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Clinical Practice Guidelines for Ostomy Surgery Samantha Hendren, M.D., M.P.H • Kerry Hammond, M.D

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Clinical Practice Guidelines for Ostomy Surgery Samantha Hendren, M.D., M.P.H • Kerry Hammond, M.D PRACTICE PARAMETERS Clinical Practice Guidelines for Ostomy Surgery Samantha Hendren, M.D., M.P.H • Kerry Hammond, M.D. • Sean C. Glasgow, M.D. W. Brian Perry, M.D. • W. Donald Buie, M.D. • Scott R. Steele, M.D. • Janice Rafferty, M.D. Prepared by the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons he American Society of Colon and Rectal Surgeons among hospitals, indicating the potential to improve is dedicated to ensuring high-quality patient care outcomes.2 Tby advancing the science, prevention, and man- However, the true morbidity of ostomy surgery agement of disorders and diseases of the colon, rectum, includes significant negative effects on quality of life, plus and anus. The Clinical Practice Guidelines Committee longer-term morbidity related to ostomy care.3–10 Up to is charged with leading international efforts in defining half of ostomies are “problematic,” presenting manage- quality care for conditions related to the colon, rectum, ment problems including skin irritation and pouching dif- and anus by developing Clinical Practice Guidelines based ficulties that require prolonged medical care and result in on the best available evidence. These guidelines are inclu- increased health care costs (prolonged length of stay and/ sive, not prescriptive, and are intended for the use of all or increased need for outpatient care).4,11,12 As with tra- practitioners, health care workers, and patients who desire ditional complication rates, rates of problematic ostomies information about the management of the conditions have also been shown to vary by hospital unit, suggest- addressed by the topics covered in these guidelines. Their ing the potential for quality improvement.4,11 Postop- purpose is to provide information based on which deci- erative management problems are exacerbated by poorly sions can be made, rather than to dictate a specific form constructed or sited ostomies, complications following of treatment. surgery, and inadequate perioperative care. The purpose It should be recognized that these guidelines should of this clinical practice guideline is to give guidance to not be deemed inclusive of all proper methods of care or surgeons and other health care providers in an effort to exclusive of methods of care reasonably directed to obtain- improve the quality of care and outcomes for patients ing the same results. The ultimate judgment regarding the undergoing ostomy surgery. propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. METHODOLOGY The focus of this clinical practice guideline is on the sur- STATEMENT OF THE PROBLEM gical care for patients requiring an ostomy, including the choice of ostomy type, technical aspects of ostomy cre- Approximately 100,000 people in the United States ation and closure, prevention and management of ostomy undergo operations that result in a colostomy or ileostomy complications, and perioperative care. The guideline is not 1 each year. Colostomies and ileostomies are created in the designed to address whether or not an ostomy should be management of a variety of medical conditions, includ- created in particular clinical circumstances, because that ing cancer, diverticulitis, and inflammatory bowel disease. topic is addressed in clinical practice guidelines for specific Unfortunately, operations in which ostomies are created diseases (eg, diverticulitis, rectal cancer, ulcerative colitis). have high rates of surgical complications in comparison In addition, the guideline focuses on colostomies and with other types of common surgical procedures. One ileostomies in adult patients, rather than on urostomies, recent population-based study based on National Surgi- continent ileostomies, or pediatric ostomies. It also does cal Quality Improvement Program data showed a 37% not extensively review the nursing literature on ostomy unadjusted complication rate for elective cases involving 2 care, such as skin care or the use of particular appliances an ostomy, and 55% for emergency operations. Further- or other management systems. more, risk-adjusted morbidity rates varied significantly The systematic review began with a search (updated Dis Colon Rectum 2015; 58: 375–387 January 29, 2014) of the National Guideline Clearing- DOI: 10.1097/DCR.0000000000000347 house and PubMed for any existing clinical practice guide- © The ASCRS 2015 lines, using “ostomy,” “stoma,” “colostomy,” “ileostomy,” DISEASES OF THE COLON & RECTUM VOLUME 58: 4 (2015) 375 376 HENDREN ET AL: PRACTICE PARAMETERS FOR OSTOMY SURGERY and “parastomal” as search terms. Five guidelines were based recommendations for ostomy