What Is an End Colostomy? Procedure and Permanence

An end colostomy is a surgical opening in the abdominal wall through which the cut end of the colon is brought to the surface, creating a stoma that diverts stool into an external collection bag. It differs from a loop colostomy, where a loop of bowel is pulled through the skin with both the functioning and non-functioning ends still connected. End colostomies are created when the downstream portion of the colon or rectum has been removed or disconnected entirely, and they can be either temporary or permanent depending on the underlying disease and the patient’s overall health.

How the Surgery Works

The most widely performed version of the end colostomy is the Hartmann procedure. In this operation, the surgeon removes the lower portion of the sigmoid colon and the upper part of the rectum, closes off the remaining rectal stump, and brings the proximal (upstream) end of the colon through the abdominal wall to form the stoma.¹ The stoma itself is a small, round piece of moist pink tissue that protrudes slightly from the skin. It has no nerve endings that sense pain, so touching it does not hurt, though it will bleed a little if rubbed.

The operation can be performed open, through a large midline incision, or laparoscopically through several small incisions. Emergency cases almost always use an open approach because speed matters more than minimizing the scar. In elective (planned) settings, laparoscopic approaches are increasingly common and tend to produce fewer wound infections and shorter hospital stays. The choice between end and loop stomas also depends on the clinical goal: end colostomies are preferred when no downstream reconnection is planned in the near future, while loop stomas are more often used as temporary diversions to protect a fresh surgical join farther down the bowel.²

Why Surgeons Create End Colostomies

The reasons fall into a few broad categories, and the split between emergency and planned surgery matters quite a bit for outcomes. In emergency settings, the most common triggers include a twisted and dying segment of sigmoid colon (sigmoid volvulus), a perforated colon from diverticular disease, traumatic abdominal injuries, and bowel obstruction from advanced cancer. A study from a large surgical center found that gangrenous sigmoid volvulus accounted for nearly half of all colostomy indications, followed by colorectal cancers and abdominal injuries.³

In elective surgery, the most frequent reason is low rectal cancer that sits too close to the anal sphincter muscles to allow a safe reconnection. An abdominoperineal resection removes the rectum and anus entirely and always produces a permanent end colostomy. Severe perianal Crohn’s disease that has destroyed the sphincter complex is another scenario in which diversion becomes necessary.² Less commonly, end colostomies are created for fecal incontinence that has not responded to other treatments, pelvic radiation damage, or complex fistulas.

Colostomies formed in emergencies carry higher rates of serious complications, including stoma ischemia (where the blood supply to the stoma is compromised), retraction, and fistula formation. One analysis found that serious complications were significantly more common when the surgery was unplanned, and the rate was higher still when a non-colorectal surgeon performed the operation in an emergency setting.⁴ Another study confirmed that necrosis of the stoma was roughly three times as common after emergency creation compared with elective cases.⁵

Whether It Is Permanent

This is the question that weighs most heavily on people facing the surgery, and the honest answer is that it depends on why the colostomy was created and on the patient’s general fitness. In principle, a Hartmann’s end colostomy is “reversible” because the rectal stump is still there and the two ends can be surgically reconnected. In practice, a substantial number of patients never undergo that second operation.

Reversal rates in the published literature range widely. One large study of over 400 Hartmann patients found that only about 29% went on to have the colostomy reversed, rising to roughly a third after excluding patients who died in the first month.⁶ Another study reported reversal in 47% of patients, noting that among those who were never reversed, about 30% chose to keep the stoma themselves while the remaining 70% were considered too high-risk or unfit for a second operation.⁷ A third study placed the non-reversal rate even higher, at roughly 60%.⁸

When the end colostomy is created specifically because the rectum and anus have been removed entirely, such as in an abdominoperineal resection for rectal cancer, there is nothing to reconnect to and the stoma is permanent from the outset. In a multicenter study of patients with mid or low rectal cancer, about a quarter ultimately ended up with a permanent stoma, including those who had planned sphincter-saving operations that later failed or required re-operation.⁹

What Predicts Whether Reversal Happens

Several factors tilt the scales toward keeping the colostomy. Across studies, the consistent predictors of non-reversal are older age, higher surgical risk scores (reflecting heart, lung, or kidney disease), the presence of advanced cancer, and having experienced multiple complications from the original operation.⁶ Younger patients without significant other health problems and those whose original colostomy was performed for a non-cancer reason like diverticulitis have the highest rates of successful reversal.⁸

