Stoma Complications: Conservative Management

INTRODUCTION

Over 150,000 ostomies are created in the United States each year to treat benign and malignant bowel conditions. These surgeries may be elective or emergent, resulting in a temporary or permanent stoma. While an ostomy can radically improve a person’s health, stoma-related complications may profoundly impact physical and mental health plus quality of life (QoL).

The reported incidence of postsurgical stoma complications, whether early (occur within 30 days of surgery) or late (occur 30 days after surgery), ranges from 21% to 70%. Such a high incidence rate is associated with economic burden due to increased length of hospital stay, readmissions, and supply costs. An interdisciplinary team approach including Wound Ostomy Continence (WOC) nurse is essential in identifying stoma complications and providing effective care.

This chapter will discuss commonly seen stoma complications and provide detailed conservative management including stoma site marking, peristomal skin breakdown, allergic contact dermatitis, retraction, hernia, prolapse, pyoderma gangrenosum (PG), and stomal intubation as novel lavage therapy.

STOMA SITE MARKING

A 2015 joint statement by the American Society of Colon and Rectal Surgeons (ASCRS) and the Wound Ostomy Continence Nurse Society (WOCN Society) recommend that patients likely to undergo ostomy surgery engage in a preoperative meeting with a trained professional (such as a WOC nurse) that incorporates counseling and stoma site marking of all patients, even if the stoma is likely temporary. Preoperative counseling and stoma site marking are linked to positive QoL perceptions. ^, In time-sensitive circumstances such as emergent surgery, up to 37% of patients who receive an ostomy are not seen by a WOC nurse for stoma site marking. Patients with an unfavorable stoma site have an increased risk of a poorly fit ostomy appliance, leakage, and difficulty with independent stoma care. Clinicians need to familiarize themselves with the principles of proper stoma site selection ( Fig. 19.1 ).

In the 2015 WOCN Society and ASCRS Position Statement on preoperative stoma site marking, the stoma site is proposed to be located within the rectus abdominis muscle, away from skin folds, creases, herniation, scar or suture lines, and at the apex of an abdominal contour. It is important to prioritize a flat, pouching surface, that is visible to the patient. When an abdomen is protuberant, we choose the apex of the abdominal contour. For patients with extreme obesity, we consider marking the site in an upper abdominal quadrant, where the adipose layer is less thick, and allows better visualization of the stoma. For patients who are wheelchair dependent or contracted, we consider the upper quadrants and ensure the pouch placement does not interfere with mobility. With multiple stoma sites, urinary and fecal stomas, we consider marking sites on different horizontal planes in case an ostomy belt is needed. When possible, we place a mark below the beltline to conceal the pouch, ensure the mark is visible to the patient, and consider the length of the pouch in proportion to the patient’s waist and pelvis ( Fig. 19.2 and Table 19.1 ).

Table 19.1

Stoma Site Marking Procedure

1	Determine surgical procedure and gather items including an indelible surgical marker, transparent film dressing, and skin barrier (when available).
2	Explain the stoma site marking procedure to the patient and encourage engagement in the site selection.
3	Assess the patient fully clothed in a seated position with feet level on the floor. Identify the beltline and note any braces or additional ostomy pouches. If a patient uses a wheelchair or assistive device, assess them in their natural position.
4	Have the patient remove obstructive clothing and examine the abdomen in various positions such as sitting, lying, bending forward, and standing. Assess for irregularities in abdominal topography such as creases, contractions, skin folds, scars, herniation, and pendulous breasts.
5	While the patient is lying supine, palpate the rectus abdominis muscles by asking the patient to raise their head off the bed surface and to cough while palpating the edge of the rectus abdominis. During this time, consider the surgical incision location and choose an area where the stoma will be 2 inches away from the incision. This will allow for a flat, pouching surface where the skin barrier can stick securely.
6	Clean skin with rubbing alcohol and let dry. When a skin barrier is available, align the skin barrier in the optimal location and mark the center of the skin barrier opening with an indelible marker in the rectus muscle.
7	Have the patient change position from lying to sitting and bending forward to assess for any abdominal creases and skin folds.
8	If more than one location is marked, label the preferred choice as #1. Use rubbing alcohol to remove any unwanted markings and place transparent film over the final mark(s).
9	Educate the patient that the final placement will be chosen during the surgery based on surgical need.

