the_american_society_of_colon_and_rectal_surgeons.5

CLINICAL PRACTICE GUIDELINES
The American Society of Colon and Rectal Surgeons

Clinical Practice Guidelines for Ostomy Surgery
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Bradley R. Davis, M.D.1 • Michael A. Valente, M.D.2 • Joel E. Goldberg, M.D.3

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Amy L. Lightner, M.D.2 • Daniel L. Feingold, M.D.4 • Ian M. Paquette, M.D.5

Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons
1 Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
2 Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
3 Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston,
Massachusetts
4 Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
5 Department of Surgery, University of Cincinnati, Cincinnati, Ohio
T
he American Society of Colon and Rectal Surgeons STATEMENT OF THE PROBLEM
ensures high-quality patient care by advancing the
science, prevention, and management of disorders Statistics regarding ostomy-related metrics remain elusive
and diseases of the colon, rectum, and anus. The Clinical in the United States because of underreporting and cod-
Practice Guidelines Committee comprises society mem- ing limitations. The estimated number of ostomates in the
bers who are chosen because they have expertise in the United States is 750,000 to 1 million, with approximately
specialty of colon and rectal surgery. This committee was 150,000 new ostomies created each year.1 Stoma creation
created to lead international efforts in defining quality has a relatively high rate of associated morbidity, rang-
care for conditions related to the colon, rectum, and anus ing from 20% to 80%; peristomal skin complications and
and develop clinical practice guidelines based on the parastomal hernia (PSH) are the most common associ-
best available evidence. Although not proscriptive, these ated morbidities.2 A population-based study using the
guidelines provide information on which decisions can Michigan Surgical Quality Collaborative, which included
be made and do not dictate a specific treatment. These 4250 patients, identified a 37% unadjusted surgical compli-
guidelines are intended for the use of all practitioners, cation rate for elective cases involving an ostomy and 55%
health care workers, and patients who desire information unadjusted surgical complication rate for emergency cases
on the management of the conditions addressed by the involving an ostomy.1 In this study, risk-adjusted stoma-
topics covered. These guidelines should not be deemed related morbidity rates varied significantly among hospi-
inclusive of all proper methods of care nor exclusive of tals, indicating a potential to improve outcomes in outlying
methods of care reasonably directed toward obtaining institutions.
the same results. The judgment regarding the propriety Beyond the typical short-term metrics captured in
of any specific procedure must be made by the physician standard databases, the morbidity of ostomy surgery may
considering all the circumstances of a patient. also be measured in terms of the stoma-related negative
effects on the quality of life and other long-term mor-
Earn Continuing Education (CME) credit online at cme.lww.com. This
bidities related to having an ostomy.3–8 Many patients
activity has been approved for AMA PRA Category 1 credit. have ostomies that are considered “problematic” and
present with management problems like skin irritation
Funding/Support: None reported. and pouching difficulties that require prolonged and spe-
cialized care and result in increased utilization of health
Financial Disclosure: None reported. care resources and increased costs.9–15 The incidence and
impact of short- and long-term stoma-related complica-
Correspondence: Ian M. Paquette, M.D., Department of Surgery,
University of Cincinnati College of Medicine (Colon and Rectal), 2123 tions can be mitigated by perioperative education and
Auburn Ave #524, Cincinnati, OH 45219. E-mail: ian.m.paquette@ marking, proper surgical technique, and attention to
gmail.com postoperative care pathways. The purpose of these clini-
cal practice guidelines (CPG) is to guide surgeons and
Dis Colon Rectum 2022; 65: 1173–1190
DOI: 10.1097/DCR.0000000000002498
other health care providers to improve the quality of care
© The ASCRS 2022 and outcomes for patients undergoing ostomy surgery.
DISEASES OF THE COLON & RECTUM VOLUME 65: 10 (2022) 1173
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
1174 Davis et al: Guidelines for Ostomy Surgery
METHODOLOGY were conducted for each statement within the guidelines

and were restricted to English language and adult patients
This CPG focuses on the surgical care of patients requiring (Fig. 1). Search strategies were based on the concepts of
an ostomy and addresses issues like choosing an ostomy intestinal stomas, and the various relevant diagnostic pro-
type, technical aspects of ostomy creation and closure, cedures, surgical interventions, and care pathways related
prevention and management of ostomy-related compli- to these diagnoses using multiple subject headings, text
cations, and perioperative care. The guideline does not words, and descriptors. The 4008 screened articles were
address whether an ostomy should be created in a given evaluated for level of evidence, favoring randomized clin-
clinical scenario because this evidence base was reviewed ical trials, meta-analyses and systematic reviews, com-
in other American Society of Colon and Rectal Surgeons parative studies, and large registry retrospective studies
(ASCRS) CPG related to specific diseases (eg, diverticu- over single-institutional series, retrospective reviews,
litis, rectal cancer, and ulcerative colitis).16–18 Urostomies, and observational studies. Additional references identi-
continent ileostomies, stomas in the pediatric population, fied through embedded references and other resources
and a comprehensive review of nursing ostomy care (eg, as well as practice guidelines or consensus statements
skin care, use of different appliances, or other manage- from relevant societies were also reviewed. A final list of
ment systems) are beyond the scope of these guidelines. 205 tabulated citations was evaluated for methodologic
These guidelines are based on the last ASCRS CPG quality, the evidence base was evaluated, and a treatment
for Ostomy Surgery published in 2015.19 Because of guideline was formulated by the subcommittee for this
the changes in the strength or quality of the evidence guideline. The final grade of recommendation and level
(Table 1), this updated CPG contains 2 new statements, of evidence for each statement were determined using the
9 modified statements, and omission of 1 statement Grades of Recommendation, Assessment, Development,
from the 2015 CPG. The remaining statements were not and Evaluation system (Table 2).20 When agreement was
changed, but the literature review and supporting state- incomplete regarding the evidence base or treatment
ments were updated. A systematic search of MEDLINE, guideline, consensus from the committee chair, vice
PubMed, Scopus EMBASE, and the Cochrane Database chair, and 2 assigned reviewers determined the outcome.
of Systematic Reviews was performed from January 1, Members of the ASCRS CPG Committee worked in joint
2014, to December 1, 2021. Individual literature searches production of these guidelines from inception to final
TABLE 1. What is new in the 2022 ASCRS Ostomy Surgery Clinical Practice Guidelines
Topic Recommendation
2022 New recommendations
Ostomy 11. Routine water-soluble contrast studies in the absence of a clinical suspicion of anastomotic dehiscence or stricture may not be neces-
closure sary 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 without clini-
cal evidence of anastomotic leak. Grade of recommendation: weak recommendation based on moderate quality evidence, 2B
2022 Updated recommendations
Perioperative 2. Appropriate potential ostomy sites should be marked preoperatively by a trained provider when possible. Grade of
management recommendation: strong recommendation based on moderate-quality evidence, 1B
Ostomy 5. When indicated, a loop ileostomy or a loop colostomy is effective for fecal diversion. Grade of recommendation: strong
creation recommendation based on moderate-quality evidence, 1B
7. In nonobese patients, the routine use of a support rod at the time of loop ileostomy construction is not necessary. Grade of
recommendation: strong recommendation based on high-quality evidence, 1A
8. The routine use of prophylactic mesh to prevent parastomal hernia at the time of ostomy creation is not recommended. Grade
of recommendation: weak recommendation based on high-quality evidence, 2A
9. Extraperitoneal tunneling of an end colostomy may decrease the risk of parastomal hernia. Grade of recommendation: weak
recommendation based on moderate-quality evidence, 2B
10. Managing patients with a new ileostomy with a perioperative care pathway may decrease the risk of hospital readmission.
Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B
Ostomy 13. Loop ileostomy closure can be performed using stapled or handsewn techniques. Grade of recommendation: strong
closure recommendation based on high-quality evidence, 1A
14. Ostomy-site skin approximation should be performed when feasible, and purse string skin closure has advantages compared
with other techniques. Grade of recommendation: strong recommendation based on high-quality evidence, 1A
15. Minimally invasive Hartmann’s reversal is a safe alternative to open reversal. Grade of recommendation: strong
recommendation based on moderate-quality evidence, 1B
2015 Recommendations excluded
Ostomy Use of antiadhesion materials may be considered to decrease adhesions at temporary ostomy sites. Grade of recommendation:
creation weak recommendation based on moderate-quality evidence, 2B
ASCRS = American Society of Colon and Rectal Surgeons.
MEDLINE Subject Heading: colostomy, ileostomy, ostomy limited to human (3702)

