Enterostomas:Enterostomas:HistoryHistory

Recent advances Recent advances ComplicationsComplications

Valentine N. Nfonsam, MD,MSValentine N. Nfonsam, MD,MSAssistant Professor of SurgeryAssistant Professor of Surgery

Colon and Rectal SurgeryColon and Rectal SurgeryUniversity of ArizonaUniversity of Arizona

IntroductionIntroduction Over 500,000 in the US have some kind of Over 500,000 in the US have some kind of

functional enterostomyfunctional enterostomy Annually 120,000 more are createdAnnually 120,000 more are created

36.1% colostomy36.1% colostomy 32.2% ileostomy32.2% ileostomy 31.7% urostomy31.7% urostomy

Average age of a patient with ostomy is 68.3 years Average age of a patient with ostomy is 68.3 years Advances in stoma surgery, enterostomal therapy Advances in stoma surgery, enterostomal therapy

and ostomy management led to better ostomates and ostomy management led to better ostomates liveslives

Colorectal surgeons have pioneered new Colorectal surgeons have pioneered new techniques and ostomy management systems that techniques and ostomy management systems that have allowed the intestinal stoma to be a barely have allowed the intestinal stoma to be a barely noticeable alternative to perianal defecationnoticeable alternative to perianal defecation

HistoryHistory•The Bible describes The Bible describes one of the earliest one of the earliest accounts of visceral accounts of visceral injury in the old injury in the old testament when Eglon testament when Eglon was stabbed by Ethud:was stabbed by Ethud:““He (Eglon) could not draw He (Eglon) could not draw the dagger out of his belly the dagger out of his belly and dirt came out”and dirt came out”

•350 BC – Praxagoras of 350 BC – Praxagoras of Kos – has a kind of stoma Kos – has a kind of stoma created by intestinal created by intestinal injuriesinjuries

HistoryHistory Hippocrates(460-377BC), Cornelius (53BC-Hippocrates(460-377BC), Cornelius (53BC-

AD7), Galen(131-201AD) knew injuries to AD7), Galen(131-201AD) knew injuries to colon and small intestine were often fatal – colon and small intestine were often fatal – but did not know what to dobut did not know what to do

1414thth Century: Artillery began to be used in Century: Artillery began to be used in wars, and patients with GSW to abdomen – wars, and patients with GSW to abdomen – mostly diedmostly died

Prior to WWI - French did pioneering work Prior to WWI - French did pioneering work on stoma surgery – which later spread to on stoma surgery – which later spread to the rest of Europethe rest of Europe

Between the Two world wars and after Between the Two world wars and after WWII – Americans took the lead in the field WWII – Americans took the lead in the field of stoma. of stoma.

HistoryHistory

•Soldier George Deppe - Soldier George Deppe - injured his back at the injured his back at the Battle of Ramillies (The Battle of Ramillies (The duke of Marlborough beat duke of Marlborough beat the French) – May 23the French) – May 23rdrd 1706. 1706.

•He sustained a wound to He sustained a wound to the lower back – and the lower back – and developed what today is developed what today is known as a fisulaknown as a fisula

•He lived with it for 14 He lived with it for 14 years. years.

HistoryHistory Earliest stomas were not envisioned or Earliest stomas were not envisioned or

created by imaginative surgeons but by created by imaginative surgeons but by forces of natureforces of nature

These patients managed these stomas on These patients managed these stomas on their owntheir own

It was only much later that physicians It was only much later that physicians ponder the surgical creation of an ostomy.ponder the surgical creation of an ostomy.

In 1757 Lorenz Heister (1683-1758) first In 1757 Lorenz Heister (1683-1758) first recommended the surgical creation of recommended the surgical creation of stomas for the treatment of abdominal stomas for the treatment of abdominal trauma. trauma.

HistoryHistory

After observing spontaneous stomas in After observing spontaneous stomas in individuals with abdominal wounds, individuals with abdominal wounds, Heister wrote:Heister wrote:

""As the lips of the intestines, so As the lips of the intestines, so wounded, would sometimes quite wounded, would sometimes quite unexpectedly adhere to the wound of unexpectedly adhere to the wound of the abdomen; and therefore it the abdomen; and therefore it seemed no reason why we should seemed no reason why we should not take hints from naturenot take hints from nature""

HistoryHistory

Time of barber surgeons such as John Time of barber surgeons such as John Bell and Gene PalfinBell and Gene Palfin

""It is surely far better to part with It is surely far better to part with one of the conveniences of life than one of the conveniences of life than to part with life itselfto part with life itself““

(Lorenz (Lorenz Heister)Heister)

HistoryHistory In 1710 Alexis Littre (1626-1726) suggested In 1710 Alexis Littre (1626-1726) suggested

the creation of an abdominal stoma in the the creation of an abdominal stoma in the treatment of imperforated anus after treatment of imperforated anus after observations made during the autopsy of a six-observations made during the autopsy of a six-day old infant.day old infant.

