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.

Use of a Convex Pouching System in the Postoperative Period: A National Consensus

Convex pouching systems have been available for ostomy patients for decades; however, controversy remains over the use of convexity in the postoperative period. A group of 10 nurses and physicians with expertise caring for patients with an ostomy completed a scoping review identifying research-based evidence and gaps in our knowledge of the safety and effectiveness related to the use of a convex pouching system following ostomy surgery. Results of this scoping review demonstrated the need for a structured consensus to define best practices when selecting a pouching system that provides a secure and reliable seal around the stoma, avoids undermining and leakage of effluent from the pouching system, and contributes to optimal health-related quality of life for patients following ostomy surgery. The expert panel reached consensus on 8 statements for the use of convex products immediately after surgery and throughout the first 6 months after stoma creation, as well as describing goals in choosing the best pouching system for the patient with an ostomy.

Survey Results on Use of a Convex Pouching System in the Postoperative Period

PURPOSE

The purpose of this study was to validate time frames for postoperative care following stoma surgery and to determine participants' current practice with convex pouching systems during the postoperative period.

DESIGN

A Cross-sectional survey.

SUBJECTS AND SETTING

The sample comprised 332 ostomy care specialists practicing in the United States. Most (n = 220; 66%) had more than 10 years' experience caring for patients with ostomies, 82% (n = 272) were certified WOC or ostomy care nurses (CWOCN and COCN), and 7% (n = 23) were board-certified colorectal surgeons.

METHODS

A 23-item online questionnaire was created for purposes of the study. Items in the questionnaire queried professional background and experience caring for patients with an ostomy. A single item was used to identify postoperative care periods following ostomy surgery. Additional items queried current practice patterns related to use of convex pouching systems and the timing of their use. Data were collected from January 18 to February 8, 2021.

RESULTS

Most respondents (n = 270; 90%) agreed with the following postoperative periods after ostomy surgery: immediate postoperative period (days 0-8); postoperative period (days 9-30); and transition phase (days 31-180). Most respondents (n = 274; 95%) indicated they would use a convex pouching system when clinically appropriate during the first 30 days following ostomy surgery and 79% (n = 228) indicated using a convex pouching system regardless of when the surgery was performed. Less than 1% (n = 2) indicated never using convexity within the first 30 days following stoma surgery, and only 3% (n = 8) indicated avoidance of convexity pouching systems in the immediate postoperative period.

CONCLUSIONS

Findings indicate that use of convexity during the postoperative period is prevalent to provide a secure seal and predictable wear time.

The association of bowel function, participation in life activities, and quality of life in rectal cancer survivors

PURPOSE

To evaluate whether limited participation in life activities is associated with quality of life (QOL) in rectal cancer survivors, and if so, whether this association is independent of bowel function difficulties.

METHODS

We surveyed rectal cancer survivors from four healthcare systems about their QOL, bowel function, and participation in life activities. Additional demographic and clinical variables were extracted from the electronic health record. We examined independent associations between bowel function, participation in life activities, and QOL, controlling for potential confounders. We also identified factors, including ostomy status, that correlate with participation in life activities.

RESULTS

Of the 527 respondents, 52% were male, 80% were non-Hispanic white, and the mean age was 63. In fully adjusted models for all rectal cancer survivors, participation in life activities was positively associated with QOL, while bowel function was not. Bowel function retained an independent association with QOL for those who previously had an ostomy and were therefore more likely to have a low rectal anastomosis. Lower participation in life activities was correlated with lower self-reported physical and cognitive function, younger age, financial difficulty, and being non-Hispanic white.

CONCLUSIONS

Rectal cancer survivors' participation in life activities was strongly associated with QOL, even when controlling for numerous confounders, including bowel function. Identifying ways to improve participation in life activities may be critical to developing rehabilitative and other supportive interventions that optimize QOL among rectal cancer survivors.

Recovering from Cystectomy: Patient Perspectives

Background:

Bladder cancer patients who undergo cystectomy and urinary diversion face functional and quality-of-life challenges. Little is known about these patients’ experiences during decision-making, surgery, and recovery, or how they vary by treatment setting.

Objective:

To learn about patients’ experiences with treatment choice, surgical care, and recovery across health settings. Understanding patient experiences is essential to closing care gaps and developing patient-reported measures.

