Huang YL, Gao YY, Zhang J, Wang L, Wu AW. Attitudes and technical maneuvers regarding enterostomy management and stoma creation among surgeons: A cross-sectional study. World J Gastrointest Surg 2026; 18(6): 118883 [DOI: 10.4240/wjgs.118883]
Corresponding Author of This Article
Ai-Wen Wu, MD, PhD, Chief, Professor, State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Beijing Key Laboratory of Carcinogenesis and Translational Research, Peking University Cancer Hospital, No. 52 Fucheng Road, Haidian District, Beijing 100142, China. drwuaw@sina.cn
Research Domain of This Article
Surgery
Article-Type of This Article
research-article
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Yong-Lin Huang, Yu-Ye Gao, Jie Zhang, Lin Wang, State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Beijing Key Laboratory of Carcinogenesis and Translational Research, Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
Ai-Wen Wu, State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Beijing Key Laboratory of Carcinogenesis and Translational Research, Peking University Cancer Hospital, Beijing 100142, China
Author contributions: Huang YL designed and conducted the study and wrote the manuscript; Gao YY contributed to data analysis; Zhang J and Wang L provided clinical advice; Wu AW supervised the study; and all authors have read and approved the final manuscript.
Supported by the National Key Research and Development Program of China, No. 2021YFF1201104; National Natural Science Foundation of China, No. 82173156; and Beijing Hospitals Authority Clinical Medicine Development of Special Funding, No. ZYLX202116.
Institutional review board statement: This study was approved by the Medical Ethics Committee of Peking University Cancer Hospital and Institute, approval No. 2024KT112.
Informed consent statement: This study involved a survey of healthcare professionals and did not include any patient data or identifiable information.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: The original anonymous datasets are available from the corresponding authors on reasonable request.
Corresponding author: Ai-Wen Wu, MD, PhD, Chief, Professor, State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Beijing Key Laboratory of Carcinogenesis and Translational Research, Peking University Cancer Hospital, No. 52 Fucheng Road, Haidian District, Beijing 100142, China. drwuaw@sina.cn
Received: January 15, 2026 Revised: February 1, 2026 Accepted: April 3, 2026 Published online: June 27, 2026 Processing time: 161 Days and 4.9 Hours
Abstract
BACKGROUND
Enterostomy is a routine procedure in colorectal surgery; however, stoma-related complications remain substantial. Variations in surgical performance, limited formal training, and insufficient collaboration between surgeons and enterostomal therapists contribute to inconsistent enterostomy management. Nevertheless, surgeons’ attitudes and technical practices toward stoma creation remain poorly characterized.
AIM
To characterize Chinese surgeons’ attitudes toward enterostomy and to describe their technical preferences in stoma creation.
METHODS
Through a comprehensive literature review, pilot testing, and expert consultation, a 37-item self-administered electronic questionnaire was developed. The survey was distributed through professional surgical networks and collaborative groups between June and July 2022, and eligible surgeons participated voluntarily. Following ethical approval in 2024, the data were retrospectively curated and analyzed. Descriptive analyses and subgroup comparisons were performed using the χ2 test, Fisher’s exact test, or Cramér’s V.
RESULTS
A total of 417 responses were received, and 16 duplicate questionnaires from the pilot phase were excluded. Among the 401 surgeons included, 60.4% reported having received formal training in stoma creation. Although 99.5% considered stoma-related complications to be related to surgical techniques, only 56.1% had participated in dedicated discussions or formal training programs. 37.2% reported that the adoption rate of preoperative stoma site marking was below 60%, and 44.6% considered the site selection performed by enterostomal therapists to be inaccurate. Substantial variability was observed in preoperative stoma site marking preferences and technical maneuvers during stoma creation, with no single approach predominant. No significant differences in self-reported attitudes toward enterostomy were observed between the junior and senior surgeons. Surgeons from secondary and lower-tier hospitals appeared to have less exposure to theoretical and practical training than those from tertiary hospitals.
