Guideline sources The following summarized guidelines for the management of ostomy surgery are prepared by our editorial team based on guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES/ASCRS 2023) and the American Society of Colon and Rectal Surgeons (ASCRS 2022; 2019; 2017; 2013). 1 2 3 4 5 Guidelines 1. Perioperative care Preoperative preparation: As per SAGES 2023 guidelines, consider allowing intake of clear liquids up to 2 hours before general anesthesia. B Show 4 more As per ASCRS 2019 guidelines: Perform mechanical bowel preparation combined with preoperative oral antibiotics for elective colorectal resections. B Do not perform preoperative mechanical bowel preparation without administering oral antibiotics, D , administer preoperative oral antibiotics without performing mechanical bowel https://web.pathway.md/diseases/rec4rr97QcJLrkzi6 1/4 6/30/23, 1:24 AM Ostomy surgery Pathway preparation, D or perform preoperative enemas without mechanical bowel preparation and oral antibiotics in patients undergoing elective colorectal surgery. D Perioperative nausea and vomiting prophylaxis: administer preemptive, multimodal antiemetic prophylaxis to reduce perioperative nausea and vomiting. A Perioperative pain control: Implement a multimodal, opioid-sparing pain management plan before the induction of anesthesia. B Consider administering thoracic epidural analgesia as an option for open colorectal surgery (but not routinely for laparoscopic colorectal surgeries), provided a dedicated acute pain team is available for postoperative management. B Perioperative hemodynamic control: tailor fluid administration to avoid excessive fluid administration and volume overload or undue fluid restriction and hypovolemia. A Show 4 more 2. Surgical interventions Choice of surgical approach: As per SAGES 2023 guidelines: Use a minimally invasive surgical approach for colorectal resection when appropriate and provided expertise is available. A Avoid using nasogastric tubes and intra-abdominal drains for colorectal surgery. D As per ASCRS 2022 guidelines, perform ostomy formation laparoscopically rather than via laparotomy, when feasible. B Preoperative marking: as per ASCRS 2022 guidelines, mark appropriate potential ostomy sites preoperatively by a trained provider, when possible. B Ostomy creation: perform a loop ileostomy or loop colostomy for fecal diversion. B Show 4 more Ostomy closure: avoid obtaining routine water-soluble contrast studies before the closure of a protective ostomy in the absence of clinical suspicion of anastomotic dehiscence or stricture. D Show 4 more Parastomal hernia repair: Perform mesh reinforcement for parastomal hernia repair. B Consider performing minimally invasive parastomal hernia repair in selected patients. B 3. Patient education Preoperative counseling: As per SAGES 2023 guidelines: https://web.pathway.md/diseases/rec4rr97QcJLrkzi6 2/4 6/30/23, 1:24 AM Ostomy surgery Pathway Conduct a preoperative discussion regarding clinical milestones and discharge criteria. B Provide preoperative stoma teaching and counseling regarding how to avoid dehydration in patients undergoing ileostomy creation. B As per ASCRS 2022 guidelines, provide preoperative and postoperative ostomy education by a specialized provider, such as a wound ostomy and continence nurse, in patients undergoing elective stoma creation. B As per ASCRS 2017 guidelines, provide ileostomy education and counseling on dehydration avoidance preoperatively. B Preoperative marking: as per ASCRS 2013 guidelines, mark the proposed ostomy site preoperatively. B 4. Follow-up and surveillance Discharge from hospital: consider offering hospital discharge before the return of bowel function in selected patients after colorectal resection. C Postoperative care (general principles): Consider managing patients with a new ileostomy with a perioperative clinical care pathway to decrease the risk of hospital readmission. C Obtain follow-up for ostomy teaching, care, and support. B Postoperative care (early mobilization): offer early and progressive patient mobilization for a shorter length of stay. B Postoperative care (ileus prevention): offer a regular diet within 24 hours after elective colorectal surgery. B Show 2 more Postoperative care (removal of urinary catheters): Remove urinary catheters within 24 hours of elective colonic or upper rectal resection, irrespective of thoracic epidural analgesia use. B Remove urinary catheters within 24-48 hours after mid/lower rectal resection. B Clinical findings Past medical history Past events Acute mesenteric ischemia Penetrating abdominal trauma Colonic volvulus Colorectal cancer Colovaginal fistula Diverticulitis Enterocutaneous fistula Fecal incontinence https://web.pathway.md/diseases/rec4rr97QcJLrkzi6 3/4 6/30/23, 1:24 AM Ostomy surgery Pathway Hirschsprung's disease IBD Intestinal perforation Radiation proctitis Past surgical history Anastomotic leak Colorectal surgery References 1. Jennifer L Irani, Traci L Hedrick, Timothy E Miller et al. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum. 2023 Jan 1;66 1 15 40. Open 2. Bradley R Davis, Michael A Valente, Joel E Goldberg et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Ostomy Surgery. Dis Colon Rectum. 2022 Oct 1;65 10 1173 1190. Open 3. Carmichael JC, Keller DS, Baldini G et al. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum. 2017 Aug;60 8 761 784. Open 4. Monson JR, Weiser MR, Buie WD et al. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum. 2013 May;56 5 535 50. Open 5. Migaly J, Bafford AC, Francone TD et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Use of Bowel Preparation in Elective Colon and Rectal Surgery. Dis Colon Rectum. 2019 Jan;62 1 3 8. Open https://web.pathway.md/diseases/rec4rr97QcJLrkzi6 4/4