KEY WORDS: parastomal hernia (372), ostomy nursing, preoperative marking, education, contrast enema, ileostomy
reversal, colostomy reversal, laparoscopy, endoscopy, prophylactic mesh, surgical mesh, transperitoneal colostomy,
extraperitoneal colostomy, dehydration, enhanced recovery after surgery, purse-string closure, linear skin closure,
surgical site infection
Databases: MEDLINE, PubMed, Scopus, and Cochrane Database of Systematic Reviews
Identification
Years covered: January 1, 2014–December 1, 2021

Language: English
Human and abstract available
Records identified through Additional records identified

database searching through other sources
(n = 4074) (n = 39)
Records after duplicates removed

(n = 4008)
Screening
Records excluded (n = 2424)

- Case report
- No abstract
Records screened
- Incorrect topic
Eligibility
(n = 4008)
- Case series
- Letter to the editor
- Proceedings
Full-text articles assessed Full-text articles excluded,

for eligibility with higher level evidence
(n = 1584) available
(n = 1379)
Included
Studies included in final

manuscript
(n = 205)
FIGURE 1. PRISMA literature search flow sheet. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analysis.
publication. Recommendations formulated by the sub- updated every 5 years. No funding was received for pre-
committee were reviewed by the entire CPG Committee. paring this guideline, and the authors have declared no
Final recommendations were approved by the ASCRS competing interests related to this material. This guide-
Executive Council and peer-reviewed in Diseases of line conforms to the Appraisal of Guidelines for Research
the Colon and Rectum. In general, each ASCRS CPG is and Evaluation checklist.
TABLE 2. The GRADE system—grading recommendations

Description Benefits vs risks and burdens Methodologic quality of supporting evidence Implications
1A Strong Benefits clearly outweigh risks RCTs without important limitations or Strong recommendation: can apply
recommendation: high- and burdens or vice versa overwhelming evidence from to most patients in most circum-
quality evidence observational studies stances without reservation
1B Strong Benefits clearly outweigh risks RCTs with important limitations (inconsistent Strong recommendation: can apply
recommendation: and burdens or vice versa results, methodologic flaws, indirect, or to most patients in most circum-
moderate-quality imprecise) or exceptionally strong evi- stances without reservation

evidence dence from observational studies
1C Strong recommendation: Benefits clearly outweigh risks Observational studies or case series Strong recommendation: may
low- or very and burdens or vice versa change when higher quality
low–quality evidence evidence becomes available
2A Weak Benefits closely balanced with RCTs without important limitations or Weak recommendation: best action
recommendation: high- risks and burdens overwhelming evidence from may differ depending on circum-
quality evidence observational studies stances or patients’ or societal
values
2B Weak Benefits closely balanced with RCTs with important limitations (inconsistent Weak recommendation: best action
recommendation: risks and burdens results and methodologic flaws, indirect may differ depending on circum-
moderate-quality or imprecise) or exceptionally strong evi- stances or patients’ or societal
evidence dence from observational studies values
2C Weak Uncertainty in the estimates of Observational studies or case series Very weak recommendation: other
recommendation: low- benefits, risks, and burdens; alternatives may be equally
or very low– benefits, risks, and burdens reasonable
quality evidence may be closely balanced
GRADE = Grades of Recommendation, Assessment, Development, and Evaluation; RCTs = randomized controlled trials.
PERIOPERATIVE MANAGEMENT evaluated the impact of a 2-hour preoperative stoma educa-

