When a stoma is formed, a loop or an end of healthy bowel is pulled up onto the surface of the abdomen to create an artificial opening where faeces (poo) can be passed out of the body, instead of through the anus (back passage).
This stoma may be either permanent – if there is no longer enough bowel left to make a continuous pathway from healthy bowel to anus – or temporary.
Temporary stomas are usually formed to allow the bowel to heal properly after it has been cut and reattached (anastomosis). This temporary stoma will usually be formed as a loop ileostomy (from the small bowel) or less commonly as a colostomy (from the large bowel).
Having a stoma reversal operation involves re-joining these ends of your bowel and closing the stoma that was formed during your first operation. It is increasingly common to plan for this kind of reversal operation at the time of your original surgery. This will only be suggested if the surgeon considers that the reversal operation will be straightforward and successful. For the patient, the anticipated benefits of having a stoma reversal can take from several months to a year or more to be fully appreciated.
Many people believe that, after a stoma reversal, their bowel habits will return to how things were before they became ill. However, the reality is that even with a successful reversal there will still be a piece of your bowel missing and this will change the way your bowel works in the longer term.
There are several factors to consider when weighing up the risks associated with stoma reversal. These include:
- where the cancer was in your bowel and how near to the anus it was. The shorter the length of bowel remaining in the rectum after surgery, the more difficult it is to create a safe join (anastomosis) and to avoid affecting the sphincter muscles of the anus. This could increase the risk of being unable to control your bowel movements and the potential to leak from your bottom (incontinence)
- if there were any complications with infection or inflammation in or around the bowel or the join (anastomosis) after your initial surgery
- if you have also had radiotherapy or chemotherapy that has affected the health or function of your bowel
- if your health has deteriorated since your surgery, or if it is not safe for you to have further surgery.
There are some important questions you may want to ask your stoma specialist nurse or consultant when discussing the possibility of a stoma reversal:
How much of your rectum was removed?
The rectum is the lowest part of the large bowel and is responsible for holding faeces (poo) until you are able to use a toilet. Some of this storage area may have been reduced if the tumour was in your rectum and the newly shaped bowel will need some time (and practice) to get used to this.
How much of your colon was removed?
The colon absorbs water back into the body as the watery faeces (poo) travels along its length. If your colon has been shortened, there is less time for this water to be reabsorbed so your poo will be looser.
How might this affect your bowel habits?
Depending on which part of your bowel was affected, and the type of surgery you had at the time, there may be scar tissue and changes to the shape of the bowel which will affect how well it is able to work and store the faeces (poo), at least for the first few weeks or even months. Looser, watery poo and wind can cause problems with urgent feelings of needing to ‘go’ quickly. Occasionally, problems with leaking poo can become an issue for some people, especially in the beginning, until they adapt to their circumstances and find a new routine. See Regaining Bowel Control After Surgery.
The surgery can either be performed using a laparoscopic technique, or as an open operation. Laparoscopy means using small cameras and instruments to work through the existing stoma and small cuts in the abdomen. Open surgery follows the same scar line from your first operation.
You reversal operation and the possible risks will be carefully explained by your specialist team. The decision to go ahead and reverse the stoma and the type of surgery planned will be based on your needs and wishes, as well as your general overall health now and your previous treatment.
Your medical team will carefully consider the timing of a stoma reversal. For example it cannot be done while you are receiving chemotherapy. However, the bowel needs to be active to maintain its health and so there is an optimum time to have the reversal operation done – usually between 3 and 12 months after it was first formed. This allows the bowel time to heal properly following the original surgery, but is also very important to reduce the risk of losing the muscle tone and health of the unused part of your bowel. Once the stoma is formed, the muscles of the pelvic floor and anus can also start to grow weaker from lack of use (unless you continue to exercise them, which is highly recommended).
No surgery is entirely without risk, however specific problems that can arise include:
Ileus – a temporary ‘shock’ reaction to the surgery and some medicines. The bowel becomes paralysed or is slow to start working again. The treatment is just to rest it, by not eating or drinking until you start to pass wind again. You may need an intravenous drip to make sure you don’t become dehydrated during this time.
Bowel obstruction – a physical blockage of the bowel or problems with adhesions (bands of tight scar tissue) causing narrowing or constriction of the bowel.
Anastomotic leak – where the newly joined ends of bowel don’t heal properly, causing a leak from the bowel into the abdomen. This can be caused by infection, or by poor blood supply to the bowel tissue at the join. It can often be treated using antibiotics, but in some cases may need another operation to repair it.
On average,12% of stoma reversal operations are unsuccessful each year, for a variety of reasons, and occasionally a new stoma will need to be formed as a result.
You will be able to leave hospital 3 – 10 days after reversal surgery, depending on the type of surgery you had, how the operation went and how well you have recovered generally. As you recover from surgery and establish a new routine, you may be supported by other members of your multi-disciplinary team. This might include a dietician, continence nurse advisor, colorectal specialist nurse and/or community nurses.
Stoma reversal surgery can be disruptive to work and social routines, and the rules about no driving and no bending for up to six weeks after surgery will apply once again. You should avoid putting strain on the repaired tissue and bowel by avoiding all heavy lifting or physical work, for up to ten months. It is important to make arrangements before your surgery for changes to your job or for support for your daily routine.