The study was carried out in the Department of Surgery of a Government Medical College having tertiary care facility. It was an institution based, prospective, single arm, observational study over a period of two years from January 2012 to December 2013. The study was approved by the Hospital Ethics Committee. A written and witnessed informed consent was obtained from all patients and formally recorded in the casesheet. Only adults aged more than 12 years of age requiring emergency ileostomy were enrolled in the study.

Sixty admitted patients (Male-36, Female-24) were recruited for the study on the basis of following inclusion and exclusion criteria. The patients were in the age group of 20-60 years with a mean age of 45 years. Most of the studied patients had a low socio-economic condition. All of them presented with an acute abdomen and needed emergency surgery and construction of a temporary ileostomy.

All the patients were found to have perforated or obstructed or gangrenous small bowel. In each case a temporary stoma was created in the ileum as a lifesaving emergency surgery.

Oral feeding was started as soon as ileostomy started functioning and the patient expressed hunger; about 48-72 hours postoperatively. Anthropometric and biochemical examination was performed to observe the outcome in nutritional parameters. Nutritional status was assessed on:-

Nutritional status was measured by using the following parameters:-

All recorded data were statistically analysed with SPSS v17, Chicago to draw an appropriate conclusion.

In the immediate postoperative period all the patients received intravenous fluids and blood transfusion. Once oral nutrition was started, intravenous fluids were discontinued. An individualized diet chart was formulated for each patient using Harris- Benedict Equation [1]. Oral diet was at first restricted to clear liquids. Gradually solid food was introduced; different food items introduced one at a time and stopped immediately if adverse symptoms developed. All patients were offered a diet to which he/she was otherwise accustomed i.e. common food items consumed locally. During entire period of study nutrition offered was purely oral and none of the patients received any intravenous nutritional supplements. Certain dietary guidelines have been recommended for these patients [2,3,5–9].

The various indications of emergency ileostomy in the patients enrolled are shown in [Table/Fig-1]. In our study ileal perforation (49.8%) due to disease or trauma was the commonest indication of construction of ileostomy. Abdominal tuberculosis (33.3%) was the commonest disease affecting the small gut with an emergency presentation of perforative peritonitis or acute intestinal obstruction. The nutritional status of the studied patients was first assessed on the 1^st day of oral nutrition [Table/Fig-2]. This initial assessment showed that the nutritional parameters were below average/subnormal in most of the studied patients. The parameters were again measured 7 days after initiation of oral nutrition. The results are shown in [Table/Fig-2,3]. The tables show that the haemoglobin level, body weight and total leucocyte count declined significantly in these 7 days (p<0.001). Mean of serum protein level was increased significantly (p<0.001) and serum albumin increased slightly. Mean of changes in serum electrolyte level increased slightly. Stomal output considerably increased, (p<0.001) the consistency mostly liquid in nature. So changes in Haemoglobin, Total leucocyte count, stomal output, serum total protein and body weight are statistically significant whereas changes in serum albumin, serum sodium and potassium level were found to be insignificant (p-value >0.005). The parameters were again measured 3 months after initiation of oral nutrition; the results are shown in [Table/Fig-4]. Mean of haemoglobin, and body weight improved optimally whereas mean of Total leucocyte count and stomal output decreased. Serum electrolytes increased slightly. Serum total proteins and serum albumin increased to reach acceptable normal values. [Table/Fig-5] shows that except for serum potassium levels, p-value of changes of all other parameters were found to be statistically significant (p <0.001). It signifies that at the end of the study, the basic parameters (haemoglobin, body weight, total leucocyte count, stomal output, serum albumin) which play pivotal roles in terms of morbidity and fitness for next surgery (stomal closure) are normalized. After 7 days of oral nutrition, stomal output increased in almost every patient and was mainly liquid in consistency. With progress of the study there was gradual decline in volume of stomal output and the consistency became semisolid or solid in nature.

Temporary ileostomy is a surgically created opening in the ileum on to the anterior abdominal wall. Created in the emergency setting of perforation or gangrene with peritonitis, temporary ileostomy is lifesaving. It enables individuals to enjoy normal activities even though they have a stoma [1–5]. Nutritional depletion occurs in patients with ileostomy due to both anatomical and functional loss of gut, ongoing inflammatory activity due to disease with sepsis, pre-existing malnutrition and the added surgical stress. All these factors are to be considered while formulating an appropriate management plan to restore and maintain nutritional status [1–3,5–9]. Enteral alimentation is the primary and preferred route for nutrition in patients with ileostomy. Enteral nutrition is physiologic, maintains intestinal integrity, reduces bacterial translocation and preserves the normal gut flora and the enteral immune system. It is more convenient, cost-effective with fewer complications [2,3,6]. Ileostomy allows early oral feeding in postoperative period, since the chances of anastomotic failure with increased morbidity is eliminated [1–4,6,7]. Traditionally three phases have been described in ileostomy patients receiving oral nutrition [2]. The first phase is the immediate postoperative phase with decrease in effective absorptive surface and capacity and patient may suffer from diarrhea. The second phase starts in the first week with the beginning of intestinal adaptation. It appears that food is a potent stimulus for secretion of gut hormones (motilin, neurotensin), mucosal development and bacterial colonization. The strategy of initiation of early oral feeding is an important component of intestinal adaptation and improved nutrition after small gut exteriorization [2,3,5–7]. The third and final phase is the phase of complete bowel adaptation which develops within a few weeks of initiation of oral feeding [1–3,6–9].