tion class led by a certified Wound Ostomy and Continence
1. P
atients undergoing elective stoma creation should Nurse (WOCN) for patients undergoing colorectal surgery
receive preoperative and postoperative ostomy edu- in which a stoma was anticipated and found that educated
cation by a specialized provider such as a wound patients (n = 124) experienced significantly fewer stoma
ostomy and continence nurse. Grade of recommen- complications than uneducated patients (n = 94). In this
dation: strong recommendation based on moderate- study, the study group had less leakage from the ostomy
quality evidence, 1B pouching system and less peristomal skin damage (20% ver-
Stoma education in the perioperative setting has been shown sus 45%; p = 0.002) but had no improvement in the length of
to reduce length of hospital stay, patient anxiety, and the stay or in the 30-day readmission rate.31
rate of peristomal complications while increasing patients’ A meta-analysis evaluating ostomy patients included
self-reported quality of life.21–28 A trial that randomized 42 38 studies and reported that several modifiable factors
patients to an intensive preoperative educational program were associated with improved quality of life, including
before ostomy surgery or postoperative teaching found that having had preoperative stoma site marking and educa-
preoperative education decreased length of stay (8 versus tion (exercise, family support, maintenance of social net-
10 d; p = 0.02), decreased need for unplanned health care works, spirituality, and financial stability were also related
interventions postdischarge, decreased time to ostomy care factors).32 In a multicenter prospective trial of 402 patients
proficiency (5.5 versus 9 d; p < 0.001), and resulted in signif- evaluating the impact of specialized ostomy nursing on the
icant cost savings.21 Some of these findings were replicated health-related quality of life of patients with new ostomies,
in a more recent retrospective study that incorporated pre- patients treated in hospitals with specialized ostomy nurses
operative stoma education into an enhanced recovery care were less concerned with appearance and were more com-
pathway, and, in this setting, preoperative education was fortable with cleaning, changing, and disposing of ostomy
still associated with a length of stay benefit (8 versus 9 d; p appliances. In addition, study patients reported less fear-
= 0.02).29 A meta-analysis of 68 studies reported that lack of fulness, improvements in sleep, and better overall health.33
preoperative stoma site marking and wound ostomy nurse
2. A
ppropriate potential ostomy sites should be marked
specialist consultation before stoma surgery was 1 of 6 risk
preoperatively by a trained provider, when possible.
factors associated with an increased likelihood of stoma-
Grade of recommendation: strong recommendation
related complications; other risk factors included age more
based on moderate-quality evidence, 1B
than 65 years, female sex, BMI more than 25 kg/m2, diabe-
tes mellitus, and abdominal malignancy as the underlying Preoperative ostomy-site marking is associated with reduced
reason for ostomy surgery.30 Another retrospective study postoperative stoma and peristomal complications and
improved patient self-care and health care quality of life. In a One randomized trial and several observational stud-
systematic review of 10 studies including 2109 patients, pre- ies support the value of postdischarge ostomy nursing
operative stoma site marking was associated with reduced care, which can be provided in the home, outpatient, or
stoma and peristomal complications (both early and late) telephone setting.46–50 Follow-up stoma care is associated
including prolapse, retraction, necrosis, skin complications with increased ability of patients to care for themselves
(OR, 0.52; 95% CI, 0.42–0.64), and hernias (OR, 0.25; 95% independently, fewer ostomy-related problems, improved
CI, 0.09–0.71).34 Another systematic review of 20 studies ostomy adjustment, increased satisfaction with care, and
found that preoperative stoma site marking was associated improved quality of life.46,47,51,52
with a reduction in complication rates (OR, 0.47; 95% CI, Over time, patients with permanent ostomies may
0.36–0.62), improvement in self-care deficits (OR, 0.34; 95% continue to have untreated ostomy-related complications
CI, 0.18–0.64), and increased health-related quality of life and challenges.12,53–57 A multicenter noncomparative study
(standardized mean difference, 1.05; 95% CI, 0.70–1.40).35 of 743 long-term ostomy patients revealed that 61% of
Although site marking by a certified ostomy nurse is patients had objective evidence of peristomal skin prob-
considered ideal, other trained providers may site stomas lems, 28% experienced frequent leakage, and 87% used
and counsel patients preoperatively, especially in emer- various accessories to facilitate pouching their ostomy;
gency situations. When surgeons and surgical trainees meanwhile, 55% had not seen a WOCN in more than 12
were evaluated after choosing ostomy sites, investigators months. After 2 visits with a WOCN, participants experi-
found that the sites chosen by surgeons were a median 2 cm enced significant decreases in the frequency of pouch leak-
away from the sites chosen by ostomy nurses. In this study, age (p < 0.001) and accessory use, improvement in skin
most “badly sited” ostomies were placed too low on the condition, and a small improvement in the mean overall
abdominal wall.36 In this study, “seniority” had no impact quality-of-life scores (Stoma-QOL: 56.8 versus 58.9; p <
on the results as trainees and attending surgeons had simi- 0.001). The greatest change in the Stoma-QOL scores was
lar outcomes and colorectal surgeons sited locations more observed in patients who were in the lowest QOL at base-
concordantly with the ostomy nurse specialists than gen- line; their mean QOL scores rose from 43.8 at visit 1 to
eral surgeons. A survey of surgical trainees showed that 50.1 at visit 2 (p < 0.001).53 These data suggest that even
their training in ostomy-site selection was haphazard and long-term ostomy patients have difficulty with ostomy
infrequently involved an ostomy nurse specialist.36 care and may benefit from expert counseling. Trained
In 2015, the ASCRS and the WOCNs Society pub- ostomy nurses provide an essential service to patients with
lished a Joint Position Statement of the value of preop- ostomies beyond the immediate perioperative period.58,59
erative stoma marking for patients undergoing fecal
ostomy surgery and subsequently expanded these rec- OSTOMY CREATION
ommendations in 2021.37,38 Surgeons who choose ostomy
sites should be familiar with the principles of proper
4. W
hen feasible, laparoscopic ostomy formation is pre-
ostomy site selection, including evaluating patients in
ferred to ostomy formation via laparotomy. Grade of
multiple positions to identify adequate sites, avoiding
recommendation: strong recommendation based on
folds and scars, considering the beltline, and siting the
low-quality evidence, 1C
ostomy within the rectus abdominus muscle. Although
preoperative site marking is strongly recommended, it is There are no randomized trials comparing ostomy cre-
acknowledged that intraoperative circumstances may not ation utilizing a conventional open surgical approach ver-
allow for the optimal skin site to be used in all situations. sus minimally invasive approach (MIS). However, multiple
Given the cumulative evidence and, in particular, the 2 observational studies have documented safety and favor-
large systematic reviews published in 2020 and 2021, the able short-term outcomes of laparoscopic ostomy creation
grade of this recommendation was changed from 1C in compared with open ostomy creation. Reported advantages
2015 to 1B. of a laparoscopic approach include reduced pain and nar-
cotic requirements, shorter hospitalization, earlier return of
3. P
atients benefit from follow-up for ostomy teaching,
bowel function, and fewer overall complications than open
care, and support. Grade of recommendation: strong
surgery.60–62 A propensity-matched cohort of 358 patients
recommendation based on low-quality evidence, 1C
who underwent elective open or laparoscopic colostomy
Patients living with an ostomy may experience negative formation reported decreased length of stay (5 versus 7 d;
effects on their quality of life, sexual difficulties, depres- p < 0.05) and wound complications (13% versus 27%; p <
sion, dissatisfaction with their appearance, and challenges 0.05) in the laparoscopic cohort.61 A case-matched analy-
with self-image and travel.4,13,15,39–44 Stoma creation can sis of 196 patients (63 laparoscopic and 133 open) indicated
also result in feelings of embarrassment or shame; patient that open surgery was associated with increased estimated
concern about disclosing their stoma status to others can blood loss (p = 0.01), longer hospital stay (p < 0.001), and
lead to self-imposed limits and isolation.45 higher postoperative ileus (p = 0.03) and readmission rates
(p = 0.002).62 Conversion to open surgery during stoma cre- Given the aggregate of the literature, both an LI and an LC
ation is uncommon, ranging from 0% to 16%, with more are effective means of diversion, and each approach has an
recent series reporting rates in the single digits.60,63 associated risk-benefit profile; therefore, a recommenda-
Although data are limited, laparoscopically created tion strongly in favor of 1 operation over another cannot
ostomies may also be easier to reverse. In a retrospective be made.
study, patients who underwent loop ileostomy closure were
6. W
hen possible, both ileostomies and colostomies
evaluated based on whether the index procedure had been
should be fashioned to protrude above the skin sur-
laparoscopic (n = 145) or open (n = 206).64 Patients in the
face. Grade of recommendation: strong recommen-

