Will I need a bag after bowel surgery?

“The doctor said a bag might be needed.” For many patients this sentence is more frightening than the illness. In this article we explain in plain language what a stoma is, when it is needed and when it is not, and what life with it is like. We make no promise here about your situation; your surgeon will tell you the likelihood before the operation, based on your own disease.

What is a stoma?

ASCRS describes an ostomy as an opening made by the surgeon between an internal organ and the surface of the body. In the bowel, a piece of bowel is brought out through a round opening in the abdominal wall and the visible part is called the “stoma”. Stool passes through it into a bag stuck to the skin.

• Ileostomy: made from the end of the small bowel (ileum).
• Colostomy: made from a part of the large bowel.
• End stoma: the end of the bowel is brought out. Loop stoma: a healthy loop of bowel is brought out and opened halfway; it is usually temporary.

Why is it sometimes needed?

ASCRS lists the reasons as: cancer, trauma, inflammatory bowel disease, obstruction, infection, fecal incontinence, severe constipation and diverticulitis. Sometimes a stoma is made only to protect a join or to rest the bowel.

• Colon cancer: usually the two healthy ends of the bowel are joined. ASCRS says a stoma is needed in only a small number of colon cancer patients. If joining is not possible, NCI says a colostomy is made, which may be temporary or permanent.
• Rectal cancer: depending on the place of the tumor and the patient’s condition, a stoma may be needed. NCI says if the cancer is very close to the anus and joining is not possible, a colostomy is made; temporary until the rectum heals, or permanent if the whole rectum is removed. ASCRS says permanent is less common.
• Severe diverticulitis: ASCRS says in an unwell patient, joining the bowel carries a higher risk of a leak (about 6 to 19%, compared with about 5% in other situations). Sometimes a temporary stoma is safer. A protective ileostomy is usually removed after 2 to 3 months.
• Ulcerative colitis: after the colon is removed, an ileostomy may be needed. In J-pouch surgery the ileostomy is usually temporary and closed later (ASCRS).
• Crohn’s disease: when the bowel cannot be reconnected with confidence, a stoma may be made, temporary or permanent (ASCRS).

Temporary or permanent?

• Temporary: keeps stool away from an area that needs to heal (a join, an inflamed area or a blockage) and is closed when the surgeon judges it right. ASCRS and the NHS do not give one time for everyone; for diverticulitis 2 to 3 months is mentioned, but it depends on your situation.
• Permanent: when the disease or treatment has disturbed the normal function of the bowel, or the anus or the control muscle has been removed or does not work (ASCRS).

Ask: How likely is a stoma in my case? If one is made, is it temporary or permanent? When will it be closed?

Life with a stoma

ASCRS and the NHS say:

• The bag: it is odor-proof, disposable and low in volume and sticks with a skin-protecting adhesive; it is not usually visible under clothes. The bag is emptied several times a day and changed completely about 2 to 3 times a week.
• The skin: at each change, look at the skin for redness, swelling and rash. Skin irritation is the most common problem and is usually solved with care or a change of adhesive.
• The site of the stoma: before the operation the surgeon or nurse marks it on the abdomen, sitting, standing and lying.
• Bathing: showering with or without the bag is safe.
• Exercise, work and travel: after recovery most activities are possible. Very rough contact sports and very heavy lifting are exceptions. Work and travel are usually not restricted, but carry spare supplies.
• Sex: ASCRS says most people return to normal intimacy without harming the stoma. Concern about body image is common; talk to the stoma nurse. Whom you tell is your own choice.
• Food: most people eat normal food. Chew well and drink enough fluids. For an ileostomy the NHS mentions a low-fiber diet for about the first 6 weeks.

The stoma nurse

A trained nurse (WOC) is with you before and after the operation to choose the equipment, teach you to change it and solve problems. Ask for this help.

Possible complications

ASCRS says:

• Skin irritation
• Dehydration, especially with a high-output ileostomy: dry mouth, dark and little urine, weakness, muscle cramps
• Obstruction: abdominal pain, cramps, a sudden fall in output
• A bulge beside the stoma (hernia) or the bowel coming out of the stoma
• Large weight changes can change how it works

In most cases they are solved with care or simple treatment. Tell the surgeon or stoma nurse about any sign.

Talking with family and partner

Having a stoma can bring difficult feelings. This is normal. The NHS says to talk to the stoma nurse about problems with relationships and body image. Include your family in the teaching session.

Questions to ask before the operation

• Is a stoma likely? In what circumstances?
• Is it temporary or permanent? When and how will it be closed?
• Will the site be marked before the operation and will a stoma nurse visit before the operation?
• What teaching will I get before discharge?

This article does not replace a doctor’s opinion; ask your doctor about your own situation.