CONCLUSION
Chinese surgeons demonstrate marked variability in the attitudes, concepts, and technical maneuvers in enterostomy creation. This heterogeneity may contribute to inconsistent clinical practices and variable patient outcomes. Future studies should focus on developing and validating a standardized training curriculum for enterostomy creation.
Core Tip: This nationwide, surgeon-centered survey provides a comprehensive overview of current attitudes, training backgrounds, and technical practices related to enterostomy management in China. The findings reveal substantial heterogeneity in surgical concepts and operative maneuvers, insufficient formal training, and suboptimal collaboration between surgeons and enterostomal therapists. By systematically mapping real-world practices across institutions and surgeon grades, this study highlights critical gaps in standardization and underscores the need for patient-centered, multidisciplinary training programs to improve enterostomy quality and reduce stoma-related complications.
Citation: Huang YL, Gao YY, Zhang J, Wang L, Wu AW. Attitudes and technical maneuvers regarding enterostomy management and stoma creation among surgeons: A cross-sectional study. World J Gastrointest Surg 2026; 18(6): 118883
Enterostomy, a procedure first documented in the 16th and 17th centuries, refers to the surgical creation of an opening in the intestinal tract onto the abdominal wall[1]. Over the last 50 years, enterostomy has gradually advanced to become the standard procedure for certain intestinal surgeries, rather than being reserved solely for emergencies or extreme cases. As the indications for stoma creation have expanded, increasing attention has been directed toward postoperative management and daily stoma care. Consequently, the first enterostomal therapy school was established with the aim of providing a comprehensive program for a patient who is about to undergo stoma surgery[2].
Although enterostomy is not as complex as routine gastrointestinal surgery in most cases, its associated morbidity and mortality rates remain substantial, and warrant careful attention[3]. Senior surgeons often delegate stoma creation to junior surgeons who may lack experience or fail to prioritize the procedure. Furthermore, the involvement of an enterostomal therapist (ET, a specialized nurse with expertise in stoma, wound, and continence care) may reduce the workload but can also limit surgeon involvement in postoperative care, potentially compromising the consistency of management. Surgeons differ considerably in their understanding of enterostomy[4-6], and most centers lack systematic management protocols for patients with ostomies.
The incidence of stoma-related complications is closely linked to surgical technique. However, consensus or standardized guidelines for enterostomy remain limited[7,8]. Furthermore, large-scale surgeon-centered data describing current practices, training experiences, and organizational patterns are lacking. Therefore, we conducted a self-administered questionnaire survey to explore surgeons’ attitudes and concepts regarding enterostomy management and their surgical strategies for stoma creation, aiming to provide a foundation for optimizing enterostomy management and promoting standardization of enterostomy procedures.
MATERIALS AND METHODS
A multicenter, cross-sectional, descriptive study was conducted to investigate the concepts and attitudes toward enterostomy management as well as the surgical strategy and technical maneuvers for stoma creation in China.
Sample selection
Responses were obtained from surgeons from 188 hospitals of different grades across 26 provinces or municipalities directly under the Central Government (Supplementary Table 1). The inclusion criteria were as follows: (1) Surgeons involved in enterostomy and stoma management across general surgery, gastrointestinal surgery, surgical oncology, emergency surgery, and other related disciplines; and (2) Surgeons at resident level or higher. The exclusion criteria were as follows: (1) Declined participation; or (2) Submission of duplicate questionnaires during the pilot survey. Ethical approval for this study, approval No. 2024KT112 was provided by the Ethics Committee of Peking University Cancer Hospital and Institute, Beijing, China, on July 26, 2024. Following ethical approval, the survey data were retrospectively curated, statistically analyzed, and used for manuscript preparation.
