Assessing peristomal skin changes in ostomy patients: validation of the Ostomy Skin Tool

Gastrointestinal Ostomies in Children: A Primer for the Pediatrician

Despite the advancement of medical therapies in the care of the preterm neonate, in the management of short bowel syndrome and the control of pediatric inflammatory bowel disease, the need to create fecal ostomies remains a common, advantageous treatment option for many medically complex children.

Evaluation of a Skin Barrier Ring With Assisted Flow: A Prospective Cohort Study

PURPOSE

The purpose of this study was to assess the effect of a skin barrier ring with assisted flow in preventing peristomal skin complications (PSCs) in patients with an ileostomy and to evaluate the participants' perceptions of the device.

DESIGN

Single-group, prospective cohort study.

SUBJECTS AND SETTING

Both inpatients and outpatients with newly created (n = 14) or established (n = 1) ileostomies were recruited from 2 clinical sites in the United States: one was an academic teaching hospital system in the Midwestern United States and the second was a teaching hospital located in the Southeastern United States.

METHODS

Participants used the skin barrier ring with assisted flow after receiving education on its use. The pouching system was changed on a routine basis as determined by the ostomy nurse specialist. The Ostomy Skin Tool (OST) was used to assess each participant's peristomal discoloration (D), erosion (E), and tissue overgrowth (T) on admission to the study (baseline) and at final assessment (60 ± 33 days). Secondary outcomes (device handling, comfort, and discretion) were assessed through a questionnaire administered during the final data collection visit.

RESULTS

The mean baseline DET score among the 14 participants with a new ileostomy was 2 or less, indicating no PSCs. The incidence of PSCs in this study was 40% (n = 6). Thirteen of 15 participants (86.7%) agreed that the skin barrier ring with assisted flow was easy to apply. Fourteen (93.4%) agreed that the device was comfortable and easy to remove. All 15 participants (100%) agreed it was discreet under clothing.

CONCLUSIONS

Sixty percent of participants (n = 9) using the investigational device experienced a PSC. More than 90% of participants agreed that the device was comfortable and easy to remove, and all participants (100%) agreed it was discreet when worn under clothing.

Psychometric validation of the Ostomy Skin Tool 2.0

Background

Peristomal skin complications (PSCs) pose a major challenge for people living with an ostomy. To avoid severe PSCs, it is important that people with an ostomy check their peristomal skin condition on a regular basis and seek professional help when needed.

Aim

To validate a new ostomy skin tool (OST 2.0) that will make regular assessment of the peristomal skin easier.

Methods

Seventy subjects participating in a clinical trial were eligible for the analysis and data used for the validation. Item-level correlation with anchors, inter-item correlations, convergent validity of domains, test-retest reliability, anchor- and distribution-based methods for assessment of meaningful change were all part of the psychometric validation of the tool.

Results

A final tool was established including six patient reported outcome items and automatic assessment of the discolored peristomal area. Follow-up with cognitive debriefing interviews assured that the concepts were considered relevant for people with an ostomy.

Conclusion

The OST 2.0 demonstrated evidence supporting its reliability and validity as an outcome measure to capture both visible and non-visible peristomal skin complications.

Feasibility and safety of specimen extraction via an enlarged (U-Plus) skin bridge loop ileostomy: a single-center retrospective comparative study

Objective

To investigate the feasibility and safety of specimen extraction via an enlarged (U-Plus) skin bridge loop ileostomy.

Methods

A retrospective analysis of 95 patients with rectal cancer who underwent laparoscopic low anterior rectal resection and skin bridge loop ileostomy between August 2018 and August 2022, including 44 patients with specimen extraction via an enlarged (U-Plus) skin bridge loop ileostomy (experimental group) and 51 patients with specimen extraction via an abdominal incision (control group). Following the application of propensity score matching (PSM), 34 pairs of data were successfully matched. Subsequently, a comparative analysis was conducted on the clinical data of the two groups.

Results

The experimental group exhibited significantly better outcomes than the control group in various aspects. Specifically, the experimental group had lower values for average operative time (P < 0.001), estimated blood loss (P < 0.001), median length of visible incision after surgery (P < 0.001), median VAS pain score on the first day after surgery (P = 0.015), and average postoperative hospitalization (P = 0.001). There was no statistical significance observed in the incidence of stoma-related complications in both groups (P > 0.05). Within each group, the stoma-QOL scores before stoma closure surgery were significantly higher than those at one month and two months after the surgery, with statistical significance (P < 0.05).

Conclusion

Specimen extraction via a U-Plus skin bridge loop ileostomy is a safe and feasible method that shortens operation time and postoperative visual incision length, decreases estimated blood loss, and reduces patient postoperative pain compared with specimen extraction via an abdominal incision.