Reversal surgery itself is not trivial. It involves reopening the abdomen, identifying the rectal stump, and creating a new join between the two bowel ends. About a quarter of patients who do undergo reversal develop complications, with anastomotic leakage being the most serious concern.¹⁰ That risk profile explains why surgeons are cautious about recommending reversal in patients who are medically fragile or who are managing well with the stoma. A study examining timing of reversal after Hartmann procedures for diverticulitis found no significant difference in major complications or mortality based on whether reversal happened earlier or later, suggesting the decision can be driven by readiness rather than a rigid calendar.¹¹

How Stoma Placement Affects Outcomes

Where exactly the stoma sits on the abdomen matters more than most people realize. The ideal location is through the belly of the rectus abdominis muscle, on a flat area of skin that the patient can see and reach, away from bony prominences, skin folds, scars, and the belt line. Having the site marked before surgery by a specialist nurse has been shown to roughly cut complications in half and improve both self-care ability and quality of life afterward.¹² A second meta-analysis confirmed that pre-marked stomas had fewer both early and late peristomal complications.¹³

Despite the evidence, preoperative marking still does not happen universally, especially in emergency cases where there is little time. If you or a family member is scheduled for planned colostomy surgery, asking for a stoma nurse consultation beforehand is one of the simplest steps that can make a concrete difference in long-term comfort.

Early Complications

In the first days and weeks after surgery, the main concerns are stoma necrosis (the tissue turning dark from poor blood flow), retraction (the stoma pulling back below skin level), mucocutaneous separation (the edges peeling away from surrounding skin), and peristomal abscess.¹⁴ Mucocutaneous separation and bleeding are more common than many patients expect. One single-center study reported that at least one complication developed in roughly two-thirds of patients regardless of whether the stoma was created electively or in an emergency, though the types of complications differed: emergency patients had more necrosis and bleeding, while elective patients had higher rates of peristomal skin irritation.¹⁵

Most early complications are managed without reoperation. Superficial necrosis that affects only the outer rim of the stoma can be watched. Deeper necrosis or complete retraction, however, usually requires surgical revision. The take-home point is that some degree of complication in the initial weeks is common and does not mean the stoma has failed.

Parastomal Hernia, the Most Common Long-Term Problem

Over months and years, the single biggest issue for end colostomy patients is parastomal hernia, a bulge that forms around the stoma when abdominal contents push through the opening in the muscle wall. The five-year cumulative rate in one study was about 38%.¹⁶ Risk factors include older age, being overweight, female sex, and having high blood pressure, diabetes, or altered connective-tissue metabolism.¹⁷ Most parastomal hernias cause cosmetic distress and appliance-fitting problems rather than dangerous bowel strangulation, but they can substantially erode quality of life.

Placing a mesh around the stoma at the time of the original surgery has been studied as a way to prevent these hernias. A systematic review and meta-analysis of randomized trials found that prophylactic mesh reduced parastomal hernia rates overall, from about 38% without mesh to about 24% with it. The picture becomes murkier in more recent studies alone, where the difference narrowed and lost statistical significance.¹⁸ A broader network meta-analysis found that placing mesh behind the muscle (the retromuscular position) appeared to offer the lowest hernia rate among the techniques studied.¹⁹ A Dutch randomized trial showed particularly striking short-term numbers, with parastomal hernia rates of about 5% with retromuscular mesh versus 24% without it.²⁰ The evidence is encouraging but not yet definitive enough for prophylactic mesh to be routine everywhere.

Living with an End Colostomy Day to Day

The stoma itself has no sphincter muscle, so stool passes whenever the colon contracts. For end colostomies placed in the sigmoid (the most common site), the output tends to be formed or semi-formed because most of the water absorption has already happened upstream. That makes management simpler than with an ileostomy, where output is liquid and continuous.