This idea remained untested for 66 yrs until This idea remained untested for 66 yrs until in1777 when Pilore, a country surgeon from in1777 when Pilore, a country surgeon from Rouen, France performed a cecostomy for the Rouen, France performed a cecostomy for the treatment of an obstructing rectal cancer. treatment of an obstructing rectal cancer. (histoire)(histoire) “…“…..for a dressing, I applied burnt charcoal and ..for a dressing, I applied burnt charcoal and

towels.”towels.”

HistoryHistory Not until 1793 that the first successful Not until 1793 that the first successful

stoma was created. stoma was created.

Duret, a naval surgeon at Brest performed Duret, a naval surgeon at Brest performed the first successful left iliac colostomy in the first successful left iliac colostomy in the treatment of imperforated anus on a the treatment of imperforated anus on a three-day old infant. three-day old infant.

He practiced on a 15 day old dead childHe practiced on a 15 day old dead child

Pt. survived till age 45Pt. survived till age 45

HistoryHistory With the advent of surgical stomas, it became With the advent of surgical stomas, it became

necessary to create a means for the collection of feces.necessary to create a means for the collection of feces.

Pts left to their own devicesPts left to their own devices

First mention of collecting device was reported by First mention of collecting device was reported by Daguesceau in 1795.Daguesceau in 1795.

He performed a left inguinal colostomy on a patient He performed a left inguinal colostomy on a patient that impaled himself on a wheat cartthat impaled himself on a wheat cart

The Farmer created his own appliance and died at age The Farmer created his own appliance and died at age 8181 “…“…he conveniently collected his feces in a small leather he conveniently collected his feces in a small leather

pouch”pouch”

HistoryHistory Until this time only loop stomas had been Until this time only loop stomas had been

surgically createdsurgically created

Prone to prolapse and often did not completely Prone to prolapse and often did not completely divert the fecal stream.divert the fecal stream.

In 1881, Schitsinger and Madelung both In 1881, Schitsinger and Madelung both described a procedure for creating a proximal described a procedure for creating a proximal “single barreled” stoma while returning the “single barreled” stoma while returning the distal loop in to the abdominal cavitydistal loop in to the abdominal cavity

This was the start of the end colostomyThis was the start of the end colostomy

HistoryHistory Stomas also played an important role in early Stomas also played an important role in early

techniques for safe intestinal anastomosistechniques for safe intestinal anastomosis

Primary anastomosis advocated in the late 1800s Primary anastomosis advocated in the late 1800s ---high morbidity and mortality---high morbidity and mortality

Johann Von Mikulicz-Radecki noted high leak rates Johann Von Mikulicz-Radecki noted high leak rates led to Morbidity and Mortality.led to Morbidity and Mortality.

He advocated a two-stage technique for intestinal He advocated a two-stage technique for intestinal anastomosisanastomosis Resection with double-barreled stomaResection with double-barreled stoma Anastomosis 2 weeks laterAnastomosis 2 weeks later Morality decreased from 50% to 12.5% in his first 100 pts.Morality decreased from 50% to 12.5% in his first 100 pts.

HistoryHistory Colostomy also become important in the treatment of Colostomy also become important in the treatment of

other conditions like diverticular disease.other conditions like diverticular disease.

In 1907 Mayo first described the use of the right In 1907 Mayo first described the use of the right transverse colostomy in the treatment of diverticulitis transverse colostomy in the treatment of diverticulitis with reversal after resolution of inflammationwith reversal after resolution of inflammation

In the 1930s, Mayo, Rankin and Braun independently In the 1930s, Mayo, Rankin and Braun independently described described a three stage approach consisting of a three stage approach consisting of - diverting transverse colostostomy and drainage, - diverting transverse colostostomy and drainage, - a secondary sigmoid resection with anastomosis and - a secondary sigmoid resection with anastomosis and - finally a colostomy closure.- finally a colostomy closure.

