Ostomy

Question 1

Indications for ostomies

Answer 1

Malignant bowel obstruction
Protection of distal anastomosis with high risk of leak
Fistula/stricture/leak

Question 2

What are risks for anastomotic leak?

Answer 2

Older age
Low age
One or more bowel resections
Manual anastomosis
Shorter distance from anal verge

Read Lago Gynecol 2019

Question 3

Describe ileostomy site creation

Answer 3

Usually RLQ - in line of sight

At leasr 5CM from umbilicus, ASIS, and incision

2cm diameter of skin excised with Kocher

Bluntly dissect through the rectust

Cruciate fascial incision

Tunnel through rectus muscle to prevent prolapse

Question 4

Describe risks of stoma in obese patients

Answer 4

Sight line might be impaired thus may do in upper quadrant due to less subcutaneous tissue

Higher rates of stoma related issue

Question 5

How far from the ileocecal valve do you make loop ileostomy?

Answer 5

> 15cm (usually 20-30) due to blood supply, when you repair you are still away from valve, adequate mesentery length

Question 6

How do you mature a loop ileostomy?

Answer 6

Avoid twisting

Note afferent and efferent limb

Bridge through the mesentery *rid or red rubber catheter

Incise bowel transversely consider larger hood for afferent limb so it is taller - semilunar incision folded back

full thickness of skin, seromuscular bowel 4cm below mucosa and full thickness through flap (afferent)

Evert mucosa incorporating bowel wall at mucosal edge and skin edge, suture afferent limb to larger circumference to allow for larger orifice

Question 7

Discuss colostomy stomas

Answer 7

Larger: Need at least 4cm - need 2-3 fingers through the stomal incision!

Need to remove epiploic appendices

Avoid tension

Question 8

What is a technique to help prevent herniation or retraction of ostomy

Answer 8

Can put an anchoring stitch on the sheath - however do not do this if considering reversal

Question 9

What is a mucous fistula?

Answer 9

Consider when unable to resect diseased bowel distally

Allows drainage of an isolated / obstructed segment

Options: End of diseased bowel brought to skin as separate ostomy or perform adjacent to end ostomy to be under same appliance

Question 10

What is a quick way to distinguish necrosis from

Answer 10

Use a flashlightin a test tube/forceps to look into stoma, if necrosis extends below anterior fascia need immediate revision, if limited to stoma consider observation as the tissue will slough

Question 11

How to manage mucocutaneous separation

Answer 11

This may be due to tension

Irrigate and probe to see how deep it is/infection/necrosis, apply calcium alginate or ostomy powder

Can be fixed at bedside with sutures vs return to OR

Question 12

When do you need to revise a stoma for retraction

Answer 12

If below the rectus sheath

Question 13

What is a high output ostomy?

Answer 13

Over 1.5L/day

Question 14

How do you manage a high output ostomy

Answer 14

Monitor symptoms

Soluble fiber - psyllium

Antimotility agents: Loperamide, Tincture of opium, opioids, diphenoxylate/atropine

Antisecretory agents: antihistamines, PPIs, ocreotide (last resort)

Electrolyte/fluid replacement

Rule out infection!

Question 15

What are risk factors for parastomal hernia

Answer 15

Obesity, advanced age, wound infection, chronic or recurrent increases of intra-abdominal pressure, COPD

Larger fascial incision
- Colostomy > ileostomy
- Loop > end

Question 16

How do you manage a parastomal hernia

Answer 16

Surgical repair

Stoma belt

Question 17

How can you reverse an ostomy?

Answer 17

Direct closure of enterotomy

Resection of loop and hand sewn anastomosis OR stapled side-to-side functional end to end

Question 18

What are symptoms of Low Anterior Resection Syndrome (takedown syndrome)

Answer 18

Variable unpredictable bowel function
Diarrhea or altered stool consistency
Postprandial urgency
Incontinence
Inability to control flatulence

Use Scoring systems: LARS or MSKCC bowel function score

Question 19

How do you manage low anterior resection syndrome/takedown syndrome

Answer 19

High soluble fiber/low fat diet
Avoid alcohol/caffeine
Frequent/small meals

Antidiarrheal agents

Perianal skin care

Pelvic floor PT

Neurostimulation

Transanal irrigation

Question 20

How long to hold bevacizumab for bowel work

Answer 20

42 days

Question 21

Discuss types of pelvic exenteration

Answer 21

PEs can be performed in different craniocaudal extents in the coronal plane as a supralevator type I (preserving endopelvic fascia and pelvic diaphragm) or infralevator (including resection of levator ani muscle) procedure. Infralevator PE is further classified as type II (including vaginectomy) or type III (including vulvectomy)