Questionnaire development
The questionnaire was developed based on a review of the literature, relevant consensus statements, and textbooks on enterostomy[4,9-16]. The survey comprised six sections: Demographic information, personnel qualifications and training, attitude toward stoma-related complications, preoperative stoma site marking, process of acquiring ostomy-related surgical skills, and awareness and use of relevant techniques (37 items in total). The questionnaire was pilot tested among a small group of surgeons (n = 66) to assess its clarity, relevance, and content validity, and minor revisions were made before formal distribution. The details are as follows.
Section 1: Demographic information, including hospital classification, department, professional title, and working years (Table 1).
Table 1 Demographic characteristics of participants, n (%).
Section 2: Personnel qualifications and training information: Who performed and was responsible for the enterostomy, knowledge source, department attitude, and individual training status (Table 2).
Table 2 Personnel qualification and training, n (%).
Items
n = 401
Stoma creation is most commonly performed by
Operator
211 (52.6)
First assistant
182 (45.4)
Second assistant or lower
8 (2.0)
Surgeon responsible for enterostomy
Associate chief surgeon or above
199 (49.6)
Attending surgeon (guided by superior surgeon)
191 (47.6)
Resident surgeon (guided by superior surgeon)
11 (2.7)
Source of ostomy-related knowledge (multiple answers)
Mentorship by senior surgeon
338 (84.3)
Mentorship by attending/resident surgeon
69 (17.2)
Learning based on surgical atlases
122 (30.4)
Mentorship combined with surgical atlases
187 (46.6)
Self-education
174 (43.4)
Have not been exposed to the relevant knowledge
1 (0.3)
Departmental attitude toward training in the prevention of stoma-related complications
Attach great importance
286 (71.3)
Attach moderate importance
109 (27.2)
Attach little importance
6 (1.5)
Have you received training related to stoma creation?
Section 4: Status of the preoperative stoma site marking questionnaire: Personal attitude, marking rate, and position selection in temporary ileostomy, permanent colostomy, or transverse colostomy (Table 4).
Table 4 Concepts and attitudes toward preoperative stoma site marking, n (%).
Items
n = 401
What do you think of preoperative stoma site marking?
Meaningful and should be strictly observed
186 (46.4)
Meaningful, and the area around the marking site is also appropriate
33 (8.2)
Meaningful, but the judgment of the surgeon should be the primary consideration
111 (27.7)
Meaningful, but not all marked sites (identified by enterostomal therapists) are suitable for stoma creation
70 (17.5)
Meaningless and can be omitted
1 (0.3)
In your impression, the rate of preoperative stoma site marking in your department is approximately
80%-100%
134 (33.4)
60%-80%
118 (29.4)
40%-60%
62 (15.5)
< 40%
87 (21.7)
In your impression, what are the reasons for not choosing the preoperatively marked stoma site by an enterostomal therapist as the primary site (multiple answers)?
Inappropriate marking
179 (44.6)
The stoma site marked preoperatively is not a suitable trocar site
219 (54.6)
Defunctioning stoma marking according to standards for permanent stoma
209 (52.1)
Prior site marking is inconsistent with the surgeon’s operating habits
108 (26.9)
Which temporary ileostomy skin site position do you prefer?
Right umbilical level, trocar site
90 (22.4)
Right lower quadrant, McBurney point (trocar site)
159 (39.7)
Right rectus abdominis muscle, specimen incision
113 (28.2)
Hypogastrium region, specimen incision
13 (3.2)
No fixed position
26 (6.5)
Which permanent colostomy skin site position do you prefer?
Left umbilical level, trocar site (outer margin of the rectus abdominis muscle)
74 (18.5)
Lower left quadrant of the umbilicus, outer margin of the rectus abdominis muscle
124 (30.9)
Lower left quadrant of the umbilicus, through the rectus abdominis muscle
160 (39.9)
Lower left quadrant of the umbilicus, lateral rectus abdominis muscle
29 (7.2)
No fixed position
14 (3.5)
Which transverse colostomy skin site position do you prefer?
