The Prevalence of Ostomy-related Complications 1 Year After Ostomy Surgery: A Prospective, Descriptive, Clinical Study

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Ostomy Wound Management 2016;62(10):34–48
Eva Carlsson, PhD, RN, ET; Jeanette Fingren, RN, ET; Anne-marie Hallén, RN, ET, MSc; Charlotta Petersén, RN, ET, BSc; and Elisabet Lindholm, RN, Med Lic

Abstract

Despite advancements in the creation and care of stomas, ostomy and peristomal skin complications are common immediately following surgery as well as in the months and years thereafter. A prospective study to determine the prevalence of ostomy and peristomal skin complications and the influence of ostomy configuration on such complications was conducted 1 year after ostomy surgery among all patients at a university hospital in Sweden.

All participants received regular (10 to 14 days post discharge, 6 weeks, 3 months, 6 months, and 1 year post surgery) ostomy follow-up care by a wound ostomy continence (WOC) nurse. All consecutive elective and emergency patients who had undergone surgery to create a colostomy (end colostomy), end ileostomy, or loop ileostomy were eligible to participate. Patients who were reoperated during their first year post-surgery, patients with a urostomy, and patients with double ostomies were excluded from the study. Patient data collected included age, gender, diagnosis, elective or emergency surgery, open or laparoscopic surgical procedure, presence of a colorectal surgeon specialist at surgery, type of ostomy (colostomy, end ileostomy, loop ileostomy), preoperative ostomy siting, counseling, body mass index, American Society of Anesthesiologists classification, and radiation and/or chemotherapy status. Ostomies were evaluated by 4 WOC nurses as to stoma configuration, convexity use, patient self-sufficiency in stoma care, and complications. All 207 patients (53% women) who were eligible agreed to participate in the study. Patient median age was 70 years (range 19–94); 74% underwent elective surgery. Main diagnoses were colorectal cancer (62%) and inflammatory bowel disease (19%). Ostomy types were: colostomy (71%), end ileostomy (26%), and loop ileostomy (3%). One or more complications occurred in 35% of the patients (27% ostomy complications, 11% peristomal skin complications). A colostomy hernia was the most common surgical complication (20%), and significantly more women (69%) and emergency surgeries were noted among patients with a colostomy and an ostomy height of ≤5 mm. The use of convexity was significantly more common among patients with a stoma height of ≤5 mm than patients with stomas >5 mm (P = 0.016) and among patients having emergency operations than among patients having elective surgery (P = 0.045). Of the emergency surgeries, 37% had not been ostomy-sited (P <0.0001). With regular WOC nurse follow-up, the prevalence of peristomal skin complications in this population was low, and adequate ostomy height might have prevented the frequent use of convexity. Explorative studies are needed that consider differences in body configuration when determining optimal stoma height, especially for patients who require emergency surgery. 

 

According to retrospective and prospective studies, review articles, and best practice guidelines in the ostomy field,1-3 ostomy-related complications can affect daily life for the patient. Assessment, management, and follow-up of ostomy and peristomal skin complications such as parastomal hernia, stomal prolapse, stomal stenosis, peristomal irritant contact dermatitis, and peristomal candidiasis dermatitis are critical to help patients succeed in adapting to a new life with an ostomy.1-3 Although significant advances, such as the enhanced recovery after surgery protocol4 to optimize recovery (key components include preoperative carbohydrate loading, no overnight fasting, immediate postoperative diet, no nasogastric tubing, avoidance of drainage and early postoperative structured mobilization, and pain control) and new surgical techniques such as laparoscopic surgery5 and laparoscopic stoma formation6 that are now available for ostomy surgery along with newly developed ostomy equipment and ostomy care, ostomy-related complications are common. A systematic British review1 reported complication occurrence of between 10% and 82%. Evaluating and comparing studies is difficult due to factors such as study design, retrospectivity, patient selection, and differences in follow-up time. Systematic reviews of clinical retrospective and prospective studies and clinical guidelines1,2,8-10 demonstrate ostomy and peristomal skin complications also differ as to their definition and association with the different ostomy types. 

Correct preoperative ostomy siting, surgical construction of the ostomy, and careful follow-up of patients have been described in retrospective and prospective studies and systematic reviews8,11,12 as the most important factors in the prevention of ostomy-related complications. In a recent British retrospective study13 to determine the incidence of and risk factors for intestinal ostomy complications, significantly more complications were shown in patients who had not been preoperatively sited. The time of onset and presence of 10 specific complications were recorded for 1216 patients (mean age 64 years) with an intestinal stoma over 10 years at 2 hospitals; musculoskeletal comorbidity, diagnosis of cancer, emergency surgery, and high American Association of Anesthesiologists (ASA) score,14 which assesses the fitness of patients before surgery, also were associated with an increased risk of complications in the study. 

