Going home following reversal of loop ileostomy – virtual ward pathway

Introduction

This leaflet has been written to provide you with information about reversal (closure) of your ileostomy. This following information will provide details about what the surgery involves, common problems which can be experienced after reversal and how to manage them.

This leaflet is designed for patients having reversal of their loop ileostomy and are being discharged from hospital within 23 hours with Virtual ward follow up.

What is the virtual ward?

Cambridge University Hospital’s (CUH) virtual ward has been introduced to support people at the place they call home, including care homes. In a virtual ward, support can sometimes include using monitoring technology via applications on a mobile phone and/or wearable technology. Every patient has an individual, personalised virtual ward care plan designed to meet their specific care needs. This will be fully discussed with you and you will be shown how to use any equipment or mobile phone applications (Apps).

About your operation

What will the operation involve?

Reversal (closure) of your stoma is not as complex as your previous surgery to create the stoma. The surgery is performed under a general anaesthetic and involves taking the two ends of your stoma and stitching or stapling (joining) them together.

A small cut (incision) will be made by the surgeon around the stoma site to free up the bowel loops used to make the stoma. The surgeon will then join the two ends of bowel back together with either stiches or staples. At the end of the surgery the wound in your abdominal wall is stitched together and the skin is then closed.

The surgery generally takes one to two hours to complete.

What happens after surgery?

After surgery you will wake up in recovery and when appropriate transferred back to Ward L2. You will have a drip in your arm that will remain until you are drinking sufficiently. You will be allowed to drink small amounts initially and have a light, low fibre meal.

Your observations will be regularly taken, this will include temperature, heart rate, blood pressure and oxygen saturations.

You will be offered regular pain killers, normally by mouth and assisted to be made comfortable.

We encourage you to mobilise soon after surgery and you will be assisted to get out of bed and to use the bathroom.

Please do let the nurse know if you need assistance or you feel your pain is not well controlled.

The morning after surgery you will have a light breakfast, and assisted to the bathroom, with assistance to wash and dress as needed.

What problems can occur after the operation?

As with any surgery, the surgery to reverse your stoma has a degree of risk of complications. There are general and specific complications which will be explained in detail to you by the surgeon. You will also be given advice on how to prevent these complications from arising.

The general complications from surgery include:

• Chest infection (pneumonia)
• Urinary tract infection
• Blood clots to the leg (DVT or deep vein thrombosis) or lungs (PE or pulmonary embolus)
• Heart irregularities due to the operation or anaesthetic
• bleeding from the operation site which may require a blood transfusion
• Injury to nearby organs, tissues or nerves
• Wound infection.

Some of the complications specific to bowel surgery are:

• Post-operative Ileus: The bowel can take a few days to work following surgery, due to the handling of the bowel and anaesthetics. Passing wind is a sign that the bowel is working again. If you feel that your abdomen is becoming more swollen, and/or you are not passing wind and you feel unwell please contact the virtual ward. The treatment is just to rest the bowel by not eating and drinking. You may require intravenous fluids and a tube inserted through your nostril and into your abdomen to drain any fluid that is in your stomach.
• Wound Infection at the old stoma site. This is normally managed with antibiotics and advice on appropriate dressings
• Bowel Obstruction: For some patients the small bowel can become obstructed. When this happens faeces cannot travel along it in the normal way. In a rare number of cases further surgery may be necessary to clear this obstruction.
• Anastomotic leak: In a small number of people, the new join in the bowel can leak. This can lead to complications such as abscess formation or peritonitis. This would require readmission to hospital and possibly further surgery
• Development of hernia at old stoma site

What to expect when your bowels start to work

The rectum acts as a reservoir or 'storage area' for faeces, and when part of this has been removed, the surgery has an impact on bowel function and control. After your reversal it will take time for your bowel function to settle into some sort of a pattern. The time period and pattern varies from person to person. It will also vary depending on how much bowel (colon) was removed at your initial surgery and whether you have had pre or post-operative treatments such as radiotherapy or chemotherapy.

Your bowel function can be erratic for the first few weeks following stoma reversal. It is difficult to predict how problematic bowel function will be. The following symptoms are regarded as common:

• Loose motions
• increased frequency
• Urgency to go to the toilet - can include some incontinence or spotting
• Difficulty determining wind from motion
• Sore skin around the back passage (requiring the application of barrier cream)
• Fragmentation of stool resulting in incomplete emptying.
• These symptoms should improve over the first year following reversal.

Skin Care

If you are going to the toilet frequently, the skin around your back passage may become sore. It is important to clean your bottom and pat dry after each bowel motion. Barrier creams such as those used for nappy rash may help your bottom from getting sore. Please contact your Stoma or Colorectal nurse if you need further guidance.