laparoscopic group had a significantly shorter mean opera-
dation based on low-quality evidence, 1C
tive time (60.9 versus 82.6 min; p < 0.001), shorter hospital
stay (4.9 versus 5.8 d; p = 0.04), and a lower overall compli- Surgical technique influences the incidence of stoma-
cation rate (14.5% versus 24%; p = 0.02). related morbidity, and stoma height, in particular, has
been reported as a modifiable risk factor for complica-
5. W
hen indicated, a loop ileostomy or loop colostomy
tions.9,10,83,84 In a report of 192 stoma patients, 52 (27.1%)
is effective for fecal diversion. Grade of recommen-
were identified with problematic stoma; significant risk
dation: strong recommendation based on moderate-
factors for having a problematic stoma were having a colos-
quality evidence, 1B
tomy, a short stoma height, a higher BMI, emergency sur-
Although proximal diversion of the fecal stream can be gery, and lack of preoperative site marking. In this study,
accomplished with an ileostomy or colostomy, loop stomas patients with problematic stomas were associated with
are often preferred for temporary fecal diversion because of having a significantly longer hospital stay and requiring
their relative ease of closure. The choice of loop ileostomy increased outpatient care.10 Another retrospective study
(LI) versus loop colostomy (usually transverse loop colos- of 279 patients who underwent loop ileostomy formation
tomy [LC]) has been evaluated in 5 randomized controlled found that surgical technique affected the incidence of
trials (RCTs) and several observational studies in an effort parastomal dermatitis, mucocutaneous separation, stoma
to determine whether 1 approach is superior.65–71 Several retraction, and stoma prolapse.85 In this study, it was the
meta-analyses have also been performed but report con- height of the efferent stoma limb that was associated with
flicting results in large part because of the heterogeneity stomal dermatitis and not the height of the proximal limb,
among studies.72–78 Both LI and transverse LC effectively whereas most other studies have demonstrated a near-lin-
divert the fecal stream79 and minimize the consequences ear inverse relationship between stoma protrusion height
of anastomotic dehiscence.72 and the likelihood of having a problematic ostomy.9,57
The main difference in an LI versus LC is the rate of In general, ileostomies should protrude at least 2 cm
complications at the time of creation and subsequent clo- over the skin surface, whereas colostomies should protrude
sure. A meta-analysis that evaluated temporary diverting at least 1 cm.86 However, it is acknowledged that this degree
LI (n = 821) and LC (n = 630) found that an LI was associ- of protrusion is not possible in all clinical circumstances.
ated with significantly lower incidence of stoma prolapse or In patients with a thicker abdominal wall, a foreshortened
retraction (OR, 0.26; 95% CI, 0.11–0.60) and rate of PSH mesentery, obesity, Crohn’s disease, or neuroendocrine or
(OR, 0.52; 95% CI, 0.30–0.88) but was associated with a desmoid tumors, it may be difficult to mature an ostomy
significantly higher incidence of dehydration (OR, 2.67; with an ideal stoma height. Nevertheless, surgeons should
95% CI, 1.18–6.06) compared with an LC.77 The incidence avoid creating ostomies flush with the skin when techni-
of stomal dermatitis, parastomal infection, stoma bleeding, cally possible. Techniques that may be used to gain length
and morbidity related to stoma reversal was the same in the for an ostomy include selective mesenteric vessel ligation,
2 groups. Postoperative ileus was significantly more com- “end-loop” ostomies, and choosing an upper abdominal
mon following LI closure (OR, 2.23; 95% CI, 1.12–4.43), site in obese patients.
whereas LC reversal was significantly more likely to have a
7. In nonobese patients, the routine use of a support
surgical site infection (SSI; OR, 0.24; 95% CI, 0.11–0.49) or
rod at the time of loop ileostomy construction is not
incisional hernia (OR, 0.39; 95% CI, 0.19–0.83).
necessary. Grade of recommendation: strong recom-
Loop ileostomy patients may have a better quality of
mendation based on high-quality evidence, 1A
life relative to colostomy patients because of decreased
odor, less need to adjust clothing secondary to prolapse, In 2006, a small RCT compared ileostomies fashioned with
and greater ease of ostomy care.65,67,80,81 However, 1 small a rigid bridge versus no bridge and demonstrated no signifi-
randomized trial did not show a difference in “social cant difference in stoma retraction rates.87 Since then, there
restriction” between the patients randomly assigned to a have been 3 additional RCTs and 2 cohort studies evaluat-
diverting colostomy (n = 39) versus ileostomy (n = 37).82 ing the use of support rods for both loop ileostomies88–90
This recommendation was changed from the 2015 CPG and colostomies.91,92 A meta-analysis of these studies
in which a loop ileostomy was preferred to a loop colostomy. included 1131 patients with a loop stoma (569 patients had
a support rod) and found no difference in stoma retraction prophylactic mesh reduced the rate of both clinical (OR,
rates (OR, 0.65; 95% CI, 0.32–1.32); however, patients with 0.27; 95% CI, 0.12–0.61) and radiological (OR, 0.39;
a support rod had significantly higher rates of stoma necro- 95% CI, 0.24–0.65) PSHs in patients with a minimum of
sis, peristomal dermatitis, and mucocutaneous separation. 12-month follow-up. However, a sensitivity analysis that
Importantly, no studies have specifically evaluated the util- included only studies with a low risk of bias showed no sig-
ity of support rods in obese patients, and the average BMI nificant benefit of prophylactic mesh in preventing PSH.110
in the aforementioned studies ranged from 19.5 to 26.2 kg/ A 2015 randomized trial of 70 patients who underwent
m2. If a support rod is used, small observational studies have end colostomy creation with or without an intraperitoneal
shown that flexible versions, such as a red rubber catheter, dual-component onlay mesh showed that mesh did not sig-
may permit easier fitting and changing of stoma appli- nificantly reduce the risk of radiologically detected PSH,
ances.93–95 Considering the evidence currently available, but mesh repair was associated with a significantly lower
this recommendation has been revised since the 2015 CPG, risk of clinically detected PSH (14.3% versus 32.3%; p =
which focused on the physical properties of a support rod. 0.04).111 The long-term follow-up of this trial, published in
2020, included 20 of the 35 patients in the original mesh
8. Th
e routine use of prophylactic mesh to prevent
group and 15 of the 35 patients in the original control group
parastomal hernia at the time of ostomy creation is
with a median follow-up of 65 months. The rates of radio-
not recommended. Grade of recommendation: weak
logically detected PSH (45% versus 58.3%, p = 0.72) and
recommendation based on high-quality evidence, 2A
clinically detectable PSH (20% versus 33.3%, p = 0.45) were
The high rate of PSH has led many surgeons to place the same in both groups. Interestingly, only 1 of 35 patients
a mesh reinforcement at the time of stoma creation as a (2.7%) in the mesh group and 6 of 35 patients (17.1%)
potential prophylaxis. Previous systematic reviews dem- in the control group underwent a PSH repair during the
onstrated a reduction in PSH rates with prophylactic long-term follow-up period (p = 0.03).112 Considering the
mesh, and this approach was shown to be cost-effec- evidence currently available, which included 2 additional
tive.96–105 A meta-analysis published in 2017 of 7 RCTs RCTs, this recommendation has been changed from the
including 432 patients found that implantation of mesh 2015 CPG. The heterogeneous nature of the interventions,
