Loop Colostomy Research Articles

SURGICAL MODALITIES FOR SIGMOID COLON CANCER COMPLICATED BY DECOMPENSATED OBSTRUCTION

AIM: to evaluate the early and long-term results of emergency two-stage surgical procedures in patients with sigmoid colon cancer complicated by decompensated bowel obstruction.PATIENTS AND METHODS: the cohort study included 112 patients with sigmoid colon cancer complicated by bowel obstruction that underwent emergency two-stage surgical procedures in general surgical and coloproctological units in 2011-2017. The group 1 (n=60) included patients who, at the first stage, underwent Hartmann’s procedure, at the second stage – stoma reversal. The group 2 (n=52) included patients with a loop colostomy at the first stage and radical elective surgery as a second stage. The comparative analysis between the groups was carried out according to the following criteria: the type of surgery, the type of intestinal stoma, the rate and type of postoperative complications, postoperative mortality, resection status (R0/R1), the number of removed lymph nodes, the rate of adjuvant polychemotherapy (PChT).RESULTS: postoperative mortality in the group 1 was 3.33% (n=2) and occurred after the first main stage (Hartmann’s procedure), there were no deaths in group 2 (p=0.28). The procedures in group 2 fully met the criteria of oncological radicalism based on the number of lymph nodes examined and resection status (p<0.0001 and p<0.0001, respectively). Three-year overall survival at stage IIB in group 1 was 44.4% vs 75.2% in group 2 (p<0.0001); with IIIB in the 1st group – 60.3% vs 68.2% in group 2 (p=0.034); at IIIС in the 1st group – 35.7% vs 60.7% in the 2nd group (p=0.009). The 3-year disease – free survival at stage IIB in the 1st group was 41.7% vs 68.8% in the 2nd group (p<0.0001); with IIIB in the 1st group – 53.6% vs 64.5% in group 2 (p=0.036); at IIIС in the 1st group – 33.2% vs 60.8% in the 2nd group (p=0.023).CONCLUSION: for sigmoid colon cancer complicated by decompensated obstruction, in general hospitals the stage treatment with the colostomy at the first stage is preferable.

Acute Large Bowel Obstruction Following Late Sequelae of Traumatic Diaphragmatic Hernia

A 33 years old patient was admitted in a Military Hospital with the features of acute large gut obstruction. Exploratory laparotomy was done and peroperatively the obstruction was seen in the transverse colon and obstruction seemed to be carcinoma of transverse colon with involvement of left hemidiaphragm which was not negotiable. Transverse loop colostomy with decompression of bowel was done. Subsequently the patient was transferred to tertiary level hospital in Dhaka. In the tertiary hospital, the patient developed left sided massive pleural effusion. With relevant investigation the condition was diagnosed as left sided diaphragmatic hernia. Thoracotomy was done and herniorrhophy was performed after reduction of the content. Post-operative management was stormy and eventful but the condition improved gradually and the patient was discharged in proper time. The patient had history of chest trauma due to RTA he met 4 years back and he received hospital indoor management for 3½ months. The patient was asymptomatic and leading normal active military life before 2nd time admission for acute intestinal obstruction. The patient had past history of trauma to left chest wall 4 years back, presented with acute large gut obstruction and there was diagnostic dilemma. There were management difficulties and post operative events were stormy. The aim of this reporting is to highlight all of these.
 Journal of Armed Forces Medical College Bangladesh Vol.15 (1) 2019: 119-120

Laparoscopic Versus Open Pre-Treatment Loop Colostomy for Fecal Diversion in Rectal Cancer Patients: Is Laparoscopic Colostomy Better?

Diversion colostomy plays a crucial role in the management of carcinoma rectum in low- and middle-income countries as significant number of patients present with partial intestinal obstruction. The aim of this study was to compare laparoscopic and open approaches for fecal diversion done in patients with adenocarcinoma of the rectum as a pretreatment procedure. The primary end point of our study was time to initiation of neoadjuvant chemo radiation. It was a retrospective study that included all patients diagnosed to have carcinoma rectum and underwent a pretreatment fecal diversion between 2012 and 2014. A total of 55 patients underwent pretreatment diversion colostomy of which 33 were performed via the laparoscopic approach while 22 had open diversion. The time for initiation of neoadjuvant therapy was shorter in the laparoscopic group compared to the open approach (16days vs. 20.5days, P = 0.31). The study concluded that pretreatment diversion colostomy using the laparoscopic approach was a safe option in low- and middle-income countries as it was associated with faster recovery and early initiation of neoadjuvant therapy in patients with partially obstructed locally advanced carcinoma rectum.