Methods:

We conducted focus groups with cystectomy patients and family caregivers at a large comprehensive health care system (N = 32 patients) and an NCI-designated comprehensive cancer center (N = 25 patients and 5 caregivers). Using standard qualitative methods, we identified themes that are not well-represented in existing research.

Results:

Across both systems, patients described variable experiences in decision-making about their cystectomy and urinary diversion. Some felt overwhelmed by information; others felt poorly informed. Many found self-care equipment challenging; many felt they knew little about what to expect regarding chemotherapy, recovery, and transitioning home. At times, health care personnel could not help manage patients’ ostomies or catheterization equipment. Our study also contributes a grounded theoretical framework for describing meaningful domains of patient experience with cystectomy and urinary diversion. We identified a common trajectory that includes decision-making, surgery and post-operative recovery, mastery of self-care, and reintegration.

Conclusions:

Patients with radical cystectomy and urinary diversion report a wide variety of experiences not captured by quantitative measures. These findings demonstrate that many cystectomy patients could benefit from additional post-operative support. We offer a framework to measure patient-centered domains in future research.

The role of obesity in the patient undergoing colorectal surgery and fecal diversion: a review of the literature

The obese colorectal surgery patient may face several challenges, including a high risk for the development of colorectal cancer, an increased risk for complications with diverticular disease, and surgical risk factors including anastomotic leaks, inability to perform a low anastomosis, and septic complications. The purpose of this literature review was to examine available data on the implications of obesity on colorectal disease and colorectal surgery, particularly stoma surgery. Obesity has been documented as a risk factor for colorectal disease, but results of studies examining surgeryrelated problems secondary to obesity are inconsistent. However, clinicians generally believe obese patients undergoing colorectal surgery may be at higher risk of complications than their non-obese counterparts. The obese patient requiring the creation of a fecal diversion may encounter stoma-related issues such as stenosis, retraction, and inability to maintain a consistent pouching system seal. Stoma site marking can be challenging because of the large shifts in subcutaneous tissue and the inability for a person with a large abdomen to be able to visualize the stoma if the stoma is placed too low on the abdomen. Additional research to elucidate complication rates and risk factors is needed to help clinicians develop optimal plans of care.

Parastomal hernia repair with acellular dermal matrix

PURPOSE

Treatment of parastomal hernia is often complicated by a high recurrence rate and likelihood of wound contamination. We reported an initial series of parastomal hernia repairs performed with acellular dermal matrix.

METHODS

We reviewed a series of 11 patients who had parastomal hernia repairs with acellular dermal matrix and recorded the type of ostomy, previous repair, associated intestinal pathology, type of repair performed, perioperative complications, and rate of recurrence.

RESULTS

Between 2004 and 2006, 11 patients underwent parastomal hernia repair with acellular dermal matrix by the senior author. Nine of 11 patients had associated Crohn's disease or ulcerative colitis and 3 had recurrent parastomal hernias that had failed initial repair. Mean follow-up was 8.7 months (range: 1-21 months). Two patients developed wound infections that did not require implant removal and healed with local wound care. Three patients developed recurrent hernias.

CONCLUSIONS

Parastomal hernia with acellular dermal matrix results in recurrence rates comparable to those reported in the literature for synthetic mesh repair. It offers the advantages of avoiding stoma relocation and of not requiring implant removal in cases of wound infection.

Survey of Wound, Ostomy and Continence (WOC) Nurse Clinicians on Stomal and Peristomal Complications

PURPOSE

Validated and reliable stomal and peristomal complication definitions and associated interventions are lacking. Available literature is either narrowly medically focused or only of case study level. The objectives of this study were to establish content validation data for the proposed stomal and peristomal complication definitions and their associated interventions, to obtain the data related to contact with stomal and peristomal complication patients, and to gain insight into the ostomy care process.

METHODS

A researcher-designed survey was sent to 2900 expert Wound, Ostomy and Continence nurse clinicians via a national mailing to a representative nonrandomized sample of participants who identified that they included ostomy care in their professional practice. In total, 686 nurses returned the survey, a response rate of 24%. The purposive sample was asked to quantify the degree of validity of the survey's stated stomal and peristomal definitions and interventions. Hand-written qualitative comments of the participants were transcribed, analyzed, and themes were derived.