In a prospective British study15 that included 3970 stomas in patients from 93 ostomy care services, 34% were evaluated as problematic within 3 weeks of surgery. Ostomy height had the greatest individual influence on the incidence of a problematic ostomy; body mass index (BMI) and emergency surgery were shown to be significant risk factors for developing ostomy-related complications. In a previous prospective study16 at the authors’ institution, 180 patients with a colostomy (n = 122, median age 69), end ileostomy (n = 20, median age 59), or loop ileostomy (n = 38, median age 61) were followed over a 2-year period regarding ostomy height and diameter and its relation to complications. The results showed that 3 months after surgery, the end colostomies and end ileostomies had decreased in diameter by a mean of 10 mm and in height by 4 to 5 mm. The height and diameter of the stoma decreased postoperatively as part of the healing process, including reduction of mucosal edema of the stoma itself and postoperative abdominal edema. After 3 months, the size and shape of the stoma were generally established. However, almost all patients with an end ileostomy or loop ileostomy and with an ostomy height <20 mm had leakage and skin problems, as did half of the patients with an end colostomy and an ostomy height <5 mm. Thus, the height of the ostomy may affect the outcome of ostomy-related complications.15,16 

Findings from a systematic review3 including 4 different cross-sectional studies (N = unclear) and 3 longitudinal studies (N = 5037) to determine the influence of intestinal ostomy surgery on health-related quality of life (HRQOL) showed impairment regarding HRQOL domains was most severe during the immediate postoperative period,  improved most dramatically during the third postoperative month, and continued to improve gradually during the first operative year. This is in line with a previous explorative prospective study17 at the authors’ institution where 57 patients who received an end colostomy because of rectal cancer completed a validated HRQOL questionnaire (Short-Form-36) preoperatively and 3 times during the 6-month follow-up period. The HRQOL post surgery (3 times) showed a significant drop in HRQOL occurred at 1 month compared to preoperatively; at 6 months, significant differences were noted in physical and emotional role functions and social function compared to a matched reference population. As reported in these studies,3,17 HRQOL tends to steadily rise during the first postoperative year after ostomy surgery. Moreover, 1 year after ostomy surgery, patients could be expected to have recovered from their surgery and after any necessary additional treatments could start their new life. 

The aim of this study was to prospectively describe the prevalence of ostomy and peristomal skin complications 1 year after ostomy surgery. A secondary aim was to describe ostomy configuration (diameter, height, and shape) and its influence on ostomy and peristomal skin complications. 

Methods

This explorative study was based on clinical assessments of ostomy and peristomal skin complications 1-year post surgery, with patients consecutively included from September 2009 to March 2012. The study took place at a university hospital in Sweden. All elective and emergency patients who had undergone surgery to create a colostomy (end colostomy), end ileostomy, or loop ileostomy were prospectively included. Patients who were reoperated during their first year post surgery, patients with a urostomy, and patients with double ostomies were excluded from the study. The included patients had regular postoperative follow-up by a wound ostomy continence (WOC) nurse on the ward and at the outpatient WOC nurse clinic at the following intervals: 10 to 14 days post-discharge, 6 weeks, 3 months, 6 months, and 1 year post surgery. Four (4) WOC nurses with a median professional experience of 15 years (range 5–23) in evaluating ostomy and peristomal skin complications performed the assessment 1 year post surgery.

Study variables and assessment. All variables included in the study were based on a review of the literature and an earlier study performed at the authors’ institution.16 The study variables were evaluated and recorded on a specially designed case report form developed for the study by the researchers. Demographic data included age, gender, diagnosis, elective or emergency surgery, open or laparoscopic surgical procedure, presence of a colorectal surgeon specialist at surgery, type of ostomy (colostomy, end ileostomy, loop ileostomy), preoperative ostomy siting (Yes/No), and counseling (Yes/No). The preoperative ostomy siting was performed according to recommendations from the Wound Ostomy Continence Nurses Society and the American Society of Colon and Rectal Surgeons.18 Variables to assess patient physical condition at the time of surgery were BMI and ASA classification,14 the latter a measurement of physical health, coexisting medical disease, and physiological stability (grade I = healthy person, grade II = mild systemic disease, grade III = severe systemic disease,  and grade IV = severe systemic disease that is a constant threat to life). The presence or absence of preoperative radiation treatment and chemotherapy treatment also were recorded due to possible influence on complications (see Table 1).2,19,20 owm_1016_carlsson_table1

