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Ostomy Reversal Pathway

Outpatient Management: Colostomy

  1. Postoperative Follow-Up

    • First visit: 7–14 days post-op OR 2 weeks post-discharge if hospitalized on POD #14
    • Second visit: 2 months post-op (telehealth if eligible)

  2. Pre-Reversal Workup

    • If age >44 and no recent colonoscopy:
      • Order colonoscopy
      • Barium enema if indicated on discharge checklist
    • If age <44 or recent colonoscopy:
      • Barium enema if indicated on discharge checklist
    • If family history of colon cancer → consider screening colonoscopy
    • If known or suspected sphincter injury:
      • In-person visit with rectal exam
      • Anal manometry at discretion of attending
      • If abnormal → refer to Colorectal Surgery
    • Schedule reversal surgery

  3. Preoperative Orders

    • Antibiotic Bowel Prep
      • Neomycin 1g TID the day before surgery (2 PM, 4 PM, 10 PM)
      • Metronidazole 500 mg TID same schedule
      • If neomycin unavailable → use erythromycin 1g TID
    • Mechanical Bowel Prep
      • Magnesium citrate (1–2 bottles) OR
      • Miralax (256 g polyethylene glycol)
    • Chlorhexidine wipes: use the day before surgery
    • NPO 6 hrs prior to procedure
    • Clear electrolyte/sports drink immediately before NPO
    • Anesthesia: Perioperative Consultation Service referral for adjunctive analgesia

Outpatient Management: Ileostomy

  1. Postoperative Follow-Up

    • First visit: 7–14 days post-op OR 2 weeks post-discharge if hospitalized on POD #14
    • Second visit: 2 months post-op (telehealth if eligible)

  2. Pre-Reversal Workup

    • If age >44 and no recent colonoscopy:
      • Order colonoscopy
      • Barium enema if indicated on discharge checklist
    • If age <44 or recent colonoscopy:
      • Barium enema if indicated on discharge checklist
    • If family history of colon cancer → consider screening colonoscopy
    • If known or suspected sphincter injury:
      • In-person visit with rectal exam
      • Anal manometry at discretion of attending
      • If abnormal → refer to Colorectal Surgery
    • Schedule reversal surgery

  3. Preoperative Orders

    • No bowel prep needed
    • Chlorhexidine wipes: use the day before surgery
    • NPO 6 hrs prior to procedure
    • Clear electrolyte/sports drink immediately before NPO
    • Anesthesia: Perioperative Consultation Service referral for adjunctive analgesia

Preoperative Risk Optimization

  1. Glycemic Control

    • If diabetic → check HgbA1c
    • Consider delaying elective surgery if HgbA1c > 7%
    • Refer to PMD or Endocrinology for long-term management

  2. Smoking/Nicotine Cessation

    • Consider referral to Tobacco Quit Line

  3. Anesthesia Referral

    • VPEC (phone/in-person) → for low periop risk
    • Hi-Rise → for elevated periop risk

Discharge Checklist (To Be Completed by Operating Surgeon)

  • Estimated Time to Reversal (default: 4 months post-colostomy unless specified)

    • If not a candidate, surgeon must discuss with patient/family

  • Time to First Post-Op Visit (default: 7–14 days)

  • Time to Second Post-Op Visit (default: 60 days)

  • Pre-Second Visit Workup

    • Patients <44 yrs: No colonoscopy unless strong personal/family history of colon cancer
    • Colonoscopy 10 years prior to youngest family member’s diagnosis if family history present
    • Avoid routine barium enema for Hartmann’s procedures at VUMC
    • All DLI patients require anastomosis evaluation prior to reversal (preferred: barium enema)

  • Hi-RISE or VPEC Referral Needed (YES / NO)

  • Barriers to Reversal

    • Smoking
    • Obesity
    • Diabetes
    • Wound healing issues