at the time of stoma creation reduced the incidence of materials, and surgical methods used was considered with
clinically detected PSHs (10.8% versus 32.4%; p = 0.001) respect to the weak recommendation.
and radiologically detected PSHs (34.6% versus 55.3%;
9. E
xtraperitoneal tunneling of an end colostomy may
p = 0.01) without increasing the incidence stoma-related
decrease the risk of parastomal hernia. Grade of
complications.100 However, a 2019 study randomized 240
recommendation: weak recommendation based on
patients to a lightweight polypropylene sublay mesh ver-
moderate-quality evidence, 2B
sus no mesh at the time of permanent end colostomy
creation and found no statistically significant difference Extraperitoneal tunneling of an end colostomy has been
between the 2 groups in the rates of clinically diagnosed proposed as a technique to decrease the risk of PSH.113–116
PSH or PSH diagnosed by CT scan at 1-year follow-up.106 In a meta-analysis of 10 studies (2 RCTs and 8 retrospec-
In this study, there was no significant difference in peri- tive studies) including 347 patients with an extraperitoneal
operative complications between the groups. A 2020 trial colostomy and 701 patients with a conventional colostomy,
randomized 200 patients to end colostomy creation with or Kroese et al117 reported that extraperitoneal tunneling was
without a synthetic lightweight monofilament mesh in the associated with significantly lower PSH rates (6.3% versus
retromuscular space and found no significant difference in 17.8%; p < 0.001) and significantly lower stoma prolapse
the rates of PSH (28% versus 31%) at 24 months.107 Again, rates (1.1% versus 7.3%; p = 0.01). In this study, there was
there was no difference in stoma-related complications in no difference in complication rates between the groups.117
this study. A 2021 trial randomized 209 patients undergo- Given the evidence, this recommendation was upgraded
ing end colostomy creation to utilizing a cruciate incision from a 2C in the 2015 CPG to a 2B.
(standard practice, n = 74), a circular fascial incision made
10. M
anaging patients with a new ileostomy with a
with diathermy and targeting a diameter that was 50% of
perioperative clinical care pathway may decrease
the width of the bowel (n = 72), or a prophylactic synthetic
the risk of hospital readmission. Grade of recom-
partially absorbable mesh in the sublay position (n = 63).
mendation: weak recommendation based on mod-
In this study, there were no statistically significant differ-
erate-quality evidence, 2B
ences between the groups regarding the PSH rate. However,
increasing age and BMI were associated with a PSH.108 Complications after ileostomy creation are common, with
A meta-analysis of 7 studies evaluating the use of a morbidity rates reaching as high as 30%. In patients with
mesh at the time of colostomy formation to prevent PSH109 a new ileostomy, dehydration is the most common cause
found no statistically significant benefit to mesh implanta- of morbidity occurring in up to 40% of patients and often
tion at 1-year follow-up. In a meta-analysis of 11 studies, resulting in hospital readmission.118–122 In an effort to
mitigate the risks of dehydration and readmission, vari- a protective ostomy. Although the literature supports the
ous perioperative care pathways have been implemented‚ sensitivity and positive predictive value of WSCE in detect-
including a variety of interventions like educating and ing anastomotic leaks, several studies have questioned the
empowering patients, standardizing discharge criteria, utility of WSCE in routine clinical practice.134–145 Dimitriou
tracking fluid input and output after hospital discharge, et al134 performed a WSCE on 339 patients after low pel-
engaging visiting nurse services, monitoring postopera- vic anastomosis before ostomy reversal and identified 24
tive serum electrolytes, administering intravenous or oral patients (7.1%) with an anastomotic leak. Of these patients,
hydration, and utilizing telemedicine visits and early fol- only 29% had an uncomplicated postoperative course from
low-up after hospital discharge. Managing patients with their index procedure, indicating that, in most cases, the
a perioperative clinical care pathway has been shown to surgeon could have a clinical suspicion of which patients
significantly decrease rates of readmission due to dehydra- were at highest risk of poorly healed anastomosis.134 A
tion.123–130 A retrospective review comparing 232 patients systematic review of 1142 contrast enemas (CE) across
treated with an ileostomy pathway and 161 patients 11 studies found that CE had high specificity (95.4; 95%
treated without a pathway reported significantly decreased CI, 92.0–97.4), negative predictive value (98.4; 95% CI,
rates of 30-day readmission (25.9% versus 35.4%; p = 0.04) 97.4–99.1), moderate sensitivity (79.9; 95% CI, 63.9–89.9),
and of readmissions due to high output and/or dehydra- and positive predictive value (64.6; 95% CI, 55.5–72.9) for
tion (3.9% versus 15.5%; p < 0.001) in patients treated on the detection of clinically significant anastomotic com-
a clinical pathway. The key components in this pathway plications including leaks and strictures. The authors also
included preoperative education with teaching materi- demonstrated a high degree of correlation between CE
als, inhospital patient engagement with an emphasis on and clinical examination findings (96.7%). Methods used
patient self-management, observing patients managing for clinical assessment in this study included digital rec-
their own ostomy, and tracking postdischarge intake and tal examination, proctoscopy, flexible sigmoidoscopy, and
output with assistance from a visiting nurse. An RCT of 79 examination under anesthesia (EUA). Across the stud-
patients who were treated with or without 1 L of isotonic ies, 754 pairs of examinations were compared, and clini-
oral solution daily for 40 days postoperatively found that cal assessment and CE were concordant in 731 patients
the readmission rate was significantly higher in the control (96.7%). Occult radiologic leaks were seen in 5.7% of CE.137
group (29% versus 10%; p = 0.001).126 Another meta-analysis compared CE with endoscopic
Meanwhile, other studies have reported that ileostomy procedures and digital rectal examination in rectal cancer
pathways do not decrease readmission rates.122,131,132 In an patients before closure of a diverting ostomy and included
RCT of 100 patients who either received an ileostomy edu- data from 2 prospective and 11 retrospective studies com-
cation and monitoring program or received routine post- prising 1903 patients. The analysis demonstrated equal or
operative care, intervention patients were more likely to better results for sensitivity and specificity of both endo-
require outpatient intravenous fluids (25% versus 6%; p = scopic procedures and digital rectal examination com-
0.008), and there were no differences between the 2 groups pared to contrast. No patient had an anastomotic leak that
in overall hospital readmissions (20.4% versus 19.6%; p = was described by a CE but not by digital rectal examina-
1.0), readmissions for dehydration (8.2% versus 5.9%; p = tion or an endoscopic procedure.143 Similarly, in a retro-
0.71), and patients developing acute renal failure (10.2% ver- spective study that compared 91 patients with low pelvic
sus 3.9%; p = 0.26). Multivariable analysis found that week- anastomoses who underwent flexible endoscopy (FE)
end discharges to home were significantly associated with before ileostomy closure versus 100 patients who under-
readmission (OR, 4.5; 95% CI, 1.2–16.9).133 Considering went both FE and contrast evaluation (CE) before rever-
the heterogeneous outcomes with respect to care pathways, sal, there were no significant differences in the detection