Ostomy complications. Ostomy complications were assessed using the definitions established by validation in the study by Colwell and Beitz.9 The stomal and peristomal definitions was content-validated by 686 WOC nurses. The overall content validity index was 0.91, demonstrating high consensus validation on the stomal and peristomal definitions. The ostomy complications evaluated in the present study included parastomal hernia (a defect in abdominal fascia that allows the intestine to bulge into the parastomal area), stomal retraction (the disappearance of normal stomal protrusion in line with or below skin level), stomal stenosis (impairment of effluent drainage to narrowing or contracting of the stoma tissue at skin of fascia level), and stomal prolapse (telescoping of the intestine through the stoma and granuloma). According to Lyon,21 a specialist dermatologist in stoma care, granulomas are characterized by papular, benign tumors appearing around stomas; they have a cauliflower appearance, are friable, bleed easily, usually occur at the mucocutaneous junction, and often precipitate stoma appliance leaks. They are caused mainly by fecal irritation.21 At the time of the present study, prophylactic mesh was not used for prevention of a parastomal hernia. When the WOC nurse detected a parastomal hernia at follow-up, the colorectal surgeon was consulted to determine the final diagnosis. A CT was not used routinely in the clinical setting in the diagnosis of a parastomal hernia. 

Peristomal skin complications. Peristomal skin complications were evaluated according to Classification of the Peristomal Skin (CPS).22 The variables included in CPS are detailed in Table 2. The classification was developed by a WOC nurse and a dermatologist who evaluated peristomal skin in 57 patients with ileal conduit urinary diversions (37 men and 20 women, mean age 61 years, time after surgery 3 to 14 years). The peristomal skin was evaluated at 2 unspecified separate occasions, and the macroscopic status of the peristomal skin was recorded on a case report form and further documented by color photographs of the peristomal skin. Analyses of these observations and color photographs formed the basis for a CPS. owm_1016_carlsson_table2

Peristomal skin status was categorized as: 1) no signs of irritative skin lesions E0/P0; 2) erythematous-erosive skin lesions, divided into mild, E+, and severe E++; and 3) pseudoverrucouse lesions divided into mild, P+, and severe P++. The different type of skin lesions can appear separately or in combination. Peristomal skin complication in the present study was documented in the case report form according to Table 2; if an ulcer was not included in the CPS, an open-ended question was added to document possible causes for peristomal skin complications. The CPS has been used to follow-up ostomy complications in both urinary and fecal ostomies by WOC nurses in Sweden since its development.

Ostomy configuration. A half-circular ostomy guide consisting of different sizes in mm was used to measure ostomy diameter and height as in a previous study.16 The diameter of the ostomy was measured at the base and the shape (round or oval), and >3-mm differences in diameter (using a clock-style guide) and height (distance of the ostomy lumen from the skin) noted. This ostomy guide is generally used at the follow-up of all patients with an ostomy at the clinic and was not developed specifically for this study. A low ostomy was classified as ≤5 mm for an end colostomy and ≤20 mm for an ileostomy. 

Skin care and self-sufficiency in ostomy care. Skin care instructions were provided during preoperative counseling as well as postoperatively in the hospital when the patient started learning about the stoma and stoma care. The WOC nurse provided at least 1 patient education session postoperatively and also a discharge consultation. Skin care also was discussed and assessed during counseling at follow-ups during the first year. The patient’s ability to manage the ostomy by him/herself was evaluated by the WOC nurse at every follow-up at the clinic through conversation with the patient and observation. 

Type of appliance. Convexity was assessed for patients using a 1-piece or 2-piece appliance. Convexity was defined according to an overview23 of peristomal skin complications as the outward curving of a baseplate that provides support to the ostomy and prevents the ostomy from lying flush to the skin or retracting. Convex appliances are used with retracted and low ostomies to prevent leakage and peristomal skin complications. 

Data and statistical analysis. All study variables were transferred to a data file and divided into 2 categories: patients with complications and patients without complications 1 year post surgery. Descriptive statistics were reported as mean, SD, median, interquartile range, and range based on the level of measurement for the outcome variable. Because the data were not distributed normally, inferential analysis was based on nonparametric analysis techniques. Continuous variables were analyzed using the Mann-Whitney U test. Categorical data were analyzed with Fisher’s Exact and chi-squared tests. A P value of <0.05 was considered significant. Data were analyzed using IBM SPSS Statistics for Windows, Version 22.0 (Armonk, NY). 

Ethical considerations. The patients were informed about the study both orally and in writing at the outpatient clinic and gave their informed consent in writing. Patient confidentiality was secured by assigning a unique code that was entered into the data sheet. The coding list was stored separately in a locked cabinet. The research project was approved by the regional ethical review board in Gothenburg (Reg. no. Ö176-03) and followed the declaration of Helsinki guidelines. 

Results 

Clinical data. The study included 207 patients (53% women) with a median age of 70 years (range 19–94 years) of whom 153 (74%) underwent elective surgery. The main diagnoses were colorectal cancer (128, 62%) and inflammatory bowel disease (40, 19%). A colorectal surgeon specialist participated in all elective and emergency operations. Ostomy types included colostomy (146, 71%), end ileostomy (54, 26%), and loop ileostomy (7, 3%). Among participants, 182 (88%) had their ostomy location evaluated and marked preoperatively, 164 (79%) received preoperative counseling by a WOC nurse, and 183 (88%) were self-sufficient in ostomy care (see Table 1). 

