Double-Barreled Wet Ileostomy Following Pelvic Exenteration (2022)

ABSTRACT

A 30-year female with history of ulcerative colitis and partial colectomy presented with rectal bleeding and fecal and urinary incontinence. She had active colitis with granulation tissue, crypt abscess formation, extensive regenerative changes, and lymphoid aggregate formation. She also had a contracted bladder and vesicovaginal fistula. She underwent total proctocolectomy and cystectomy. Simultaneous urinary and fecal diversion was achieved with a double-barreled wet ileostomy (DBWI). The anterior pelvic exenteration was technically challenging secondary to prior surgery, but no major complications were encountered. This is the second known reported case following development of the DBWI technique in 2005. The case shows that DBWI can be safely performed after total colectomy and pelvic exenteration, with no serious complications or morbidity in the first 19 months. This technique may be particularly advantageous for patients with fistulous intestinal tracts.

KEYWORDS: Pelvic exenteration; Urinary diversion

CORRESPONDENCE: Sertac Yazici, MD, Hacettepe University School of Medicine, Department of Urology, Sihhiye, Ankara 06100, Turkey ().

CITATION: Urotoday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.02

ABBREVIATIONS AND ACRONYMS: DBWI, double-barreled wet ileostomy; UC, ulcerative colitis.

(Video) Double-barrelled wet colostomy for urinary reconstruction after pelvic exenteration

Double-Barreled Wet Ileostomy Following Pelvic Exenteration (1)

INTRODUCTION

Reconstruction of the urinary and gastrointestinal tracts after pelvic exenteration is a difficult procedure, even for experienced surgeons. The present complex case involves a patient who had a total proctocolectomy and cystectomy. This is the second known case reported in the literature where a double-barreled wet ileostomy (DBWI) was used.

CASE REPORT

A 30-year-old female with a history of ulcerative colitis (UC) presented with rectal bleeding and total fecal incontinence. She had undergone a partial colectomy 5 years previously because of the UC. She reported intensive rectal bleeding for the last 6 months, despite receiving sulfasalazine and steroid treatment for the previous 6 years. The bleeding was also resistant to cyclosporine and infliximab therapy. In addition, the patient reported total urinary incontinence for the last 6 months. She had a history of Fournier gangrene due to traumatic catheterization 3 years ago.

(Video) Double-barrelled Wet Colostomy.

Evaluation

Colonoscopy demonstrated active ulcers and numerous pseudopolyps throughout the colon. Histological examination confirmed active colitis with granulation tissue, crypt abscess formation with eosinophilic infiltration, extensive regenerative changes, and lymphoid aggregate formation.

The urethral meatus was not visualized on physical examination. Cystoscopic examination under general anesthesia revealed that the external meatus was localized 2 cm inside the anterior vaginal wall. The bladder capacity was < 50 mL, and a fistula tract was seen between the bladder and vagina. Methylene blue injected into the bladder extravasated into the vagina. The fistula tract between the posterior bladder wall and the anterior fornix of the vagina was also seen on pelvic magnetic resonance imaging (MRI) (Figure 1).

Management

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The patient underwent total proctocolectomy and cystectomy. A DBWI was performed, with 15 cm of ileum sustained at the distal end. The ureters were spatulated for a distance equal to the diameter of ileum, and their posterior edges were joined side-by-side. Then, the joined ureters were anastomosed to the open ileal segment, as described previously by Wallace [1]. The loop was exteriorized to the abdominal wall following the implantation of the ureters (Figure 1). Pigtail ureteral stents were placed bilaterally to prevent twisting and angulation. The stents were kept in the ureters for 3 weeks.

Follow-up Evaluations

No perioperative or postoperative complications were encountered. The 1-year follow-up evaluation revealed no metabolic complications, with normal serum creatinine levels. The patient reported no difficulty maintaining the stoma bag. At the 19-month follow-up evaluation, bilateral grade 1 ureterohydronephrosis was observed on ultrasonographic imaging. However, the patient did not develop any electrolyte disturbances, deterioration in renal function, or pyelonephritis during the follow-up period.

DISCUSSION

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Extensive surgical procedures such as anterior pelvic exenteration require the reconstruction of the urinary and gastrointestinal tracts, which may be a technical challenge for the surgeon. In such cases, 2 separate stomas are typically used for fecal and urinary diversion, and an ileal segment is used for the ureteral anastomoses [2]. Simultaneous urinary and fecal diversion into a single stoma using the colon was first described by Carter et al [3]. This procedure was called a double-barreled wet colostomy. The authors reported good results, with no serious metabolic problems or urinary tract infections. These successful results were later reproduced by other surgeons [3,4,5,6].