Section 5: Technical maneuver details were examined using nine items, including management of the skin incision, subcutaneous tissue, abdominis aponeurosis incision, abdominal wall muscle, proximal intestine, fixation (defunctioning and permanent stoma), and opening direction of the intestine (Table 5).
Table 5 Technical maneuvers in stoma creation, n (%).
Items
n = 401
Shape of skin incision
Straight
110 (27.4)
Subcircular
286 (71.3)
Other
5 (1.3)
What do you think about the correlation between skin incision length and the size of the exteriorized intestine?
Incision size should be larger than the diameter of the intestine
111 (27.7)
Incision size should be close to the diameter of intestine
244 (60.9)
Incision size should be smaller than the diameter of intestine
46 (11.5)
Management of subcutaneous tissue
Excision
207 (51.6)
Preservation
110 (27.4)
Selective management
84 (21.0)
Shape of the obliquus externus abdominis aponeurosis incision
Cruciform
217 (54.1)
Cross shape, random direction
44 (11.0)
Straight shape, along the long axis
103 (25.7)
Straight shape, along the abdominal fascia
29 (7.2)
Flexible performance
8 (2.0)
Management of rectus abdominis/ abdominal wall muscle
Blunt dissection without complete muscle rupture
214 (53.4)
Partial dissection until the posterior sheath or peritoneum is exposed
145 (36.2)
Sharp dissection of the muscle in the projection region of the stoma
10 (2.5)
Selective management
32 (8.0)
Retention length of the proximal intestine in permanent stoma
Preserve the shortest possible length while ensuring adequate exteriorization of the bowel
123 (30.7)
Preserve as long as possible
92 (23.0)
Selectively performance
186 (46.4)
Layers for suturing and fixation in defunctioning stoma creation (multiple answers)
Peritoneum (or posterior rectus abdominis sheath)
274 (68.3)
Muscle
18 (4.5)
Anterior rectus abdominis sheath
218 (54.4)
Subcutaneous tissue
107 (26.7)
Skin
323 (80.6)
No suture or fixation
12 (3.0)
Layers for suturing and fixation in permanent stoma creation (multiple answers)
Section 6: The practice of relevant procedures and instruments: Awareness and utilization of support rods, iodoform gauze, circular stapler, extraperitoneal ostomy, mucosal eversion suture (Brooke), and protective negative-pressure wound therapy (Table 6).
Table 6 Awareness and utilization of relevant procedures and instruments, n (%).
Relevant procedure and instrument
Awareness
Utilization
Known
Unknown
Regular use
Occasional use
Rare use or non-use
Application of support rod in loop ileostomy
382 (95.3)
19 (4.7)
226 (56.4)
85 (21.2)
90 (22.4)
Application of iodoform gauze in intestine and skin
303 (75.6)
98 (24.4)
131 (32.7)
77 (19.2)
193 (48.1)
Application of circular stapler in permanent stoma creation
257 (64.1)
144 (35.9)
54 (13.5)
89 (22.2)
258 (64.3)
Application of extraperitoneal ostomy in permanent stoma creation
345 (86.0)
56 (14.0)
139 (34.7)
149 (37.2)
113 (28.2)
Application of mucosal eversion suture (Brooke) in loop ileostomy
312 (77.8)
89 (22.2)
180 (44.9)
110 (27.4)
111 (27.7)
Application of mucosal eversion suture in permanent end colostomy
356 (88.8)
45 (11.2)
263 (65.6)
89 (22.2)
49 (12.2)
Application of protective negative-pressure wound therapy
Between June and July 2022, the QR code was distributed to hospital department contacts and domestic surgical collaborative groups. These contacts shared the survey within routine online workgroups, and eligible surgeons participated voluntarily (Figure 1). Real-time feedback was updated using Sojump, a professional online platform, through questionnaire surveys, examinations, assessments, and voting. Detailed questionnaire information is provided in https://www.wjx.cn/vm/O9fSRMA.aspx (Supplementary Table 2).
Figure 1
Flow diagram showing the questionnaire development process and participant flow in this cross-sectional survey.