Indocyanine green fluorescence during pediatric stoma closure

Abstract In this paper, we discuss the first two cases who underwent colostomy closure using ICG fluorescence system (Stryker, PINPOINT System®). Case 1 11-months-old female with 21 trisomy and anorectal malformation (rectal atresia without fistula). She had sigmoid loop colostomy in neonatal period and Posterior Sagittal Anorectoplasty (PSARP) in 9 months of life. During the colostomy closure, ICG was intravenously administered to evaluate blood flow of anastomotic site. Twenty-two hours after operation, she had the first defecation which was positive for ICG fluorescence. Case 2 16-months old male with postoperative state of tracheoesophageal fistula and rectovestivular fistula. He had transverse loop colostomy in neonatal period and PSARP in 12 months of life. During the colostomy closure, ICG was intravenously administered to evaluate blood flow of anastomotic site. Twenty-five hours after operation, he had the first defecation which was negative for ICG fluorescence. Forty hours after operation, he had ICG-positive defecation. There were no postoperative complications for both of patients. ICG fluorescence system has two merits for pediatric colostomy closure evaluation of anastomotic blood flow and postoperative bowel function.

Comparison of frequency of complications in loop versus divided colostomy in patients with high variety anorectal malformation

Background: The objective of this study was to compare frequency of stoma related complications of loop versus divided sigmoid colostomy for the management of high variety anorectal malformations. Methodology: This RCT was conducted in the department of Pediatrics Surgery Department of the Children’s Hospital and the Institute of Child Health Lahore, for the period of one year from 1st May 2016 to 1st June 2017. One hundred and twenty patients (Sixty patients in each group) of anorectal malformation meeting inclusion criteria were taken in this study. Patients were divided into two groups randomly using lottery method; loop sigmoid colostomy in Group-A and divided sigmoid colostomy in Group-B. After surgeries patients were followed weekly up till 8 weeks. Stoma related complications (as per operational definition) were noted. Results: The mean age in group –A and group-B were 3.34 ± 1.12 days and 3.36 ± 0.97 days, respectively. In group – A there were 52(86.67%) male and 8(13.33%) females, and in group-B there were 45(75%) male and 15(25%) female patients. In group-A 22(36.66%) patients had complications [3(5.00%) patients had retraction, 8(13.33%) had prolapse, 4(6.67%) had stoma obstruction, parastomal hernia were seen in 4(6.67%), stoma necrosis were seen in 3 (5.00%)] and in group-B, 16(26.66%) patients had different complications [1(1.67%) patients had retraction, 3(5.00%) had prolapse, 5(8.33%) had stoma obstruction, parastomal hernia were seen in 2(3.3%), stoma necrosis were seen 5(8.33%)]. The complications in group-A were higher when compared to group-B, but (p-value = 0.650) were not significant statistically except for stoma prolapse. Conclusion: Though complication rate in both techniques is not statistically different but frequency of stoma prolapse is more in loop colostomy group. Therefore, divide colostomy should be opted as preferred technique.

Loop ileostomy versus loop colostomy as temporary deviation after anterior resection for rectal cancer.

Construction of a temporary stoma is a common adjunct to low anterior resection for rectal cancer and can be accomplished either with loop ileostomy (LI) or loop colostomy (LC) with the question of the most appropriate one still remaining controversial. The aim of this study is to compare stoma-related morbidity between the two groups. A retrospective review was conducted including 148 consecutive patients (LI: 55/LC: 93) who underwent anterior resection for rectal cancer between January 2004 and December 2018 in our department. Time interval between low anterior resection and stoma reversal was similar for both groups. Comparison between the two groups was made regarding stoma-related morbidity after stoma construction and after stoma reversal, respectively. A total number of 17 patients suffered from complications after the construction of a protective LI compared with 25 patients after the construction of a LC (LI vs LC: 17/55 (30.1%) vs 25/93 (26.9%); p = 0.59). The most common morbidity noted in both groups before stoma closure was parastomal hernia, with the difference being statistically not significant (LI vs LC: 11/55 (20%) vs 21/93 (22.6%); p = 0.84). However, patients with LI suffered from significantly more peristomal skin irritations compared with the patients with LC (LI vs LC: 5/55 (9.1%) vs 1/93 (1.1%); p = 0.027). Overall morbidity rate after stoma closure was found to be comparable in both groups (LI vs LC: 7/37 (18.9%) vs 6/64 (9.4%); p = 0.16). The most common complication after stoma reversal was wound infection (LI vs LC: 5/37 (13.5%) vs 5/64 (7.8%); p = 0.49). With the exception of a higher rate of skin irritation after LI construction, all other postoperative outcomes were found to be comparable in both study groups. Further randomized clinical trials are required to verify these findings. The study was registered in the German Registry for Clinical Trials (DRKS00020766, date of registration: 11.02.2020).

