Abstract
The American Society of Colon and Rectal Surgeons ensures high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee comprises society members who are chosen because they have expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. Although not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information on the management of the conditions addressed by the topics covered. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The judgment regarding the propriety of any specific procedure must be made by the physician considering all the circumstances of a patient. STATEMENT OF THE PROBLEM Statistics regarding ostomy-related metrics remain elusive in the United States because of underreporting and coding limitations. The estimated number of ostomates in the United States is 750,000 to 1 million, with approximately 150,000 new ostomies created each year.1 Stoma creation has a relatively high rate of associated morbidity, ranging from 20% to 80%; peristomal skin complications and parastomal hernia (PSH) are the most common associated morbidities.2 A population-based study using the Michigan Surgical Quality Collaborative, which included 4250 patients, identified a 37% unadjusted surgical complication rate for elective cases involving an ostomy and 55% unadjusted surgical complication rate for emergency cases involving an ostomy.1 In this study, risk-adjusted stoma-related morbidity rates varied significantly among hospitals, indicating a potential to improve outcomes in outlying institutions. Beyond the typical short-term metrics captured in standard databases, the morbidity of ostomy surgery may also be measured in terms of the stoma-related negative effects on the quality of life and other long-term morbidities related to having an ostomy.3–8 Many patients have ostomies that are considered “problematic” and present with management problems like skin irritation and pouching difficulties that require prolonged and specialized care and result in increased utilization of health care resources and increased costs.9–15 The incidence and impact of short- and long-term stoma-related complications can be mitigated by perioperative education and marking, proper surgical technique, and attention to postoperative care pathways. The purpose of these clinical practice guidelines (CPG) is to guide surgeons and other health care providers to improve the quality of care and outcomes for patients undergoing ostomy surgery. METHODOLOGY This CPG focuses on the surgical care of patients requiring an ostomy and addresses issues like choosing an ostomy type, technical aspects of ostomy creation and closure, prevention and management of ostomy-related complications, and perioperative care. The guideline does not address whether an ostomy should be created in a given clinical scenario because this evidence base was reviewed in other American Society of Colon and Rectal Surgeons (ASCRS) CPG related to specific diseases (eg, diverticulitis, rectal cancer, and ulcerative colitis).16–18 Urostomies, continent ileostomies, stomas in the pediatric population, and a comprehensive review of nursing ostomy care (eg, skin care, use of different appliances, or other management systems) are beyond the scope of these guidelines. These guidelines are based on the last ASCRS CPG for Ostomy Surgery published in 2015.19 Because of the changes in the strength or quality of the evidence (Table 1), this updated CPG contains 2 new statements, 9 modified statements, and omission of 1 statement from the 2015 CPG. The remaining statements were not changed, but the literature review and supporting statements were updated. A systematic search of MEDLINE, PubMed, Scopus EMBASE, and the Cochrane Database of Systematic Reviews was performed from January 1, 2014, to December 1, 2021. Individual literature searches were conducted for each statement within the guidelines and were restricted to English language and adult patients (Fig. 1). Search strategies were based on the concepts of intestinal stomas, and the various relevant diagnostic procedures, surgical interventions, and care pathways related to these diagnoses using multiple subject headings, text words, and descriptors. The 4008 screened articles were evaluated for level of evidence, favoring randomized clinical trials, meta-analyses and systematic reviews, comparative studies, and large registry retrospective studies over single-institutional series, retrospective reviews, and observational studies. Additional references identified through embedded references and other resources as well as practice guidelines or consensus statements from relevant societies were also reviewed. A final list of 205 tabulated citations was evaluated for methodologic quality, the evidence base was evaluated, and a treatment guideline was formulated by the subcommittee for this guideline. The final grade of recommendation and level of evidence for each statement were determined using the Grades of Recommendation, Assessment, Development, and Evaluation system (Table 2).20 When agreement was incomplete regarding the evidence base or treatment guideline, consensus from the committee chair, vice chair, and 2 assigned reviewers determined the outcome. Members of the ASCRS CPG Committee worked in joint production of these guidelines from inception to final publication. Recommendations formulated by the subcommittee were reviewed by the entire CPG Committee. Final recommendations were approved by the ASCRS Executive Council and peer-reviewed in Diseases of the Colon and Rectum. In general, each ASCRS CPG is updated every 5 years. No funding was received for preparing this guideline, and the authors have declared no competing interests related to this material. This guideline conforms to the Appraisal of Guidelines for Research and Evaluation checklist. TABLE 1. - What is new in the 2022 ASCRS Ostomy Surgery Clinical Practice Guidelines Topic Recommendation 2022 New recommendations Ostomy closure 11. Routine water-soluble contrast studies in the absence of a clinical suspicion of anastomotic dehiscence or stricture may not be necessary before closure of a protective ostomy. Grade of recommendation: weak recommendation based on low-quality evidence, 2C 12. Early closure of protective ileostomies may be performed in select low-risk patients with