Colostomy reversal

A colostomy reversal is surgery to close a temporary colostomy and reconnect the bowel so that stool passes through the rectum again.

When a colostomy is created, part of the colon is brought through the abdominal wall to form an opening on the belly called a stoma. This is often done to let the bowel heal after illness or surgery. Once healing has taken place, the colostomy can sometimes be reversed. Most reversals are planned six weeks to six months after the first surgery, but the exact timing depends on your health, the reason for your colostomy and your care team’s judgment. Your care team tells you when they think it is safe to reverse the colostomy.

Although the reversal surgery is usually shorter and technically less demanding than colostomy surgery, it is still considered a major operation. Recovery can take weeks, and bowel function is often not regular at first. Many people notice frequent or urgent passing of stool and loose stools until the intestine adapts.

Types

There are two main types of colostomy reversal surgery. The method used depends on the type of stoma you have and the details of your original bowel operation.

• Loop colostomy reversal. A loop colostomy brings a loop of bowel with two openings to the skin surface. Reversal of a loop colostomy, often called a stomal closure, is usually straightforward since both ends of the bowel are already close together. The surgeon detaches the loop from the abdominal wall and reconnects the bowel before returning it inside. This procedure is generally shorter, less invasive and associated with a quicker recovery compared with an end colostomy reversal.
• End colostomy reversal. An end colostomy has only one opening. The other end of the colon or rectum is closed inside the abdomen. This end is called the colon stump or rectal stump. Reversal of an end colostomy is often called a stoma takedown or Hartmann reversal. This procedure is more complex than a loop colostomy reversal. This is because the surgeon must reopen the prior scar, locate the internal colon or rectal stump and reconnect it to the colostomy end. This operation carries higher risks, often requires a larger cut, also called an incision, and usually has a longer recovery period.

A colostomy reversal restores the natural passage of stool after a temporary colostomy. Surgeons typically create a temporary stoma to let the bowel heal after conditions such as colorectal cancer, diverticulitis, inflammatory bowel disease or trauma. Once healing is complete and you’re considered fit for another surgery, the stoma can be closed and the colon rejoined so that stool passes through the rectum again.

Reversal also can improve comfort and quality of life by eliminating the need for an ostomy pouch and reducing stoma-related complications such as skin irritation, pouch leakage or hernias. Many people see reversal as an important step in recovery and a return to typical life.

Not every colostomy can be reversed. Surgeons may advise against reversal if:

• The bowel has not healed well or is too short to reconnect safely.
• The anal sphincter muscles are weak, raising the risk of incontinence after reversal.
• Your overall health is too fragile for another abdominal operation.
• The original condition has returned or gotten worse.

If any of these reasons apply to you, the colostomy may remain for the rest of your life to protect your health and quality of life.

Colostomy reversal is generally safe, but like any abdominal surgery, it carries risks. The most common risks include:

• Infection at the wound site. Wound infections are fairly common after reversal because the skin around the stoma already has a lot of natural bacteria.
• Leakage at the bowel connection. Sometimes, the connection between the two bowel ends leaks. This also is called an anastomotic leak. This leak can cause abdominal infection and sometimes requires another surgery.
• Bowel obstruction, called ileus. The bowel may be slow to start working again, leading to bloating, pain or nausea. Adhesions from scar tissue also can block the bowel.
• Hernia at the stoma site. A weakness in the abdominal wall may allow tissue to bulge through after closure.
• Bleeding or blood clots. As with other abdominal surgeries, there is a small risk of bleeding or blood clots.
• Changes in bowel function. After reversal, many people have frequent, loose or urgent stools. In some cases, temporary leakage or incontinence can happen.

The overall complication rate varies, but studies show that up to 40% of people may experience a complication after reversal, with infection being the most common.

Preparing for colostomy reversal surgery typically involves these steps:

Medical check-ups and tests

Before colostomy reversal, your surgeon confirms that your bowel has healed and you are fit for another operation. You may have a physical exam, blood tests, heart tests, and imaging or endoscopy to check the bowel and the rectal stump.

Preoperative review

This is a time for you to talk with the care team about topics that may affect the procedure and recovery. These topics may include:

• Diet and fasting. You are usually asked not to eat for six hours before surgery, but you can continue to drink water up to two hours before the operation. In the days before surgery, eating well and staying hydrated support healing. After the reversal, a low-fiber diet is often recommended at first.
• Medicines or supplements that you take. You may need to stop taking certain medicines or supplements before surgery.
• Health optimization. It helps to stop smoking, limit alcohol, and aim for good nutrition and physical activity before the operation, since these improve recovery and reduce risks.
• Bowel preparation. Some surgeons may recommend an enema or other bowel prep to clear the rectum before surgery, especially in Hartmann reversals. Whether you need to do this depends on your specific situation.

