08. Indications and Construction of Colostomy

In this class, we're going to discuss indications for and surgical construction of colostomy and adults. We'll talk about the four options for surgical construction and why they might do one or another and indications for both temporary and permanent colostomy. So first of all, you review the anatomy of the colon. So you have the ascending colon coming up the right side, transverse colon coming across the mid abdomen, and then the descending and sigmoid colon running down the left. A colostomy can actually be constructed at any point along the length of the colon and the specific location for a colostomy and any individual patient is going to be determined by the reason for diversion and the sight of the pathology. So basically, the stoma will always be created proximal to the area of damage, the area of obstruction, the area where there's an issue. Colostomy can be temporary or can be permanent. And the duration, whether it's temporary or permanent, will be determined by the reason for the diversion, whether or not the anal sphincter remains intact, and also the patient's ability to tolerate a takedown procedure. Many times we have patients who undergo what is intended to be a temporary colostomy, but if that patient subsequently has medical issues that preclude takedown, that colostomy becomes permanent. There are four distinct options for surgical construction of a colostomy, and that will be determined. The selection of the specific option will be determined by the reason for the diversion and the sight of the pathology, and you want to be very clear on these four options for surgical construction. So I'm going to walk you through each of these, and then we will come back to this many times in our discussion of colostomy management. So option number one is an end stoma, where everything beyond that point has been removed. So that's what you see when you have an abdominal perineal resection, that means that they have removed the rectum, they've removed the anal canal, they've removed the sphincters, and the colostomy is now the end of the light, and that situation is always a permanent diversion. You can't do a reconnection because there's nothing left. So when you see the term abdominal perineal resection, when you see the term proctectomy, that tells you that the rectum has been removed, anal sphincters have been removed, and the colostomy is permanent. The second option is to divide the bowel, bring the proximal end out as a stoma, as an end stoma, and then over sow the distal bowel, close the distal bowel, but leave it in place. So that's what you see in the middle of your screen on the bottom. That is what is known as a heartmins pouch, named after Henry Hartman, the British surgeon who popularized this procedure. So you can see if you look at the illustration in the middle of the screen, a section of bowel has been removed. The proximal bowel has been brought to the abdominal wall as a stoma. The distal bowel has been over some, but left in place. Now, in this situation, because the distal bowel remains viable and functional, it's intended to be temporary. We can do a reconnection, assuming that the patient can tolerate that procedure. The third option is to remove the section of bowel that is damaged or diseased, and then to bring both ends out to the abdominal wall. That's what you see in the illustration on top. So you have both ends of the bowel brought to the abdominal wall as stomas. The proximal end, the proximal stoma, will drain stool. The distal stoma will drain only mucus. Sometimes you'll hear this referred to as a double barrel because there are two openings. That terminology is fortunately rarely used today. More commonly you'll hear this described as an end stoma with a mucus fistula or a sigmoid colostomy with a mucus fistula. The fourth option is to do a loop colostomy, and that's what you see on the bottom, and you can see exactly how they do this. So they make a little incision in the abdominal wall. They reach into the abdominal cavity, bring an entire loop of bowel out to the abdominal surface. Some type of support device is placed through the mesenteri and underneath the bowel to provide temporary support until healing is complete. Then they open the anterior wall of the bowel, turn it back on itself and suture it down, and that provides both separation of the proximal and distal bowel and very effective fecal diversion. Now with this option, again it's intended to be temporary because the bowel itself, the posterior bowel wall remains continuous, the rectum remains intact, the anal canal remains intact, the sphinctures remain intact. Why do people require colostomy? It's always because of either something catastrophic that has occurred distally, maybe there's a blockage, maybe there's a perforation with major contamination of the abdominal cavity, or you might do a colostomy to protect an area distally where you have a surgical enastemosis that needs to heal, where you have acute inflammation that needs to subside, or where there's some other issue that requires diversion in order for healing to take place. You