Healthcare resource use and associated costs for patients with an ileostomy experiencing peristomal skin complications

Peristomal skin complications (PSCs) have a significant impact on quality of life and ostomy treatment costs. This study aimed to assess the healthcare resource use for patients with an ileostomy and PSCs symptoms. Two surveys were developed and, after validation by healthcare professionals and patients, data were collected on healthcare resource use while not experiencing any PSCs symptoms and while experiencing complications of various severities, as defined by the modified Ostomy Skin Tool. Costs applied to resource use were assigned from relevant United Kingdom sources. Additional healthcare resource use associated with PSCs, relative to no complications, was estimated to result in a total cost per instance of £258, £383, and £505 for mild, moderate, or severe PSC, respectively. The average estimated total cost per complication instance, weighted across mild, moderate, and severe PSCs, was £349. Severe-level PSCs were associated with the highest cost, because of the treatment-level required and the longer duration of symptoms. There is potential for clinical benefits and economising in stoma care if interventions are implemented that reduce the incidence and/or severity of PSCs.

Nursing Management of Abdominal Wound Dehiscence of an Infant With Severe Undernutrition and Peristomal Moisture-Associated Dermatitis After Ileostomy Closure: A Case Study

BACKGROUND

Abdominal wound dehiscence (AWD) is a costly postoperative complication; its management is particularly challenging for WOC nurses when it occurs secondary to an ostomy closure.

CASE

We present a case of AWD secondary to ileostomy closure in Baby Q, a 9-month 19-day-old female infant. A silver wound contact dressing was used on her dehisced wound followed by negative pressure wound therapy and adhesive tape to pull the wound edge together and promote granulation. We used a combination of enteral nutrition, parenteral nutrition, total parenteral nutrition, and total enteral nutrition adjusting the feeding plan stepwise according to her nutritional status.

CONCLUSIONS

Malnutrition and severe peristomal skin complications may contribute to the risk of AWD in infants undergoing reversal of a temporary ostomy. Assessing and treating nutritional status and peristomal skin is imperative before performing ostomy closure.

Cultural Adaptation and Validation of the Ostomy Skin Tool to the Brazilian Portuguese

PURPOSE

To adapt the Ostomy Skin Tool (discoloration, erosion, and tissue overgrowth) to the Brazilian culture and to analyze psychometric properties of the adapted version.

DESIGN

Psychometric (methodologic) evaluation of the instrument.

SUBJECTS AND SETTING

Three ostomy/enterostomal therapy nurses evaluated the extent and severity of peristomal skin conditions in a sample of 109 adults 18 years or older with peristomal skin complications. These participants were receiving care in an ambulatory care center in outpatient health services in Sao Paulo and Curitiba, Brazil. In addition, interobserver reliability was measured using a group of 129 nurse participants who attended the Brazilian Congress of Stomatherapy held from November 12 to 15, 2017, in Belo Horizonte, a city located in the state of Minas Gerais, Brazil. Nurse participants assessed the descriptions of peristomal skin complications of the Portuguese version, using the same photographs used in the original DET score, purposely placed out of original order.

METHODS

The study was performed in 2 stages. The instrument was translated into Brazilian Portuguese by 2 bilingual translators, and back-translated into English. The back-translated version was sent to one of the developers of the instrument for additional evaluation. During stage 2, content validity was evaluated by 7 nurses with expertise in ostomy and peristomal skin care. Convergent validity was evaluated by correlating the severity of peristomal skin complications to pain intensity. Discriminant validity was evaluated based on type and time of ostomy creation, presence of retraction, and preoperative stoma site marking. Finally, interrater reliability was evaluated using standardized photograph evaluation reproduced in the same sequence as the original English language version of the instrument, along with paired scores from assessment of adults living with an ostomy generated by an investigator and nurse data collectors.

RESULTS

The Content Validity Index for the Ostomy Skin Tool was 0.83. Levels of mild agreements were obtained for the nurses' observations in the evaluation of peristomal skin complications using standardized photographs (κ= 0.314). In contrast, moderate to almost perfect agreements were obtained when scores were compared in the clinical setting (κ= 0.48-0.93, according to the domains). Positive correlations between the instrument and pain intensity (r = 0.44; P = .001) indicate convergent validity of the adapted version of the Ostomy Skin Tool. In contrast, analysis of discriminant validity was mixed and definitive conclusions about this form of construct validity cannot be made based on this study.

CONCLUSION

This study supports convergent validity and interrater reliability of the adapted version of the Ostomy Skin Tool.

The effects of continuous nursing via the WeChat platform on neonates after enterostomy: a single-centre retrospective cohort study

BACKGROUND

Temporary enterostomy is an effective treatment for various neonatal intestinal diseases. However, family caregivers find it challenging to provide the required nursing care. Nursing management is very important for reducing parents' anxiety and improving the patients' quality of life. This research aimed to compare the effects of continuous nursing using the WeChat platform with traditional nursing for neonates after enterostomy.