Dietary advice is an important aspect of the maintenance of oral nutrition. The aim of dietary management is to prevent stoma blockages after surgery, to promote healing of stoma wound and to minimize unpleasant gastrointestinal symptoms. The goal of the dietary approach is to provide a stepwise management of care. It is planned to progress from a liquid to a semisolid/solid diet. It is important to provide a high energy, high protein diet that is low in excess insoluble fibre [2,3,5–7,9]. It is advisable to add one new food at a time to observe its effects. Offending foods can be thus identified and avoided if felt necessary [2,3,5,7–9]. Most people can return to a normal diet after few weeks of oral feeding [2–5,8,9].

In the present study, the initial nutritional assessment on the 1^st day of oral feeding showed subnormal parameters. This is probably because the studied patients mostly came from a low socioeconomic background, were already malnourished and their nutritional status had worsened due to the surgical pathology compounded with the stress of emergency surgery. The initial assessment was useful because it provided baseline values to which subsequent changes at the end of the study could be compared. The choice of various parameters employed was decided on the basis that they were simple to measure, required no elaborate equipment, results were quickly available and the results provided a fairly accurate estimate of all body components [1,5–7,9,10]. When the nutritional assessment was done after 7 days, all the studied patients had a remarkable weight loss.

The probable reasons are:-

After few months of oral diet the functioning intestine subsequently adapts to hold fluid and nutrients to regain homoeostasis and nutritional equilibrium with gain of weight [2–10]. In our study after 3 months, all our patients gained weight satisfactorily.

At the time of initial assessment, our patients were mildly anaemic. This is due to pre-existing malnourishment aggravated with perioperative blood loss. With oral feeding, patients were started on oral iron supplements. Yet after 7 days, the haemoglobin level went down. It appears that the loss of functional terminal ileum contributed to this anaemia in a background of persisting inflammation and catabolism [2,5,7,9]. With intestinal adaptation, at the end of the study, all the patients regained the standard Haemoglobin level desirable for elective stomal closure. During initial assessment there was marked leucocytosis. After 7 days Total leucocyte count declined significantly after proper antibiotic coverage. After 3 months of complete resolution of sepsis, Total leucocyte count was within normal limits.

Serum albumin traditionally considered as nutritional marker is also considered as an inflammatory marker [1,2,6,7,9]. Serum albumin was below normal at the start of study. Rapid decrease in albumin levels can occur due to severe catabolism induced by sepsis. After 7 days of oral feeding albumin is slightly increased (possibly with the initiation of the anabolic phase). As absorption improved with time, and in absence of inflammation and sepsis, serum albumin became normalized. During the study initial serum electrolyte levels were slightly altered due to tissue injury, fluid retention or overzealous fluid replacement [1,5,7]. At the end of the study, p-value of changes in serum potassium levels was >0.005 i.e. statistically insignificant. However, p-value of changes in serum sodium level is statistically significant (p<0.001).

The amount, and consistency of the ileostomy output is influenced by the diet [2–9]. In our study after 7 days of oral nutrition stomal output increased in volume, was mostly liquid in nature- due to dampened mucosal integrity and poor absorptive capacity of the small gut. Amount decreased gradually and the consistency became liquid<semisolid<solid in nature with recovery of mucosal integrity and normal transit time at the end of the study.

Several similar studies have been done where emergency temporary ileostomy has been performed for almost same etiologies as documented in our study. Those studies have mentioned the stoma related nutritional complications and have noted the impact of ileostomy on diet and nutritional status of the patients. In our study, patients had a significant decline in nutritional status after 7 days of oral feeding. In the study of Mohil et al., there was an initial decline in nutritional status despite adequate nutritional support after 6 weeks of oral feeding [1]. In the study of Sinha et al., 66% of patients had a remarkable change in their diet after 6 weeks of postoperative oral feeding [11]. In our study patients had their nutritional status gradually restored after 3 months. Similar studies like that of Chowdhury et al., have noted a significant weight gain with improvement of BMI after 2months (8 weeks) of oral feeding [12]. A study of Saini et al., have shown that with few diet modifications, the stoma patients had a satisfactory nutritional status at about 4-5 months (19 weeks) of oral feeding [4]. A study by Shaffy et al., has shown that with time, all ileostomy patients learn to adjust to a simple and bland diet to avoid flatus, odour, constipation, obstruction etc [13]. All the studies have shown that though there is an initial decline in nutritional status; with intestinal adaptation and appropriate diet modification, the digestion and absorption of patients with ileostomy gradually improve with a restoration of nutritional status after few months [4,11–14]. The patients in our study also showed improved appetite, weight gain with satisfactory nutritional parameters at the end of our study.

There are few limitations in our study. The sample size was small with only 60 patients included in the study. Only a few nutritional parameters were considered. Many anthropometric, biochemical and immunological parameters were not measured. Even though the nutritional status was restored favourably, it is not clear how far the patients had to modify their diet and whether at all they were satisfied with their diet after 3 months of oral feeding.

Ileostomy is an emergency life saving procedure in patients with peritonitis. Maintenance of postoperative nutrition in these patients is a challenge for the surgeon. After 7 days of oral diet the nutritional status deteriorated. However, at the end of the study after 3 months of oral diet, intestinal adaptation helped in the gradual improvement of nutritional status. Proper dietary advice and oral nutrition is sufficient for gradual restoration and maintenance of satisfactory nutritional status in the postoperative period.