The tip of the iceberg of colorectal perforation from enema: a systematic review and meta-analysis.

Although rare, perforation following an enema used to treat constipation is a dangerous complication. However, no recommendations or guidelines for enema use are available. So, in common clinical practice, the diagnostic approach and the treatment are not standardized. In an attempt to resolve this clinical dilemma associated with high mortality and potential medicolegal claims for malpractice, we have performed a systematic review and meta-analysis of studies reporting on colorectal perforation secondary to enema use for adult patients with constipation. A systematic search of PubMed, Web of Science and Scopus was performed according to the PRISMA statement up until February 2020. Studies that reported on colorectal perforation from enema use in adult patients with constipation were included. The primary outcomes were the rate of hospital mortality and pooled prevalence estimates of mortality from perforation secondary to enema use. The secondary outcomes were the administration of rectal enemas, site of visceral perforation, signs, symptoms, radiological evaluation, and type of treatment RESULTS: A total of 15 studies were included in the final analysis (49 patients). Across all studies, the pooled prevalence estimate of mortality for patients with perforation secondary to enema use was 38.5%, (95% CI [22.7%, 55.5%]). This rate was lower in patients who had surgery (35%) than in patients treated conservatively (57.1%). The sites of perforation were intraoperatively reported in 84% of cases, but in 16% of patients the rectal perforation was undiagnosed, and surgical decision making was problematic. The primary location of the perforation was the rectum in 80.9% of the patients. The enema was administered by a nurse in 90% of the cases, self-administered in 7.5% and a family doctor in 2.5%. The main objective of emergency surgery in this setting is resection of the perforation caused by the enema; when it is not possible to resect the perforated rectum, faecal diversion is needed. Hartmann's procedure was most commonly performed by the surgeons in this review (60.7%), with other reported treatments included a diverting proximal loop colostomy and sigmoid segment exteriorization CONCLUSIONS: Considering the studies available, it is not possible to undertake a thorough evaluation of enema use, including the associated complications and their management. Further data are required to allow the development of guidelines to advice on safe enema use and management of complications.

Outcomes of stapler repair with anastomosis for stoma prolapse.

The published data on the outcomes of an operative repair for stoma prolapse are limited. This study aimed to clarify the long-term outcomes of stapler repair with anastomosis for stoma prolapse. Twenty-four patients (15 men, median age 64years, range 33-88years) undergoing 25 stapler repairs with anastomosis were prospectively registered, and their medical records were retrospectively reviewed. The median length of prolapse was 10cm (range 5-22). Stoma prolapse repair was performed by means of 16 loop colostomies, four end colostomies, three loop ileostomies, and one end ileostomy. A stapler was used 4.6 times on average (range 4-8). The average operative time and bleeding were 40.8 (range 15-75) min and 40 (range 0-214) mL, respectively. No mortality and morbidity were observed after surgery. A recurrence of stoma prolapse was reported in only one of 25 repairs (4%) at the proximal limb of loop ileostomy during a median follow-up period of 1year (range 1-120months). However, a new stoma prolapsed in one untreated limb of loop stoma. Stapler repair with anastomosis is a safe and minimally invasive treatment option for stoma prolapse with a low recurrence. However, the effectiveness of reparing stoma prolapse on the proximal limb of loop ileostomy might be limited.