METHODS

Neonates who underwent enterostomy from January 2014 to December 2020 in our hospital were retrospectively analysed. The patients were divided into the traditional nursing group and the continuous nursing group. The peri-stomal skin was evaluated with the DET scale. The mental status of the families was evaluated with the SAS and SDS.

RESULTS

There were 143 patients in the traditional nursing group (TG) and 165 in the continuous nursing group (CG). The mean weight was 2.7 ± 0.6 kg in TG and 2.8 ± 0.5 kg in CG. The mean age at surgery was 4.9 ± 7.3 d in TG and 4.8 ± 7.55 d in the CG. No statistically significant differences between the two groups were found in the demographic information. The continuous nursing group had an obviously lower DET score for the peri-stomal skin than the traditional nursing group (P = 0.003). Three months after discharge from the hospital, the continuous nursing group replaced 7.2 ± 1.8 ostomy bags every week, significantly less than the traditional nursing group (P = 0.002). Three months after discharge, the continuous nursing group had better SAS and SDS scores than the traditional nursing group.

CONCLUSIONS

Continuous nursing based on WeChat can effectively improve the quality of life of neonates after enterostomy. Family members can also receive proper psychological counselling to relieve their anxiety and depression.

Peristomal Skin Itch: An Integrative Review

Survey data from the United Stated, the United Kingdom, and the Netherlands indicate peristomal itch is prevalant among ostomy patients. Pruritus has a significant negative impact on health-related quality of life, resulting in discomfort and interrupted sleep. In ostomy patients, peristomal skin scratching also may interfere with adherence of the ostomy pouching system. This article reviews the classification and pathophysiology of itch in the peristomal skin, along with options for its management.

The Ostomy Skin Tool 2.0: a new instrument for assessing peristomal skin changes

BACKGROUND

Peristomal skin complications (PSCs) are frequently reported postoperative complications. PSCs can present visibly or as symptoms such as pain, itching or burning sensations.

AIM

To develop a new tool that can capture a range of sensation symptoms together with visible complications and an objective assessment of discolouration in the peristomal area.

METHOD

Consensus from qualitative interviews with health professionals and people with an ostomy, and input from expert panels, formed the basis of a patient-reported outcome (PRO) questionnaire. A decision tree model was used to define a combined score including PRO and objectively assessed discolouration area.

FINDINGS

Six elements were included in the PRO questionnaire and four health states representing different severity levels of the peristomal skin were defined.

CONCLUSION

The Ostomy Skin Tool 2.0 is a sensitive tool that can be used to follow changes in the peristomal skin on a regular basis and thereby help prevent severe PSCs.

Factors predictive of optimal peristomal skin status in patients with an ostomy: a secondary analysis

Peristomal skin problems are common in ostomy patients and are connected to decreased quality of life and patient independence, as well as increased treatment costs. This study analysed the factors related to peristomal skin changes in order to better define the clinical profile of patients with optimal peristomal skin status. Secondary analysis of data from a nationwide, cross-sectional, retrospective, multicentre study performed in Spain (Uses and Attitudes in Ostomy) (Bueno Cruz et al, 2021) evaluated clinical data, including demographics, preoperative stoma site marking, type of ostomy, device used, frequency of leakage and scores from the Ostomy Skin Tool (OST) and quality of life (QoL) questionnaires. Risk factors for peristomal skin changes were analysed using multivariate analysis, and a predictive nomogram to anticipate optimal peristomal skin status (defined here as discolouration (D), erosion (E), and tissue overgrowth (T) (DET) score of 0) was developed. Some 871 patients with an ostomy using different commercial devices in Spain were evaluated. Multivariate analysis to predict optimal peristomal skin status revealed leakage frequency, patient age, type of ostomy, preoperative siting and type of baseplate used were independent predictors of peristomal skin status. Optimal peristomal skin care should be a treatment goal for nurse specialists in stomal therapy, and its individual influencing variables should be taken into account by nurses specialising in ostomy care.

Multinational survey on living with an ostomy: prevalence and impact of peristomal skin complications

BACKGROUND

Peristomal skin complications (PSCs) impair life for people with an ostomy. Visual signs of PSCs include discolouration, but sensation symptoms like pain, itching, and burning are equally important and underreported.

AIM

To provide improved understanding of PSC prevalence and associated challenges in the communities of ostomy patients and ostomy care nurses.

METHODS

The Ostomy Life Study 2019 encompassed a patient survey (completed by 5187 people with an ostomy) and a nurse survey (completed by 328 ostomy care nurses).

FINDINGS

In total, 88% of patients experienced PSCs and 75% experienced PSC symptoms in the absence of discolouration. Eighty per cent of nurses considered ostomy-related issues to be the main reason for PSCs, and a correlation between PSC severity and number of nurse consultations was demonstrated.