a colorectal anastomosis clinical evidence of anastomotic Grade of recommendation: weak recommendation based on quality evidence, 2022 recommendations management potential ostomy should be by a Grade of recommendation: recommendation based on evidence, Ostomy creation When a or a is for Grade of recommendation: recommendation based on evidence, In patients, the use of a the of is not Grade of recommendation: recommendation based on high-quality evidence, The use of to parastomal hernia the of ostomy creation is not Grade of recommendation: weak recommendation based on high-quality evidence, of an may the of parastomal Grade of recommendation: weak recommendation based on evidence, patients with a new with a perioperative care may the of Grade of recommendation: weak recommendation based on evidence, Ostomy closure closure can be performed using or Grade of recommendation: recommendation based on high-quality evidence, skin should be performed and skin closure has with other Grade of recommendation: recommendation based on high-quality evidence, is a to Grade of recommendation: recommendation based on evidence, 2015 Recommendations Ostomy creation of may be considered to ostomy Grade of recommendation: weak recommendation based on evidence, ASCRS American Society of Colon and Rectal TABLE - The recommendations and quality of supporting evidence recommendation: high-quality evidence and or vice or evidence from observational studies recommendation: can to most patients in most circumstances recommendation: evidence and or vice with methodologic or or evidence from observational studies recommendation: can to most patients in most circumstances recommendation: or evidence and or vice studies or recommendation: may quality evidence available recommendation: high-quality evidence with and or evidence from observational studies recommendation: best may on circumstances or or recommendation: evidence with and with and methodologic or or evidence from observational studies recommendation: best may on circumstances or or 2C recommendation: or evidence in the of and and may be studies or weak recommendation: other may be Grades of Recommendation, Assessment, Development, and randomized literature search for Systematic Reviews and 1. undergoing elective creation should and postoperative ostomy education by a specialized as a ostomy and Grade of recommendation: recommendation based on evidence, Stoma education in the perioperative has to of patient and the rate of peristomal complications quality of A that randomized patients to an before ostomy surgery or postoperative that education of for health care to ostomy care 9 and in of these were in a retrospective study that education an care in this education was associated with a of 9 A of studies that of and ostomy before surgery was 1 of associated with an increased of stoma-related other included and as the for ostomy retrospective study evaluated the impact of a education by a Ostomy and for patients undergoing colorectal surgery in which a was and that patients significantly complications patients In this study, the study from the ostomy pouching system and peristomal skin but no in the of or in the A ostomy patients included studies and that were associated with quality of having and education of and were also related In a of patients the impact of specialized ostomy nursing on the quality of life of patients with new patients in with specialized ostomy were with and were with and of ostomy In study patients in and potential ostomy should be by a Grade of recommendation: recommendation based on evidence, is associated with postoperative and peristomal complications and patient and health care quality of In a systematic review of studies patients, was associated with and peristomal complications and skin complications and systematic review of studies that was associated with a in complication rates in and increased quality of life Although by a ostomy is considered other providers may stomas and patients in emergency When surgeons and surgical were evaluated choosing ostomy that the chosen by surgeons were a 2 from the chosen by ostomy In this study, most ostomies were on the In this study, no impact on the as and surgeons outcomes and colorectal surgeons with the ostomy A of surgical that in was and an ostomy In the ASCRS and the Society published a of the of for patients undergoing ostomy surgery and these recommendations in Surgeons who ostomy should be with the of proper ostomy patients in multiple to and considering the and the ostomy within the Although is is that circumstances may not for the skin to be in all the evidence in the 2 large systematic published in and the grade of this recommendation was from in 2015 to from for ostomy care, and Grade of recommendation: recommendation based on low-quality evidence, with an ostomy may negative effects on quality of with and with and Stoma creation can also result in of or patient to can lead to and randomized and observational studies the of ostomy nursing care, which can be in the or care is associated with increased of patients to care for ostomy-related ostomy increased with care, and quality of patients with ostomies may to have ostomy-related complications and A study of long-term ostomy patients that of patients evidence of peristomal skin and various to pouching 55% not a in 2 with a in the of and in skin and a in the The in the was in patients who were in the from 1 to 2 These that long-term ostomy patients have with ostomy care and may from ostomy provide an to patients with ostomies beyond the perioperative When ostomy is to ostomy Grade of recommendation: recommendation based on low-quality evidence, are no randomized ostomy creation a surgical multiple observational studies have and short-term outcomes of ostomy creation with ostomy of a and of and complications A of 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Routine water-soluble contrast studies in the absence of a clinical suspicion of anastomotic dehiscence or stricture may not be necessary before closure of a protective ostomy. Grade of recommendation: recommendation based on low-quality evidence, 2C are no randomized the use of water-soluble contrast or any other of anastomotic before of a protective ostomy. 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