always tell patients like when there's road work and they tell you no, you cannot drive through this area, you have to go around until the road work is complete. So sometimes we are providing temporary diversion to allow a section of bowel to heal or to protect a new enastemosis. So that could be, as we said, for a distally enastemosis, it could be to allow resolution of an area of acute inflammation. Or sometimes I know you've seen this, you'll have a diversion to try to promote healing of a pressure injury, maybe you have an extensive issue of pressure injury, and you can't get the wound to heal because of constant fecal contamination, we might do a temporary diversion to get stool out of that area so that the pressure injury can heal. If you have a fistula involving the distal bowel like recto vesicle, recto vaginal, you might do a temporary diversion to allow that fistula strike to heal. If you have a patient who has complex perineal wounds, they may require temporary diversion just to allow that area to heal. So now we're going to talk about each reason in a little bit more detail, and we're going to begin with perforation of the bowel. So of course, anytime you have bowel perforation, you have major contamination of the abdominal cavity, and you have to take immediate action to save the patient's life and to promote resolution of that acute intra-abdominal infection. The most common causes for bowel perforation are either trauma like a gunshot wound or a stab wound. Sometimes this is scheming damage. You might have a volvulus with a closed loop obstruction where you get rapid development of both ischemia and distinching, or it could be a severe inflammatory process, such as diverticulitis, which is one of the most common reasons for temporary diversion. No matter what causes the perforation, the end result is the same. You have a hole in the bowel, and that is permitting spillage of fecal contents and very high levels of bacteria out into the abdominal cavity, resulting in peritonitis. trauma with San It's most likely to be they're a gunshot wound or a stab wound, typically gunshot wounds and stab wounds involve the left colon simply because most of the salons are right handed. So we get people into the emergency room, they have a gunshot wound or stab wound to the left abdomen, perforation of the colon, rapid development of paratonitis and a surgical emergency. You can also get eye adrogenic trauma, fortunately this is not common, but we do get patients who sustain bowel perforation during a colonoscopy and they require urgent diversion to permit healing. You could also have a patient who develops openings in the bowel following the abdominal surgery following colonic surgery where there was inadvertent nick to the bowel or an enterotomy as it's termed on a surgical report. So you think when they're doing abdominal surgery, especially in a patient who's had a prior surgical procedure, they're working their way through adhesive bands, they're trying to get to the area of disease and it's very easy to nick the bowel to create a small enterotomy. Ideally, they recognize that immediately and they repair it and there's no harm done. But occasionally an enterotomy gets missed and then 24, 48, 72 hours later we have a patient with acute distinction, abdominal pain, elevated white count. We take them back to surgery, we find, oh, we have spillage into the abdominal cavity from this very small nick in the bowel. So trauma, gunshot wound, stab wound, inadvertent perforation of the colon during a diagnostic or therapeutic procedure. And can also occur as a result of ischemia. Of course, when the bowel wall becomes ischemic, it is extremely vulnerable and then even this normal distinction can cause perforation. Probably the most common cause of ischemic perforation is a volvulus and that's what you see on the bottom. You can see that the bowel has twisted on itself, the mesentery has twisted on itself. This causes a very dangerous situation where you have rapid distinction of that loop of bowel and at the same time you lose blood flow to that loop of bowel, so it becomes ischemic and distended and perforation is inevitable unless we get them back to surgery very quickly. We also see ischemic perforation in patients who have undergone major cardiac surgical procedures and then they throw a little clot to the mesenteric artery. If you throw a clot to the mesenteric artery, you're going to get an area of ischemia. So it's not uncommon to have a patient who comes in because of maybe a perforation of an abdominal irregularism. They undergo major surgery for that one to two weeks later, they're back in the operating room because they have thrown a clot to the mesenteric artery that have had acute ischemia resulting in perforation and acute abdomen. So some of our patients have been through so much and never ever expected to have to have an ostomy. Severe inflammation, probably the most common reason for bowel perforation and for temporary colostomy is diverticular disease. I'm sure all of you are familiar with diverticular disease. You know that what happens and you can see this on the slide, you