this recommendation was downgraded from strong to weak of pelvic anastomotic leak (2.2% versus 1%), anastomotic
based on moderate-quality evidence from the previous CPG. stricture (1.1% versus 6%), or postoperative anastomotic
complications (4.4% versus 9%) between the groups.146
OSTOMY CLOSURE Similar findings published in the setting of IPAA call
into to question the routine use of preoperative poucho-
gram. A retrospective study of 52 pouch patients with-
11. R
outine water-soluble contrast studies in the absence
out immediate postoperative complications evaluated
of a clinical suspicion of anastomotic dehiscence or
patients with a contrast study performed at a median
stricture may not be necessary before closure of a
of 14 weeks (range, 7–71 weeks) after IPAA and by an
protective ostomy. Grade of recommendation: Weak
EUA on the day of the ileostomy closure. In this study,
recommendation based on low-quality evidence, 2C
1 asymptomatic patient (2%) had an anastomotic leak
There are no randomized trials evaluating the use of water- demonstrated on contrast study, which was subsequently
soluble contrast enemas (WSCE) or any other preopera- confirmed at EUA‚ and 2 patients (3%) with a nor-
tive evaluation of anastomotic integrity before reversal of mal pouchogram, 1 symptomatic and 1 asymptomatic,
subsequently had an anastomotic leak demonstrated at no clinically significant differences in health-related qual-
EUA.147 Another study evaluated 61 patients following ity-of-life questionnaire scores between the groups at 3, 6,
IPAA before ileostomy closure148 with a pouchogram or 12 months.151 Using a sensitivity analysis and consid-
and pouchoscopy. Preoperatively, both pouchogram and ering protocol-mandated examinations, the investigators
pouchoscopy were negative for leakage in all 61 patients, demonstrated an overall difference in the mean cost per
and subsequently, the ileostomies were reversed. Fourteen patient of $3608 (US dollars) in favor of EC (p = 0.02). In
months after ileostomy closure, a single patient presented this analysis, the predominant cost factors were reopera-
with a pouch vaginal fistula. The negative predictive value tions, readmissions, and endoscopic examinations.152
of the double assessment was 98.4%. Their combination In the most recent randomized trial, Elsner et al153
did not alter the diagnostic accuracy or have any effect in reported EC in patients who underwent an open low
further management. anterior resection with colorectal anastomosis. The study
included 37 patients in the EC group (2 weeks) and 34
12. E
arly closure of protective ileostomies may be per-
patients in the LC group (12 weeks), and all patients under-
formed in select low-risk patients with a colorectal
went preoperative CE studies and digital rectal examina-
anastomosis without clinical evidence of anasto-
tion. The study was closed early because of safety concerns,
motic leak. Grade of recommendation: weak recom-
with 10 of 37 EC patients having failed stoma closure. Of
mendation based on moderate-quality evidence, 2B
note, 86% of the EC patients had a transverse coloplasty of
A temporary ileostomy is effective in reducing the sever- the colonic conduit to improve their postoperative func-
ity of anastomotic complications in a variety of clinical tion, and the average distance of the anastomosis was 3 cm
conditions. Long-term stomas can manifest stoma-related from the anal verge. All patients in the EC group who had
complications such as prolapse, hernia, dehydration, and an anastomotic dehiscence noted before ileostomy closure
skin-related problems. Three adequately powered RCTs (4/37) were assigned to the EC group in this intention-to-
have evaluated the outcomes of early versus late ileostomy treat analysis. Of the remaining 6 patients who failed EC, 3
closure in patients with a low rectal anastomosis. It is had a leak of the colorectal anastomosis, 2 had a leak from
important to recognize that the data are new and emerg- the ileostomy closure, and 1 had a wound infection of the
ing regarding early closure (EC), and this recommenda- ostomy closure site.153 In a meta-analysis of 6 studies com-
tion could subsequently change pending new clinical data. paring EC (defined as closure within 6 weeks, n = 269) ver-
In 1 study, 186 patients were randomized to EC on day sus LC (defined closure after 6 weeks, n = 259), the rates of
8 or late closure (LC) on day 60 if there was no radiographic major complications (5.2% versus 3.6%) and anastomotic
sign of anastomotic leak by postoperative day 7. A total of leak (3.3% versus 3.5%) were similar in the 2 groups.154
39% of the EC group and 41% of the LC group received pre- These results confirmed the findings of an earlier meta-
operative radiation. There were no deaths within 90 days, analysis of 4 studies including 142 patients.155
and overall morbidity rates were the same in the EC and A multicenter randomized trial of early (7–12 days)
LC groups (31% versus 38%; p = 0.254). Overall surgical versus late (8 weeks or more) ileostomy closure following
complications (15% in both groups) and need for reopera- proctectomy with IPAA was closed early after interim anal-
tion (8% in both groups) were similar, but wound compli- ysis because of increased complications in the EC group.
cations were more frequent after EC (19% versus 5%; p = The median Comprehensive Complication Index was 14.8
0.007), whereas small-bowel obstruction (3% versus 16%; in the EC group versus 0 in the LC group (p = 0.02).156
p = 0.002) and medical complications (5% versus 15%; p = In total, the data on early protective ostomy closure
0.02) were more common with LC. Functional outcomes at are new and emerging. Early ileostomy closure appears
90 days were the same in both groups. Of note, 5 patients to be contraindicated in high-risk cases such as coloanal
in the EC group developed enterocutaneous fistula versus anastomosis with transverse coloplasty or IPAA. This rec-
1 patient in the LC group, but no p value was reported, and ommendation is subject to change as new clinical evidence
all of these were managed conservatively.149 becomes available.
A more recent multicenter RCT evaluated EC (clo-
13. L
oop ileostomy closure can be performed using
sure 8–13 days after index procedure, n = 55) versus LC
stapled or handsewn techniques. Grade of recom-
(closure >12 weeks after index procedure, n = 57) in 112
mendation: strong recommendation based on high-
patients with a low rectal anastomosis without clinical
quality evidence, 1A
signs of postoperative complications and a normal CT
scan or FE or both. The median time from index surgery Four RCTs compare stapled versus handsewn techniques
to closure was 11 days in the EC group and 148 days in for the closure of a loop ileostomy.157–160 In general, the
the LC group. The mean number of complications within results across the trials are the same with a trend toward a
12 months of the index procedure was significantly lower higher risk of postoperative bowel obstruction and longer
in the EC group than that in the control group (p < operative time in the handsewn groups.161 In 1 of the RCTs,
0.001).150 A follow-up survey of these patients indicated the HASTA trial, which enrolled 337 patients across 27
centers, 10.3% of the stapled patients and 16.6% of hand- 15. Minimally invasive Hartmann reversal is a safe alter-
sewn patients developed postoperative bowel obstruction native to open reversal. Grade of recommendation:
(p = 0.10), and 3% of stapled patients and 1.8% of hand- strong recommendation based on moderate-quality
sewn patients developed anastomotic leak (p = 0.46).157 In evidence, 1B
this trial, operative time was significantly shorter in the
Although Hartmann reversal with a colorectal anastomosis176
stapled group by 15 minutes (p < 0.001).157 Several obser-
carries a high-risk profile, a variety of minimally invasive