Complications. Of the 207 patients, 73 (35%) had 1 or more complications, 56 (27%) had ostomy complications, and 23 (11%) had peristomal skin complications. No significant differences were noted between patients who had undergone elective surgery versus emergency surgery or those who had or had not been preoperatively ostomy sited (see Table 1). Of the 54 (26%) patients that had undergone emergency surgery, 20 (37%) were not sited preoperatively compared to 5 of 153 (3%) patients who had nonemergent surgery (P <0.0001). Of the emergency surgeries, 24 (44%) had an ASA classification of III+IV, compared to 41 (27%) in the elective group (P = 0.03). 

Ostomy complications. Overall, 56 stomas (27%) had ostomy complications at 1 year: 29 (20%) with a colostomy and 3 (6%) with an end ileostomy had a parastomal hernia evaluated by the WOC nurse. Of the 29 patients with a colostomy, 24 were evaluated as having a parastomal hernia by the surgeon, 4 were not examined, and for 1 patient the surgeon was uncertain of the diagnosis. The 4 patients that were not examined by a surgeon did not experience any problems with the colostomy hernia and were residing in nursing homes. Twenty-two (22) patients (76%) with a colostomy hernia experienced complications that included a dragging/heavy sensation, a dull ache, leakage (3), bowel evacuation problems, clothing problems, and anxiety. Sixteen (16) patients used a hernia belt, and 6 used a support belt. All 3 patients with an end ileostomy and a hernia were worried and concerned about their hernia. 

Additional complications at 1-year follow-up included granulomas almost equally distributed between the ostomies (13 patients, 6.3%), retraction (5 patients, 2.4%), stenosis (3 patients, 1.4%), and prolapse (2 patients with a colostomy, 1%). 

Peristomal skin complications. Among all patients with peristomal skin complications (23, 11%), 9 patients (6%) had a colostomy and 14 (23%) had an end ileostomy or loop ileostomy (P = 0.002). Among the patients with peristomal skin complications, 16 had mild erythematous-erosive skin lesions (E+), 5 had severe erythematous-erosive skin lesions (E++), and 2 had ulcerations diagnosed as pyoderma gangrenosum (see Table 2).

Peristomal skin complications were related to 3 factors (see Figure 1): the construction of the ostomy (stenosis, sliding ostomy, ostomy opening/lumen at skin level); peristomal skin disease (unspecific dermatitis around the ostomy, candidiasis, pyoderma gangrenosum, no obvious reason, and skin irritation at the outer part of the appliance); or appliance- or routine-related issues (pressure from convexity, ostomy appliance worn for too long, rich hair growth, leakage, or the ostomy appliance opening was too large). owm_1016_carlsson_figure1

Ostomy shape and height and clinical variables. The majority of colostomy and end ileostomy sites in this study were round (89%, 130 colostomies and 48 ileostomies ). The ostomy configurations in different ostomy types are shown in Table 3. Sixty-one (61) patients (41.8%) with a colostomy had an ostomy height ≤5 mm (see Table 4); these included significantly more women (P = 0.002). In addition, significantly more emergency surgeries were noted among persons with an ostomy height of ≤5 mm (P <0.045). A colostomy height of ≤5 mm was significantly associated with the presence of a parastomal hernia (P = 0.020) and use of convexity (P = 0.016). No significant differences in complications were noted in end ileostomies ≤20 mm compared to >20 mm, although 15 patients (39.5%) used convexity in ostomies with a lower ostomy height compared to 3 (18.8%) of the ileostomies >20 mm (see Table 4).

owm_1016_carlsson_table3owm_1016_carlsson_table4

Type of ostomy appliance. The majority of patients (103 [71%] colostomy, 48 [78%] ileostomy/loop ileostomy) used a 1-piece appliance. Overall, use of convexity included 43 patients (29%) with an end colostomy, 18 patients (33%) with an end colostomy, and 3 patients (43%) with a loop ileostomy. Of the patients that had undergone emergency surgery, 25 (46%) used convexity compared to 38 (25%) having nonemergent surgery (P = 0.006). 

Discussion  

The principal findings of this prospective study in which 207 patients received regular and standardized follow-up care by a WOC nurse during the first year after stoma surgery are that, after 1 year, 35% of this patient population had 1 or more complications. More than a quarter of the patients (27%) had ostomy complications, and 11% had peristomal skin complications. The majority (88%) of all patients had their ostomy location evaluated and marked preoperatively and were able to manage their ostomy themselves, but 20 (37%) patients that had undergone emergency surgery had not had their ostomy preoperatively sited. 