Participation was voluntary and anonymous, and respondents were instructed to complete the questionnaire independently without consulting external resources. Data were extracted from the online questionnaire platform upon completion of the survey.
Statistical analysis
Descriptive analysis of the responses was performed. The rate was calculated as a measure of the trend of each item for categorical variables. Multiple-response analysis was used to analyze questions with multiple selectable responses. The χ2 test was applied and the effect sizes were estimated using Cramér’s V. If the sample size was too small, Fisher’s exact test was performed, and the significance level was maintained at P < 0.05. Subgroup analyses were performed in an exploratory manner to describe potential differences across predefined surgeon- and institution-level characteristics. All statistical tests were performed using Statistical Package for Social Sciences (SPSS Version 23.0).
RESULTS
In 2022, a total of 417 actively practicing surgeons responded to the survey. After excluding 16 duplicate responses from participants who had taken part in the pilot survey, 401 surgeons from 188 hospitals across 26 provinces or municipalities directly under the Central Government were included in the final analysis (Figure 2). Of the 401 participants, 360 (89.8%) were from tertiary hospitals, and most held senior titles and had extensive clinical experience. The results are summarized in Table 1.
Figure 2
Distribution of 401 responding surgeons in 26 provinces or municipalities.
The survey results regarding personnel qualifications and training are presented in Table 2. Only 60.4% (242/401) of the surgeons received stoma creation training. Mentorship by senior surgeons was the primary source of ostomy-related knowledge (84.3%, 338/401), followed by mentorship by others and surgical atlases (46.4%, 187/401). Senior surgeons performed nearly half of the stoma procedures. More than two-thirds of the departments attached great importance to the prevention of stoma-related complications.
Part two of the survey examined surgeons’ attitudes and concepts regarding stoma-related complications (Table 3). Overall, 99.5% of surgeons were concerned about the correlation between stoma-related complications and surgical strategies, indicating that surgeons should place greater emphasis on postoperative complication management. Among them, 47.4% believed that the listed complications (irritant dermatitis, stomal bleeding and necrosis, and parastomal hernia) were related to the surgical procedure. Only 56.1% of the respondents had participated in discussions or training on the prevention or treatment of stoma-related complications, whereas 99.0% considered joint training and discussion between surgeons and ET to be indispensable.
Part three explored surgeons’ views on preoperative site marking and site selection for various ostomies. Almost all respondents reported paying attention to site marking; however, a considerable proportion prioritized their own preferences first. As shown in the Table 4, 33.4% reported that the rate of preoperative site marking exceeded 80%, 29.4% estimated a rate of 60%-80%, and 21.7% reported a rate of less than 40%. The main reasons for stoma placement inconsistent with preoperative marking were that the marked site was not suitable as a trocar site (54.6%, 219/401), followed by marking defunctioning stomas according to standards for permanent stomas (52.1%, 209/401), inappropriate marking (44.6%, 179/401), and inconsistency between the marked site and the surgeon’s operating habits (26.9%, 108/401). Site selection was relatively evenly distributed among temporary ileostomies, permanent colostomies, and transverse colostomies; however, no preferred position was identified among these procedures (Table 4).
Part four investigated participants’ technical practices in stoma creation. Most operational procedures were heterogeneous among the participants. A subcircular skin incision was preferred by 71.3% of the surgeons, and 60.9% indicated that the incision size should approximate the intestinal diameter. Subcutaneous tissue excision was preferred by 51.6% of surgeons, with 54.1% preferring a cruciform incision for the obliquus externus abdominis aponeurosis and 53.4% favoring blunt dissection during muscle mobilization. Less than half of the participants (46.4%) maintained a flexible attitude toward the length of the proximal intestine in permanent stomas. The peritoneum (or posterior rectus abdominis sheath), anterior rectus abdominis sheath, and skin were the most commonly used layers for fixation and suturing in temporary and permanent stomas. Finally, the opening direction was more commonly oriented along the long axis of the intestine (Table 5).