Henry Hartmann (1860-Henry Hartmann (1860-1952)1952)

Born in France and graduated from the university Born in France and graduated from the university of Paris Medical school in 1877of Paris Medical school in 1877

Performed more than 30,000 operationsPerformed more than 30,000 operations

Somewhere between 1909 and 1923 devised the Somewhere between 1909 and 1923 devised the “Hartmann procedure” for obstructing sigmoid “Hartmann procedure” for obstructing sigmoid cancer. Unknown if he ever performed this for cancer. Unknown if he ever performed this for diverticulitisdiverticulitis

Unknown surgeon in the 1930s first performed Unknown surgeon in the 1930s first performed this two-staged resection and anastomosis for this two-staged resection and anastomosis for diverticulitisdiverticulitis

HistoryHistory Though the first colostomy was performed in 1776, Though the first colostomy was performed in 1776,

the first ileostomy was performed more than a century the first ileostomy was performed more than a century later.later.

In 1879, Baum, in Germany, performed the first In 1879, Baum, in Germany, performed the first diverting ileostomy for treatment of obstructing right diverting ileostomy for treatment of obstructing right colon cancercolon cancer

In 1883 Maydl, of Vienna, performed the first In 1883 Maydl, of Vienna, performed the first successful ileostomy in combination with a colonic successful ileostomy in combination with a colonic resectionresection

J. M. T. Finney described the flush-loop ileostomy for J. M. T. Finney described the flush-loop ileostomy for treatment of SBO- Much complications, skin irritationtreatment of SBO- Much complications, skin irritation

HistoryHistory In 1888, the support rod was introduced to prevent In 1888, the support rod was introduced to prevent

retraction of the loop stoma until it has granulated retraction of the loop stoma until it has granulated to the abdominal wallto the abdominal wall Major advancement. Produced protruding stoma. Provided Major advancement. Produced protruding stoma. Provided

almost complete diversion of fecal stream.almost complete diversion of fecal stream.

Widespread use of Ileostomy came as a result of the Widespread use of Ileostomy came as a result of the work of John Y. brown, a St. Louis Surgeon in 1912.work of John Y. brown, a St. Louis Surgeon in 1912. Reported experience with 10 ptsReported experience with 10 pts Ileostomy at lower pole of laparotomy incisionIleostomy at lower pole of laparotomy incision Stoma protruded 2-3 inches beyond abdominal wall and Stoma protruded 2-3 inches beyond abdominal wall and

was emptied by a catheter sewn in placewas emptied by a catheter sewn in place Catheter removed eventually and stoma matured by itself. Catheter removed eventually and stoma matured by itself.

HistoryHistory The single most The single most

important advance in important advance in ileostomy history was ileostomy history was described by Bryan described by Bryan Brooke, university of Brooke, university of Birmingham, LondonBirmingham, London

In a 1952 article, entitled In a 1952 article, entitled “Management of “Management of Ileostomy and its Ileostomy and its Complications”, Complications”,

Brooke in a single Brooke in a single sentence, dramatically sentence, dramatically advanced surgical advanced surgical treatment and life with treatment and life with an ileostomy.an ileostomy. Bryan Brooke

HistoryHistory

‘‘A more simple device is to evaginate the A more simple device is to evaginate the ileal end at the time of operation and ileal end at the time of operation and suture the mucosa to the skin; no suture the mucosa to the skin; no complications have occurred from this’ complications have occurred from this’ - Bryan Brooke (1952) - Bryan Brooke (1952)

HistoryHistory Crile in 1942 also suggested Crile in 1942 also suggested

the "mucosal grafted the "mucosal grafted ileostomy" to prevent ileostomy" to prevent ileostomy dysfunction. ileostomy dysfunction.

He recommended removing He recommended removing the distal 3 to 4 cm of the distal 3 to 4 cm of serosa and muscle from the serosa and muscle from the ileostomy and folding over ileostomy and folding over and suturing the redundant and suturing the redundant mucosa to the abdominal mucosa to the abdominal skin in order to "mature" skin in order to "mature" the ileostomy at the time of the ileostomy at the time of surgery.surgery.