vational studies have suggested an association between
options have been described for this procedure‚ including
stapled stoma reversal and shorter hospital length of stay;
robot-assisted closure and single and multiport laparosco-

however, the possibility of selection bias in these studies
pies.177–180 Although no randomized trials have compared
must be considered.162–164 A meta-analysis of 4917 patients
open Hartmann reversal (OHR) versus laparoscopic
across 15 studies (3406 handsewn and 1511 stapled stoma
Hartmann reversal (LHR), observational studies have
reversals) reported similar anastomotic leak rates in 2
documented the safety of a laparoscopic technique in this
groups of patients (2.9% versus 2.0%) and a higher rate
setting.181,182 An National Surgical Quality Improvement
of small-bowel obstruction in the handsewn group com-
Program study evaluating patients who underwent either
pared to the stapled group (7% versus 5.5%; p = 0.01).165
OHR or LHR between 2005 and 2014 demonstrated a 2.8%
The addition of the large meta-analysis led to an upgrade
annual increase in the use of the laparoscopic approach
to a 1A recommendation. In patients undergoing ileos-
with a concomitant decrease in open surgery from 100%
tomy closure after an ileoanal anastomosis, some surgeons
to 74.2%.183 In this study, laparoscopic colostomy rever-
recommend a handsewn ileostomy closure, as this avoids
sal patients had fewer complications than those who had
the wider lumen and staple line caused by a stapled anasto-
open surgery (OR, 0.56; 95% CI, 0.50–0.63; p < 0.001) and
mosis in case a redo ileoanal anastomosis is ever required.
shorter length of stay (mean change, −1.77 d; p < 0.001). A
14. O
stomy-site skin approximation should be per- meta-analysis of 13,740 patients from 26 studies compared
formed when feasible, and purse-string skin closure the MIS (n = 3170) with OHR (10,570 patients).184 Although
has advantages compared with other techniques. the overall conversion rate was 17%, postoperative morbid-
Grade of recommendation: strong recommenda- ity was significantly lower in the LHR (18.5% versus 29.3%;
tion based on high-quality evidence, 1A OR, 0.43; p < 0.001). In addition, patients undergoing LHR
had fewer anastomotic leaks (2.6% versus 4.6%; OR, 0.58;
Traditionally, ostomy closure wounds were left open and
p < 0.001) and significantly shorter postoperative hospitaliza-
allowed to heal by secondary intention because of the risk
tion (−3.72 mean days; p < 0.001). These results have been
of SSI, which has been reported to be as high as 41%.166–170
replicated in other reviews, which demonstrate that LHR has
Nonetheless, many surgeons close the skin, either partially
less short-term complications than OHR in terms of overall
or completely, to avoid the need for prolonged wound care.
morbidity, wound infection, postoperative ileus, and length
Closure techniques include primary closure, delayed primary
of hospital stay.185 Although these data support the safety
closure, secondary closure, negative pressure wound therapy,
and utility of the laparoscopic approach in centers with sur-
closure incorporating a drain, and purse-string closure.
geons experienced in this technique, it is important to note
In a meta-analysis of 20 studies (6 RCT and 14 obser-
the potential for selection bias in these observational studies.
vational), including 1812 patients (826 purse-string clo-
Given the additional evidence available since the 2015 CPG
sure versus 986 primary closure) undergoing ostomy
(the large meta-analysis and the National Surgical Quality
reversal, rates of SSI were significantly lower in patients
Improvement Program study), this recommendation was
with a purse-string closure (3.1%) versus primary closure
upgraded from a 1C to a 1B recommendation.
(20.2%; OR, 0.14; 95% CI, 0.09–0.21). Length of hos-
pital stay, hernia rates, and operative times were similar
between the 2 groups.170 Subgroup analysis, including only PARASTOMAL HERNIA
the 6 RCTs, confirmed these results. In another system-
atic review of 319 patients from 4 RCTs that compared 16. P
arastomal hernia repair should typically utilize mesh
purse-string closure versus primary closure,171 there were reinforcement. Grade of recommendation: strong rec-
no significant differences in the rates of incisional hernia, ommendation based on low-quality evidence, 1C
length of hospital stay, or operative times between the Although there has been a significant increase in the
study groups. However, patients with a purse-string clo- annual number of PSH repairs performed in the United
sure had higher satisfaction with their cosmetic outcomes States, from 4150 in 1998 to 7623 in 2011,186 there are no
(standard mean difference, 0.7; 95% CI, 0.13–1.27) and a RCTs comparing methods of PSH repair. The routine use
significantly lower rate of SSI (risk difference, –0.25; 95% of mesh in the setting of PSH repair is based on the multi-
CI, −0.36 to −0.15).172–175 Given the aggregate of the litera- ple retrospective observational studies that demonstrate
ture, this recommendation was upgraded from a 1B rec- high rates of hernia recurrence (46%–78%) with primary
ommendation in the 2015 CPG to a 1A recommendation. suture repair.187 A systematic review of 30 observational
studies concluded that primary suture repair of a PSH patients whose ostomies are taken down, rematured, or
was associated with a 69.4% risk of recurrent hernia.187 resited. A surgeon’s experience and increasing case vol-
In a study by the American Hernias Society Quality ume favor an MIS approach.188 The use of MIS techniques
Collaborative, 94% of PSH repairs used mesh, and the appears to be increasing over time, with 1 retrospective
most common mesh used was a permanent synthetic multicenter study showing a 75% utilization rate in elec-
mesh. Overall, only 21% of the repairs were performed tive PSH repairs.189 In a retrospective study of 62 patients