get these little sack like outpouchings along the colon wall. And what is causing those little outpouchings, those sack like formations is actually herniation of the mucosal and submucosal layers through little defects in the muscle layer. So these are very thin walled sacks because they're very thin walled sacks. If you get a little bit of fecal material trapped in those sacks, it can rapidly undergo dehydration then it can abrade the mucosal wall and create an acute inflammatory process that can result either in a minor leak or in a major perforation. So who's at risk for diverticular disease, the major risk factors seem to be age. If you look at autopsy reports and patients who died for a variety of reasons as age advances past 60, 70, 80, the percentage of individuals with unrecognized diverticular disease rises exponentially. So age is one risk factor, possibly due to changes in tissue strength. The other risk factor is thought to be chronic constipation and high intraluminal pressures. And we think essentially these are little hernias and we know that pressure creates hernia formation so it makes sense that high intraluminal pressures would force the mucosal and submucosal layer to herniate along little defects or through little defects in the muscle. The role of constipation is reinforced by the fact that almost all diverticular occur on the left side of the colon along the descending or sigmoid colon, where still is the driest and hardest. So let's say you have diverticular disease, you have all of these little sacks that's known as diverticulosis. What can go wrong? Well some of the things we've already talked about. One of the most common complications of diverticular diseases bleeding, diverticular disease is actually the most common cause of lower GI bleeding because these little sacks develop right along blood vessels. And so any inflammatory process can cause inflammation of the adjacent blood vessel in erosion of the vessel wall. Ridiculitis is the complication that is most likely to result in diversion so we've already said what can happen is you get a little bit of fecal material trapped in the sack. It becomes dry and abrasive, causes mucosal damage, causes a leak through the bowel wall or free perforation through the bowel wall. The very occasionally not often, but you can get fissula formation as a result of diverticulitis because when the bowel wall is inflamed, the outer layer becomes very sticky. It can become adherent to adjacent organs. In the inflammatory process can cause fissula development. But before the two most common are bleeding and diverticulitis, how do we manage diverticular disease? I'm sure you probably already know a lot of this because this is such a common condition. So if you have the diverticular sacks, let's say you have someone who's undergone routine screening colonoscopy, they didn't find any cancer, maybe they removed a polyp, but they also found significant diverticular disease and a very common question from individuals with diverticular diseases, okay well what should I do? And we don't have very definitive recommendations. We know we're trying to prevent bleeding, we're trying to prevent diverticulitis. That means we want to prevent trapping a fecal material in those little sacks. So current thinking is that the best protection is to keep that person on a high fiber diet with plenty of fluids so that their stool is soft and bulky and that they don't have any little pellets that could get trapped in the sacks. But there's still a lot of controversy and we don't have great data regarding the impact of a high fiber diet. That is the most common recommendation, but you should know that the data supporting that recommendation is limited. You should also know that many times patients are told don't eat anything with seeds and there's no data to support that. What if I have diverticulitis, I have only mild symptoms, so I have some pain, tenderness, maybe my white counts up a little bit, but I'm not acutely ill. I don't have severe distinction, I don't have nausea and vomiting, I don't have significant leucositosis. This suggests that there's a very minor leak, and that many times we can manage them with clear liquids and antibiotics until that leak seals. But if you have a patient who is acutely ill, a patient who comes in with fever, they have increasing pain and tenderness. Their white count is significantly elevated. We're going to put that patient in PO, put them on bowel rest. We don't want to add anything to the mix. We're going to put them on IV fluids and IV antibiotics to try to resolve the acute infection. We're going to cover anaerobes and gram negative bacteria, because that's what populates the colon. And we're going to hope that we can get the patient over this hump, get everything under control without having to take them back to surgery. But if they become progressively more symptomatic, their pain gets worse, their white count goes higher, their CT looks worse. If we have a patient who comes in literally with an acute abdomen, acute distinction, acute pain, fever, nausea, vomiting, that's indicative of perforation. And then