CONCLUSION

This study revealed a remarkably high PSC incidence in the absence of discolouration and highlighted direct consequences of having compromised skin and the health-economic consequences.

Usability of a Novel Instrument to Measure Damaged Peristomal Skin in Patients with an Ostomy

OBJECTIVE

To evaluate the usability of a novel instrument (stoma ruler) to measure damaged peristomal skin in patients with an ostomy.

METHODS

A wound ostomy and continence nurse used both the stoma ruler and a linear ruler to assess DET (discoloration, erosion, tissue overgrowth) scores and the height of protrusion above the skin of 10 patients with ileostomies and took photographs. The photographs were presented to five ostomy care nurses for reliability testing. The difference between the two methods was determined using paired Wilcoxon signed ranks test.

PRIMARY OUTCOME MEASURE

Interrater reliability of the linear versus stoma ruler.

RESULTS

The interrater reliabilities of the stoma ruler versus the linear ruler for the domain-area DET score were 0.95 (95% confidence interval, 0.89-0.99) and 0.68 (95% confidence interval, 0.42-0.89), respectively. Only nurse 5 reported a significant difference between the two rulers (z = -2.24, P = .03).

CONCLUSIONS

In busy clinical settings, the stoma ruler is easy for ostomy care nurses to use to obtain accurate DET scores and the height of stoma protrusion above the skin. Observing the position of damaged skin using the clock marks on the stoma ruler enhance clinical description and reduce assessment variation among professionals.

Evaluation of a Novel Ostomy Barrier Ring with Assisted Flow for Individuals with an Ileostomy

OBJECTIVE

To determine the performance and user experience of a novel ostomy barrier ring over a 4-week period.

METHODS

This single-arm investigation conducted across three clinical sites included 25 adult participants with an ileostomy for 3 months or longer. The participants used their standard ostomy pouching appliance along with a novel barrier ring for a period of 4 weeks. Skin condition was assessed using the Ostomy Skin Tool. Change in skin condition over the study period was recorded for each participant. The participants' experience in using the novel barrier ring was measured using a five-point Likert-type scale.

RESULTS

Twenty of the 25 participants (80%) completed the trial. Of those participants, the median Ostomy Skin Tool score at both the beginning (range, 0-8) and end was 0 (range, 0-6). In terms of skin condition, 7 participants experienced an improvement in skin condition, 11 experienced no change, and 2 got worse. A median score of 5 out of 5 was recorded for all questions relating to user experience.

CONCLUSIONS

Although not statistically significant, there was a clear trend toward improvements in peristomal skin condition using the novel barrier ring, even for participants who were already using a barrier ring. User feedback was positive with respect to comfort, device handling, and the perception of the device's ability to protect the skin. Further, most participants who already used a barrier ring indicated that the novel barrier ring would result in a longer wear time.

Automated Assessment of Peristomal Skin Discoloration and Leakage Area Using Artificial Intelligence

For people living with an ostomy, development of peristomal skin complications (PSCs) is the most common post-operative challenge. A visual sign of PSCs is discoloration (redness) of the peristomal skin often resulting from leakage of ostomy output under the baseplate. If left unattended, a mild skin condition may progress into a severe disorder; consequently, it is important to monitor discoloration and leakage patterns closely. The Ostomy Skin Tool is current state-of-the-art for evaluation of peristomal skin, but it relies on patients visiting their healthcare professional regularly. To enable close monitoring of peristomal skin over time, an automated strategy not relying on scheduled consultations is required. Several medical fields have implemented automated image analysis based on artificial intelligence, and these deep learning algorithms have become increasingly recognized as a valuable tool in healthcare. Therefore, the main objective of this study was to develop deep learning algorithms which could provide automated, consistent, and objective assessments of changes in peristomal skin discoloration and leakage patterns. A total of 614 peristomal skin images were used for development of the discoloration model, which predicted the area of the discolored peristomal skin with an accuracy of 95% alongside precision and recall scores of 79.6 and 75.0%, respectively. The algorithm predicting leakage patterns was developed based on 954 product images, and leakage area was determined with 98.8% accuracy, 75.0% precision, and 71.5% recall. Combined, these data for the first time demonstrate implementation of artificial intelligence for automated assessment of changes in peristomal skin discoloration and leakage patterns.

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

Background

Laparoscopic approach is now a widespread technique used worldwide, but there are few recent studies on risk factors for parastomal hernia. Therefore, this study was performed to analyze the incidence of parastomal hernia in laparoscopic and open surgery in which a loop stoma was created and was intended to be temporary, and to determine risk factors for parastomal hernia formation. Associations between parastomal hernia and other stoma-related complications were also analyzed.