Medications

Sometimes medication is needed if your bowel pattern does not settle with time or you find coping with a new bowel pattern very troublesome. It is important to speak to one of the doctors, your surgeon or Clinical Nurse Specialist for advice before starting taking any prescribed medication.

Support and practical strategies are available to improve your bowel control, bowel motion consistency and decrease any frequency and urgency you may be experiencing. Detailed bowel assessment, dietary advice, medications and pelvic floor exercises can help and require specialist input. Please contact your Clinical Nurse Specialist if you experience these problems.

What should I do about my diet after surgery?

The advice is much the same as given to you previously after the formation of your stoma. For the first 12 hours following surgery, as you start eating again, it is important to start slowly.

Foods containing fibre may effect how your bowels work. They may cause your motion to be softer or they may make your bowels act more often than normal.

In addition, fibre is a food that is not easily digested and may cause you to have some abdominal discomfort (tummy ache). Foods which are high in fibre are most fruits, vegetables and some cereals. Therefore, to begin with (for the first two to three weeks) we recommend that you eat foods containing fibre (cereals, fruit and vegetables) in small amounts. If you find they give you a tummy ache stop eating them for a few days and then gradually re introduce them into your diet.

Remember always to chew your food thoroughly before swallowing. It is also better to eat small amounts of food more often, rather than eating large meals twice daily. Eating large meals may make you feel bloated and uncomfortable in the first couple of weeks after your reversal operation.

Remember, everyone is different so this is just to guide you.

Drinks

Some people may find that drinking lots of caffeine drinks such as tea and coffee can make their bowel motions looser. If this is the case, you may find you have to reduce the amount of tea and coffee you drink in a day. Alcohol can also make the bowel motion looser. This does not mean to say you cannot drink alcohol in moderation, just be aware that it may have an effect on your motion.

Fizzy drinks may make the bowel produce more wind and therefore cause your bowel motion to come out in an explosive way (faster and with urgency). If this is the case, try to avoid fizzy drinks. However if you wish to drink them leave them to stand after pouring to allow the fizz to die down.

Remember it is important to have enough fluid in a day. Aim to drink between 1.5 to 2 litres (8 to 10 cups) in 24 hours unless you have been advised otherwise. Think about keeping a jug of water in the fridge for you to drink instead of tea, coffee and fizzy drinks.

When will I be allowed home?

If your observations as satisfactory, you are comfortable, mobile and tolerating food and fluids you will be allowed home.

You will meet a member of the virtual ward team prior to going home and they will introduce themselves, explain the virtual ward and set up monitoring equipment and communication. They will explain how to use any equipment or mobile phone applications.

Wound care

You will have a small wound where the stoma was. The wound is closed either with dissolvable sutures or staples. You will be given clean dressings when you go home and these can be changed daily. The dressing can remain off if the wound is dry. If the sutures of staples need removing the ward will advise you to make an appointment at your Doctors surgery for the Practice Nurse to remove.

Recovery time

Generally you will recover quickly following stoma reversal. It is normal to feel weak and tired on discharge home, mainly because your body is recovering from the stress of a general anaesthetic and surgery. However, it is important to allow yourself some time to return to normal activity.

Gentle exercise such as walking is encouraged upon discharge.

You will be able to start driving again when you are able to make an emergency stop without feeling pain. This may take up to six weeks and you are advised to contact your insurance company before driving again.

Returning to work varies from one person to another. People with jobs that are not physically demanding (for example office work) can often return to work within three weeks of their operation. Physically demanding jobs may require a longer (4 - 6 weeks) time resting.

You can begin to lift light objects (less than 10lbs or 5kg) after you leave hospital and gradually increase the amount you lift over the next few days. Always stop lifting anything if it causes any pain or discomfort.

Follow-up

The Stoma/ Colorectal Nurse Specialists will contact you 1 week after going home and can be contacted if any concerns or queries.

You will have a clinic follow up appointment with the Colorectal Clinical Nurse Specialists 6 weeks after going home.

If any of the following occur, contact the Clinical Nurse Specialist team or Virtual ward immediately for advice:

• if you are always feeling sick (nausea) or being sick (vomiting)
• if you are losing blood from your bottom
• if your body temperature is higher than 101.5°F or 37.5°C
• if you have any pus coming out of your wound or any increase in redness around the wound
• if you have an increase in pain
• if you have diarrhoea that does not go away (more than 5 days)
• if you feel unwell and you are not improving

MyChart

If you have not already done so, we would encourage you to sign up for 'MyChart', CUH's electronic patient portal. It allows you to securely access parts of your health record, and is available via your home computer or smartphone.

If you are interested in this, please ask us for more information, or visit the My Chart section on our website.

Contact information

Call the Colorectal clinical nurse specialists on : 01223 217923

Call the Stoma clinical nurse specialists on: 01223 216505

Call the Virtual Ward: 01223 806806