Total Colectomy: What to Expect

A Total Colectomy is an operation to remove all of the colon (also called the large intestine). A colectomy may be necessary if a person has a disease of the colon that cannot be treated with medications alone. The most common diseases of the colon that require this operation include ulcerative colitis, polyposis, severe constipation, colonic dysmotility or Hirschsprung’s disease involving the entire colon.

Surgery to remove the colon is done through an opening made in the abdomen to remove the diseased colon. The patient will also have a diverting ileostomy, ileorectal pull-through or ileoanal pull-through.

• Diverting ileostomy: A portion of the small intestine is brought through the abdominal wall to the surface of the skin. The patient will pass stool (or poop) into a collection bag on the outside of the abdomen.
• Ileorectal Pull-through: The small intestine is connected to the rectum on the inside of the patient’s body.
• Ileoanal pull-through is a surgical procedure where the small intestine is brought down (pulled-through) and connected to the anus on the inside of the patient’s body. A “J” pouch is created during that same operation, which creates a pouch for the stool to collect on the inside of the patient’s body (the rectum is removed during the total colectomy).

Preparing for surgery

• Before surgery, all of the stool must be removed from the colon. Your surgeon will prescribe medications including antibiotics and laxatives that will “clean out” the colon. Ideally the medications will produce clear, watery stools the day before surgery. The child may either take these medications at home or may be admitted to the hospital the day before the surgery. It is very important that the patient drink plenty of fluids to stay well hydrated during a clean out. Your child will be on a clear diet the day before surgery to make sure that the clean out is successful. A clear diet includes all clear juices, clear broths, popsicles, and Jell-O®. Your surgeon will determine and discuss with you the best way to perform the clean out.
• Your surgeon’s office will call to give you instructions on what you should eat and drink before surgery. Most patients will not be able to drink or eat after bedtime the night before surgery.
• The surgeon’s office will give instructions for your expected arrival time. You should arrive in the Same Day Surgical Center on the 3rd floor of the Wang Building.
• Your child will be in the hospital for 5-7 days after surgery.
• Additional information about preparing for your child’s surgery and answers to commonly asked questions, are included in the pamphlet and video “Preparing for your child’s surgery”. These resources are available in the Pediatric Surgery Outpatient Clinic or online at www.massgeneral.org/children/pediatricsurgery.

What to expect the day of surgery

• After surgery your child will go to the recovery room (also known as the PACU). Then later transferred to the pediatric floor of the hospital.
• Your child will have an intravenous (IV) catheter. An IV is a small tube inserted in the vein of the hand or arm. Through the IV, your child will receive pain medication, antibiotics, and other fluids.
• Your child may have a tube in their nose for the first few days after surgery to drain fluid (gastric secretions) from their stomach. This helps prevent vomiting. They may receive medication through the IV to prevent them from feeling nauseated.
• Your child may have a have a tube in their bladder to drain urine. This usually stays in place for 1-2 days.
• Your child will receive antibiotics through the IV, that help to prevent infection.
• Your child may receive a medication through the IV called Dextran®, which helps to promote blood flow to the newly created J pouch.
• Your child may receive pain medications through a tube placed in their back (called an epidural catheter) or through the IV in their hand or arm. The patient and family, along with the surgeon and the anesthesiologist will decide the best way to give the child pain medications after surgery.