A colostomy height of ≤5 mm (versus >5 mm) was more common in women (69%) (P = 0.002) and in patients who had emergency surgery (P = 0.045), and this was associated with a parastomal hernia (P = 0.020) and use of convexity (P = 0.016). Regular follow-up during the first year after ostomy surgery meant patients’ ostomy-related problems were evaluated, diagnosed, and treated or referred to a dermatologist. This, in addition to the shorter patient follow-up time in the cited studies, may help explain the low prevalence of peristomal skin complications (11%) in this study compared to 2 previously published studies  — a prospective cohort study from the United Kingdom24 and a cross-sectional study from Denmark25 in which patients did not receive regular follow-up care. In the British study,24 patients that had been operated during a 10-year period and did not have regular follow-up regarding their stoma were invited to attend a clinic to have their skin problems assessed by a dermatologist and a stoma care specialist nurse. Of the 323 participating patients, 73% had skin problems that affected normal ostomy appliance use. In the Danish study,25 all individuals with a permanent stoma in a Danish community population (N = 630) were invited to participate. The study reported peristomal skin disorders were higher for participants with an ileostomy (57%) or urostomy (48%) than a colostomy (35%). Of the diagnoses of skin disorders, 77% could be related to contact with stoma effluent. More than 80% of the participants did not seek professional health care. The authors concluded more education and annual follow-up visits at local stoma care clinics were needed. 

The present study also included causes for peristomal skin complications (see Figure 1) rarely reported in literature. The peristomal skin complications in the present study were related to 3 factors (see Figure 1): the construction of the ostomy (stenosis, sliding ostomy, ostomy opening/lumen at skin level); peristomal skin disease (unspecific dermatitis around the ostomy, candidiasis, pyoderma gangrenosum, no obvious reason, and skin irritation at the outer part of the appliance); or appliance- or routine-related (pressure from convexity, ostomy appliance worn for too long, rich hair growth, leakage, or the ostomy appliance opening was too large). 

Previous studies24,25 have shown a high number of peristomal skin complications, in contrast to the present study, where stoma-related complications were more frequent (27%) and parastomal hernia was the most frequent complication (20%) in patients with a colostomy. The incidence of a parastomal hernia increases over time. A literature review by Shabbir and Britton7 of studies addressing complications associated with stoma formation published between 1980 and 2008 showed an occurrence of parastomal hernia ranging from 4% to 48%. In a previous longitudinal study16 at the authors’ institution, 122 patients with a colostomy were included, but only 67 remained to follow-up at the 1-year visit, and prevalence of parastomal hernia after 1 year was 10%. In the present study, 3 times as many patients were evaluated than in the previous study,16 the majority (22 of 29) of whom experienced a parastomal colostomy hernia and were concerned about the hernia, which influenced clothing choice and caused a dragging sensation, aches, and anxiety. A nonsystematic review of American literature by Kwiatt and Kawata8 showed hernia repair or relocation of the ostomy to the other side of the abdomen to surgically fix the parastomal hernia did not show promising results; recurrence rates ranging from 46% to 100% in hernia repair and 24% and 40% in relocation have been reported. 

Granulomas can influence ostomy appliance fit, and patients worry because they cause bleeding. In the present study, 6.3% of patients had granulomas, which was lower than in 2 previous prospective studies  — 1 from the Netherlands26 reporting 10% and 1 from the authors’ institution16 reporting 9% granulomas, respectively. Two (2) patients (1%) in the current study developed colostomy prolapse, which is lower than the 6% reported 1-year post-surgery study in the Netherlands’ study that included 100 patients (mean age 67, 48% women and 41% emergency surgery) and 8 follow-up time points. 

It is important to distinguish between peristomal skin complications in colostomies (6% in this study) and end ileostomies (23% in this study), a statistically significant difference. However, the majority (70%) of complications in this study were classified as mild. The regular follow-up by the 4 WOC nurses may have prevented difficult cases of peristomal skin complications from occurring. In the present study, only 6% of patients with a colostomy had peristomal skin complications and only 2% of patients had problems with leakage compared to 41% and 59%, respectively, in a recent population-based, cross-sectional Danish survey study27 that included 644 patients (response rate 88%) with a permanent ostomy created due to rectal cancer (median age 72, 64% men). The study used a nonvalidated patient questionnaire developed by experts (no WOC nurse) that was revised after patient evaluation. Quality of life was reported to be affected by the stoma in 68% of patients; the authors concluded that the high number of patients reporting leakage and skin problems indicated a need for restructuring patient counseling. Likewise, in a systematic review from the US,3 patients reporting severe peristomal skin complications, severe leakage, and severe problems adjusting to the ostomy were noted to have significantly lower HRQOL scores than patients reporting less severe or no problems.3 

The number of patients preoperatively sited before ostomy surgery varies. In 2 large retrospective studies, 1 from Turkey12 where only 38% were preoperatively sited and 1 from the United Kingdom13 where 89% were preoperatively sited, complication rates were significantly higher in patients that were not preoperatively sited. The Turkish study sought to determine the effect of stoma site marking on stomal and peristomal complications and included 748 patients (mean age 56.6, men 54.5%). Complications were significantly higher in patients where the stoma site was not marked than among those whose stoma site was marked (22.9% and 46%, respectively, P <0.001). Stomal/peristomal complications developed in 248 patients; the most frequently observed complications were peristomal skin complications (49%) followed by mucocutaneous separation (18.6%) and retraction (11%).  