we're going to have to take them to surgery. Now, there's two things that may be done. Sometimes they will resect the area of bowel that's involved. They'll thoroughly irrigate the abdominal cavity to eliminate any spillage, any visible fecal contents to reduce bacterial loads as much as possible. And then they'll reconnect the bowel. They'll ennast the most the bowel. That is typically done if there's very limited spillage. And if the patient is basically healthy and expected to heal normally. But if there's massive contamination, if the patient has other comorbid conditions that would interfere with healing, like, let's say, they're on steroids for arthritis. Or let's say they're a poorly controlled diabetic. Anything that would interfere with healing or, again, massive contamination is not safe to put the bowel back together because in the presence of acute inflammation that anastomosis will not heal. So in that case, they would remove the involved section of bowel, irrigate the abdominal cavity thoroughly. They would bring the proximal bowel out as a colostomy to provide temporary diversion. And then they would close the distal bowel as a heart man's pouch. So they would basically divert and buy time to eradicate the inflammation. And then they'll come back and reconnect. So summarizing surgical management when there is perforation of the bowel, regardless of cause, whether it's because of ischemia, because of inflammation, because of trauma, whatever. Ideally, you will be able to remove the damaged section, thoroughly irrigate the abdominal cavity, reconnect the bowel, and no stoma is required. But remember, this is appropriate only if there's limited contamination, only if normal healing is expected. This approach would be considered contraindicated if you have extensive spillage and contamination. If you have a patient who's septic at the time of surgery, or they have comorbid conditions that would delay healing. And just to review one more time, you're going to hear some of these things multiple times. That tends to help with clarity and with retention. So what are the options when primary anestimosis is not advisable when there was extensive spillage, or when there are comorbid conditions that would interfere with healing? Okay, remember, you could resect the damaged bowel, you could bring the proximal end out as a stoma, and you could close the distal end as a heart man's pouch, leave it in place for reconnection later. And that's what you see on the bottom right side of the slide. Or you could resect the damaged bowel, bring both ends out to the abdominal wall. The proximal end will drain still, the distal end will drain mucus, and again, it's a temporary diversion. You should be able to put the bowel back together once all the acute inflammation has been resolved. That's what you see on the far left, and again, that's rarely done. The other option would be remove the damaged section, go on and do your anestimosis, put the bowel back together, but do a proximal diversion so that no stool goes through that anestimost area until healing is complete. Because we know healing's gonna take a long time because of the level of inflammation. We know that if we allow stool to pass through the area of an anestimosis, we're very likely to get leakage, and the patient's gonna be back in surgery, even sicker. So we don't want any stool going through that reconnected area, until inflammation's resolved, healing is complete. And we can manage that by coming up the line and creating a diversion. That's just what they do with road work. You can't go through here, you have to go around until this road work is complete. So we're saying to the bowel, you can't send stool through the descending sigmoid colon is under repair. You're gonna have to send stool out through this oleostomy stoma or through a colostomy. Today it's usually done as a diverting oleostomy, so it's uncommon for you to have a temporary diverting colostomy in this situation, it could be done. So looking at rationale for a temporary colostomy, in the setting of diverticular disease or another cause of perforation, basically you have two major approaches, and you want to be clear on this. So it'll take you a little while if you've never worked with these patients before, to be very clear, but you want to be clear so you can help patients understand. If they do an end colostomy and a heart miss pouch, or if they didn't end colostomy and amucus fissula, what you're doing is you are delaying the reconnection. You're delaying the anastomosis until the infection has resolved, the anastomosis can be done safely, and normal healing can be anticipated. So if they do a heart miss pouch, a colostomy with a heart miss pouch, or if they do a colostomy with amucus fissula, they have decided to delay the anastomosis. The second option is to go ahead and do the anastomosis at the time of the original surgery, but protect it with a proximal diverting ostomy. And in this case, you're saying, I went on and did the primary work, I went on and did the reconnection, but I recognize that anastomosis is extremely vulnerable and that it's not safe to