CLASSIC ARTICLE Marvin L. Corman, M.D.

, Contributor

Bryan N. Brooke
1915-

Bryan Brooke graduated from Cambridge and St. Bartho-

lomew's Hospital in 1940, achieving his F.R.C.S. in 1942
and his Masters in Surgery in 1944. After military service
in the second world war, he was appointed senior lecturer
in Aberdeen in 1946 and reader in surgery at the Univer-
sity of Birmingham in 1947. In 1963, he was offered the
Chair in Surgery at St. George's Hospital in London, a
position he occupied until 1976. Many of Brooke's im-
portant writings were in the field of colon and rectal
surgery, including that of ulcerative colitis and Crohn's
disease. In 1952, he proposed a signal advance in ileos-
tomy construction, the subject for this Classic Article
reproduction. In this paper, he suggested, "A more simple
device is to evaginate the ileal end at the time of operation
and [to] suture the mucosa to the skin . . . . " As a conse-
quence of his u n i q u e contributions to the development
of improved surgical techniques for stomal construction,
he was motivated to become founder and president of the
Ileostomy Association of Great Britain and Ireland, a post
he held for 26 years. A recipient of many awards, Brooke
was recognized by Corpus Christi College of Cambridge
University through the Copeman Medal for scientific re-
search. Additionally, he received the A.B. Graham Award
of the American Proctologic Society (now the American
Society of Colon and Rectal Surgeons) in 1961 and is an
Bryan N. Brooke
honorary fellow of many international organizations.
Brooke has been described as an individual with a great paid to the minutiae of technique and to subsequent
zest for life, coupled with a wonderful sense of humor.
He has held numerous one-man exhibitions of his paint- care.
ings, many of which can be found at prominent public The ileum should be divided and the ends sep-
institutions throughout the world. Professor Brooke re- arated so that the functioning stoma presents as a
sides in London, retired from the active practice of sur-
gery, but not from painting or from writing.
terminal vent about 1-189 in. long (Hardy et al.
1949). A loop ileostomy is still regarded by some
Brooke BN. The management of an ileostomy including
its complications. Dis Colon Rectum 1993;36: surgeons as justifiable in a serious case (Lahey
512-516. 1951); but it should be avoided if possible, because
an ileostomy bag cannot be applied effectively to
it. Where a primary colectomy without pre-existing
THE MANAGEMENT OF AN ILEOSTOMY ileostomy is done, the terminal ileum forms the
INCLUDING ITS COMPLICATIONS stoma, and the same principles apply.
B. N. B r o o k e , M . C h i r . C a m b . , F.R.C.S.
I l e o s t o m y Bags
Reader in Surgery in the University of Birmingham
Generally an ileostomy acts after meals and dur-
AN i l e o s t o m y m u s t w o r k p e r f e c t l y if t h e s u r g i c a l ing the night, though some of the contents of the
t r e a t m e n t of u l c e r a t i v e c o l i t i s is n o t to fall i n t o
small bowel may be voided at any time. It must not
disrepute; the closest attention must therefore be be thought that one type of bag suits all patients--
indeed a few prefer the old rigid cup appliance--
Reprinted with permission from B. N. Brooke. The management but usually the Koenig-Rutzen type of bag is most
of an ileostomy including its complications. Lancet 1952;2: favoured, and most makes of bag act on the same
102-4.
No reprints are available. principle of adherence to the skin, from the simple
512
Vol. 36, No. 5 CLASSIC ARTICLE
disposable type to the m o r e c o m p l i c a t e d kind in
two pieces with an a d h e r e n t flange and removal
bag.
The c e m e n t or glue is not always satisfactory, but
this is occasionally the fault of the patient, w h o is
unaware that it s h o u l d not be applied too liberally
to the flange of the bag, and that the flange s h o u l d
not be pressed on to the skin until the c e m e n t
begins to b e c o m e tacky--just like m e n d i n g a punc-
ture. If the glue fails, further support and a m o r e
perfect seal can be o b t a i n e d by strapping the flange
to the abdominal wall with a w a t e r p r o o f a d h e s i v e - -
e.g., 'Sleek.'