A 2-year, prospective study from Israel11 that included 105 patients with a colostomy or ileostomy (median age 65, 57% men) undergoing elective surgery studied the impact of preoperative ostomy site marking on different parameters. The results showed the stoma site of 49.5% of patients was preoperatively selected. In the preoperatively sited patients, complication rates were significantly lower and independence parameters and quality-of-life scores were significantly higher than in those whose stoma site was not preoperatively selected. In the present study, 88% were preoperatively ostomy-sited, similar to the study by Nastro,13 but no differences in complications between groups were noted. 

One of the most important issues for a patient to be able to start a new life with an ostomy is managing its care. In the present study, 88% were self-sufficient in ostomy care compared to only 15% in the previously cited study from Israel.11 The protective influence preoperatively and continued involvement of a WOC nurse have been reported to prevent progression of relatively common minor problems to more severe conditions.1,2,8,18

In a Danish case control study,28 BMI >30 was directly associated with skin complications. In that study, the importance of suggested risk factors for developing skin complications was studied in a group of patients with an ostomy from the general population. Of the 199 participants, 45% exhibited a skin problem for which they had not sought help.   The retrospective study by Nastro et al,13 with a minimum 2-year follow-up, found that a BMI >25 was a risk factor for the development of a parastomal hernia. A prospective study by Cottam et al15 of 3970 ostomies found problematic stomas when patients had a mean BMI of 25.4. The current study found no association between a higher BMI and complications. However, BMI may not be the only important variable because the body configuration of men and women can differ. In a cross sectional Finnish study29 of 132 patients in their early forties, women were reported to have twice as much subcutaneous abdominal fat as men (P <0.0001). This could be one of the reasons why significantly more women had a colostomy height ≤5 mm in the present study. 

The risk of developing a major ostomy complication has been calculated to be about 1 in 3 patients with ASA I or II and no musculoskeletal comorbidities whose ostomy was preoperatively sited before operation and who underwent surgery for indications other than cancer.13 In the present study, 35% of the participants had complications and more patients presented with ASA III+IV among those who underwent emergency surgery, but no differences in stoma-related complications were noted (see Table 1). One contributing factor could be that a colorectal surgeon specialist participated in all elective and emergency operations. 

Selecting ostomy appliances that are appropriate for the type of stoma, the size and contour of the stoma, and type and volume of effluent is important to preventing peristomal skin complications related to product selection. The appliances may need to be refitted in the recovery period after surgery or when the body weight increases or decreases significantly.1 The WOC nurse has numerous options to address complications such as leakage, ostomy complication or peristomal skin compromise, adjusting the appliance to fit the size and contour of the ostomy, and using different aids adapted for ostomy care. 

An ostomy appliance with convexity can be of help in avoiding stool leakage because it allows the ostomy to protrude more when the ostomy height is low. Convex appliances are more expensive but can solve problems such as stoma retraction and low ostomy and prevent leakage, especially if surgical revision of an ostomy is not possible. The present study data related to convexity use show a higher rate of convexity usage than in a previous study performed at the authors’ institution16 and also in comparison to the prospective study by Arumugam et al10 that was designed to determine the nature of complications and their relationship with various risk-factors and their management. Among the 97 patients (mean age 65) studied, complications developed in 50.5% of ostomies and 22% of patients (colostomy and ileostomy) used convexity compared to 31% in the same ostomy types in the present study where convexity use was related to ostomy height. Patients with an end colostomy with a height of ≤5 mm had significantly more use of convexity (P = 0.016), and patients with an ileostomy with an ostomy height of ≤20 mm used convexity more frequently (39.5%) than patients with an ileostomy height >20 mm (18.8%), although the difference was not significant. In cases of emergency surgery, as many as 46% of patients used an appliance with convexity 1 year post surgery. Despite the high use of convexity and its reported risk of causing pressure to the skin,2,21 only 1 patient in the study had a peristomal skin complication related to convexity use (see Figure 1). The patients in the present study were carefully followed by a WOC nurse, and their ostomy-related problems were treated (eg, topical medications, adjusting the size of the appliance to fit the size and contour of the ostomy, use of convexity) during the 1-year follow-up period, which probably contributes to the low number of peristomal skin complications compared to other studies.24,25,27 

The frequency of parastomal hernia needs to be reduced. However, the responsibility for the construction of an ostomy lies with the surgeon. Several studies of the prevention of parastomal hernias are ongoing at the authors’ institution30 and worldwide (personal communication). According to best practice guidelines from the WOCN,2 several factors may reduce the risk of developing a hernia: patients should lose excess weight before surgery, stop smoking, use abdominal support belts and garments when doing heavy lifting or heavy work, and abstain from active abdominal exercises or lifting heavy objects for at least 3 months following surgery. However, the evidence is not strong for some of these recommendations (eg, support belts, lifting heavy objects) and further studies are needed. Of note: convexity is not (but can address problems) related to parastomal hernia.