Dr George Crile – Co founder of

Cleveland Clinic

HistoryHistory Turnbull and Crile Turnbull and Crile

(Cleveland clinic) and (Cleveland clinic) and Brooke made advances in Brooke made advances in ileostomy surgeryileostomy surgery

Turnbull and Gill coined the Turnbull and Gill coined the term “enterostomal term “enterostomal therapist” in 1958therapist” in 1958

Turnbull opened the first Turnbull opened the first school of enterostomal school of enterostomal therapy in 1961therapy in 1961

First real pouch was First real pouch was created in 1944 by Henry created in 1944 by Henry Koenig (ileostomate)Koenig (ileostomate)

Rupert Turnbull

History of Ileostomy History of Ileostomy Ileostomy – relatively newer Ileostomy – relatively newer

terminologyterminology

First recorded Ileostomy – First recorded Ileostomy – 1879 by Wilhem Baum, a 1879 by Wilhem Baum, a German Surgeon from Danzig German Surgeon from Danzig – created a ileostomy in a – created a ileostomy in a patient with malignant tumor patient with malignant tumor – Patient died 9 weeks later– Patient died 9 weeks later

Successful recovery after Successful recovery after ileostomy – reported by ileostomy – reported by Maydi from Vienna in 1883Maydi from Vienna in 1883

Lauenstein (1894) created Lauenstein (1894) created the first protruding the first protruding ileostoma. ileostoma. Wilhem Baum

Types of StomasTypes of Stomas

ColostomyColostomy End colostomyEnd colostomy Loop colostomyLoop colostomy

IleostomyIleostomy End IleostomyEnd Ileostomy Loop ileostomyLoop ileostomy

End Loop ostomyEnd Loop ostomy CecostomyCecostomy UrostomyUrostomy

Types of Ostomy Types of Ostomy

Stoma types Stoma types

End ostomy types End ostomy types

 (A) End stoma (inset shows everting maturation); (B) double-barrel stoma: End stoma and mucous hop-Koop stoma; and (F) fistula are divided and brought through the same incision (inset shows closed mucus fistula sutured to abdominal wall); (C) loop stoma; (D) decompressing blowhole stoma; (E) Bis Santulli stoma

IndicationsIndications

To provide fecal diversion for both elective To provide fecal diversion for both elective and emergent proceduresand emergent procedures Colonic obstructionColonic obstruction Bowel perforation with peritonitisBowel perforation with peritonitis TraumaTrauma Protection of low colorectal/coloanal Protection of low colorectal/coloanal

anastomosisanastomosis Perianal sepsisPerianal sepsis Radiation proctitisRadiation proctitis Rectovaginal fistulaRectovaginal fistula incontinenceincontinence

Preoperative Preoperative ConsiderationsConsiderations

Preoperative CounselingPreoperative Counseling Stoma nurse/therapistStoma nurse/therapist Assuage anxietyAssuage anxiety Explain post op careExplain post op care

Stoma site selectionStoma site selection Visibility (pt. able to care for stoma)Visibility (pt. able to care for stoma) Colostomy vs ileostomyColostomy vs ileostomy Assess pt supine, sitting, standing and bending forwardAssess pt supine, sitting, standing and bending forward IndividualizedIndividualized Pass through Rectus abdominis muscle ( parastomal hernia)Pass through Rectus abdominis muscle ( parastomal hernia) Superior aspect of the infra-umbilical fat fold in the lower Superior aspect of the infra-umbilical fat fold in the lower

quadrant (pt. visibility)quadrant (pt. visibility) Obese pts –better located in upper abdomenObese pts –better located in upper abdomen Avoid skin creases, bony prominences, scars, drain sites and Avoid skin creases, bony prominences, scars, drain sites and

belt lines.belt lines. Mark siteMark site

Advances Advances

Improvement in Stoma creation – Improvement in Stoma creation – Laparoscopic / Single port Laparoscopic / Single port techniquestechniques

Placement of mesh at the time of Placement of mesh at the time of ostomy constructionostomy construction

Improvements in stoma appliances Improvements in stoma appliances including including

Laparoscopic options Laparoscopic options

Laparoscopic Laparoscopic colostomy / colostomy / IleostomyIleostomy

3 ports usually, 3 ports usually, SILS SILS

Operative time Operative time usually ~ <1 hour usually ~ <1 hour

Lap Transverse Lap Transverse Colostomy Colostomy

Advantages of Advantages of Laparoscopy Laparoscopy

Better selection of stoma site – as no Better selection of stoma site – as no midline incision is involvedmidline incision is involved

Early post operative recoveryEarly post operative recovery Better pain controlBetter pain control Short length of hospital stay Short length of hospital stay Cosmesis Cosmesis