A collar can be p l a c e d in the n e c k b e t w e e n bag
and flange and attached to a light belt to give
patients an a d d e d sense of security; or an elastic
corset can be worn with a hole cut to a c c o m m o d a t e
the bag. A belt is attached to the flange of s o m e
bags (fig. 1), but this tends to interfere with an
adhesive seal.
A bag s e l d o m sticks firmly from the outset, and
there is often a t e n d e n c y to leak on the outer side
during the first m o n t h or two. This naturally dis-
appoints the patient, w h o should b e reassured, for,
if the stoma has b e e n p l a c e d correctly, the leak
will cease as the patient puts on weight and the
gutter b e t w e e n stoma and anterior superior iliac
spine fills up. T h e r e is a further t e n d e n c y to leak
at night, for r e c u m b e n c y causes the ileal contents
to form a pool over the stoma instead of draining
into the bag; the leak occurs on the lateral side and
is controlled by r e i n f o r c e m e n t with adhesive.
Most patients r e m o v e the bag o n c e or twice daily,
Figure 1. Koenig-Rutzen bag with belt.
513
but it can be worn without change for longer pe-
r i o d s - e v e n up to a week. O d o u r is hardly notice-
able, since the contents of the ileum are inoffensive
and do not react with r u b b e r in the same way as
those from the large bowel. Most r u b b e r bags re-
quire renewal after 4 - 6 months, t h o u g h s o m e pa-
tients s e e m able to maintain t h e m in adequate
repair for a longer time.
Excoriation
Excoriation of the skin often develops r o u n d the
ileostomy and may last for six weeks after the
operation. Once the skin heals, the trouble s e l d o m
recurs; but o n e w o m a n r e p o r t e d r e p e a t e d excoria-
tion at the time of her periods, and a n o t h e r devel-
o p e d skin sensitivity to the c e m e n t three years after
operation. A faulty stoma, or a fistula which con-
stantly discharges at skin level, will induce persist-
ent ulceration; similarly a persistent retrograde
discharge of pus will damage the skin r o u n d the
distal stoma.
Several factors s e e m to contribute to this, chief
of which are the c o n t i n u o u s moisture and the
trauma resulting from r e p e a t e d application of the
bag. Theoretically, responsibility might rest with
the proteolytic e n z y m e s s o m e t i m e s present in the
ileal contents, for they act u p o n d e n a t u r e d protein
and could therefore digest the outer layer of the
skin. However, no correlation has b e e n f o u n d be-
tween the p r e s e n c e of e n z y m e and excoriation;
wetting agents, such as cetyl sulphate, which de-
stroy e n z y m e activity have not given c o m p l e t e pro-
tection to the skin, and the application of dressings
containing ileal contents have not caused excoria-
tion in areas r e m o t e from the ileostomy, even w h e n
ulceration has b e e n p r e s e n t r o u n d the stoma.
It is helpful to obtain drainage into a bag from
the outset and, to avoid the shearing effect of the
a d h e r e n t flange on the outer layers of constantly
moist skin, it is best to build up a pad of gauze
r o u n d the stoma for the flange to rest on. Both
flange and dressing are next sealed off with adhe-
sive, which adheres to the skin w h e r e it is not
affected by i l e o s t o m y drainage. Protection in this
m a n n e r may c o n t i n u e for two or three weeks after
operation, by which time it should be possible to
start using the cement.
When excoriation persists because an inefficient
stoma discharges its contents at skin level, only
further operation and refashioning of the ileostomy
will bring about any i m p r o v e m e n t ; to rely on dress-
514 CLASSIC ARTICLE
ings and ointments in such cases is only to encour-
age vain hope.