Most people wear a two-piece pouching system: a flat or convex adhesive wafer that sticks to the skin around the stoma, and a detachable collection bag that clips or locks onto the wafer. Bags are either drainable (opened from the bottom to empty) or closed (discarded after a single use). For sigmoid-end colostomies with predictable output, some patients use colostomy irrigation, a technique in which warm water is instilled through the stoma every day or two to flush the colon. Patients who irrigate can achieve continence between irrigations, avoid wearing a full bag, and use just a small cap over the stoma the rest of the time.²¹ Irrigation is not appropriate for everyone: it works best with end sigmoid colostomies, requires a certain level of manual dexterity, and takes about 30 to 45 minutes per session. Still, for motivated patients, it offers the closest experience to pre-surgery continence.

Peristomal skin breakdown is the other persistent daily-life challenge. The skin around the stoma is constantly exposed to moisture, adhesives, and occasional contact with stool. Irritant contact dermatitis is the most common skin complication, and it can become a cycle: sore skin causes poor wafer adhesion, which causes leakage, which worsens the skin. A randomized trial found that a modified ostomy appliance designed to reduce stool contact with the skin more than doubled the 28-day healing rate for peristomal dermatitis compared with standard care.²² Beyond appliance design, practical steps include cutting the wafer opening precisely to the stoma size, using skin barrier rings or paste to fill gaps, and changing the wafer on a regular schedule before leakage starts rather than waiting for it.

Psychological and Sexual Health

Body image disturbance is real and measurable in people living with stomas. A descriptive study found that younger patients, overweight patients, and those who reported depressive feelings or thoughts of self-harm after surgery scored significantly higher on body image disturbance scales. Interestingly, patients with temporary stomas reported higher body image distress than those with permanent ones, possibly because the uncertainty about reversal adds its own psychological burden.²³ Self-efficacy, the confidence that you can manage the stoma competently, was negatively correlated with body image distress, meaning that practical mastery of stoma care appears to buffer psychological harm.

A systematic review and qualitative synthesis of multiple studies confirmed that people living with permanent stomas report limitations in mobility, sleep, self-care, and sexual life, and that many need to reorganize daily routines, social roles, and work activities.²⁴ Sexual dysfunction deserves specific mention because it is underreported. For rectal cancer patients, the stoma itself is only part of the picture; nerve damage from the surgery, pelvic radiation, and chemotherapy all compound the problem.²⁵ Erectile dysfunction and vaginal dryness are common physiological consequences, and the psychological overlay of wearing a bag during intimacy compounds them. Raising these issues proactively with your surgical or oncology team rather than waiting for them to ask is important, because many centers now have access to pelvic-floor physiotherapy, sexual health counseling, and stoma-specific intimacy resources.

The Financial Side of a Permanent Stoma

Pouching supplies, barrier products, skin-care items, and accessories add up. The exact cost depends heavily on where you live and what insurance or public health system covers. A Canadian cross-sectional survey documented that living with an ostomy can result in meaningful financial burden, with regional variations in government funding and access to specialized nursing making the experience uneven across provinces.²⁶ A separate study of U.S. veterans found that difficulty paying for ostomy supplies was independently associated with lower overall quality of life, even after accounting for income, physical health, and demographics.²⁷

In the United States, Medicare Part B covers ostomy supplies up to a monthly allowance, but copays and the gap between the allowance and actual costs can still leave patients out of pocket. Private insurers vary widely. Organizations like the United Ostomy Associations of America maintain lists of patient-assistance programs, and many manufacturers offer sample programs or compassionate-use discounts. If cost is limiting how often you change your wafer or which products you use, that is worth raising with your stoma nurse, because stretching supplies beyond recommended intervals directly increases the risk of skin breakdown and infection.

Diet Adjustments with a Colostomy Versus an Ileostomy

End colostomy patients often hear sweeping dietary advice that actually applies more to ileostomy patients. Because the entire colon is still functional up to the sigmoid in most end colostomies, water and electrolyte absorption is largely intact, and the risk of dehydration is far lower than with an ileostomy. Most people with a well-functioning end colostomy can return to a fairly normal diet within a few weeks of surgery.

That said, some general principles help in the early weeks. Gas-producing foods like beans, onions, carbonated drinks, and certain vegetables can cause noisy or ballooning bags. Foods that thicken stool, including bananas, rice, pasta, and cheese, are helpful if output is too loose. Chewing thoroughly matters more than it did before surgery because large unchewed pieces of fibrous food can cause a partial blockage at the stoma. After the initial recovery period, most people discover through trial and error which foods they tolerate and which cause trouble, and the list varies from person to person.