Stoma and recreation Stoma and recreation Can swim – without Can swim – without

harming the stoma harming the stoma /spillage. Bag and /spillage. Bag and adhesive are adhesive are waterproof. Mini waterproof. Mini bags , Stoma caps are bags , Stoma caps are availableavailable

Diving: Yes. A suit Diving: Yes. A suit including the bag including the bag would be betterwould be better

Sauna: Yes. Sauna Sauna: Yes. Sauna belts are availablebelts are available

ComplicationsComplications 20-41% of patients will have complications20-41% of patients will have complications Nearly 50% of these will require a revisionNearly 50% of these will require a revision

Ileostomy vs colostomyIleostomy vs colostomy

Early complicationsEarly complications Ischemia, hemorrhage, stenosis, fistula and retraction. Ischemia, hemorrhage, stenosis, fistula and retraction.

TechnicalTechnical

Late complicationsLate complications 6% -76% incidence6% -76% incidence Prolapse, obstruction, hernia and skin irritationProlapse, obstruction, hernia and skin irritation Complication due to poor technique and poor care and Complication due to poor technique and poor care and

management. management. Could also be due to recurrent disease.Could also be due to recurrent disease.

Stoma Ischemia/NecrosisStoma Ischemia/Necrosis 2.3-17% incidence2.3-17% incidence

Ranges from harmless mucosal Ranges from harmless mucosal sloughing to frank Necrosissloughing to frank Necrosis

CausesCauses Aggressive stripping of Aggressive stripping of

mesenterymesentery Stenotic fascia defectStenotic fascia defect Extensive tensionExtensive tension

Assess depth of necrosisAssess depth of necrosis

Necrosis beyond fascial defect Necrosis beyond fascial defect warrants immediate warrants immediate reconstructionreconstruction

Consider End loopConsider End loop

HemorrhageHemorrhage Mild hemorrhage common and self Mild hemorrhage common and self

limiting. limiting. Usually mucosal.Usually mucosal. Apply pressureApply pressure

Active bleedingActive bleeding Implies failure to ligate a mesenteric vesselImplies failure to ligate a mesenteric vessel Identify and ligate prior to leaving ORIdentify and ligate prior to leaving OR

Stomal Stomal Stenosis/StrictureStenosis/Stricture

2-14% incidence2-14% incidence

Could manifest early or lateCould manifest early or late

Ischemia is usual Ischemia is usual underlying factorunderlying factor

Other causes: -Infection and Other causes: -Infection and retractionretraction

R/o Crohn’s or recurrent R/o Crohn’s or recurrent malignancy malignancy

Treat initially with dilationTreat initially with dilation

Definitive Stoma revisionDefinitive Stoma revision

Mucocutaneous Mucocutaneous SeparationSeparation

Separation along Separation along mucocutaneous bordermucocutaneous border

Occurs to some extent in Occurs to some extent in many patientmany patient

Caused by underlying Caused by underlying tension and or separation of tension and or separation of suturessutures

Supportive care usually Supportive care usually resolve problemresolve problem

Could lead to eventual Could lead to eventual stricture, serositis or stricture, serositis or infectioninfection

Infection/FistulaInfection/Fistula Incidence of 2-14.8%Incidence of 2-14.8% Peristomal abscess Peristomal abscess

infected hematoma infected hematoma Stoma revisionStoma revision Foliculitis for mature Foliculitis for mature

stomasstomas I &DI &D

Fistula may form from Fistula may form from AbscessAbscess

Beyond immediate post Beyond immediate post op, fistula formation or op, fistula formation or infection could be signs of infection could be signs of recurrent Crohn’s diseaserecurrent Crohn’s disease

Stoma RetractionStoma Retraction

1-6% for colostomy and 3-17% for 1-6% for colostomy and 3-17% for ileostomyileostomy

Most common reason for re-Most common reason for re-operationoperation

Tension:Tension: TensionTension ObesityObesity Steroids use. Poor wound healingSteroids use. Poor wound healing

Can lead to leakage and severe Can lead to leakage and severe skin problem, more in ileostomyskin problem, more in ileostomy

Convex stoma plate or use of Convex stoma plate or use of protective barrier helpsprotective barrier helps

Most eventually need revisionMost eventually need revision

ProlapseProlapse 2-26% incidence2-26% incidence

Seen mostly in transverse Seen mostly in transverse loop colostomy (30%)loop colostomy (30%)