Site selection is most effective when paired with preoperative education. Stokes et al. conducted a retrospective, comparative cohort study of 124 patients who received a 2-hour preoperative course for anticipated fecal ostomy creations. This study found that the likelihood of frequent leakage and peristomal skin irritation significantly decreased compared to ostomates (persons with an ostomy) who did not receive preoperative education (20.2% vs. 44.7%). Preoperative teaching promotes a patient-centered approach that provides information regarding ostomy management in advance, identifies barriers to self-care, and delivers psychosocial support. During this time, it is best to explain to the patient that the final site is chosen by the colorectal surgeon after the abdominal cavity is entered and the condition of the bowel is evaluated. ^,

PERISTOMAL SKIN BREAKDOWN SECONDARY TO LEAKAGE

More than 80% of individuals with ostomies will experience some type of stomal or peristomal complication within 2 years of undergoing surgery. Irritant contact dermatitis is the most common peristomal complication and generally occurs due to increased body mass index, flush stomas (<1 cm), high output (>1 L/day), or continuous leakage ( Fig. 19.3 ). The lack of access to a WOC nurse increases the risk of developing peristomal skin complications. Without trained intervention, minor issues with stoma fitting and optimal appliances can lead to hospitalization and more expensive treatments.

Peristomal skin damage is characterized by discoloration, loss of pigmentation, erosion, and tissue overgrowth. The skin tissue damage may be categorized into mechanical, vascular, chemical, infectious, or allergic origins. In mechanical injuries, the improper removal of a skin barrier may result in the stripping of the epidermal layers causing a medical adhesive–related skin injury ( Fig. 19.4 ). We routinely ask the ostomate to explain how they remove the skin barrier and enforce the importance of using adhesive remover. We also find out how often the skin barrier is changed. If it is shorter than 3 days, we assess the reasoning behind the frequent appliance change to offer education or trial of a different skin barrier. Treatments include the application of a barrier film/skin sealant to damaged areas or the use of a skin barrier infused with ceramide to prevent transepidermal water loss and restore the skin mantel and resiliency. Ostomates presenting with open, denuded skin will be instructed to use the “crusting technique” to form a dry, pouch-able surface. After establishing the ostomate is not sensitive to barrier film/skin sealants, we apply a thin layer of stoma powder to the area and dust away excess (the powder will only stick to the open skin). Next, we apply a barrier film/skin sealant over the powder. If necessary, we repeat the procedure until a crust is formed. Other mechanical injuries include medical device–related pressure injuries (MDRPI) and shearing force from tightly fitting convex skin barriers or ostomy belts. Ulcerations that develop can be treated with an alginate/hydrofiber dressing paired with a hydrocolloid sheet to fill the depth. We recommend alternative pouching systems and wider belts to remove the source of pressure and shear.