Part five of the survey examined the surgeons’ awareness of and utilization of enterostomy-related procedures (Table 6). Although awareness of these procedures was generally high, the rate of routine utilization remained low.
In the subgroup analysis based on professional title, participants were categorized as senior (chief and associate chief surgeons) or junior (attending and resident surgeons). No significant differences were observed between the two groups in most attitudes or technical maneuvers. However, weak but statistically significant associations were observed with respect to the source of acquiring ostomy knowledge, understanding of stoma positioning principles, site selection for temporary ileostomy or transverse colostomy, skin incision methods, management of subcutaneous tissue, fascia incision, and utilization of support rods (Supplementary Table 3).
In the subgroup analysis based on hospital grade, participants were further divided into tertiary general hospitals, tertiary specialized hospitals, and secondary or lower-level hospitals. In the univariate analysis, weak but statistically significant associations were observed in some comparisons of stoma-related concepts, concepts, training, and surgical procedures among the three groups (Supplementary Table 4). Surgeons working in tertiary general or specialized hospitals appeared to place greater emphasis on stoma creation training, theoretical knowledge, and understanding. Furthermore, differences were also observed in specific technical procedures.
DISCUSSION
The primary objective of this study was to characterize surgeons’ attitudes and practices regarding enterostomy and stoma-related complications. The principal findings of the study revealed that: (1) Surgeons demonstrated a positive attitude toward reducing the incidence of stoma-related complications through improved surgical techniques. However, the percentage of surgeons who had received relevant training was not high; (2) No significant differences were observed in self-reported attitudes toward enterostomy across different grades of surgeons, and the vast majority of surgeons exhibited high variation in stoma creation performance and predominantly relied on their own habits; and (3) Collaboration between surgeons and ETs appeared fragmented, indicating a lack of effective interdisciplinary cooperation.
Currently, indications for defunctioning stoma are becoming more widespread in oncological rectal resection as a result of population aging and the increasing use of neoadjuvant therapy[9], with stoma rates of up to 58.8%-73.5%[9]. The number of individuals living with a stoma in the United States has reached approximately 750000 and increases by 130000 annually[17]. The incidence of stoma-related complications can reach 70%, substantially affecting prognosis and quality of life[18]. Moreover, 20% of temporary stomas were eventually converted to permanent stomas because of complications[19], which often receive insufficient attention and are still traditionally classified according to time of occurrence (acute or chronic) or severity (minor or major)[20]. However, a simple and effective system for identifying, classifying, and grading stoma-related complications has yet to be established, limiting the efficiency of clinical practice. The Australian Nursing Association proposed a grading system that classifies stoma-related complications into three categories: Normal, parastomal, and peristomal. This framework provides an alternative approach to classification and offers a comprehensive summary of the sites and causes of these complications[21]. Similar efforts have been reported elsewhere; for example, multidisciplinary collaboration between Italian surgeons and nursing staff has resulted in consensus recommendations for enterostomy procedures and patient management[11]. Complications involve multiple structural levels, including stoma location, peristomal skin, subcutaneous wounds, abdominal wall tunneling, and mesenteric handling. Procedures performed at specific layers of the abdominal wall are associated with corresponding complications. A classification system linking complications to operative performance may be more suitable in clinical practice. Although complications are sometimes regarded as inevitable, many are in fact closely related to surgical procedures.