The double-barreled wet colostomy is surgically simple, provides patient comfort, and is reported to be safe. Operative morbidity is expected to be lower, because the surgery time is short when compared with the time needed to create separate stomas. The single stoma also decreases the amount of time that the patient needs to spend on daily care. Most importantly, the antireflux mechanism eliminates the risk of pyelonephritis.

For the patient in the present report, the surgeons used the ileal segment for both urinary and intestinal diversion because the patient needed complete resection of the colon. This DBWI procedure was first described by Guimaraes et al in 2005 [7]. These authors performed the DBWI in a patient following neoadjuvant radiotherapy for a rectal tumor that was associated with familial adenomatous polyposis. They reported successful outcome at a 14-month follow-up evaluation.

In the present case, the possibility of short bowel syndrome was ruled out. Although the distal ileal segment in which the ureters were anastomosed was antiperistaltic in nature, the ureters were implanted into the distal segment of the loop ostomy using a nonreflux technique. Because the urinary and intestinal stream meet at the stoma level, the contact of intestinal output with the ureterointestinal anastomosis is decreased. The authors did not observe any upper urinary tract infection resulting from possible reflux. Assessment of the renal function 1 year after the procedure showed that serum creatinine level was normal, and ultrasonography revealed minimal dilatation of the upper urinary tract bilaterally. No metabolic changes were observed during the follow-up period.

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The present report adds to the limited literature on this topic. This case shows that DBWI can be safely performed after total colectomy and pelvic exenteration, with no serious complications or morbidity in the first 19 months. This technique may be particularly advantageous for patients with fistulous intestinal tracts, such as those with ulcerative colitis or Crohn's disease. There appears to be a significant improvement in the patient's quality of life, probably due to the advantages of a single stoma. The DBWI technique was first reported 5 years ago. Therefore, additional long-term follow-up with more patients is needed to show if the risks of carcinoma, metabolic derangements, pyelonephreitis, or renal deterioration are increased for patients with this procedure, when compared with the more traditional ileal conduit and ileostomy.

REFERENCES

  1. Wallace DM. Uretero-ileostomy. Br J Urol. 1970;42(5):529-534.
  2. PubMed; CrossRef
  3. Crowe PJ, Temple WJ, Lopez MJ, Ketcham AS. Pelvic exenteration for advanced pelvic malignancy. Semin Surg Oncol. 1999;17(3):152-160.
  4. PubMed; CrossRef
  5. Carter MF, Dalton DP, Garnett JE. Simultaneous diversion of the urinary and fecal stream utilizing a single abdominal stoma: the double-barreled wet colostomy. J Urol. 1989;141(5):1189-1191.
  6. PubMed
  7. Carter MF, Dalton DP, Garnett JE. The double-barreled wet colostomy: long-term experience with the first 11 patients. J Urol. 1994;152(6 Pt 2):2312-2315.
  8. PubMed
  9. Osorio Gullon A, de Oca J, Lopez Costea MA, et al. Double-barreled wet colostomy: a safe and simple method after pelvic exenteration. Int J Colorectal Dis. 1997;12(1):37-41.
  10. PubMed; CrossRef
  11. Lopes de Queiroz F, Barbosa-Silva T, Pyramo Costa LM, et al. Double-barreled wet colostomy with simultaneous urinary and fecal diversion: results in 9 patients and review of the literature. Colorectal Dis. 2006;8(4):353-359.
  12. PubMed; CrossRef
  13. Guimaraes GC, Terabe F, Rossi BM, et al. The double-barreled wet ileostomy: an alternative method for simultaneous urinary and intestinal diversion without intestinal anastomosis after total colectomy and pelvic exenteration. Int J Colorectal Dis. 2005;20(2):190-193.
  14. PubMed; CrossRef

FAQs

What is double-barrel ileostomy? ›

A double-barrel colostomy divides the colon into 2 ends that form separate stomas. Stool exits from one of the stomas. Mucus made by the colon exits from the other. This type of transverse colostomy is the least common.

What is Double-Barrel wet colostomy? ›

Purpose: Double-barreled wet colostomy represents simultaneous urinary and fecal surgical diversion performed most commonly after pelvic exenteration as a palliative procedure or after actinic damage.

Can a double-barrel stoma be reversed? ›

For those who need a cancer related colostomy, they may only need a stoma for a few months while the colon and rectum heals. There may be the option of having this reversed when all treatment is completed.

