1. Challenging Ostomies: A
Colorectal Surgeon’s
Perspective

2. Peter Hofmann, MD
 Department of Colon & Rectal Surgery
 Springfield Clinic, LLP

3. Objectives
 REVIEW WHY PATIENTS MIGHT REQUIRE AN OSTOMY
 OUTLINE HOW OSTOMIES ARE ACTUALLY CREATED
 DISCUSS CHALLENGING OSTOMY PATIENTS
 REVIEW ISSUES WITH STOMAS

4. INDICATIONS
 DIVERSION
 OBSTRUCTION
 INFLAMMATORY BOWEL DISEASE
 MOBILITY ISSUES
 CONTINENCE ISSUES

5. INDICATIONS: OBSTRUCTION
 CANCER
 BENIGN DISEASE

6. INFLAMMATORY BOWEL
DISEASE
 CROHN’S AND ULCERATIVE COLITIS
 PERIANAL CROHN’S DISEASE
 DIVERSION AFTER SURGERY FOR IBD
 RESTORATIVE PROCTOCOLECTOMY

7. Total proctocolectomy with end
ileostomy
 Surgical treatment for ulcerative colitis

8. MOBILITY ISSUES
 WHEELCHAIR-BOUND PATIENTS
 PATIENTS WHO CANNOT PERFORM ACTIVITIES OF
DAILY LIVING

9. CONTINENCE ISSUES
 DUE TO A PHYSICAL IMPAIRMENT
 FECAL INCONTINENCE WHICH IS REFRACTORY TO
OTHER MEDICAL AND SURGICAL INTERVENTIONS

10. OSTOMY CONSTRUCTION
 YOU NEED A PIECE OF BOWEL AND A “HOLE”
 BOWEL IS TETHERED BY ITS BLOOD SUPPLY
 THE “HOLE” CAN BE DIFFICULT TO CREATE

11. OSTOMY CONSTRUCTION
 VARIES WITH COLOSTOMIES VERSUS ILEOSTOMIES
 MAY HAVE DIFFERING CHALLENGES BASED ON
FUNCTION
 TEMPORARY VERSUS PERMANENT
 EMERGENT VERSUS ELECTIVE

12. CHALLENGING PATIENTS
 OBESE
 CACHECTIC
 PREVIOUS SURGERIES/SCARS
 PREVIOUS OSTOMIES OR
CONCURRENT OSTOMY

13. OBESITY
 INCREASINGLY COMMON ISSUE IN SURGERY

14. WHAT IT MEANS IN OSTOMY
CONSTRUCTION
 CHALLENGES!

15. GENDER DIFFERENCES IN
OBESITY
 MEN HAVE THIN ABDOMINAL WALLS
 BUT CAN HAVE VERY THICK, STIFF MESENTERY
 PRESENTS ITS OWN SET OF CHALLENGES
 WOMEN HAVE THICK ABDOMINAL WALLS
 A LOT OF SUBCUTANEOUS FAT LIES BETWEEN THE
ABDOMINAL WALL AND THE SKIN

16. DIAGRAM OF OSTOMY
CONSTRUCTION
 COLOSTOMY

17. AGAIN, OBESE PATIENTS ARE A
CHALLENGE

18. EXTREMELY THIN PATIENTS
CAN PRESENT A CHALLENGE,
TOO!
 NEED TO WATCH OUT FOR BONY PROMINENCES!

19. PREVIOUS SURGERY
 YOU DECIDE WHAT’S TOUGH ABOUT THIS…

20. Previous surgery
 Or this…

21. STOMA COMPLICATIONS
 PROLAPSE
 SKIN ISSUES
 PARASTOMAL HERNIA

22. prolapse

23. Skin issues
 Vexing problem, worse with poorly-positioned stomas

24. Parastomal hernias
 Very common problem

25. SUMMARY
 STOMA FORMATION CAN BE A CHALLENGE

26. SUMMARY
 FIRST SURGERY IS THE TIME TO GET IT RIGHT

27. SUMMARY
 WOUND-OSTOMY SPECIALISTS ARE CRITICAL TO
SUCCESSFUL PLACEMENT AND CARE OF OSTOMIES

28. SUMMARY
 “BAD” OSTOMIES EXACT A TERRIBLE TOLL ON
PATIENTS

29. SUMMARY
 TEAM APPROACH IS ALWAYS BEST
 ENTEROSTOMAL THERAPIST
 COLORECTAL SURGEON
 PATIENT
 STAFF AND VISITING NURSES
 PHARMACIST/HOME HEALTH SUPPLY
SPECIALIST
 FAMILY/FRIENDS

30. QUESTIONS…