A significant number of surgeons, particularly senior surgeons, demonstrated limited attention to stoma construction and exhibited limited comprehension of emerging concepts and techniques. Based on these results, approximately 50% of the stomas were performed by attending or resident surgeons. Furthermore, nearly one-quarter of the departments did not emphasize training, and 40% of the surgeons had not participated in training programs designed for stoma creation. Interestingly, no differences were observed in self-reported attitudes toward enterostomy among surgeons of different grades, with some junior surgeons reporting greater awareness of relevant concepts. In addition, our findings are consistent with previous studies, suggesting that surgical approaches to stoma creation are primarily influenced by the surgeon’s preferences and habitual practices[5,6]. One possible explanation is the coexistence of heterogeneous local practices and multiple training curricula across China. However, China does not seem to be an exception, as international atlases also present inconsistent descriptions of stoma creation techniques[9,10,22]. Furthermore, a multicenter randomized controlled trial conducted in Sweden and Denmark evaluated whether different fascial incision techniques for end colostomy influence the development of parastomal hernias[23].
Stoma formation involves a fresh wound, an abdominal wall defect, and an open bowel, resulting in a structurally complex construct. Standard stoma creation includes skin incision, management of subcutaneous tissue, fascial incision, handling of abdominal wall muscles, peritoneal incision, bowel mobilization and extraction, bowel fixation, and stoma opening, all of which are associated with postoperative complications[4,24]. A multicenter retrospective study by Miyo et al[5] found that specific surgical techniques had a significant effect on stoma-related complications, and the risk factors included the length and shape of the skin incision, length of fascial incision, distance of the stoma from the ileocecal flap, segmentation of rods, and height of the stoma. Pilgrim et al[25] similarly reported that each 1-cm increase in stoma aperture diameter increased the risk of hernia by approximately 10%. However, most studies on the risk factors for stoma-related complications have focused on patient characteristics, such as advanced age, obesity, smoking, and poor nutritional status, which are challenging to modify in the short term[13]. Evidence addressing surgical techniques is scarce and retrospective, and various studies have reached conflicting conclusions[26,27]. The lack of systematic training and professional guidance from supervisory surgeons may lead to wide variation in surgical procedures. Drawing on training models from other surgeries[28], modularization of stoma construction and standardization of each step of the operation may be breakthroughs. Nevertheless, optimal maneuvers require further discussion and clinical research. Recognition of improper surgical practice as a major contributor to complications is essential, and the primary responsibility lies with the surgeon. Recent advances in structured surgical workflow modeling and simulation-based training have demonstrated that complex procedures can be decomposed into standardized phases and tasks, aiding in quality control and training. This approach has been widely adopted across various specialties, including cardiothoracic surgery, neurosurgery, and general surgery, further enhancing surgical efficiency and consistency[29,30]. Additionally, emerging artificial intelligence (AI) systems, such as real-time phase recognition and skill assessment, provide real-time feedback during surgery[31,32]. These technologies help improve surgical precision, safety, and consistency. Furthermore, AI-based simulation and training tools can accelerate the learning curve for junior surgeons, offering objective assessments and targeted feedback, ultimately enhancing overall surgical performance and outcomes.
Since Turnbull founded the School of Ostomy Therapy in 1961, stoma care has developed into a specialized profession, with ETs playing an indispensable role in the comprehensive management of patients with stomas[2]. The responsibilities of ET include preoperative stoma site marking, postoperative stoma care, and patient education after discharge[33]. Although ETs are intended to collaborate closely with surgeons, our study revealed insufficient communication and interaction between the two groups, which often operate in parallel rather than in a coordinated manner. Regarding stoma site marking, an international consensus, including the guidelines from the American Society of Colon and Rectal Surgeons, recognizes that standardized preoperative marking protocols performed by trained ETs can reduce complications[16]. However, this self-reported survey suggests that preoperative marking remains suboptimal, and site selection often depends on individual surgeon habits rather than standardized protocols. These findings may indicate the presence of barriers between surgeons and ETs, which could potentially limit the full benefits to patients[34].
