition is resolved and the initial surgical site is confirmed to be sound, the reversal procedure is scheduled to allow stool to exit the body through the rectum, eliminating the need for an external appliance or pouch.
Reasons for Reversal and Optimal Timing
The decision to proceed with stoma closure requires confirming the resolution of the original issue that necessitated the stoma creation. Surgeons evaluate the healing of the distal bowel segment, often using imaging tests like a contrast enema or endoscopy to verify the integrity and patency of the original surgical join. Patient health status is also a significant factor, as the individual must be in good physical condition to safely undergo a second major operation.
Timing is a careful consideration, as the body needs sufficient time to recover from the initial surgery and for any inflammation to subside. The optimal window for a stoma reversal commonly falls between six weeks and twelve months after creation. Waiting too long may increase the technical difficulty due to the formation of dense adhesions or the bowel becoming narrowed from disuse. For many temporary loop ileostomies, the procedure is often scheduled around eight to twelve weeks, provided the patient is not undergoing active chemotherapy or radiation treatment.
The Surgical Reconnection Process
The stoma closure is performed under general anesthesia. The surgeon begins by making a circular incision around the stoma site to detach the bowel from the skin and abdominal wall. The mobilized ends of the intestine are carefully freed from any scar tissue.
Loop Stoma Reversal
For a simple loop stoma, both ends of the bowel are present at the stoma site, making the reconnection straightforward and typically requiring only a peristomal incision. The surgeon trims the exposed ends of the bowel and joins them together, a process called anastomosis. This reconnection may be achieved using either surgical staples or fine sutures, creating a leak-proof seal.
End Stoma Reversal
In contrast, the reversal of an end colostomy, such as a Hartmann’s procedure reversal, is a more complex operation because the lower portion of the bowel (the rectal stump) is sealed and left inside the abdomen. This often requires opening the patient’s previous midline abdominal incision to locate and free the sealed rectal segment before the two ends can be reconnected. Once the anastomosis is complete, the newly reconnected bowel is placed back into the abdominal cavity, and the opening at the former stoma site is closed with stitches. The total operating time for a simple loop stoma closure is often less than an hour, but it can extend to several hours for more involved reversals.
Immediate Recovery and Bowel Function Changes
Following the procedure, patients typically remain in the hospital for three to five days, though more complex reversals may require a stay of up to ten days. Medical staff manage pain with medication and encourage early mobilization to stimulate the return of normal bowel activity. The return of bowel function is monitored by checking for the passage of gas and the first bowel movement through the rectum, which usually occurs within one to three days after surgery.
The initial recovery involves a progression of the diet, starting with clear liquids and advancing slowly to soft foods as the intestines begin to tolerate them. Once the bowel is reconnected, the most noticeable change is the high frequency and loose consistency of stool, as the rectum and colon need time to re-acclimate to processing waste. Patients often experience urgency, needing to use the restroom many times a day, sometimes with temporary mild incontinence. This frequent, watery output can cause significant skin irritation around the perianal area, necessitating the use of barrier creams and gentle cleansing to protect the skin.
Specific Risks Associated with Closure
Stoma closure carries specific risks related to the surgical reconnection. Anastomotic leak is one of the most serious complications, occurring when the newly formed bowel connection fails and leaks contents into the abdominal cavity, potentially leading to severe infection or sepsis. This leak is reported to occur in approximately 3% to 12% of cases.
Other common complications include:
- Surgical site infection (SSI) at the former stoma site, which is the most common complication and can delay wound healing.
- Small bowel obstruction (SBO) or postoperative ileus, where the bowel temporarily stops moving, often caused by scar tissue or swelling.
- Incisional hernia at the former stoma site, which is reported to occur in up to 20% of patients.