What is a wet stoma? ›

A colostomy in the left side of the colon distal to the point where the ureters have been anastomosed to it. Thus the urine and fecal material are excreted through the same stoma. Ureterocolostomy has been abandoned in favor of other extra-intestinal urinary diversion procedures. See also: colostomy.

Can you still poop with ileostomy? ›

Since the ileostomy has no sphincter muscles, you will not be able to control your bowel movement (when stool comes out). You will need to wear a pouch to collect the stool. The stool coming out of the stoma is a liquid to pasty consistency.

What is the difference between loop and double barrel colostomy? ›

A loop colostomy is most often performed for creation of a temporary stoma to divert stool away from an area of intestine that has been blocked or ruptured. Double-Barrel Transverse Colostomy: This colostomy involves the creation of two separate stomas on the abdominal wall.

What is a pelvic exenteration operation? ›

Pelvic exenteration is surgery to treat cancer of your reproductive organs. During the procedure, healthcare providers remove your vagina, cervix, ovaries and uterus. They may also remove your bladder, anus and part of your intestine.

Are ileostomy and colostomy the same? ›

A colostomy is an operation that connects the colon to the abdominal wall, while an ileostomy connects the last part of the small intestine (ileum) to the abdominal wall.

What happens after an ileostomy reversal? ›

Recovering from ileostomy reversal surgery

Most people are well enough to leave hospital within 3 to 5 days of having ileostomy reversal surgery. While you recover, you may have diarrhoea and need to go to the toilet more often than normal. It can take a few weeks for these problems to settle.

What is the success rate of stoma reversal? ›

Previous studies have demonstrated rates of reversal of end colostomy from 35% to 69%,8,13,15,20,22 but most studies included mixed groups of patients, who may have undergone diversion for diverticulitis, cancer, and other indications.

What is the most common postoperative complication after reversal of a loop ileostomy? ›

Although the mortality rate after the reversal of ileostomy is 0.1-4% [4,5,6], wound infection and small bowel obstruction remain the most common and irritating complications [6,7].

Do you still urinate with an ileostomy? ›

The skin barrier, also called a wafer, fits over your stoma and is designed to protect your skin. You empty the urine by opening a valve on the pouch and drain the urine into a toilet.

Do people with stomas use the bathroom? ›

Immediately after your surgery, your anus may continue to expel poop and other fluids that were left inside. But new poop will now exit through your stoma. Most people will be able to feel their bowels move and know when poop is about to come out. But you won't be able to control it anymore.

What does a urostomy stoma look like? ›

This nurse may also be called an ostomy nurse.) The stoma will look pink to red and will be moist and shiny. The shape will be round to oval, and it will shrink over time after surgery. Some stomas may stick out a little, while others are flat against the skin.

Which is worse a colostomy or an ileostomy? ›

Conclusion: A loop ileostomy has a number of advantages over a colostomy. However, in patients with an increased risk of dehydration or compromised renal function, colostomy construction should be seriously considered given the higher complication risk if a high-output stoma develops.

Can you fart after an ileostomy? ›

Passing wind, mucous or even faecal matter via your anus can also be normal though and will depend on your stoma and the type of operation you have had. Some ostomates may still have a section of large bowel connected to their anus.

Why are there two holes in a loop ileostomy? ›

One of the openings is connected to the functioning part of your bowel. This is where waste products leave your body after the operation. The other opening is connected to the "inactive" part of your bowel that leads down to your rectum.

What are the two main long term complications of colostomies? ›

After surgery, risks include: Narrowing of the colostomy opening. Scar tissue that causes intestinal blockage. Skin irritation.

What is life expectancy after pelvic exenteration? ›

Although pelvic exenteration is intended to be curative, in the most recent literature the five-year overall survival has been reported between 30 - 60%(5-12).

What to expect after a pelvic exenteration? ›

After having pelvic exenteration

After your operation you will be in an intensive care or high-dependency unit for the first few days. You will probably stay in hospital for 2 to 3 weeks. When you wake up after the operation, you will have dressings on your wounds from the surgery. You may also have drips and drains.

How long is recovery after pelvic exenteration? ›

You will usually stay in hospital for 2 to 3 weeks. Once you're at home, it can take 2 to 3 months or even longer to fully recover and get your strength back. You will still have medical care at home, such as: injections to thin your blood and reduce the risk of blood clots.

What happens to the large intestine after an ileostomy? ›

What does an ileostomy do? After the colon and rectum are removed or bypassed, waste no longer comes out of the body through the rectum and anus. Digestive contents now leave the body through the stoma.