Joint development of clinical standards together with interdisciplinary training programs may represent key priorities for future clinical practice[8,35,36]. Training programs should be developed with a patient-centered focus on preoperative assessments, perioperative management, and postoperative follow-up education. Preoperative evaluation should include selection of the appropriate stoma type based on the underlying disease, as well as individualized site selection according to patient-specific factors such as body habitus, distribution of skin folds, and belt line position. In this context, ETs may shift from point-based markings to region-based markings, allowing surgeons to make appropriate intraoperative adjustments. With regard to surgical training, the technical practices summarized in the fifth section of our questionnaire (Technical maneuvers) provide a practical reference, as they encompass operative steps across all tissue layers. Importantly, surgical techniques may need to be adapted according to stoma type. For temporary stomas, simplified suturing and fixation may not increase the risk of complication risk while facilitating subsequent stoma reversal. In contrast, for permanent stomas, strict adherence to fixation and suturing principles, with careful handling of muscle and subcutaneous tissues, may be critical for reducing long-term complications such as parastomal hernia. Nevertheless, details of each operative layer remain areas of active discussion and warrant consensus development to facilitate standardized procedures for different stoma types. Joint training programs could help ETs better understand the technical performance of different stoma types and tailor postoperative care while reducing the learning curve for junior surgeons and improving surgical quality.
The progress and development of enterostomies have been rapid. However, some studies have challenged this traditional approach. For instance, support rods were not recommended for routine use in the American guidelines (2022 version) and French guidelines (2023 version)[8,22] as a result of numerous studies showing that the use of rods in stoma creation does not reduce the risk of stoma retraction, but rather increases the risk of stomal edema, necrosis, and bleeding[14,15,37]. In addition, maintaining a certain stoma height is recommended to reduce fecal irritation to the surrounding skin[38]. The low-risk features and operational diversity of enterostomies render it difficult to obtain consistent and robust recommendations for their use. To deepen the understanding of enterostomies among surgeons, it is necessary to strengthen and update the study of basic theories, such as physiological changes in the structure of the abdominal wall and abdominal pressure[39,40]. Further basic experiments may lead to new solutions for stoma formation.
This study has several limitations. First, although efforts were made to ensure a broad regional and professional representation of surgeons across China, the use of convenience sampling may have introduced selection bias and limited the generalizability of the findings. In addition, the self-reported nature of the questionnaire may have led to recall bias. Second, the questionnaire raised issues that were primarily concerned with the perceptions and attitudes of the surgeons but still lacked real-world data as well as patient-level outcomes to support them, thereby limiting ability to infer the actual impact on patient care. Third, the scarcity of prior literature or established questionnaires in this field, together with the questionnaire design and exploratory nature of the analysis, may have limited the validity of our findings. Finally, it may not be possible to extrapolate our results from China to other Asian countries because of differences in training curricula, healthcare infrastructure, and surgical culture, which should be addressed in broader survey validation.
This study provides a nationwide overview of surgeons’ attitudes and practices regarding enterostomy management in China. Management of enterostomies depends on proper planning decisions, experienced surgeons, ETs, and systematic perioperative management strategies. We hoped that this article will raise surgeons’ awareness of enterostomy management and that detailed considerations will be given greater emphasis in clinical practice.
CONCLUSION
This national cross-sectional study revealed substantial heterogeneity in Chinese surgeons’ attitudes, knowledge, and technical practices regarding enterostomy and its management. A patient-centered training program, including modules for preoperative assessment, surgical quality control, postoperative care and follow-up, as well as multidisciplinary collaboration and joint training, may represent priorities in future clinical practice to improve patient outcomes.
ACKNOWLEDGEMENTS
We wish to acknowledge the support and encouragement provided by all participating surgeons and clinical staff for their contributions to this study.
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Corresponding Author's Membership in Professional Societies: Chinese Anti-Cancer Association.
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific quality: Grade C, Grade C, Grade C
Novelty: Grade B, Grade C, Grade C
Creativity or innovation: Grade B, Grade B, Grade C
Scientific significance: Grade C, Grade C, Grade C
P-Reviewer: Çiftçi B, PhD, Academic Fellow, Associate Professor, Türkiye; Tasci B, PhD, Associate Professor, Türkiye S-Editor: Bai Y L-Editor: A P-Editor: Wang WB