May occur with May occur with parastomal herniaparastomal hernia

Managed by reduction and Managed by reduction and supportive care until supportive care until definitive surgerydefinitive surgery

Convert to end colostomy Convert to end colostomy if need beif need be

Ileostomy ProlapseIleostomy Prolapse

Parastomal HerniaParastomal Hernia “ “ It doesn’t matter if God It doesn’t matter if God

Himself made your ostomy. If Himself made your ostomy. If you have it long enough you you have it long enough you have a 100% risk of a have a 100% risk of a parastomal hernia”parastomal hernia”

J Byron Gathright, J Byron Gathright, 19961996

50% of patients50% of patients

Predisposing factorsPredisposing factors Stoma placement lateral to rectusStoma placement lateral to rectus Large stoma apertureLarge stoma aperture ObesityObesity Prior abdominal incisionsPrior abdominal incisions MalnutritionMalnutrition Wound infectionWound infection

Minor cases- Abdominal binderMinor cases- Abdominal binder

Symptomatic – Repair with mesh, Symptomatic – Repair with mesh, RelocationRelocation

Acute Parastomal Acute Parastomal hernia/Bowel obstructionhernia/Bowel obstruction

Incidence 4.6-13% in early post opIncidence 4.6-13% in early post op

CausesCauses TechnicalTechnical Too large fascial defectToo large fascial defect

Rarely seen in mature stomasRarely seen in mature stomas

Signs of bowel obstructionSigns of bowel obstruction

Repair hernia with mesh Repair hernia with mesh

Skin ComplicationSkin Complication 3-42% Incidence3-42% Incidence

Range from mild skin dermatitis to Range from mild skin dermatitis to full- thicknes skin necrosis and full- thicknes skin necrosis and ulcerationulceration

More common with illeostomyMore common with illeostomy

Skin Erosion from constant exposure Skin Erosion from constant exposure to stoma effluentto stoma effluent

Contact dermatitisContact dermatitis

Fungal infectionFungal infection

InterventionIntervention Better fitting applianceBetter fitting appliance Improve cleaning of peristomal skinImprove cleaning of peristomal skin Application of desents and skin barriersApplication of desents and skin barriers Anti fungals and antibioticsAnti fungals and antibiotics Stoma pasteStoma paste

Effluent Irritation

Contact Dermatitis

EdemaEdema

Skin ComplicationsSkin Complications

Foliculitis

Candida albicans infection

Skin ComplicationSkin Complication(Pyoderma Gangrenosum)(Pyoderma Gangrenosum)

First described First described associated with Crohn’s associated with Crohn’s in 1970in 1970

Diagnosis mainly by Diagnosis mainly by physical exam (80%)physical exam (80%)

““Cookie cutter” Cookie cutter” appearanceappearance

Treatment conflictingTreatment conflicting Wound debridementWound debridement Steroids injectionSteroids injection Systemic therapySystemic therapy

Skin ComplicationsSkin Complications(Pyoderma Gangrenosum)(Pyoderma Gangrenosum)

Skin ComplicationsSkin Complications(Granulomas)(Granulomas)

Granulomas are lumpy Granulomas are lumpy lesions due to lesions due to inflammation in the inflammation in the dermis.dermis.

Stomal granulomas may Stomal granulomas may be due to: be due to:

Granulation tissue (poor Granulation tissue (poor wound healing and wound healing and infection)infection)

Bowel metaplasia (stomal Bowel metaplasia (stomal skin morphing into bowel skin morphing into bowel tissue) tissue)

Crohn's diseaseCrohn's disease

Stoma warts Stoma warts

Stoma AppliancesStoma Appliances

ConclusionConclusion In the last century, there have been In the last century, there have been

dramatic improvements in surgical dramatic improvements in surgical techniques for the creation of stomastechniques for the creation of stomas

Life with a stoma has also changed Life with a stoma has also changed dramaticallydramatically

The development of enterostomal therapy The development of enterostomal therapy and the improvement of ostomy and the improvement of ostomy management systems have made life with a management systems have made life with a stoma nearly as routine as life with an anus.stoma nearly as routine as life with an anus.

ConclusionConclusion

“ “care and expertise are important care and expertise are important in creating intestinal stomas because in creating intestinal stomas because some patients must live with the some patients must live with the technical result for the rest of their technical result for the rest of their lives”lives”

Thank youThank you