allow stool to pass through there. So I've created a proximal diversion, a proximal detour. So you just want to understand why a surgeon might do option A versus option B, so you can help the patient understand what's going on, what's been done, why? Okay, so we've spent a good bit of time talking about perforation is always an emergent situation, multiple causes, and several options for surgical management. Now we're going to talk about obstruction. Now obstruction is a less common reason for temporary diversion, but a very obvious reason. If you have any kind of obstructing lesion, you have an emergency situation, because nothing is going through, and the patient's going to become progressively more ill. So when somebody is obstructed, they come in, most of the time they're not eating, they're distended, they are frequently complaining of nausea and vomiting, and they're telling you, no, I'm not passing any stool, I haven't had a bowel movement in this many days. What would cause that? Before the most common reason is an obstructing tumor. along the left colon usually at the level of the descending sigmoid colon and I want you to look at the illustration on the left of your screen that is what you commonly see on the left side of the colon they sometimes call this an apple core lesion because the tumor on the left side of the colon gradually reduces the lumen of the bowel as it fills the bowel wall and see you can see you go from a normal lumen of two to two and a half inches to literally something that looks like an apple core and where hardly anything can get through many times these patients tell you have been taken higher and higher doses of laxatives just to keep going yes because laxatives fluid as the stool liquid can get through solid cannot so tumor is probably the most common reason stricter has much the same effect stricters can occur as a result of chronic acute inflammatory conditions like if you have a patient who has Crohn's colitis and they've had recurrent episodes of inflammation every time that inflammation resolves you as scar tissue to the bowel wall and then you can end up with a very near lumen so it could be tumor it could be stricter occasionally it's volvulus and we've already talked about volvulus and the fact that it creates a closed loop obstruction where you have rapid distinction and also rapid development of bowel walliskemia when you have a blockage your number one goal is to restore fecal elimination give create a pathway for stool elimination and to prevent perforation because untreated obstruction results in massive distinction and eventual perforation so when we talk about options for fecal diversion in the presence of an obstructing lesion some of these are going to sound familiar so we could do a loop that is a quick and easy way to divert so you think somebody who comes in and they're obstructed usually they're pretty sick if you do a loop cluster me it's literally a 20 to 30 minute procedure so you put the patient under anesthesia you make a little incision in the abdominal wall you reach in you get the bowel you bring it out above the abdominal surface you place a support through the mesenterity to keep that loop of bowel from going back into the abdominal cavity then you open the anterior wall to permit fecal elimination turn the bowel back on itself and you're out of surgery so for a patient who's acutely ill a loop colostomy is a quick first step in managing their situation so what have you done here you've restored fecal elimination and you've prevented perforation you haven't addressed the underlying problem you haven't done anything about the tumor you haven't done anything about the structure but you have addressed your initial goals which is to restore elimination of stool and prevent perforation now the good thing about a loop is it's pretty easily reversed once the original pathology has been addressed and obviously it's intended to be temporary you do retain the anal canal you retain the sphinters so there's always the potential to do reconnection what else could you do if you have a blockage well you could do an end colostomy with a heartmins pouch if you have a patient who maybe is partially obstructed not completely obstructed maybe they have an enlarging tumor and maybe it's unresectable they can't really eradicate the cancer but the patient's developing progressive symptoms related to the obstruction then you could relieve the obstruction pretty simply by doing a heartmins pouch and an end colostomy so you could go in there you could take out the bowel with the primary tumor not necessarily any kind of purative procedure just remove the section of bowel with the tumor bring the proximal end out as the stoma leave the distal end as a heartmins pouch and that's that can be a very good option if you're able to resect the area bowel where the obstruction is we can do that with the tumor sometimes we can do that as well with volubulus what about an end colostomy with a mucous fistula and that situation you bring both ends out to the abdominal wall that can be helpful when you have a distal tumor maybe you have a rectal tumor sometimes