What to expect in the days following surgery

• Eating: Your child will receive fluids through the IV to keep them hydrated. They will not eat or drink while the tube is in their nose. The tube will be removed once the patient has active bowel sounds (sounds that can be heard with a stethoscope), when they pass flatus (gas), and when there is a smaller amount of fluid (or gastric secretions) drained from the patient’s stomach. Typically the tube is removed a few days after surgery. Once it is removed, the patient will start drinking clear fluids and then will gradually begin eating solid foods. Your surgeon may recommend that your child eat a low residue diet for several weeks after surgery. (Please see attached information on a low residue diet).
• Pain Management: Once your child is drinking and eating normal foods, they will start taking pain medications by mouth. Your child will take a combination of prescription pain medications and either Tylenol® or ibuprofen. When you are discharged home from the hospital, your child will be on these same medications.
• Bowel Movements:
  • Diverting Ileostomy: If your child has an ileostomy, gas and stool are usually visible in the collection bag within 2 or more days. An Ostomy Nurse will meet with the patient and determine the appropriate collection bag for stool. They will teach you about caring for the ileostomy. Before the patient is discharged, the case manager will help to coordinate and order all of the supplies you will need at home. Ileorectal Pull-through: If your child had an ileorectal pull through procedure, they will start to pass stool through their anus after a few days. In the beginning the stools are usually watery and frequent. In the beginning your child may leak stool or have accidents. This happens because the stool may passes quickly or the sensation may feel different. Once your child eats solid foods the patient will have more control over their bowel movements. They may need a fiber supplement or other medications to help make their bowel movements more formed.
  • Ileoanal Pull-through: If your child had an ileoanal pull through procedure, they will start to pass stool through their anus after a few days. In the beginning the stools are very watery and frequent. Your child may leak stool. They may also have accidents. This happens because the stool may pass quickly or the sensation may feel different. This is all expected and completely normal, but it can be very stressful for both the child and the family. Once your child starts eating solid foods the stools will become less watery. The surgeon may also start your child on medications that will help to make the stools less watery and less frequent. Your child will go home on these same medications. As your child recuperates from surgery over the next 4-6 months the stools will become less frequent and more predictable. Your child is expected to have 4-6 formed stools per day.
• Activity: The patient is encouraged to sit in a chair the day after surgery and is encouraged to walk a few days after surgery. They also need to take deep breaths frequently throughout the day to prevent pneumonia. The patient will be able to walk independently and will be able to climb a few stairs at the time of discharge. It is expected that they will be out of school for 2-3 weeks.

Your child will be ready for discharge when:

• They are able to eat and drink a regular diet and are able to stay well hydrated.
• They are able to take pain medications by mouth and their pain is well managed by these medications.
• Your child has no signs of bleeding or infection (fever).
• Your child is able to walk and move independently.

Discharge instructions

• Caring for the incision: The bandage that covers the incision will be removed before you leave the hospital. Beneath the dressing are Steri-strips® (or paper tape), which will fall off on their own 1-2 weeks after surgery. The stitches beneath the Steristrips® do not need to be removed; your body will absorb them. The incision may get wet with normal bathing including showering, tub baths and swimming. Please call the office if your child develops redness, swelling, or drainage at the incision site. If your child has an ileostomy a visiting nurse will assess your child’s ileostomy at home. The nurse will provide you with additional support and teaching.
• Physical Activity: Your child will continue to recuperate at home for an additional 1-2 weeks. They may return to school as soon as they feel ready and no longer require prescription pain medications. It may be helpful for your child to start with partial days at school. They can then work up to full days as tolerated. Your child may not participate in gym class, contact sports or heavy lifting until your follow up appointment with your surgeon. This is typically 2-3 weeks after surgery. Teenagers may not drive until they are off prescription pain medications for at least 24 hours.

Medications:

Your child may take the following medications for pain:

• _____ Oxycodone
• _____ Tylenol®
• _____ Ibuprofen (Advil®/Motrin®)
• _____ Other:

Your child may be prescribed a stronger pain medication, if needed.

Your child may take the following medications to make the stools less watery (called bulking medications) and less frequent (prevent diarrhea):

• _____ Colestid® 1 gram tablet, 2 tablets by mouth twice daily to bulk the stools
• _____ Welchol® 625 mg tablet, 3 tablets by mouth twice daily to bulk the stools
• _____ Lomotil® 2.5 mg tablet, 1-2 tablets by mouth every 6-8 hours as needed for diarrhea
• _____ Imodium® 2 mg tablet, 1-2 tablets by mouth every 6 hours as needed for diarrhea
• _____ Fiber Supplement (Metamucil®, Fibercon®, etc.) ______________________________by mouth 2-3 times daily as needed for diarrhea
• _____ Cholestyramine Ointment: Topical ointment to prevent skin breakdown from the frequent watery stools

Your child’s gastroenterologist has requested that you resume the following medications (medications that the patient had been taking prior to surgery)

• _____ Asarco®
• _____ Prednisone

  Maintaining Hydration and Electrolyte Balance

  Because your child has undergone total colectomy, they are at risk for dehydration and electrolyte imbalance. Dehydration can occur if your child has frequent watery stools and is not drinking enough fluids. Electrolyte imbalance occurs when levels of minerals in your body become too high or too low.