Preventive Loop Colostomy in Colorectal Cancer Surgery

Introduction. The problem of colonic anastomosis failure remains unsettled in colorectal surgery, since the use of various techniques of anastomotic protection does not preclude the development of complications.The aim of the study was to highlight surgical treatment outcomes of colorectal cancer using preventive stomas.Material and methods. The study included clinical outcomes of 248 patients with colorectal cancer. Group 1 included 85 patients who had a preventive colostomy after rectum resection and restoration of intestinal continuity. Group 2 (control) included 163 patients who had rectum resection without unloading stomas. The following parameters were evaluated in the study: gender, age, presence or absence of the preventive intestinal stoma, duration of stay in the surgical department, anastomotic failure.Results. In patients of group 1, colorectal anastomosis failure was manifested in 1 case (1.2%), in patients of group 2 - in 14 cases (8.6%). The average number of inpatient day in group 1 was 18, the average number of inpatient days in group 2 was 21.Conclusion. The application of a preventive intestinal stoma can reduce the incidence of failure, duration of hospital stay and improve long-term treatment outcomes

A Prospective Study of Intestinal Stomas

Background and Objectives: Intestinal stomas are commonly constructed in an emergency as well as elective setting for a variety of indications. Historically associated with a high morbidity, evolution of skills on the part of the surgeon has lead to better understanding of the indications, complications and management of a stoma. This study aims to evaluate the above mentioned parameters and hence improve the outcome of patients undergoing a stoma. Method 50 patients admitted in MMIMSR, Mullana (Ambala) and later operated and managed with a stoma were closely followed up from the date of admission to the date of discharge and the various parameters were studied. Results The indications, technique, complications and its management were studied in detail by following patients in person or through phone and the results were analyzed in detail. Interpretation and Conclusion Construction and management of stoma was associated with a few complications. Most patients however tolerated the procedure well and the overall compliance was satisfactory. Loop ileostomy was the commonly constructed stoma and the one associated with most complications. Transverse loop colostomy was associated with no complications and was extremely well tolerated.

Risk factors for parastomal hernia of loop stoma and relationships with other stoma complications in laparoscopic surgery era

BackgroundLaparoscopic approach is now a widespread technique used worldwide, but there are few recent studies on risk factors for parastomal hernia. Therefore, this study was performed to analyze the incidence of parastomal hernia in laparoscopic and open surgery in which a loop stoma was created and was intended to be temporary, and to determine risk factors for parastomal hernia formation. Associations between parastomal hernia and other stoma-related complications were also analyzed.MethodsA retrospective analysis of patient and surgical characteristics was performed in 153 consecutive patients who underwent a temporary diverting loop ileostomy or colostomy after surgery related to malignant diseases at our hospital from January to December 2016.ResultsParastomal hernia developed in 77 cases (50.3%), including 39 (25.5%) diagnosed by physical examination and 38 (24.8%) detected by CT alone. On multivariate analysis, a stoma not passing through the middle of the rectus abdominis muscle was the only independent risk factor for parastomal hernia formation (p = 0.005) during the median follow-up of 245.0 days. When we analyzed the factors that were associated with a stoma not passing through the middle of the rectus abdominis muscle, the only independent factor associated with this misplacement of the stoma was a laparoscopic approach (p = 0.012). An analysis of stoma-related complications showed that peristomal skin disorders were significantly associated with parastomal hernia (p = 0.049).ConclusionsThis study showed that a stoma that is not formed through the middle of the rectus abdominis muscle is a risk factor for parastomal hernia formation, and that a laparoscopic approach is associated with this risk factor. Moreover, parastomal hernia is significantly associated with peristomal skin disorders.

Anorectal Malformations: the Brooke Ileostomy Technique Moves to the Colon

Colostomy is considered by most authors the first step of treatment for neonates affected by high or intermediate anorectal malformations (ARMs). However, for this subset of patients, the debate between total diverting colostomy (TDC) and loop colostomy (LC) is still ongoing among the paediatric surgeons community. The aim of this paper is to present our experience consisting in applying the Brooke technique, until now used only for ileostomy, in order to perform a functionally diverting loop colostomy (FDLC) in patients with high or intermediate ARMs. At our institution, from January 2014 to December 2018, 12 patients (6 males and 6 females) with high or intermediate ARMs underwent colostomy according to the Brooke ileostomy technique. The only complication observed was mild proximal stoma prolapse in 1 patient. Creation and closure of the stomas were easy, and the final cosmetic result was very satisfying in all patients. We believe that this is a promising technique since it might overcome the drawbacks of a TDC as it is less invasive, easier, and quicker to perform. Furthermore, it guarantees final better cosmetic results, albeit functioning as a TDC.

