Ostomy Complications and Management
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Ostomy Complications and Management
Ostomy Surgery (2022)- Management of Rectal Cancer (2020)
Benign Disease- A morbidly obese patient is undergoing a total abdominal colectomy for fulminant colitis. He is receiving high-dose steroids and biologic therapy, and he has been preoperatively marked by an enterostomal therapist. The ileal mesentery is foreshortened, and the abdominal wall is thick. You are unable to bring the divided end of the ileum to the skin without tearing the mesentery. What is the best next step in management?
- A 43-year-old morbidly obese man is undergoing a Hartmann procedure for Hinchey IV perforated diverticulitis. Two days postoperatively, the ostomy has retracted below the skin and appears purple. The patient remains afebrile and hemodynamically normal without peritonitis. Intubation of the colostomy with a test tube reveals black mucosa proximal to the fascia. What is the next step in management?
- A 62-year-old man presents to the emergency department with acute-onset left lower quadrant abdominal pain. He is mildly tachycardic but is otherwise hemodynamically stable. On abdominal examination, he has diffuse peritonitis. Laparoscopy reveals sigmoid diverticulitis with purulent fluid throughout the abdomen without fecal contamination. What is the best next step in management?
- You operate on a 23-year-old man who sustained multiple stab wounds to the abdomen. His injuries include a grade II splenic hematoma and a sigmoid colon laceration involving 40% of the colonic wall. The perisigmoid mesentery is intact. He has received 3 units of blood in the operating room. What is your recommendation for repair of his colonic injury?
Benign Disease- A 56-year-old healthy male patient presents to the emergency room because he has been experiencing left-sided abdominal pain for the past 4 days. He reports localized tenderness on examination. Screening colonoscopy performed 3 years prior was normal. His vital signs are 98% SpO2, heart rate of 112, blood pressure of 120/76, and respiratory rate of 14. White blood cell count is 16, and other lab results are normal. You obtain a computed tomography (CT) of the abdomen and pelvis, which shows the following abcesses: He was placed on IV antibiotics but failed to progress. Interventional radiology is unable to safely place a drain. What is the best next step?
- A 43-year-old woman presents to the emergency room with 24 hours of nausea, vomiting, and bloating. She has history of Crohn’s disease with no prior surgery and is currently not taking any medications. She smokes one pack of cigarettes per day. Computed tomography (CT) is obtained (see figure below). Magnetic resonance enterography (MRE) shows mucosal edema and hyperenhancement. She is treated with intravenous (IV) fluid resuscitation, bowel rest, and nasogastric decompression. Inpatient colonoscopy performed 4 days later demonstrates inflamed ileal mucosa and narrowed lumen. What is the best next step in this patient’s management?
- A 56-year-old patient with a BMI of 41 is transferred to your hospital after undergoing emergent sigmoid colectomy with colostomy for perforated diverticulitis. On postoperative day 3 she is found to have sloughed the distal portion of the ostomy due to necrosis and retraction of the stoma (see figure below). Bedside evaluation demonstrates ischemia that extends proximal to the fascia. The patient is currently hemodynamically stable. Computed tomography angiogram of the abdomen and pelvis demonstrates patency of the celiac and superior mesenteric arteries and no visualization of the the inferior mesenteric artery. What is the best next step in management?
- A 55-year-old man with obesity has completed neoadjuvant chemoradiation therapy for CT3 N2 M0 distal rectal cancer. During his posttreatment evaluation, he is found to have a partial clinical response and is offered a low anterior resection. His total mesorectal excision is completed uneventfully; however, the mesentery to his terminal ileum is thickened and foreshortened causing difficulty in getting the bowel to reach the abdominal wall in the ideal location. The best option for fecal diversion in this patient is
Benign Colorectal Disease Trauma of the Colon and Rectum- Radiation, Microscopic, and Ischemic Colitis
- Intestinal Stomas
- Enhanced Recovery After Colon and Rectal Surgery from ASCRS and SAGES (2023)
- Anastomotic Complications
- Ulcerative Colitis: Surgical Management
- Evaluation of Constipation and Treatment of Abdominal Component
- Management of Colon Cancer (2022)
- Abdominal Wall Reconstruction and Parastomal Hernia Repair
- Treatment of Left-Sided Colonic Diverticulitis (2020)
- Perioperative
- A 56-year-old man undergoes a low anterior resection after neoadjuvant chemoradiation for a T3N0M0 rectal cancer located 9 cm from the anal verge. Eight days later, he presents to the emergency department with mild abdominal pain and a temperature of 102.2°F (39°C). Laboratory results are significant for a white blood cell count of 14,000/µL (14×109/L). Computed tomography of the abdomen and pelvis shows pneumoperitoneum with contrast extravasation into the pelvis. Abdominal examination shows focal peritonitis in the left lower quadrant. Intraoperative findings demonstrate a 3-mm anastomotic disruption anteriorly. In addition to abdominal washout, what is the best surgical option for this patient?
- A 50-year-old woman who has had a hysterectomy undergoes an exploratory laparotomy with extensive lysis of adhesions for a small bowel obstruction. She has an uneventful postoperative course and is discharged. She presents to your clinic 2 weeks later with an apparent midline wound infection and skin separation. Local wound care is initiated to include damp to dry dressings twice daily. One week later, the patient presents with bilious drainage from the wound. Physical examination demonstrates small bowel mucosa extruding from the upper portion of the wound. What is the best next step in management?
- Endoscopic Management of Polyps and Endoluminal Surgery
- Parastomal and Perineal Hernias
ASCRS Webinars- Evaluation and Management of Chronic Constipation (2024)
- Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction (2021)
- Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula (2022)
- Surgical Management of Ulcerative Colitis (2021)
- Complications of the Pelvic Pouch
- Indications for Fecal Diversion
- Bowel Dysfunction Low Anterior Resection Syndrome
- Rectovaginal Fistula
- Optimizing Outcomes with Enhanced Recovery
- Management of Fecal Incontinence (2023)
- Preventing Surgical Site Infection (2024)