Intestinal Obstruction
Intestinal obstruction is the commonest serious
complication of ileostomy, but not much has been
published about it. Warren and McKittrick (1951),
however, have given a good account of it, using
the title "ileostomy dysfunction" for the particular
syndrome arising from partial obstruction which
more often occurs; it was a major complication in
61.9% of their 210 patients. In my series of 37
ileostomies there have be e n 10 cases of obstruc-
tion, 1 causing the death of the patient, 2 requiring
laparotomy for relief of adhesions, and 7 recovery-
ing without operation. Obstruction has not fol-
lowed ileostomy done as part of the operation of
primary colectomy in 9 further cases.
The site of obstruction may be at the stoma, at
the abdominal wall, or within the abdom e n owing
to internal herniation or to adhesions. (Stenosis of
the stoma is considered below.) If any part of the
abdominal wall, especially the anterior rectus
sheath or external oblique aponeurosis, is sewn
with tension round the emerging ileum, this may
precipitate obstruction in the relatively adynamic
phase which follows the operation; it is avoided by
relieving incisions in these structures. Likewise
obstructions from snaring in the para-ileal gutter
or at the site of mesenteric fixation (Hardy et al.
1949) is due to technical failure and can be
avoided. It may even be that the fine adhesions
which cause angulation and fixation of normally
mobile small bowel (Brooke 1951) can be pre-
vented; in the last 9 cases streptodornase and strep-
tokinase have b e e n injected into the peritoneal
cavity in the hope of preventing the formation of
these adhesions, and no obstruction has arisen in
these 9 cases compared with an incidence of 1 in
3 before this.
The treatment Of obstruction has been discussed
elsewhere (Warren and McKittrick 1951, Brooke
1951) and needs no further mention here.
Stenosis
Stenosis at the stoma arises, as Warren and
McKittrick (1951) state, from scar tissue formed by
the granulations that cover the raw serosal surface
of the protruding ileum during the two postopera-
tive weeks before the gradual evagination of the
mucosa has brought that surface into continuity
Dis Colon Rectum, May 1993
with the skin edge. It has complicated 4 of the 37
cases previously mentioned. Skin grafting (Drag-
stedt et al. 1941) should eliminate this but has not
always proved satisfactory; for the graft, whether it
be full-thickness or split-skin, is not infrequently
followed by ulceration, stenosis, and even a fistula,
though it is only fair to say that these difficulties
have not been encountered at the Mayo Clinic (C.
W. Mayo, personal communication).
Wells (1952) describes a "spout" ileostomy and
states that the results are good, but his report is
couched only in very general terms. A more simple
device is to evaginate the ileal end at the time of
operation and suture the mucosa to the skin (figs.
2 and 3); no complications have accrued from this.
For the first few days the "bud" appears flattened
on the skin, but it does not retract and should not
do so if the m e s e n t e r y has been tethered to the
anterior abdominal wall; it soon stands out in con-
ical form. Prolapse, which might be expected to
follow this manoeuvre, has not been encountered.
When stenosis develops it can sometimes be
relieved by simple dilatation but may necessitate
operation for its relief. It occasionally presents as
retraction of the "bud"; in these cases contraction
of the bowel wall causes the stoma to be withdrawn
below the constriction, from which it cannot es-
cape.
Prolapse
Prolapse, in the experience of most workers in
this field, is a c o m m o n c o m p l i c a t i o n - - I 3 % accord-
ing to Warren and McKittrick (I.951).. In my series
of 37 ileostomies 2 have prolpased, and none of
the 9 pr!mary colectomies have given trouble in
this way:
SKIN
N "~'
x
~ABDOMINAL
WALL
ILEUM
ILEUM
Figure 2. Usual iteostomy (above) and ileostomy with ev-
erted end (below),
Vol. 36, No. 5 CLASSIC ARTICLE
Figure 3. Everted ileostomy, with mucosa sutured to skin,
immediately after operation.