  Increased salt loss (called hyponatremia) is common and also occurs due to frequent watery stools. Patients are also at risk during the summer months, during physical activities, or if they develop a fever.

  Your surgeon may monitor your child’s hydration and level of salt in your body through blood and urine samples as an outpatient.

  Your surgeon has recommended the following to prevent dehydration:

  • Older school age children and teenagers should drink a minimum of 10 (eight ounce) glasses of fluid each day. Avoid caffeinated beverages. Beverages such as Gatorade®, PowerAde® and other sports drinks can help to replenish electrolyte losses and are encouraged.
  • Infants and young children should be encouraged to drink frequently. Infants should have 4-6 wet diapers and young children should urinate frequently throughout the day.
  • Your child’s urine will appear clear or light yellow when they are well hydrated

  Your surgeon has recommended the following to prevent hyponatremia (low salt level in the blood):

  • _____ Sodium Chloride supplement 1 gram tablet, 3 tablets by mouth 1-2 times each day
  • _____ Add salt to your foods at each of your meals
  • _____ Your surgeon does not recommend a salt supplement at this time.

  Low-Residue Diet

  Foods to Eat

  Milk and Dairy Products:

  • Soy milk, Lactaid®, Rice milk
  • Eat no more than 2 servings per day of:
    • Regular cow’s milk (8 oz)
    • Cheese (1 oz)
    • Yogurt (4 oz)

  Meats, Legumes, and Nuts:

  • Chicken, turkey, eggs, fish
  • Smooth peanut butter

  Grains:

  • Mashed potatoes, rice, noodles
  • White breads
  • Plain bagels and English muffins
  • Cheerios®, Cornflakes®, Rice Krispies®
  • Saltine crackers
  • Baked products using white flour

  Vegetables:

  • Vegetable juices
  • Canned vegetables
  • Well cooked vegetables except those listed in foods to avoid
  • Mushrooms

  Fruits:

  • Applesauce, canned fruits
  • Melons and cooked fruit
  • Bananas and peeled apples

  Desserts:

  • Cakes, cookies, and pies made without nuts, seeds, or whole grains.
  • Desserts made with cooked fruit, gelatin, and custard
  • Regular gum

  Beverages:

  • Water
  • Decaf coffee and decaf tea

  Foods to Avoid

  Milk and Dairy products:

  • Limit to 2 servings of dairy each day

  Meats, Legumes, and Nuts:

  • Pork, beef, lamb
  • Any made with whole grain ingredients, seeds, or nuts
  • Beans, lentils, peas, chunky peanut butter

  Grains:

  • Any baked product with whole wheat
  • Whole grains crackers, pasta, breads, rice, bagels, and muffins
  • Cereals with whole grains, bran, granola, seeds, nuts, coconut, dried fruit Cornbread and graham crackers
  • Popcorn

  Vegetables:

  • All raw vegetables
  • Beets, broccoli, brussels sprouts, and cauliflower
  • Potato skins, vegetables with seeds, sauerkraut, peas

  Fruits:

  • All raw fruit (except bananas and peeled apples)
  • Dried figs, prunes, raisins, cranberries, and other dried fruit
  • All fresh berries

  Desserts:

  • Any made with whole grains, bran, nuts, seeds, coconut, or dried fruit
  • Sugar-free gum

  Beverages:

  • Juice, soda, lemonade, carbonated water
  • Alcohol, coffee, and tea

  Rev. 12/2019. Mass General for Children and Massachusetts General Hospital do not endorse any of the brands listed in this handout. This document is intended to provide health related information so that you may be better informed. It is not a substitute for a doctor's medical advice and should not be relied upon for treatment for specific medical conditions.