What is the life expectancy of ileostomy patients? ›

The 10-year and 20-year pouch survival was 87 and 77 percent, respectively. Patients had an average of 3.7(range, 1-28) complications and 2.9 (range, 1-27) pouch revisions during follow-up.

What are the more common complications of an ileostomy? ›

Some of the main problems that can occur after an ileostomy or ileo-anal pouch procedure are described below.
  • Obstruction. Sometimes the ileostomy does not function for short periods of time after surgery. ...
  • Dehydration. ...
  • Rectal discharge. ...
  • Vitamin B12 deficiency. ...
  • Stoma problems. ...
  • Phantom rectum. ...
  • Pouchitis.

How long does it take to have normal bowel movements after an ileostomy reversal? ›

This most often takes at least 6 to 8 weeks. But in some cases it can take up to 12 months. Your bowel and anal muscles need to be working for the reversal to work well. The doctor rejoins the ends of the bowel that were separated.

Is ileostomy reversal major surgery? ›

The reversal is a small operation lasting approximately 30 to 60 minutes but still involves a general anaesthetic. You will usually be in hospital for about three to five days. You will have a small wound where your stoma (ileostomy) was.

How long after ileostomy reversal will I poop? ›

Patients often start passing stool through the rectum in 24 to 48 hours (1 to 2 days), but sometimes it takes 72 hours (3 days). By the third or fourth day after surgery, patients are usually discharged from the hospital.

Does it hurt to poop after stoma reversal? ›

Your bowel habits may be a bit erratic for some time after the surgery. You may experience loose motions or even constipation, a feeling of urgency, some discomfort/pain when passing motions, sore skin from the back passage, incomplete emptying, and some degree of incontinence for up to a few months following surgery.

What can you eat after an ileostomy reversal? ›

A person's surgeon will suggest a diet that they can follow after their ileostomy surgery. A bland, low fiber diet known as the BRAT diet can help minimize how often a person has bowel movements.
...
These include:
  • chocolate.
  • coffee.
  • dairy products.
  • fruit juices.
  • high fat meats.
  • spicy foods.
  • sugar-free foods.
1 Mar 2021

Can you eat salad with an ileostomy bag? ›

Fibrous foods are difficult to digest and may cause a blockage if they are eaten in large quantities or are not properly chewed, so for the first 6 to 8 weeks after your operation you should avoid fibrous foods such as nuts, seeds, pips, pith, fruit and vegetable skins, raw vegetables, salad, peas, sweetcorn, mushrooms ...

What are the symptoms of an anastomotic leak? ›

Symptoms of an anastomotic leak include:
  • Rapid heart rate.
  • Fever.
  • Stomach pain.
  • Drainage from a surgical wound.
  • Nausea and vomiting.
  • Pain in the left shoulder area.
  • Low blood pressure.
  • Decreased urine output.

What is the early postoperative complication of ileostomy? ›

Commonly seen early postoperative stomal complications include improper stoma site selection, vascular compromise, retraction, peristomal skin irritation, peristomal infection/abscess/fistula, acute parastomal herniation and bowel obstruction, and pure technical errors.

How common is anastomotic leak? ›

How common are anastomotic leaks? Anastomotic leaks are reported in about 5% of anastomosis surgeries. About 75% of anastomotic leaks are associated with colectomy, removal of some part of your colon. They're most common when the resection is located toward the end of your large bowel (in your rectum or sigmoid colon).

How do you stop diarrhea after an ileostomy reversal? ›

Drinking black tea can also help. Sometimes separating food from liquids when you eat can help to slow the bowels and passage of stool. If you drink large amounts of liquid with your meals, food may move through you more quickly.
...
The BRAT diet is made up mostly of:
  1. Bananas (B)
  2. White rice (R)
  3. Applesauce (A)
  4. Toast (T)
16 Apr 2019

How do you relieve gas after ileostomy reversal? ›

You may also need to do any of the following to help your symptoms:
  1. Eat 5 to 6 small meals per day. Chew your food well. Take your time to eat.
  2. Change your diet. If you are having several bowel movements in a day, you may need a bland diet. You may need to eat white rice, bananas, and apple sauce.
31 Aug 2022

Is a stoma a hidden disability? ›

Having a stoma is generally invisible to others - and this comes with the added worry of using disabled facilities and being chastised by people who do not understand that not all disabilities are visible.

What are the signs of dehydration with an ileostomy? ›

12. Dehydration and Electrolyte Imbalance (Ileostomy)
  • Increased thirst, dry mouth, dry skin, decreased urine output, fatigue, shortness of breath, stomach cramps.
  • Loss of appetite, stomach cramps, cold arms, and/or legs, fatigue, feeling faint.

