Emergency ostomies have a high clinical relevance
The creation of an ostomy is frequently necessary and mostly unavoidable during life-prolonging emergency or elective surgery. According to the retrospective analysis and survey presented here, emergency surgery accounted for about one third of all ostomy creations. However, one has to considered that these data were collected at a large university hospital treating a heterogeneous patient population. The survey was presumably completed by younger patients with more frequent diagnoses of chronic inflammatory bowel disease. Thus, our results cannot easily be generalized. Nevertheless, emergency ostomy creations make up a considerable proportion of all ostomies. It seems appropriate to pay special and detailed attention to this particular ostomy subgroup. This article specifically addresses the differences between ostomies created during emergency versus elective surgeries. In the following paragraphs, our analysis and survey results will be discussed and integrated into a wider context.
Emergency ostomies are created under difficult circumstances
Both medical and logistical circumstances are disadvantageous during emergency surgery. As expected, patients who received an ostomy during emergency surgery were more seriously ill at the time of surgery and had diagnoses with acute indication for surgery. The technical creation of the ostomy during an emergency surgery is more challenging and the patient is more susceptible to complications. Due to the urgency and the often-unfavorable time of day, less time and resources are left for preoperative medical education. It is difficult to provide comprehensive patient information without unsettling the patient. Likewise, the extent of the upcoming emergency surgery cannot be fully estimated preoperatively, which can lead to a lack of information and, thus, to a lower satisfaction of the affected patient. There is need for improvement. A comprehensive preoperative assessment of a patient prior to an ostomy creation includes knowledge of lifestyle, employment, clothing preferences, stool behavior and possible personal impairments.
Preoperative marking of the future ostomy position is extremely important
Only a single survey participant with emergency and only 79.82% of patients with elective ostomy creation had received preoperative marking of the future ostomy position. This is alarming, as all national and international guidelines explicitly recommend preoperative marking(5, 12, 13). Scientific evidence suggests that the absence of marking is a risk factor for postoperative leakage and peristomal skin irritation(14, 15). It is preferred to have the future ostomy position determined by a certified ostomy therapist(5). However, marking can also be performed by an experienced surgeon, especially in emergency situations. In 2007, the American Society of Colon and Rectal Surgeons, together with the Wound, Ostomy and Continence Nurses Society, published a position paper on professional preoperative marking of the ostomy position(13). In addition to a detailed examination of the abdomen for shape, skin folds, scars, contractures, possible hernias or preexisting ostomies, and the position of the waist, patient-specific aspects such as age, mobility, occupation, and mobility (e.g., using a wheelchair or rollator) should also be considered. Based on these aspects, which will be assessed in the standing, sitting and lying position, and according to the type of ostomy planned, a transrectal ostomy site (to avoid a parastomal hernia or ostomy prolapse) will be selected that is clearly visible and accessible to the patient. A position below the waistline allows the ostomy appliance to adhere easily to the skin and to be concealed inconspicuously under clothing. In patients with very large or obese abdomens, an ostomy position in the upper abdominal quadrants may be necessary. It is important to find the most favorable ostomy position for each patient individually, taking into account underlying conditions, technical-surgical possibilities and these recommendations, so that the ostomy can be handled as unproblematically as possible.
Intraoperative challenges
Various pathophysiological factors significantly complicate the surgical-technical circumstances and can make ostomy creation highly demanding. The systemic dysregulation of the microcirculation during sepsis, for example, impairs the vitality of the intestine making it difficult to create a vital, well-perfused ostomy from a partially ischemic distended intestinal wall caused by a bowel obstruction(16). The mobility of the obstructed intestinal segment may be limited, impairing the tension-free mobilization of the intestinal segment sufficiently above the skin level. This can result in ischemia or retraction of the ostomy. An ostomy created from a dilated intestinal segment requires a larger fascial gap, which can become the point of passage of a parastomal hernia after the swelling of the intestinal segment has subsided. In contrast, elective surgery is not usually associated with pathophysiological imbalance or bowel obstruction.
Emergency ostomies were less frequently created during laparoscopic surgery. This is understandable, since emergency procedures are often performed openly for a variety of reasons (e.g. preoperatively unclear exact diagnosis or exact extent of pathology, massive adhesions due to previous operations, non-tolerance of the pneumoperitoneum, expertise of the surgeon). However, a laparoscopic ostomy creation is preferable over an open surgical approach, analogous to the general advantages of a laparoscopic visceral surgery(17): reduced postoperative pain, reduced need for opoid analgesia, earlier mobilization, faster return to normal stool behavior, shorter hospital length of stay and lower morbidity(18-20). Also, a recent study suggests that laparoscopically-constructed ostomies are more easily reversed than ostomies created during open surgical approaches(21).
Perioperative support by an ostomy therapist
Several studies have shown an advantage of perioperative care by a specially trained ostomy therapist (22, 23), which results in a faster ability to perform stoma care, a reduced rate of unplanned ostomy interventions, a shorter hospital stay and ultimately cost savings (14, 24). The German professional association Stoma, Kontinenz und Wunde e.V. developed a detailed advanced training curriculum. The perioperative training, practice and psychosocial support includes a variety of topics(5, 25): Preoperatively, the basic principles of gastrointestinal anatomy and physiology, the planned operation, possibilities of subsequent ostomy care, changes in lifestyle and psychological aspects should be discussed. Postoperatively, the anatomy and function of the ostomy, the characteristics of different ostomy appliances, the handling of leakage and peristomal dermatitis can be demonstrated, and dietary, clothing and leisure habits as well as psychological and sexual issues can be discussed. In this way, affected patients are given detailed instructions and support in dealing with their newly constructed ostomy.
Outpatient care
The majority of patients with an ostomy are able to change their ostomy appliance independently and without problems at home (Fig. 4C and D). However, there is often insufficient expertise of ostomy care by the family medicine physician (Fig. 4E). An important resource is the connection of those affected with a patient support group. These support groups produce and publish a wide range of information materials on ostomy care, facilitate regional and national networking among patients with the same problems, and participate in the training and further education of ostomy therapists at specialist congresses. In addition, patient support groups actively participate in health policy discussions on the legal framework for the care of patients with ostomies.