Methods

A retrospective analysis of patient and surgical characteristics was performed in 153 consecutive patients who underwent a temporary diverting loop ileostomy or colostomy after surgery related to malignant diseases at our hospital from January to December 2016.

Results

Parastomal hernia developed in 77 cases (50.3%), including 39 (25.5%) diagnosed by physical examination and 38 (24.8%) detected by CT alone. On multivariate analysis, a stoma not passing through the middle of the rectus abdominis muscle was the only independent risk factor for parastomal hernia formation (p = 0.005) during the median follow-up of 245.0 days. When we analyzed the factors that were associated with a stoma not passing through the middle of the rectus abdominis muscle, the only independent factor associated with this misplacement of the stoma was a laparoscopic approach (p = 0.012). An analysis of stoma-related complications showed that peristomal skin disorders were significantly associated with parastomal hernia (p = 0.049).

Conclusions

This study showed that a stoma that is not formed through the middle of the rectus abdominis muscle is a risk factor for parastomal hernia formation, and that a laparoscopic approach is associated with this risk factor. Moreover, parastomal hernia is significantly associated with peristomal skin disorders.

Evaluating evidence for stoma care nursing: appraising a randomised controlled trial of ostomy skin barriers

Background:

Nursing practice should be evidence-based. As such, nurses should be able to rank sources according to a hierarchy of evidence and critically appraise the validity of studies. This is especially important in stoma care, where high-quality evidence is limited.

Methods:

Evidence appraisal is made easier by tools, such as the Critical Appraisal Skills Programme (CASP) for Randomised Controlled Trials (RCT). CASP was used to critique the ADVOCATE Trial, ( Colwell et al 2018 ), A Randomised Controlled Trial Determining Variance in Ostomy Skin Condition and the Economic Impact (ADVOCATE Trial), which had an adaptive design and compared the cost efficiency and efficacy of a ceramide-infused two-piece skin barrier with a comparator. The participants were randomised, and the trial was double blinded.

Results:

The trial addressed clearly focused issues. The improvement in cost efficacy for the trial group was statistically significant (p=0.017); in addition, three of six tertiary objectives were also statistically significant. Improvement in peristomal skin health was noticeable but not statistically significant. The results can be applied to other ostomy patient populations, and all clinically important outcomes were considered.

Conclusion:

CASP provided a staged and structured approach to review an RCT. It can help specialist nurses to find and apply relevant study findings to practice. CASP assessment found the ADVOCATE trial to be a reliable evidence base on which stoma care nurse could adjust their practice to optimise costs and peristomal skin health.

Innovative appliance for colostomy patients: an interventional prospective pilot study

Background

The control of body waste emptying is a constant research topic in stoma care. The aim of this pilot study was to assess the efficacy and safety of an innovative colostomy appliance.

Methods

An interventional prospective non-comparative pilot study was conducted in seven French centers. The study device is a new type of two-piece appliance including a base plate and a “capsule cap” (CC) composed of a capsule cover and a folded collecting bag. The device gently seals the stoma to provide stoma output control. When the bowel movement pressure increases the patient may control the deployment of the folded bag and collect stools. Patients with left-sided colostomy all using a flat appliance, were enrolled in a 2-week trial. Outcome measures were type of CC removal and peristomal fecal leaks while wearing the device.

Results

Of 30 patients (females 66.7%), with left-sided colostomy (permanent 76.7%), 23 (76.7%) completed the 2-week trial. A total of 472 CC changes were analyzed. Efficacy: of 404 (85.5%) CC changes reported in diaries, 302 (74.8%) were linked with stool and/or gas. In 244 (60.3%) changes, the patient controlled stoma bag deployment and it occurred with bowel emptying 301 (74.5%) times. No leaks around the appliance were observed in 400 (85.3%) changes. Safety: no serious adverse event occurred. Peristomal skin was not modified during the trial.

Conclusions

In the short term this new device has provided an increased control over bowel emptying at no risk in half of the trial population suggesting that an alternative approach to bag wearing is achievable.

Design and validation of a "Peristomal Lesion Scale" for peristomal skin assessment

Many people in Italy undergo ostomy because of illness, and this can have negative psychological and physical effects. It is estimated that 15%-43% of ostomates suffer from skin complications in the peristomal area. During their life, many ostomates experience at least one peristomal lesion, and they turn to stomal therapy centres where trained nurses provide patient care and manage skin complications. To ensure a good quality of life for patients, and to take prompt action for the prevention and treatment of stomal lesions, it is essential to use appropriate assessment tools. The aim of this study was to develop a reliable peristomal skin assessment tool (Peristomal Lesion Scale [PLS]) for classifying lesions based on their severity; and to compare its validity with the most widely used peristomal tool in Italy, SACS. The new tool was designed by a team of experts, focusing on patients' demographics, clinical characteristics, and classification of the lesions by severity and topography. The results of this comparative validation study indicate that the PLS better discriminates lesions by their severity because of its level of detail, using a standardised terminology, and its completeness. The PLS is a valid tool for use in the daily work of stomal therapists.

