Stoma Surgery - Trying to Get It Right
by Joshua Katz M.D.

Department of Colorectal Surgery
Cleveland Clinic Florida
Weston, Florida

Creation of a stoma (ileostomy, colostomy, or urostomy) represents a major, immediate, and sometimes permanent change in the life of a human being. This can have profound effects upon lifestyle, intimacy, employment, recreation, and travel. Fear, misunderstanding, loss of self image and social isolation can compound the situation.

Colorectal surgeons and nurses who care for patients with a stoma must recognize that to save someone from a life threatening condition means little if the life the person returns to is made miserable by a poorly functioning stoma. The objective of any operation involving a stoma is to create a stoma that the patient can care for with simple routine using an appliance that fits reliably, comfortably, and protects the surrounding skin. Time between faceplate (wafer) changes should be at least three, and preferably five to seven days. There should be no leakage of feces around the appliance.

Creation and utilization of a stoma is a team approach, involving the patient, the Enterostomal Therapy nurse (ET), and the colorectal surgeon. Patients must assume responsibility for their own health and well being. They need to learn about their disease and understand what operation is being performed and why. They need to know whether they have a colostomy or ileostomy, and whether it is permanent or temporary. An important rule to keep in mind is "WHEN YOU DO NOT KNOW, ASK."

It is useful to keep a medical summary of one's medical and surgical history written down. List current medications, physicians' names, addresses and telephone numbers. If a relative or friend has power of attorney or is a health proxy, or if there is a living will, this should be recorded too. One may also choose to obtain copies of operative notes and discharge summaries from recent or complex procedures and hospitalizations. This record is particularly critical when traveling or relocating. It is important to know that by law all information about a patient must be made available upon request of the patient. This means that at any time, you can request a copy of your medical record. In particular, patients planning a long journey (more than one week) or relocation, should notify their doctor, travel with a copy of their medical record, and prior to leaving, seek and obtain the name and number of a physician at their destination

The Enterostomal Therapy nurse (ET) also plays a critical role in the preoperative and postoperative management. Prior to surgery (in elective or nonemergent cases) the surgeon and ET sit down and review with the patient what procedure is being done and why. The patient then has his/her body examined while standing, sitting, and lying down to determine the best place on the abdominal wall to locate the stoma. One or more sites are then marked so that surgeon knows where to place the stoma during the procedure. Principles of stoma location and creation include:
· Keeping the stoma away from bony landmarks (ribs, hips) scars, creases.
· Make sure the patient can see the stoma.
· Do not place the stoma in the midline abdominal incision.
· If possible keep the stoma within the rectus muscle to prevent parastomal hernias.
· Prevent tension and assure adequate blood supply.
· The stoma should be everted (budded) to permit proper pouch placement.
(This is particularly important for ileostomies, so that the pouch can be placed right next to the stoma with no exposed underlying skin and thus prevent skin irritation, ulceration and breakdown.)

Enterostomal therapists can help patients adapt postoperatively to living with their stoma by assessing the quality of the appliance and its fit and modifying the pouching method. Particularly in the several months following surgery, patients may gain or lose weight depending on their disease and may undergo several different pouching methods before developing regiment with which they are comfortable. The ET can facilitate and direct the process. Patients with ostomies should consider a yearly visit with an ET to reassess pouching methods and to assess for problems.

While these principles of preoperative assessment and operative management are considered standard of care by colorectal surgeons, there is as yet no data that prove the validity of these principles. Also, there are some patients with optimally constructed stomas who are miserable and some patients with extremely poorly constructed stomas who function well. For this reason, Cleveland Clinic Florida is conducting research to determine if the currently espoused methods actually impact upon quality of life and stoma function. We have developed a "stoma scoring system" and have used this to assess 70 patients in conjunction with validated quality of life estimates as well as appliance wear time and leak rate. Data are currently undergoing statistical analysis and the results will be published.

The Cleveland Clinic gratefully acknowledges the participation of UOA and its members and is always pleased to participate in UOA activities. We look forward to presentation our data formally to the UOA after peer review and publication.

Those seeking care, a second opinion or information from colorectal surgeons in the United States and Canada may contact:

American Board of Colorectal Surgery
734-282-9400
http://www.abcrs.org/

American Society of Colorectal Surgery
847-290-9184
http://www.fascrs.org/

Department of Colorectal Surgery
Cleveland Clinic Florida
954-659-5251
http://www.clevelandclinic.org/florida/depts/colorectal/