we have more than one tumor if you bring both ends out that provides for primary fecal diversion stool elimination but it also gives a way for mucous from the rectum to be eliminated so when you have an obstructing lesion within the rectum very occasionally the very best option is to do the colostomy with a mucous fistula when you're doing a colostomy to protect a distal enastomosis so anytime that the enastomosis is under tension you need temporary diversion to prevent any stool going through the area until healing is complete anytime you anticipate delayed healing because of other comorbid conditions because the patient's own steroids whatever or anytime you anticipate delayed healing because of intense inflammation those are the indications and if you need to protect a distal enastomosis again your options are pretty much the same you could do a loop colostomy you could do a loop iliestomy the advantages of a loop stomer remember this is a quickly done procedure and it's easily reversed when would they do a loop colostomy when would they do a loop iliestomy typically a loop colostomy is done when you anticipate a longer time prior to take down like if you have a patient who has a rectovisual fistula or a rectovesicle fistula we know that fistula healing can take a very long time it might be six months it might be longer and we know that a loop colostomy is easier to manage than a loop iliestomy so in that situation you might very well see them doing a loop colostomy but if you're primarily protecting a distal enastomosis and you know healing is going to be complete within something like six to eight weeks then most commonly they will do a diverting iliestomy why because studies have shown that take down of a loop iliestomy is associated with fewer complications than take down of a loop colostomy so they're looking ahead they're saying we're almost positive that we are going to close this temporary ostomy probably in eight to twelve weeks we won't closure to be as simple as possible we want to minimize the risk of complications at the time of closure therefore we're going to do a loop iliestomy rather than a loop colostomy in contrast we have a patient with a fistula we don't know how long it's going to take to get it to close we're not confident that it will close so this could turn into a long term diversion colostomies are easier to manage than iliestomies and in that case they might very well do a diverting loop colostomy what about when you're dealing with severe inflammation and you just need bowel rest for a period of time like maybe you have a patient who has Crohn's proctitis or Crohn's disease involving the sigmoid colon you think you know we haven't been able to get their secured inflammation under control with medications and we think one reason we haven't been able to get it under control a stool is still going through there what if you have a patient with Crohn's disease involving the rectum and the anal canal and you have a lot of little fishers and you can't get the fishers to close. You can't get those little fishers to close. You can see where it could be extremely beneficial to divert the fecal stream, to leave that area isolated so that nothing's going through there and to continue to treat the acute inflammation. See if you can get it resolved and if you can get it resolved, then hopefully we can close the ostomy, let everything go through normally and not have a recurrence. So the most common indications for temporary diversion just to provide bowel rest is a patient with Crohn's colitis, Crohn's Proctitis and an erectile disease that does not respond to primary medical management. What are your options? The same things. You could do a loop colostomy or you could do an end colostomy with a heart miss pouch. Either one would work, either one protects the anal canal and this fincters and maintains options for takedown as soon as the inflammation is under control. Again, the anatomic site for the colostomy for the diversion depends on where's the area of inflammation. You always divert proximal to that point. And then finally, sometimes we're doing a diversion because there's major trouble in the pelvic area and we cannot get healing of some injuries, some wound because of frequent fecal contamination. So recto vaginal fistula, you've got a little hole between the rectum and the vagina, you've got bacteria and small amounts of stool constantly passing through that channel and the only way you're going to get that to heal is to eliminate passage of stool and bacteria through the channel. You've got to shut that down. So you've got to do a diversion above that point. We've talked about patients with complex pressure injuries. You've seen these patients so maybe they come in plastic surgery as consulted. They're looking at maybe doing a myocutaneous flap to close the pressure injury, but the patient's in cognitive stool. And the plastic surgical team is going to say we cannot do this until you divert the fecal stream. We've got to have a clean area to get this pressure injury to heal. And then many of you have seen patients with necrotizing fasciitis involving the