An ostomy should be constructed to an adequate length15,16 that takes into account differences in body configuration, especially during emergency surgery. Surgeons and WOC nurses also need to develop strategies for enabling preoperative ostomy siting on patients regardless of time of day. These measures could significantly improve the situation for patients undergoing ostomy surgery.12-14 Moreover, WOC nurses need to address ostomy-related complications as well as investigate their underlying causes. In the present study, the 3 factors most commonly noted for patients with peristomal skin complications were related to 1) the construction of the stoma, 2) the presence of peristomal skin disease, and/or 3) the ostomy appliance or appliance routines used by patients (see Figure 1). Surgeons13 and WOC nurses3 believe the number of ostomy-related complications described in the literature underestimate the actual incidence because many ostomy-related problems are solved by a WOC nurse and not brought to the surgeon’s attention. If problems are related to ostomy construction, WOC nurses should communicate and discuss this with the surgeons so improvements can be made; surgeons need to collaborate more with WOC nurses when performing studies regarding ostomy-related complications. This, in turn, may help prevent complications, which will reduce health care costs for ostomy equipment (number of pouches used, convexity use) and outpatient visits while ultimately, improving patient quality of life. More studies are needed that use a prospective design, are consistent operational definitions, use valid and reliable measurement methods, and involve colorectal surgeons and WOC nurses as equal partners. These recommendations will help increase the availability of standardized data to make comparisons among studies possible.

Limitations

A limitation of the study is that surgeons knew WOC nurses had diagnosed a parastomal hernia when they conducted their evaluation. The surgeon and WOC nurse should have assessed the hernia simultaneously but independently of each other, and a further CT scan would have strengthened the diagnosis. The study was conducted in 1 hospital with 4 experienced WOC nurses following a detailed protocol of patient follow-up. The external validity of these study results remain to be examined. 

Conclusion

In a clinical study that investigated ostomy and peristomal complications 1 year post surgery, the number of peristomal skin complications was low (11%) compared to other studies. Regular follow-up by a WOC nurse and standardized measures after ostomy construction seemed to be a factor in the low prevalence of peristomal skin complications observed. Convexity use was related to ostomy height, suggesting the need for increased ostomy height. Explorative prospective studies are needed that consider differences in body configuration when determining stoma height at the time of ostomy construction with special attention to patients requiring emergency surgery. 

References 

1. Stelton S, Zulkowski K, Ayello EA. Practice implications for peristomal skin assessment and care from the 2014 World Council of Enterostomal Therapists International Ostomy Guideline. Adv Skin Wound Care. 2015;28(6):275–284.

2. Wound Ostomy and Continence Nurses Society. Stoma Complications: Best Practice for Clinicians. Mt. Laurel, NJ;2014.  

3. Pittman J, Kozell K, Gray M. Should WOC nurses measure health-related quality of life in patients undergoing intestinal ostomy surgery? J Wound Ostomy Continence Nurs. 2009;36(3):254–265.

4. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630–641.

5. Bonjer HJ, Deijen CL, Abis GA, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med. 2015;372(14):1324–1332.

6. Abbas MA, Tejirian T. Laparoscopic stoma formation. J Soc Laparoscop Surg. 2008;12(2):159–161.

7. Shabbir J, Britton DC. Stoma complications: a literature overview. Colorectal Dis. 2010;12(10):958–964.

8. Kwiatt M, Kawata M. Avoidance and management of stomal complications. Clin Colon Rectal Surg. 2013;26(2):112–121.

9. Colwell JC, Beitz J. Survey of wound, ostomy and continence (WOC) nurse clinicians on stomal and peristomal complications: a content validation study. J Wound Ostomy Continence Nurs. 2007;34(1):57–69.

10. Arumugam PJ, Bevan L, Macdonald L, et al. A prospective audit of stomas—analysis of risk factors and complications and their management. Colorectal Dis. 2003;5(1):49–52.

11. Person B, Ifargan R, Lachter J, Duek SD, Kluger Y, Assalia A. The impact of preoperative stoma site marking on the incidence of complications, quality of life, and patient’s independence. Dis Colon Rectum. 2012;55(7):783–787.