using an MIS approach.188 Another retrospective study of that compared open (n = 31) with laparoscopic (n =
235 PSH repairs across 9 Finnish hospitals reported that 31) approaches, hernia repairs with mesh, operative times
mesh was used in 90% of cases.189 The safety of a perma- (p < 0.001), and median length of stay were shorter after
nent synthetic mesh was evaluated in a meta-analysis of laparoscopy (3 versus 7 days; p < 0.001). In this study,
469 patients who underwent elective mesh repair of their overall wound complications, other complications, and
PSH. In this study, the overall postoperative morbidity need for reoperation or readmission were similar between
rate was 24.9%, and the most common complication was the 2 groups. However, long-term follow-up of patients
SSI, which was seen in 3.8% of patients (95% CI, 2.3–5.7). in the laparoscopic cohort showed a significantly longer
Mesh infection was observed in 1.7% of patients (95% CI, time to hernia recurrence.202
0.7–3.1), and obstruction requiring reoperation occurred The most common MIS techniques for PSH repair
in 1.7% of patients as well (95% CI, 0.7–3.0).190 are the modified Sugarbaker technique and the keyhole
Biologic mesh has been evaluated in the setting of technique, which can be done with either 1 or 2 pieces of
PSH repair, but no study has compared synthetic and bio- mesh (sandwich technique). In Sugarbaker-type repairs,
logic mesh in a randomized fashion. In a systematic review an intact sheet of mesh is placed as an underlay, with the
of 4 retrospective studies with a combined 57 PSH repair stoma limb exiting from under the mesh lateral to the
patients that utilized biologic mesh, 15.7% of patients abdominal wall defect. The keyhole or slit mesh tech-
developed recurrent hernias, and 26.2% developed nique uses 1 or 2 pieces (sandwich—a piece of mesh
wound-related complications.191 A retrospective study above and below the fascia) of mesh with an aperture
evaluating 58 patients who underwent PSH repair with cut for the stoma limb to pass through because it enters
biologic mesh demonstrated a comparable recurrence rate the abdominal wall. In 1 prospective randomized study,
of 18% at a median of 3.8 years of follow-up.192 In general, the recurrence rate after the laparoscopic keyhole was
biologic mesh should not be considered a superior alterna- 35.9%, Sugarbaker was 21.5%, and sandwich technique
tive to synthetic mesh for elective PSH repair.193 was 13.5%.189 Issues related to recurrence have been dem-
There is no consensus as to when a stoma should be onstrated in several retrospective studies that show sig-
relocated, and there is no literature to guide this decision. nificantly higher rates of hernia recurrence after a keyhole
Relocation typically occurs as a joint decision between technique (58%–72.7%) compared with a Sugarbaker
the patient and the physician when it becomes clear that technique (0%–15.4%).203,204 However, the average dura-
keeping the ostomy at its current location is problematic. tion of follow-up for patients in the slit mesh group was
For example, in setting a large hernia sac, the overlying greater than twice that of the Sugarbaker group.203 A
skin may not be healthy enough or may have stretched to meta-analysis examining pooled data from 15 studies
the point that adherence of the ostomy appliance may be with a total of 469 patients demonstrated a PSH recur-
problematic; thus, stoma relocation may be necessary. A rence rate of 10.2% (95% CI, 3.9–19.0) after a laparoscopic
patient’s body habitus may have changed over time with Sugarbaker approach compared with a 27.9% recurrence
weight gain or loss, making relocation the preferred option. (95% CI, 12.3–46.9) for the keyhole approach.190 In a
Whatever the reason, relocating a stoma is associated with more recent retrospective study evaluating the long-term
the same high risk of hernia formation, and patients need results of a keyhole technique (74 patients, using a 2-layer
to be counseled regarding the expected outcomes.194–196 mesh of polypropylene and polytetrafluoroethylene with
a self-cut slit) or the Sugarbaker technique (61 patients,
17. M
inimally invasive parastomal hernia repair may
using a coated polypropylene mesh) demonstrated 5
be performed in selected patients. Grade of recom-
recurrences in the keyhole group (7%) and 6 recurrences
mendation: strong recommendation based on low-
(10%) in the Sugarbaker group. Late mesh-related mor-
quality evidence, 1C
bidity occurred in 6 patients after keyhole (8%) and in 6
There are no RCTs comparing the MIS approach to open patients after Sugarbaker repair (10%).205
PSH repair. However, a number of observational studies
have established the feasibility of laparoscopic mesh PSH
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CLINICAL PRACTICE GUIDELINES

The American Society of Colon and Rectal Surgeons

Bradley R. Davis, M.D.1 • Michael A. Valente, M.D.2 • Joel E. Goldberg, M.D.3

Amy L. Lightner, M.D.2 • Daniel L. Feingold, M.D.4 • Ian M. Paquette, M.D.5

DISEASES OF THE COLON & RECTUM VOLUME 65: 10 (2022) 1173

METHODOLOGY were conducted for each statement within the guidelines

MEDLINE Subject Heading: colostomy, ileostomy, ostomy limited to human (3702)

Years covered: January 1, 2014–December 1, 2021

Human and abstract available

Records identified through Additional records identified

Records after duplicates removed

Records excluded (n = 2424)

Full-text articles assessed Full-text articles excluded,

Studies included in final

TABLE 2. The GRADE system—grading recommendations

moderate-quality imprecise) or exceptionally strong evi- stances without reservation

PERIOPERATIVE MANAGEMENT evaluated the impact of a 2-hour preoperative stoma educa-

face. Grade of recommendation: strong recommen-

carries a high-risk profile, a variety of minimally invasive

robot-assisted closure and single and multiport laparosco-

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