perineum. This is typically known as 40A's gain green. And obviously when you have a patient with 40A's gain green, they're going to be getting constant fecal contamination of the site. Many times we want to do negative pressure to these wound sites. However we're managing them, we have to get stool out of the area. So diversion would be indicated and of course would be intended to be temporary. Now what about permanent clostomy? We've spent a lot of time talking about temporary. We've said we might do temporary because of an acute inflammatory process. We might do it because of an obstruction. We might do it because of bowel perforation or because of major problems in the pelvic perineal area. And we've said if we do a temporary, we're either going to do an end-clostomy with a heart miss pouch or a loop clostomy or very occasionally an end-clostomy with a mucus fissure. But now we're going to switch gears and we're going to talk about permanent clostomy. So permanent clostomy is typically done either because of extensive rectal cancer that requires removal of the anal canal in this fincter or because of intractable fecal incontinence. So that's why. How? What's different about construction of a permanent clostomy as compared to a temporary clostomy? Well you can see in these illustrations, they do a procedure called an abdominal perineal resection of the rectum, APR. And that means that they're removing the rectum, removing the anal canal, removing the fincters. And they're doing that because of irreversible disease distal to that point, involving the distal rectum and the anal fincters. So you can see in the illustration on the right admit point that the clostomy is now the end point for the GI tract. There is nothing distally. You've removed the rectum, you've removed the anal canal, you've removed this fincters. It has to be permanent. There's nothing to reconnect to. And we've said the major indication is cancer involving the distal rectum. You know that curative resection of any malignancy always involves removal of the tumor itself, but also removal of the adjacent tissue that might contain malignate cells as well as frequently removal of lymph nodes. If you have a tumor in the distal rectum, so if you look at the illustration on top and you look at that tumor, it's sitting right at the anal rectal junction, right at this fincter. So by the time you remove the tumor and you remove enough adjacent tissue to remove all the cancer cells, you're past this fincter and it does no good to do any kind of reconnection because it'd be incontinent all the time. So anytime you have a distal rectal tumor, anytime that curative resection extends beyond this fincters, then you have to just remove everything and do a permanent colostomy. And then occasionally you'll see a permanent colostomy done for intractable inflammation, Crohn's disease involving the rectum in anal canal. I have had patients where we started out with a temporary. They had severe Crohn's disease involving the rectum. So we started out with a temporary diversion. Symptoms resolved, inflammation resolved. We reconnected them. Symptoms recurred. And so then the patient frequently says, "You know what? This is miserable. I can't live like this. Just take it out and give me a permanent colostomy. I was much better off when I had the ostomy." An uncommon condition is intractable fecal incontinence because of nerve damage typically. So you might see this in a patient with illness. You might see this in a patient with a spinal cord injury where they have lost innervation to this fincters. They have lost bowel control. And many times these individuals will elect a permanent colostomy because it gives them back manageability, it gives them back control. So to summarize all of this, a colostomy may be temporary or permanent. It's temporary if you're dealing with reversible pathology like a bowel perforation, like intense inflammation. If you're trying to protect a distal anestimosis, if you're trying to permit healing of a perineal or pelvic wound, it's permanent. If you have a malignancy involving the distal rectum and if curative resection extends beyond this fincters. And it's permanent if you're doing this procedure because of intractable fecal incontinence. There's always four surgical options. Three or temporary or designed to be temporary, one is permanent. So if you remove the rectum, the anal canal and the spincters, the colostomy is now the end of the line that is permanent. That's APR. Three options for temporary. One is to take out the disease section of bowel, bring the end of the healthy bowel out as a colostomy, over sow the distal bowel as a heartmins pouch. Just leave it in place until you're ready to reconnect. The next option is to take out the disease section of bowel, bring both ends of the colon out to the abdominal wall, proximal end is a colostomy, distal end drains only mucus and is known as a mucus fissula. And the third option is just make a little incision, bring the entire loop of bowel out, open the anterior wall, a loop colostomy. And you'll hear more about it. every one of these in later classes. Thank you.