Instrumentos de avaliação das complicações na pele periestoma: revisão integrativa

Objetivo: identificar y analizar las herramientas utilizadas para evaluar las complicaciones de la piel periestoma a través de revisión integradora de la literatura. Materiales y método: la búsqueda se dio en estas bases y portales de datos: Biblioteca Virtual de la Salud (BVS), PubMed/MEDLINE, CINAHL, Scopus y Web of Science, de enero a febrero de 2018. Durante la búsqueda en las bases de datos, se utilizaron los descriptores: ostomía, colostomía, dermatitis y las palabras clave: instrumentos, complicaciones de la piel periestoma y evaluación de la piel periestoma. Se incluyeron estudios que cumplieron los siguientes criterios: que estén disponibles en su totalidad, que estén publicados en español, inglés y portugués, no se tuvo en cuenta el rango de tiempo y tenía que ser acerca de las herramientas de evaluación de las condiciones de la piel periestoma. Resultados: el análisis identificó la existencia de nueve instrumentos con diferentes parámetros para describir la piel periestoma. En general, los instrumentos describen los cambios basados en la clasificación de la complicación, en la causa del daño a la piel o en las características clínicas presentes. Los estudios evidenciaron, además, que la mayoría de los instrumentos no poseen propiedades de medida probadas. Conclusión: de los nueve instrumentos de evaluación identificados, solo cuatro tienen propiedades de medidas probadas. El enfermero debe conocer los instrumentos existentes confiables y válidos para describir y clasificar la gravedad de los problemas de la piel periestoma, lo que aporta a la sistematización de un diagnóstico más preciso y mejora, por lo tanto, la calidad del cuidado.

Safety and Feasibility of Umbilical Diverting Loop Ileostomy for Patients with Rectal Tumor

BACKGROUND

Fashioning an ileostomy in the umbilicus and combining the trauma from extraction of colorectum with that from ileostomy should be less invasive and lead to improved cosmetic outcomes. However, there are only a few reports regarding umbilical ileostomy.

METHODS

We retrospectively collected data for 121 consecutive patients with rectal tumor who underwent elective laparoscopic rectal resection with diverting loop ileostomy between 2010 and 2015 at Osaka University Hospital, Japan. The safety and feasibility of umbilical diverting loop ileostomy and its influence on stoma care were investigated.

RESULTS

A total of 83 patients were included in this study; of these, 30 underwent umbilical diverting loop ileostomy and 53 underwent conventional diverting loop ileostomy, which was created in the right lower quadrant of the abdomen. The umbilical and conventional groups showed similar rates of postoperative and stoma-related complications (26.7 vs. 32.1%, p = 0.804 and 3.3 vs. 3.8%, p = 1.000, respectively). Level of parastomal dermatitis was evaluated by DET score at three time points (stoma self-management establishment, first outpatient review post-discharge, and just before stoma closure). DET scores at any time points did not differ significantly between the two groups.

CONCLUSIONS

Umbilical diverting loop ileostomy is comparable to conventional ileostomy with regard to safety and feasibility. Our methods for umbilical ileostomy using the umbilical skin flap were less invasive and did not have a negative impact on stoma care and parastomal dermatitis. Umbilical ileostomy may be a promising alternative to conventional ileostomy in selected cases.

A Randomized Controlled Trial Determining Variances in Ostomy Skin Conditions and the Economic Impact (ADVOCATE Trial)

PURPOSE

To compare ostomy-related costs and incidence of peristomal skin complications (PSCs) for ceramide-infused ostomy skin barriers and control skin barriers.

DESIGN

The ADVOCATE trial is a multi-centered randomized controlled trial, and double-blinded international study with an adaptive design.

SUBJECTS AND SETTING

The sample comprised 153 adults from 25 sites from the United States, Canada, and Europe. Participants were seen in hospital and outpatient care settings.

METHODS

Data were collected by investigators at each site during face-to-face visits and during telephone check-in calls between visits. Cost of care data were collected using a questionnaire developed specifically for the study. The peristomal skin was assessed using the Ostomy Skin Tool. Health-related quality of life was measured using the SF-12v2. Patient-reported outcomes were collected using a patient-centered study-specific questionnaire. Cost of care was analyzed via analysis of covariance comparing total cost of care for 12 weeks between the 2 groups. The incidence of PSC was analyzed via Barnard's exact test comparing the incidence of PSCs between the control and treatment groups. Tertiary outcomes were exploratory in nature and not statistically powered.