To prevent this complication the first principle
is to fix the mesentery, as has been described
elsewhere (Hardy et al. 1949, Brooke 1951). Mes-
enteric fixation will not, however, secure the bowel
if the abdominal wall round the stoma has been
damaged by infection or by further operation. In
these circumstances the abdominal wall adjacent
to the ileum becomes thin and fibrotic, and the
gap through which the ileum passes widens so that
herniation inevitably ensues; herniation thus initi-
ates this type of prolapse (fig. 4). It is significant
that 1 of the 2 cases of prolapse occurred after
colectomy when the mesentery of the emerging
ileal limb became detached and was not sutured
1 l I ~ ASKI
NMN
BDO I AL
WALL
ILEUM
Figure 4. Prolapse starting as herniation owing to damage
to abdominal wall (cf. fig. 2).
515
down; this was cured by refixing the mesentery. In
the other case prolapse followed a revision of the
ileostomy for fistula; this was curedby removing
the ileostomy stoma to a site where the tissues o f
the abdominal wall were undamaged.
The herniation type of prolapse can sometimes
be controlled by pressure from outside the bag
through a pad held opposite the stoma, but this
will not prevent most cases of prolapse, for these
develop as a form of intussusception. The opera-
tion, so commonly done for prolapse, of simply
lopping off the extruded bowel is to be condemned
outright. It is quite indefensible for two reasons:
(1) it does not cure the prolapse, which almost
invariably recurs; and (2) it removes an absorptive
area of the bowel, every inch of which the patient
requires.
For the operative cure of prolapse the abdomen
should be opened through an incision remote from
the ileostomy, which is then inspected from within
as well as outside. If it is found by palpation that
the abdominal wall alongside the ileum is atten-
uated, or that a finger passed from inside the ab-
domen presents at the stoma submucosally (fig.
4), the ileostomy should be detached and drawn
out through a stab incision elsewhere, and finally
the mesentery should be attached with care across
the para-ileal gutter. If the ileum is discovered to
be adherent throughout the depth of the abdominal
wall in the normal way, mesenteric fixation with
non-absorbable sutures should suffice.
Fistulae
Fistulae form for two reasons. The ileal wall may
be damaged or weakened at the time of operation;
a fixation suture through serosa and muscle alone
without penetration of the mucosa is particularly
liable to cause a subsequent breakdown of the
whole thickness of the bowel wall. A suture or
ligature lying close to the ileum but not penetrating
it in any Way can lead to the same result. In these
circumstances the fistula will appear in the first ten
days or so after the operation. A fistula at skin level
develops at any time after the operation through
chafing of the stoma against the flange of the bag
(figs. 5 and 6). The site of this fistula is inferior,
and the fistula is probably caused where a stoma is
placed too close to the groin, with the result that
the flange is pushed up against the stoma when the
patient sits down. It is also more liable to occur
when the flange is reinforced with metal.
516 CLASSIC ARTICLE
Figure 5.
Fistulae are avoided t h e r e f o r e by the elimination
of fixation sutures, by suturing without tension the
structures r o u n d the ileum, and by the p r o p e r siting
of the stoma; it is also advisable not to use a bag
with a flange r e i n f o r c e d with metal. The formation
Dis Colon Rectum, May 1993
Figures 5 and 6. Fistulae due to chafing by flange of
ileostomy bag.
of a n e w ileostomy by further operation is the only
cure for either type of fistula, and this must be
d o n e because persistence of a fistula, even t h o u g h
it may not pass d e e p to the skin, will cause excor-
iation and r e n d e r the bag inefficient.
I wish to thank Dr. H. G. Sammons, of the department
of pharmacology, University of Birmingham, for assess-
ing the proteolytic activity of ileal discharges.
REFERENCES
Brooke, B. N. (1951) Ann. R. Coll. Surg. 8, 440.
Dragstedt, L. R., Dack, G. M., Kirsner, J. B. (1941) Ann.
Surg 114,653.
Hardy, T. L., Brooke, B. N., Hawkins, C. F. (1949) Lancet,
ii, 5.
Warren, R., McKittrick, L. S. (1951) Surg. Gynec. Obstet.
93,555.
Wells, C. A. (1952) Brit. o~ Surg. 39,309.