Chemical injuries occur when peristomal skin is exposed to intestinal effluent which often appears as reddened and moist lesions. The extent of injury depends on the type of effluent (small bowel effluent being the most caustic), the duration of exposure, and the amount of skin uncovered. Stoma size and abdominal contours change during the lifetime of the stoma. Optimal ostomy products are selected through trialing different product styles to find the best fit. The treatment strategies for eroded peristomal skin include the crusting technique and a well-fitted stoma appliance that covers injured skin and allows the peristomal skin to heal ( Fig. 19.5 ). To protect the skin, we often use skin barriers with convexity and add accessory items such as hydrocolloid barrier rings, hydrocolloid sheets and/or belts to fit around the stoma. Peristomal skin chronically exposed to effluent may develop a discolored, thickened epidermis with papules known as pseudoverrucous lesions ( Fig. 19.6 ). In areas with peristomal bleeding, we use silver nitrate to cauterize the lesions. Peristomal inflammatory responses can lead to hypergranulation tissue called granulomas, a term different from histologic granulomas used in CD or tuberculosis. The granulomas can appear as friable, raised, tender nodules in the presence of suture materials, repeated traumas at the mucocutaneous junction, and chronic exposure to intestinal effluent ( Fig. 19.7 ). For the treatment of peristomal suture-associated granulomas, we gently probe the affected area to locate any retained sutures and, if possible, remove them. For painful and bleeding lesions, we apply silver nitrate to the elevated areas of tissue one to three times a week for one month. We resize the ostomy skin barrier to fit closely around the stoma. We apply the crusting technique to the affected area to absorb excess moisture before the pouching system is used.

The peristomal skin is at a high risk for pathogen overgrowth due to the dark, warm, and moist environment around the stoma and/or under the adhesive barrier. Cutaneous candidiasis is the most common peristomal skin infection from the overgrowth of fungal organisms (e.g., Candida albicans ). This causes cutaneous inflammation that may itch or burn and appears as satellite lesions ( Fig. 19.8 ). We assess the fit of the skin barrier, any recent exposure to antibiotics or corticosteroid use, and conditions where sweat or moisture collect under the adhesive. Treatments include thorough drying of peristomal skin and application of topical antifungal powder. We apply the powder onto the affected area and seal it with barrier film/skin sealant ^, ( Fig. 19.9 ).

Peristomal folliculitis can result from trauma to hair follicles generally due to skin barrier removal or shaving under the skin barrier ( Fig. 19.10 ) . Inflammation, erythema, and pustules may resemble candidiasis but lack satellite lesions and a defined border. Treatment strategies include antibiotic soap cleansing, antibiotic powder, and the use of a noncytotoxic, pure hypochlorous acid solution that inhibits organism growth and restores the skin pH. We provide information on techniques to reduce traumatic injury to hair follicles by using adhesive remover, electric shavers, and reducing shaving frequency. During shaving, an ostomate should use soap and water and shave in the direction of the hair growth then dry the peristomal skin completely before applying a barrier film and the skin barrier. Ostomates who are immunocompromised are more at risk for inflammatory skin reactions around their stoma ( Fig. 19.11 ).

Identification and treatment of peristomal skin complications require expert assessment and knowledge of ostomy appliances and accessories. An optimal skin barrier maintains sufficient adhesion to keep stomal effluent off the skin and should closely fit around the base of the stoma at the mucocutaneous junction. Different skin barriers and accessories will be discussed in more detail in the section on stomal retraction.

ALLERGIC CONTACT DERMATITIS

Peristomal allergic contact dermatitis is the inflammatory reaction of the skin to chemical components within an ostomy appliance’s adhesive, ring, paste, powder, or liquid barrier. Eczematous skin eruptions with erythema, vesicles, bullae, and/or intense pruritus develop unrelated to leakage of stoma effluent ^, ( Fig. 19.12 ). The inflammation of the skin initially mirrors the size/shape of the allergen and enlarges as the inflammatory reaction progresses. The incidence rate of allergic contact dermatitis is historically low (0.6–4.7%) but recent studies suggest that numbers are underreported. Less than 20% of ostomates with skin problems are referred to dermatology or given a patch test. ^, It is important to ask for a history of prior skin allergies or reactions related to tape, adhesives, or other topical products. When sensitivity is suspected, we evaluate the characteristics, distribution, exact pattern, and onset of the erythema and rash. We determine if dermatitis began with a change in the products applied ( Figs. 19.13 and 19.14 ). A patch test can be used to evaluate the ostomate’s sensitivity to each item used in their ostomy care ^, by applying small pieces of the items to the side of the abdomen opposite to the stoma or the inner thigh. We wait three or more hours to assess for a reaction ( Fig. 19.15 ).