creation surgery are identified, all on the topic of ostomy care and/or patient presented. Techniques for ostomy site selection are dis- education; the full text of each of these was reviewed.13–17 cussed in a separate section of this guideline (see “Evi- References from existing guidelines relevant to this clinical dence for the Value of an Ostomy Nurse”). practice guideline were also obtained in full text. 1. When feasible, laparoscopic ostomy formation is pre- Next, Ovid Medline and the Cochrane Database of ferred to ostomy formation via laparotomy. Grade of Collected Reviews were systematically searched through Recommendation: Strong recommendation based on January 29, 2014, by using the following MeSH headings: low-quality evidence, 1C. ostomy (focus); colostomy (focus); and ileostomy (focus). The 3 searches were limited to English language, abstract There are no randomized trials comparing ostomy cre- available, and human studies. We identified 2394 refer- ation via traditional open surgical approaches versus ences by this primary search, and the titles and abstracts minimally invasive approaches. However, multiple obser- of all of these were reviewed. After this initial screening, vational studies have documented the safety and favorable subtopics for the review were confirmed: 1) ostomy cre- short-term outcomes of laparoscopic ostomy creation ation; 2) ostomy closure; 3) ostomy complications (pre- in comparison with surgery requiring a laparotomy. vention and management); and 4) evidence for the value Reported advantages to the laparoscopic approach include of an ostomy nurse. For each of these 4 topics, all system- reduced pain and narcotic requirements, shorter hos- atic reviews, trials, other comparative studies, noncom- pitalization, earlier return of bowel function, and fewer parative studies with ≥20 patients (although a few smaller overall complications relative to open surgery.19–22 Lapa- studies were included), and selected review articles were roscopic ostomies also may be easier to reverse.23 Most obtained in full-text form. Selected searches of the refer- laparoscopic techniques use 2 to 3 trocars, including 1 ence lists from these articles revealed additional relevant positioned through the premarked ostomy site.24,25 Con- articles, particularly in the area of the ostomy nurse, and version to open surgery is uncommon, ranging from 0% these were also obtained in full-text form. to 16%, with more recent series reporting rates in the sin- A separate Ovid Medline search for studies on the gle digits.19–22,26–29 When creating an ostomy laparoscopi- topic of parastomal hernia was performed through Janu- cally, particular attention should be paid to avoid twisting ary 29, 2014, using keyword “parastomal hernia,” because the exteriorized bowel (for a loop ostomy) or kinking the no MeSH heading was available (limits: English language, mesentery (for an end ostomy).30 Marking proximal and abstract available, human). Of the 228 references identi- distal ends and repeating peritoneal insufflation may be fied, title and abstract reviews were performed, and the used to confirm the correct orientation of the bowel after full text was obtained for reports with primary patient it is passed through the fascia.26,28,30 data, with the exception of case reports and very small In selected cases, a minimally invasive alternative to case series. The reference lists of these articles were also laparoscopic ostomy surgery is trephine ostomy creation, searched for additional studies, and those were obtained. in which the ostomy is created through a small incision at At the end of these searches, 263 relevant articles were the planned ostomy site. Trephine ostomy creation can be reviewed in full-text form. The evidence from these arti- performed under regional anesthesia in most cases, with cles was summarized in an evidence table for each topic. reported success rates at avoiding a laparotomy of 89% Although the overall quality of the evidence for this guide- to 94%.31,32 A prospective evaluation of laparoscopic ver- line is weak, the statements included were supported by sus trephine fecal diversion found acceptable short-term higher-quality observational studies and limited experi- results by using either approach.32 mental studies. The final grade of recommendation for 2. Loop ileostomy is preferred over transverse loop colos- each statement was selected by using the Grades of Rec- tomy for temporary fecal diversion in most cases. Grade ommendation, Assessment, Development, and Evaluation 18 of Recommendation: Weak recommendation based on (GRADE) system (Table 1). moderate-quality evidence, 2B. OSTOMY CREATION At least 5 small, randomized trials and many observational studies have been performed to attempt to resolve whether Gastrointestinal ostomies may be performed for benign or
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