Today in the United States, approximately 1 in every 500 individuals lives with an ostomy [1]. Used to treat various diseases of the digestive and urinary systems, an ostomy is a surgical procedure carried out to create an opening in the abdomen, creating a new way for waste to leave the body. Ostomy surgeries often remove fecal waste (poop), though they can involve urine (pee) as well. A colostomy in particular is a type of ostomy that allows the body to pass stool when the colon is not working properly; there are no major procedural differences between a colostomy specifically and an ostomy. Given the prevalence of ostomy surgery, it is important to consider best practices for anesthesia during the procedure.
Ostomy surgery is generally performed under general anesthesia, though sometimes under regional anesthesia, to keep the patient comfortable and to facilitate the surgeon’s work. The surgeon may either create a long incision in the patient’s abdomen or choose to perform the procedure minimally invasively, or laparoscopically. A laparoscopy requires smaller incisions, uses a camera inside the body, and typically allows for swifter recovery.
Although ostomy surgeries have traditionally been carried out under general anesthesia in order to ensure maximal patient comfort, other forms of anesthesia have emerged as viable alternatives. Indeed, as a result of advances in ultrasound guidance and ability to visualize the planes, nerves, and vasculature, regional anesthesia has grown in popularity in the management of peri- and postoperative pain for ostomy procedures.
Regional anesthesia even presents a number of advantages depending on the clinical context. One research study demonstrated that minimally invasive, endoscopically assisted colostomy could be performed without laparotomy or general anesthesia [2]. The study specifically sought to assess the possibility of performing fecal diversion with the assistance of a colonoscope, and without the additional morbidity of general anesthesia or abdominal exploration. To this end, a total of fifteen patients were reviewed within a period of five years, all of whom were successfully diverted using minimally invasive techniques with the colonoscope. Further, four of these patients were diverted using local or regional anesthesia, without incurring any complications over the subsequent five-year period. Regional anesthesia may be able to avoid the morbidity associated with general anesthesia in critically ill patients. The researchers concluded endoscopically assisted colostomy is an acceptable method for fecal diversion and can be accomplished using regional anesthesia with sedation.
In addition, one case report documented the case of a patient having suffered a recent pulmonary embolism and supraventricular tachycardia who required colostomy refashioning [3]. Ultrasonography-guided regional anesthesia was administered using a combination of ilioinguinal-iliohypogastric, rectus sheath, and transversus abdominis plane blocks. These were supplemented with dexmedetomidine and propofol sedation in addition to intermittent fentanyl and ketamine boluses to cover for visceral stimulation. According to the authors of this study, it is critical to discuss the anatomical rationale for the choice of anesthetic block, including in light of similar clinical cases [3].
In the end, a number of key elements must be taken into consideration when selecting regional versus general anesthesia for ostomy surgery. Indeed, in rare instances, when the risks of general anesthesia outweigh the benefits of surgery, surgeons must consider other anesthetic options like regional and local anesthesia for bowel diversion. Importantly, these interventions and successful outcomes require the coordinated efforts of the entire surgical team and explicit communication and collaboration between patients and all healthcare providers involved [4].
References
1. Ostomy: Definition, Types, Procedure, Care & Recovery. Available at: https://my.clevelandclinic.org/health/treatments/22496-ostomy. (Accessed: 16th October 2023)
2. Mattingly, M., Wasvary, H., Sacksner, J., Deshmukh, G. & Kadro, O. Minimally invasive, endoscopically assisted colostomy can be performed without general anesthesia or laparotomy. Dis. Colon Rectum (2003). doi:10.1007/s10350-004-6534-0
3. Ng, O., Thong, S. Y., Chia, C. S. & Teo, M. C. C. Revision of loop colostomy under regional anaesthesia and sedation. Singapore Med. J. (2015). doi:10.11622/smedj.2015081
4. Hughe, A. J., Mankarious, M. M., Deutsch, M. J. & Scow, J. S. Awake Colostomy Under Regional Anesthesia in Frail Patients. Am. Surg. (2022). doi:10.1177/00031348221129507
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