Plan for your hospital stay and coming home

Most people need a short hospital stay after colostomy reversal, but the exact length can vary depending on the type of surgery and how quickly they recover. Some people go home within a day or two, especially after a simple loop reversal. More-complex reversals usually require a longer stay.

Think ahead to what you might like to have with you while you’re recovering in the hospital. Things you might pack include:

• A robe and slippers.
• Toiletries, such as your toothbrush and toothpaste and, if needed, your shaving supplies.
• Comfortable clothes to wear home. Loose-fitting clothes are ideal after surgery to avoid pressure on the closed stoma.
• Activities to pass the time, such as books, magazines or games.

Arrange support at home since you may feel tired for a few weeks. Plan for time off work, and avoid heavy lifting during early recovery to lower the risk of hernia.

During colostomy reversal

Colostomy reversal surgery can be performed using either an open or a minimally invasive laparoscopic approach. The choice depends on factors such as your overall health, the reason for the colostomy and the surgeon’s recommendation.

• Open colostomy reversal. Open surgery involves making a long incision in the belly. This approach gives the surgeon full access to the bowel and surrounding structures. Open surgery typically requires a longer hospital stay and recovery time. Open surgery may be necessary for complex surgeries.
• Minimally invasive colostomy reversal. This technique is done laparoscopically, which means that several small incisions are used. A camera is used to see inside the abdomen, while specialized tools are used to reconnect the bowel. This type of surgery offers advantages such as fewer complications, less pain and a shorter hospital stay. However, sometimes the surgeon may need to switch to an open operation for safety.

Colostomy reversal typically involves the following steps:

• Anesthesia. Usually, general anesthesia is used. This ensures you are asleep and pain-free during the operation.
• Incision around the stoma. The surgeon makes a cut around the stoma and carefully frees the bowel from the abdominal wall and surrounding scar tissue.
• Rejoining the bowel, called anastomosis. How this is done depends on whether you have a loop colostomy or an end colostomy:
  • Loop colostomy reversal. In this procedure, the two ends of the loop of intestine are reconnected directly, often with staples or stitches. This is usually straightforward since both ends of the intestine are close together.
  • End colostomy reversal, also called Hartmann reversal. In this procedure, the surgeon must also locate and free the rectal or colon stump inside the abdomen. The stoma end is then reconnected to this stump. This technique is more complex and may require opening the abdominal scar from the previous surgery.
• Returning the bowel to the abdomen. Once the ends are joined, the surgeon places the bowel back into the abdomen.
• Closing the abdominal wall and skin. The muscle layers and skin are closed. Sometimes the skin is closed in a certain way, such as a purse-string closure. Or it may be left partially open to reduce the risk of wound infection.

After colostomy reversal

After colostomy reversal surgery, your body needs time to heal and adjust to the return of typical bowel function. In general, here’s what to expect:

• Hospital stay. After colostomy reversal surgery, a hospital stay can range from one day to about one week, depending on the type of procedure. Your care team makes sure you can eat, drink, pass urine and manage pain before you go home.
• Diet and bowel function. At first, your diet is usually fluids and soft, low-fiber meals. It is typical to have frequent or urgent passing of stool and loose stools after reversal. This can last for weeks or months as your bowel adjusts. You may have trouble managing gas or stool at first, but this usually gets better as the bowel heals.
• Wound care. The stoma site is closed with stitches. Sometimes the skin is left partially open to lower the risk of infection. The wound may feel sore, and keeping it clean and dry helps it heal. You may have a scar at the site of the stoma. You also may have a scar if you had an end colostomy reversal. In most people, scars fade with time and are not very noticeable.
• Activity and recovery at home. You’ll likely feel tired for several weeks. Your care team may suggest light walking to improve circulation, but avoid heavy lifting for about six weeks to reduce the risk of hernia. Many people return to their usual activities and work within six weeks, depending on the type of surgery.
• Possible complications. After colostomy reversal, the most common complications are wound infection, bowel leakage at the connection, slow bowel recovery and hernia at the stoma site. While many issues are minor and improve with time, some complications can be serious and may require another operation. It’s important to watch for increasing pain, fever, bloating or vomiting and to contact your care team if these happen.

After colostomy reversal, complication rates range from 6% to 40%. Wound infection is the most common issue. Bowel blockage, hernia or leaking at the bowel connection also can happen, but serious complications are less common.

If the bowel heals well and there are no complications, most people have good bowel function again. However, many people experience frequent or loose stools, urgency, or minor stool leakage for weeks to months after surgery. These side effects usually improve with time.

If a colostomy reversal fails or you have serious complications, you may need a second operation. This can involve repairing the bowel connection, clearing a blockage or creating a temporary stoma again to protect the bowel until healing is complete.