RESULTS

Use of the ceramide-infused barrier significantly reduced stoma-related cost of care over a 12-week period, resulting in a $36.46 decrease in cost (14% relative decrease). The adjusted average costs were $223.73 in the treatment group and $260.19 in the control group (P = .017). The overall incidence of PSCs in the study was 47.7%; PSC incidence was 40.5% for the treatment group versus 55.4% for controls (P = .069, 95% confidence interval of the difference: -1.2 to 30.4). Significantly more participants using the ceramide-infused skin barrier were "very satisfied" with barrier performance (75% vs 55%; P = .033), prevention of leakage (63% vs 38%; P < .01), and prevention of itching (53% vs 31%; P = .016). General postoperative improvement in health-related quality of life was noted in both groups.

CONCLUSIONS

The use of a ceramide-infused barrier significantly decreased cost and increased satisfaction with patient-reported outcomes.

Randomized clinical trial of intracutaneously versus transcutaneously sutured ileostomy to prevent stoma-related complications (ISI trial)

Background

Ileostomy construction is a common procedure but can be associated with morbidity. The stoma is commonly secured to the skin using transcutaneous sutures. It is hypothesized that intracutaneous sutures result in a tighter adherence of the peristomal skin to the stoma plate to prevent faecal leakage. The study aimed to compare the effect of intracutaneous versus transcutaneous suturing of ileostomies on faecal leakage and quality of life.

Methods

This randomized trial was undertaken in 11 hospitals in the Netherlands. Patients scheduled to receive an ileostomy for any reason were randomized to intracutaneous or transcutaneous suturing (IC and TC groups respectively). The primary outcome was faecal leakage. Secondary outcomes were stoma‐related quality of life and costs of stoma‐related materials and reinterventions.

Results

Between April 2011 and February 2016, 339 patients were randomized to the IC (170) or TC (169) group. Leakage rates were higher in the IC than in the TC group (52·4 versus 41·4 per cent respectively; risk difference 11·0 (95 per cent c.i. 0·3 to 21·2) per cent). Skin irritation rates were high (78·2 versus 72·2 per cent), but did not differ significantly between the groups (risk difference 6·1 (95 per cent c.i. –3·2 to 15·10) per cent). There were no significant differences in quality of life or costs between the groups.

Conclusion

Intracutaneous suturing of an ileostomy is associated with more peristomal leakage than transcutaneous suturing. Overall stoma‐related complications did not differ between the two techniques. Registration number: NTR2369 ( http://www.trialregister.nl).

More leaks with intracutaneous

[LSD score. A new classification system for peristomal skin lesions]

BACKGROUND

Peristomal skin lesions are frequent complications of ostomy; however, there is no generally accepted nomenclature and classification system.

OBJECTIVE

An interdisciplinary German expert panel (GESS) composed of ten members, developed an innovative semiquantitative classification system for peristomal skin lesions for further stratification of ostomy therapy. This score is based on criteria which can be assessed by stomal therapists and treating physicians.

RESULTS

The new peristomal skin lesion score grades three categories: lesion (L), status of ostomy (S) and disease (D). The L category describes the integrity of the skin as normal (L0), lesion with sustained integrity of skin (L1), integrity destroyed (L2) and local infection (L3). The S category rates the complexity of ostomy therapy as normal (S0), increased (S1) and high but not sufficiently effective (S2). The additional letters for categorization O. R. P. H. E. US describe anatomical pathologies of the stoma itself: ostomy stenosis (O), retraction (R), prolapse (P), hernia (H), edema (E) and unfavorable site (US). A systemic disorder is either absent (D0), irrelevant (D1) or relevant (D2). The LSD score is the basis for a management algorithm.

CONCLUSION

The LSD score is comprehensive, standardized and holistic. Its straightforward use by health professionals can improve the consistency of the description of skin lesions and enhance the quality of ostomy therapy.

Stoma appliances and accessories: getting it right for the patient

This article will examine some of the appliances and accessories that can be used to care for a stoma. There are three types of stoma that can be surgically formed and each will be discussed. Furthermore, there will be brief explanations of why stomas might be formed and what the output from each stoma type will be. Complications are associated with stomas, such as sore skin, which is commonly seen within the first few months after the stoma is formed. This important topic is examined and some of the accessories that can be used to treat these issues will be explored. To aid the reader to undertake their own research on the topic, the websites from some of the stoma manufacturers are included. These websites contain more details about appliances, accessories and information for people with a stoma that can be of benefit to nurses too.

Ostomy care and management: a systematic review

The frequency of ostomy surgery in Canada is not known, but it is estimated that approximately 13,000 ostomy surgeries are performed annually in Canada. This systematic review incorporates evidence for the assessment and management of colostomies, ileostomies, and urostomies, as well as the peristomal skin. The review was completed as part of a best practice guideline document generated by a task force appointed by the Registered Nurses' Association of Ontario.