12. Baykara ZG, Demir SG, Karadag A, et al. A multicenter, retrospective study to evaluate the effect of preoperative stoma site marking on stomal and peristomal complications. Ostomy Wound Manage. 2014;60(5):16–26.

13. Nastro P, Knowles CH, McGrath A, Heyman B, Porrett TR, Lunniss PJ. Complications of intestinal stomas. Br J Surg. 2010;97(12):1885–1889.

14. The American Society of Anesthesiologists. ASA. New classification of physical status. Anesthesiology. 1963(24):111.

15. Cottam J, Richards K, Hasted A, Blackman A. Results of a nationwide prospective audit of stoma complications within 3 weeks of surgery. Colorectal Dis. 2007;9(9):834–838.

16. Persson E, Berndtsson I, Carlsson E, Hallen AM, Lindholm E. Ostomy related complications and ostomy size — a two year follow-up. Colorectal Dis. 2010;12(10):971–976.

17. Carlsson E, Berndtsson I, Hallen AM, Lindholm E, Persson E. Concerns and quality of life before surgery and during the recovery period in patients with rectal cancer and an ostomy. J Wound Ostomy Continence Nurs. 2010;37(6):654–661.

18. Wound Ostomy Continence Nurses Society (WOCN). ASCRS and WOCN joint position statement on the value of preoperative stoma marking for patients undergoing fecal ostomy surgery. J Wound Ostomy Continence Nurs. 2007;34(6):627–628.

19. Rolstad BS, Erwin-Toth PL. Peristomal skin complications: prevention and management. Ostomy Wound Manage. 2004;50(9):68–77.

20. Lavery I, Erwin-Toth PL. Stoma therapy. In: Cataldo P, MacKeigan J, eds. Intestinal Stomas: Principles, Techniques, and Management, 2nd ed. New York, NY: Marcel Dekker;2004.

21. Lyon CC, Smith A. Abdominal Stomas and Their Skin Disorders: An Atlas of Diagnosis and Management, 2nd ed. London, UK: Informa Healthcare;2010.

22. Borglund E, Nordstrom G, Nyman CR. Classification of peristomal skin changes in patients with urostomy. J Am Acad Dermatol. 1988;19(4):623–628.

23. Erwin-Toth P, Stricker LJ, Rijswijk L. Wound wise: peristomal skin complications. Am J Nurs. 2010;110(2):43–48.

24. Lyon CC, Smith AJ, Griffiths CE, Beck MH. The spectrum of skin disorders in abdominal stoma patients. Br J Dermatol. 2000;143(6):1248–1260.

25. Herlufsen P, Olsen AG, Carlsen B, et al. Study of peristomal skin disorders in patients with permanent stomas. Br J Nurs. 2006;15(16):854–862.

26. Formijne Jonkers HA, Draaisma WA, Roskott AM, van Overbeeke AJ, Broeders IA, Consten EC. Early complications after stoma formation: a prospective cohort study in 100 patients with 1-year follow-up. Int J Colorectal Dis. 2012;27(8):1095–1099.

27. Feddern ML, Emmertsen KJ, Laurberg S. Life with a stoma after curative resection for rectal cancer. A population-based, cross-sectional study. Colorectal Dis. 2015;17(11):1011–1017.

28. Nybaek H, Bang Knudsen D, Norgaard Laursen T, Karlsmark T, Jemec GB. Skin problems in ostomy patients: a case-control study of risk factors. Acta Derm Venereol. 2009;89(1):64–67.

29. Westerbacka J, Corner A, Tiikkainen M, et al. Women and men have similar amounts of liver and intra-abdominal fat, despite more subcutaneous fat in women: implications for sex differences in markers of cardiovascular risk. Diabetologia. 2004;47(8):1360–1369.

30. Correa Marinez A, Erestam S, Haglind E, et al. Stoma—the technical aspects of stoma construction: study protocol for a randomised controlled trial. Trials. 2014;15(254):1–7.

 

Potential Conflicts of Interest: none disclosed

 

Dr. Carlsson is a registered nurse, enterostomal therapist, and lecturer, Surgical Department, Institute of Clinical Sciences, Sahlgrenska University Hospital/Östra and Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Sweden. Ms. Fingren, Ms. Hallén, and Ms. Petersén are registered nurses and enterostomal therapists, Surgical Department, Institute of Clinical Sciences, Sahlgrenska University Hospital/Östra. Ms. Lindholm is a registered nurse and research nurse, Surgical Department, Institute of Clinical Sciences, Sahlgrenska University Hospital/Östra. Please address correspondence to: Eva Carlsson, PhD, RN, ET, Surgical Department, Colorectal Unit, Sahlgrenska University Hospital/Östra Diagnosvägen 11, Gothenburg 416 85 Sweden; email: eva.k.carlsson@vgregion.se.

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