Sigmoid Volvulus in a Neonate with Anorectal Malformation: A Case Report

Background: Sigmoid volvulus in the neonate is an extremely rare condition needing emergency treatment. Sporadic cases of neonatal sigmoid volvulus and some in association with Hirschsprung’s disease have been documented. Sigmoid volvulus has been described only twice in the literature in association with anorectal malformation. However, newborns with anorectal malformations might be especially at risk for sigmoid volvulus due to increased intraluminal intestinal weight caused by bowel obstruction and its existence might be underreported. Case presentation: This is the case report of a full-term neonate with trisomy 21 who was diagnosed with anorectal malformation upon birth. An abdominal X-ray on his second day of life showed typical radiological findings of sigmoid volvulus as described by the radiologist. However, the findings were interpreted as a dilated rectosigmoid sling typical for anorectal malformation by the surgeon and a transverse loop colostomy was placed. On the fourth postoperative day sigmoid perforation occurred and led to meconium peritonitis and septic shock. An emergency laparotomy was performed and a perforation at the distal sigmoid colon was found. Conclusion: There is an urgent need to raise awareness as to the existence of sigmoid volvulus in the neonate with anorectal malformations. The distinct radiological findings of the “coffee bean sign”, the “northern exposure sign” and an empty rectum allow to distinguish the extremely rare sigmoid volvulus from the common finding of a dilated rectosigmoid in patients with anorectal malformations. Detorsion of sigmoid volvulus is vital to preventing sigmoid perforation.

Stapler-assisted stoma prolapse repair with real-time fluorescent angiography using indocyanine green

AbstractStoma prolapse is an increase in the size of the stoma secondary to intussusception of the proximal bowel segment. Transverse loop colostomy is most commonly involved. Although ostomy function is rarely impaired, large prolapses may cause patients distress and impair stoma dressing. Strangulation and ischemia of the prolapsed segment have been reported as complications. Herein, we report a stapler-associated repair of a prolapsed transverse loop colostomy with real-time perfusion studies using indocyanine green.

A rare case of colonic perforation presenting as Fournier’s gangrene

A 48-year-old obese gentleman with mild pain over abdomen for 10 days followed by pain and swelling in the right side of scrotum with skin discolouration for 2 days. Clinically necrotic patch with pus discharge was noted on the right side of scrotum. Extensive debridement over scrotum was done following which inflamed omentum and fecal contents were noticed from the inguinal canal. Patient underwent laparotomy and an ascending colonic perforation was found. A loop colostomy with partial omentectomy and inguinal hernia repair along with serial debridement of scrotal wound was done. Although uncommon, gastrointestinal perforations should be considered as a potential etiology in Fournier’s gangrene.

Evaluation of short-term loop colostomy in dogs using conventional and supporting subcutaneous silicone drain techniques.

Objective:This study aimed at evaluating the supporting and non-supporting loop colostomy techniques in dogs.Materials and Methods:In this study, 12 adult healthy mongrel dogs were used to carry out a short-term (21 days) temporary flank loop colostomy. The dogs were divided into two groups (n = 6). In the first group (Con group), conventional stoma fixation was operated without loop support. In the second group [subcutaneous silicone drain (SSD) group], an SSD was used as a supporting bridge. The stoma was fixed by a modified, interrupted seromuscular vertical mattress suture pattern. Both peristomal and stomal complications were recorded.Results:Results showed that a total of seven dogs (58%) suffered complications. There was a significant tendency toward less peristomal (p = 0.012) and stomal complications (p = 0.001) in the SSD group. The intensity of pain was significantly (p < 0.05) different between the two groups in the first week post surgery. Comfort with stoma care was significantly (p = 0.015) better in the SSD group, experiencing the best results.Conclusion:It is concluded that an appropriate stoma location, using a soft supporting bridge, stoma fixation using modified interrupted neuromuscular vertical mattress sutures, and proper appliance fixation by adhesive tapes and a tight T-shirt may overcome the complications of short-term loop colostomy in dogs and introduce a satisfaction for stoma care.

