Intestinal Stomas
Intestinal stoma creation significantly impacts the patient and his or her support system. Stoma-related complications are common, but even absent complications stomas can negatively impact quality of life for the ostomate. Conscientious surgical stewards
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Key Concepts • Preoperative stoma site marking and patient education improve stoma-related clinical outcomes, patient quality of life, and experience, while decreasing healthcare resource utilization. • The finished stoma should protrude from the skin which improves appliance sealing and decreases complications. • Optimal care for patients undergoing ostomy surgery includes preoperative and postoperative care by an ostomy nurse specialist, such as a WOCN-certified nurse. • Early stoma-related complications such as leakage, peristomal dermatitis, and dehydration can often be remedied with stoma care and education. • Loop ileostomy is preferred over transverse loop colostomy for temporary fecal diversion in most circumstances. • Stapled and hand-sutured techniques are both acceptable for loop ileostomy closure. • Asymptomatic parastomal hernias do not mandate repair, while mild symptoms may benefit from appliance modifications or stomal support belt. Suitable-risk patients with significant parastomal hernia symptoms may be candidates for repair.
Introduction Stomas are employed as temporary or permanent means of fecal diversion in the management of a variety of gastrointestinal, neurologic, and genitourinary conditions. Approximately 120,000 stomas are created annually in North America, with an estimated prevalence of 450,000–800,000 ostomates [1]. Stomas can be fashioned in an “end” or “loop” configuration depending on surgical strategy and perioperative conditions and are classified by the location of exteriorized bowel (e.g., colostomy, ileostomy, jejunostomy). Intestinal stoma creation, often relegated as a minor component of a larger operation, will significantly impact
the patient and his or her support system. Stoma-related complications are common, but even absent complications, patient dissatisfaction with stoma appearance, and body image can negatively impact quality of life. Societal stigmas, ignorance, and misunderstandings can further complicate care. Conscientious surgical stewardship and collaborative nursing care can decrease complications and improve quality of life for ostomates. As such, mastery of preparing, creating, caring for, and reversing stomas are a hallmark of the colorectal surgeon’s armamentarium.
Colostomy Configuration Creation of an end colostomy may be indicated in several benign and malignant diseases for permanent or temporary enteric drainage (Figure 55-1a). Low rectal cancer, recurrent anal cancer, severe anorectal Crohn’s disease, or severe radiation proctitis may require a permanent end colostomy. An end colostomy may be used emergently for severe sigmoid diverticulitis (i.e., Hartmann’s procedure) and as a means of trauma-related damage control. An end colostomy may be required in patients who are not candidates for restorative procedures that establish continuity with the anus or rectum such as those with fecal incontinence, severe neurologic impairment, old age, prohibitive medical comorbidities, and prior resection of the anal sphincter complex. Although sphincterpreserving opera
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