Is an ileostomy considered a disability? ›

The Blue Book also considers ileostomy and colostomy surgery to "not preclude gainful activity if you are able to maintain adequate nutrition and function of the stoma.” Meaning that a good surgical outcome with an ostomy where everything is going well is not considered a reason for disability.

How do you stay hydrated with an ileostomy? ›

Tips for staying hydrated with a stoma
  1. Always carry a water bottle with you and make sure you refill it whenever it is empty.
  2. Sip fluids! ...
  3. Eat before drinking to helps absorb fluids.
  4. Vary what you drink, try infusing water with fruits or try smoothies.
6 Mar 2019

What is a wet stoma? ›

A colostomy in the left side of the colon distal to the point where the ureters have been anastomosed to it. Thus the urine and fecal material are excreted through the same stoma. Ureterocolostomy has been abandoned in favor of other extra-intestinal urinary diversion procedures. See also: colostomy.

Can you still have a bowel movement with a ileostomy? ›

Since the ileostomy has no sphincter muscles, you will not be able to control your bowel movement (when stool comes out). You will need to wear a pouch to collect the stool. The stool coming out of the stoma is a liquid to pasty consistency.

Can I shower without my stoma bag? ›

You can bathe or shower with or without wearing your pouching system. Normal exposure to air or water will not harm or enter your stoma. If you're showering without your pouch, remove the skin barrier too. Try to create a routine that coincides with when you're due for a pouch change.

What is the difference between urostomy and ileostomy? ›

An ileostomy is needed when sections of your small intestine and colon (large intestine) have been bypassed or removed. Ileostomies allow for fecal waste to empty through an opening in your skin. Urostomy. This procedure bypasses your bladder by attaching tubes that carry urine to the stoma.

What is the life expectancy with a urostomy? ›

The studies revealed the average age of a person with a colostomy to be 70.6 years, an ileostomy 67.8 years, and a urostomy 66.6 years.

How long does a urostomy stoma last? ›

The surgeon will attach the ureters to the tube leading to the stoma. The surgery could last as long as six hours.

What is the difference between an end and loop ileostomy? ›

loop ileostomy – where a loop of small intestine is pulled out through a cut (incision) in your abdomen, before being opened up and stitched to the skin to form a stoma. end ileostomy – where the ileum is separated from the colon and is brought out through the abdomen to form a stoma.

How long can you have a loop ileostomy? ›

There's no time limit for having an ileostomy reversed, and some people may live with one for several years before it's reversed. Reversing a loop ileostomy is a relatively straightforward procedure that's carried out under general anaesthetic.

Do you still urinate with an ileostomy? ›

The skin barrier, also called a wafer, fits over your stoma and is designed to protect your skin. You empty the urine by opening a valve on the pouch and drain the urine into a toilet.

What happens to the colon after an ileostomy? ›

After the colon and rectum are removed or bypassed, waste no longer comes out of the body through the rectum and anus. Digestive contents now leave the body through the stoma. The drainage is collected in a pouch that sticks to the skin around the stoma. The pouch is fitted to you personally.

What are the more common complications of an ileostomy? ›

Some of the main problems that can occur after an ileostomy or ileo-anal pouch procedure are described below.
  • Obstruction. Sometimes the ileostomy does not function for short periods of time after surgery. ...
  • Dehydration. ...
  • Rectal discharge. ...
  • Vitamin B12 deficiency. ...
  • Stoma problems. ...
  • Phantom rectum. ...
  • Pouchitis.

What is the point of a loop ileostomy? ›

A loop ileostomy is when a distal loop of the ileum is brought out to the skin with 2 lumens draining into the stoma bag and is commonly used as a temporary diversion of stool usually to protect a distal anastomosis such as a colonic anastomosis in segmental colonic resections.

How long do you stay in hospital after an ileostomy? ›

You may need to stay in hospital for up to 2 weeks after the operation, although this varies depending on things like your general health and the type of operation. Your stoma nurse or surgeon will give you advice about activities to avoid while you recover.

What foods should you avoid with an ileostomy? ›

  • High-sugar foods.
  • Legumes (such as cooked or dried beans)
  • Licorice.
  • Milk and dairy products with lactose, if you're lactose intolerant.
  • Nuts and seeds.
  • Peas.
  • Spicy foods.
  • Stone fruits (such as apricots, peaches, plums, and prunes)
11 Jan 2022

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