Large bowel obstruction from advanced prostate cancer in a 41-year-old: the role of genetic testing

SUMMARY We report a rare presentation of an advanced prostate cancer (Gleason 10) in a 41-year-old man with complete large bowel obstruction relieved by loop colostomy. His young age prompted a search for a cause and genetic testing confirmed chromosome 10 PTEN deletion. His immediate family members were screened and counselled appropriately. This case outlines the role of genetic testing in young males with prostate cancer.

Two-stage repair for delayed presentation of anorectal malformation with vestibular and perineal fistulae in females

Background/aim In spite of advances in knowledge and techniques in the management of anorectal malformation (ARM), delayed presentation of female ARM with vestibular and perineal fistulae is quite common especially in developing countries. In this literature, there is no standardized surgical algorithm for late presentation of these female ARM. This study aimed to present the experience of two pediatric surgery tertiary centers regarding delayed presentation of vestibular and perineal fistulae using two-stage procedures. Patients and methods This prospective study was conducted on 28 female patients with late presentation of vestibular and perineal fistulae from November 2014 to April 2019. Lower contrast study was done for all patients. Laxative, frequent rectal wash enemas, and Hegar’s dilators were used for 2–3 weeks preoperatively. All patients were repaired by anterior sagittal anorectoplasty (ASARP) with covering high sigmoid loop colostomy, and colostomy closure was performed after 2–3 months. Krickenbeck continence score was used for assessment of anal continence. Results Of 28 patients included, 25 patients completed the study. There were 14 patients with perineal and 11 with vestibular fistulae. The age of patients ranged from 8 months to 18 years. The main reasons for delay were socioeconomic, unawareness, and overlapping causes. Sphincter-saving ASARP was used in 15 patients and the classic ASARP was used in 10 patients. Tapering proctoplasty was needed in one patient. Minor wound infection developed in three patients. Constipation occurred in 11 (44%) patients. Follow-up period ranged from 6 to 50 months (median 30 months). Good continence was obtained. Conclusion Although delayed presentation of vestibular and perineal fistulae in female patients is accompanied by comorbidities, with good surgical management, successful results can be obtained by using two-stage procedure.

Novel Application of the EK Glove Port for Single-Incision Diverting Sigmoid Loop Colostomy in Advanced Rectal Cancer.

Background and Objectives:In patients with obstructing rectal cancers who require intestinal diversion before neoadjuvant therapy, minimizing diversion-related recovery and instituting early chemoradiation are critical to optimizing outcomes.Methods:A novel, simple, safe, and inexpensive technique was developed for single-port laparoscopic diverting sigmoid loop colostomy in a low-resource environment.Results:Ten consecutive patients with locally advanced rectal cancer underwent single-port, diverting sigmoid loop colostomy using a novel application of the EK glove port. Operative time averaged 59.5 min (range 40–75 min). There were no conversions to multiport laparoscopy or open surgery. There were no intraoperative or early postoperative surgical complications. All patients started chemoradiation therapy within 1 week of diverting colostomy. No surgical reinterventions were required.Conclusion:Single-port laparoscopic diverting sigmoid loop colostomy utilizing an EK glove port is a novel, technically simple, safe, and cost-effective procedure, especially applicable to patients with obstructing rectal cancer who receive care in a low resource environment.

Indications and complications of colostomy in newborn: our experience

Background: The aim of the present study was to evaluate the indications, complications and outcome of colostomy in newborn patients.Methods: This is a descriptive, retrospective study carried out in the Department of Pediatric surgery, Gandhi Medical College Bhopal to evaluate acceptance and outcome of colostomy in newborn over a one year period from March 2018 to March 2019. All newborn with diagnosis of anorectal malformation, Hirshsprungs disease and other emergency conditions underwent transverse loop colostomy by expert and trained pediatric surgeon.Results: Out of 40 patients operated complications of colostomy was seen in 18 (45%) patients. Most common complication was skin excoriation in 08 patients (20%), bleeding from stoma site in 02 (05%) cases. Stoma prolapse occurred in 02 (05%) patients. Wound infection, dehiscence, stomal stenosis and parastomal hernia was seen in one patient each 2 (2.5%). 2 (0.5%) patient died due to multiple congenital anomalies.Conclusions: Colostomy in children is associated with significant morbidity in developing country. To minimize these problems, the pediatric surgeon should focus on the management and early closure of a colostomy.