Factors impacting the quality of life of people with an ostomy in North America: results from the Dialogue Study

PURPOSE

The purpose of this study was to evaluate skin condition and quality of life following the use of a double-layer adhesive pouching system. This article reports results from North American participants.

DESIGN

The study was an open-label, noncomparative, multicenter study.

SUBJECTS AND SETTING

Seven hundred forty-three persons with ostomies who reside in North America participated in the study.

INSTRUMENTS

A stoma-quality of life (QOL) questionnaire consisting of 20 questions was used to measure health-related quality of life. The Ostomy Skin Tool was used to assess peristomal skin condition.

METHODS

Peristomal skin and health-related quality of life were assessed by WOC nurses at baseline and again after 6 to 8 weeks following the use of a double-layer adhesive ostomy pouching system. The participants recorded self-reported leakage level, presence of peristomal skin disorder, use of appliance type (e.g., convex, 1- or 2-piece), and frequency of consultation with the WOC nurse.

RESULTS

Participants experienced a significant decrease in frequency of pouch leakage (P < .0001) and accessory use, improvement of skin condition, and overall significant improvement in mean quality of life score (56.8 vs. 58.9, P < .0001). The greatest change on the Stoma-QOL scores was observed in the quartile of participants with the lowest QOL at baseline. Their QOL scores rose from a mean 43.8 at visit 1 to 50.1 at visit 2 (P < .0001).

CONCLUSION

The combination of a regular contact with a WOC nurse and the use of a double-layer adhesive appliance led to a significant reduction in leakage and accessory use, improved skin condition, and significant improvement in health-related quality of life.

Peristomal skin complications are common, expensive, and difficult to manage: a population based cost modeling study

BACKGROUND

Peristomal skin complications (PSCs) are the most common post-operative complications following creation of a stoma. Living with a stoma is a challenge, not only for the patient and their carers, but also for society as a whole. Due to methodological problems of PSC assessment, the associated health-economic burden of medium to longterm complications has been poorly described.

AIM

The aim of the present study was to create a model to estimate treatment costs of PSCs using the standardized assessment Ostomy Skin Tool as a reference. The resultant model was applied to a real-life global data set of stoma patients (n = 3017) to determine the prevalence and financial burden of PSCs.

METHODS

Eleven experienced stoma care nurses were interviewed to get a global understanding of a treatment algorithm that formed the basis of the cost analysis. The estimated costs were based on a seven week treatment period. PSC costs were estimated for five underlying diagnostic categories and three levels of severity. The estimated treatment costs of severe cases of PSCs were increased 2-5 fold for the different diagnostic categories of PSCs compared with mild cases. French unit costs were applied to the global data set.

RESULTS

The estimated total average cost for a seven week treatment period (including appliances and accessories) was 263€ for those with PSCs (n = 1742) compared to 215€ for those without PSCs (n = 1172). A co-variance analysis showed that leakage level had a significant impact on PSC cost from 'rarely/never' to 'always/often' p<0.00001 and from 'rarely/never' to 'sometimes' p = 0.0115.

CONCLUSION

PSCs are common and troublesome and the consequences are substantial, both for the patient and from a health economic viewpoint. PSCs should be diagnosed and treated at an early stage to prevent long term, debilitating and expensive complications.

Comparison of standardized peristomal skin care and crusting technique in prevention of peristomal skin problems in ostomy patients

PURPOSE

This study was performed to compare the effects of standardized peristomal skin care (SPSC) and crusting technique (CT) on the peristomal skin of ostomates. SPSC was developed by a consensus among the expert group based on a comprehensive review of the relevant literature and hospital protocols.

METHODS

A randomized controlled pilot trial with 2 parallel arms was used. A total of 81 ostomates, who were recruited from a tertiary hospital, completed the baseline, 1-month, 2-month, and 3-month follow-up (SPSC group, n=45; CT group, n=36). SPSC consisted of water cleansing and direct application of ostomy appliances. CT involved crusting hydrocolloid powder and patting with water sponge or protective barrier liquid film. The outcomes of the study were assessed by skin problems, such as discoloration, erosion and tissue overgrowth; the domains of the evaluation tool used in examining the peristomal skin. A generalized estimating equation model was used to examine the effects according to time and group.

RESULTS

In both SPSC and CT groups, the likelihood of occurrence of discoloration (OR, 1.99; 95% CI, 1.61-2.46), erosion (OR, 1.87; 95% CI, 1.55-2.25) and tissue enlargement (OR, 1.94; 95% CI, 1.36-2.77) increased with time. There was no significant difference in discoloration between the groups, whereas the probability of erosion (OR, 0.38; 95% CI, 0.16-0.89) and tissue overgrowth (OR, 0.09; 95% CI, 0.02-0.55) was lower in the SPSC group than in CT group.

CONCLUSION

SPSC was sufficient in preventing peristomal skin problems of ostomates compared to the CT.