RESULTS

On a scale of 1 to 4, the mean score for all definitions and interventions was 3.64 (SD=0.30). The overall survey's content validity index was .91. Ratings demonstrated high consensus validation on the stomal and peristomal definitions and interventions, with definitions scoring higher. The mean scores and the content validity index results on selected items were slightly lower for interventions, especially stomal interventions. Qualitative analysis of participants' comments about the whole instrument generated 10 themes and associated subthemes related to omitted complications and interventions and general observations about the ostomy care process and the validation research process.

CONCLUSION

The proposed stomal and peristomal definitions and interventions were rated as generally valid. Further research documenting validation of participants' comments is necessary. Given the findings, additional complications and interventions not identified in the literature were noted and need to be further scrutinized and researched.

Descriptive study of peristomal complications

OBJECTIVE

The objective of this study was to assess new ostomy patients for the presence of peristomal complications when they returned for their 2-month postoperative follow-up at a major university hospital.

DESIGN

A prospective descriptive design was used.

SETTING AND SUBJECTS

For 1 year, new ostomy patients were seen at a 540-bed university-based hospital. Subjects included 220 patients with ostomies who underwent a fecal or urinary diversion at a university-based hospital.

INSTRUMENTS AND METHODS

For 12 months, each patient who returned for a 2-month follow-up visit was assessed by 1 of 3 WOC nurses for the presence or absence of peristomal complications using a tool developed by the investigators. The study was conducted from August 2001 to August 2002. Descriptive statistics were used to summarize the data.

RESULTS

A total of 220 new ostomy patients were examined, 35 of whom had peristomal complications for a frequency of 16%. Sixteen of the 35 patients had ileostomies, 10 patients had colostomies, and 9 patients had ileal conduits. Of the 35 patients with peristomal complications, 24 had irritant dermatitis, 7 had mechanical injury, and 3 had Candida infections. The WOC nurses determined the causes of the peristomal complications to be related to flush stomas, peristomal hernias, inappropriate opening in the skin barrier, and mechanical injury from the pouching systems. Nine of 35 patients had flush stomas; 5 patients developed peristomal hernias. For 7 patients, the skin barrier in the pouching system was larger than the stoma, allowing the effluent to contact the peristomal skin, resulting in denuded peristomal skin; and 7 patients had pressure areas on the peristomal skin and were wearing convex pouching systems.

CONCLUSIONS

With more laparoscopic ostomy surgeries resulting in decreased hospital stays, there is less opportunity for the patient to learn pouching techniques and problem solving regarding peristomal complications. Patients require more education regarding peristomal issues and follow-up after discharge to ensure the maintenance of a secure pouching system. Decreased hospital stays and decreased reimbursement for outpatient and home health services will continue to be a challenge for the WOC nurse. There is also a need for universal definitions of complications and the need for continued studies examining the frequency of these complications, as well as the role of stoma site marking in reducing these complications.

Care of the Obese PatientWith an Ostomy

Obesity has become the number one health problem in the United States. The patients who is obese and undergoing a surgical procedure that results in the formation of fecal or urinary diversion requires advanced skills of a multidisciplinary healthcare team. Patients who are obese carry a high risk of wound and cardiopulmonary complications and often present a serious challenge in terms of stoma creation and management. The purpose of this article is to examine the risk factors that face the patient who is obese and undergoing stoma surgery, the challenges of stoma creation, and the resultant stoma management problems.

Preparing a Grant Proposal—Part 5

Translating a research idea into a well-written grant proposal takes planning and commitment. This Spotlight is the fifth in a series by the members of the Center for Clinical Investigation (CCI) of the Wound, Ostomy and Continence Nurses (WOCN) Society. The aim of this series is to facilitate high-quality grant writing and encourage submissions to WOCN's grants program. This article provides guidance on the development of a grant proposal and the revisions necessary to result in a polished final product.

The state of the standard diversion

A fecal or urinary diversion is frequently recommended for a variety of patient conditions. This article will review some of the history of stoma creation, discuss current practices in stoma care, and summarize the current literature regarding stomal complications. Outcomes of fecal and urinary diversion procedures will be depicted, and postoperative quality of life will be described. An update of current ostomy equipment will be presented, along with the crucial role of the WOC nurse in stoma care rehabilitation. Areas for future research in the ongoing drive for evidence-based practice will be highlighted.

A review of radiation proctitis in the treatment of prostate cancer

Pelvic radiation is a common therapy for the treatment of prostate cancer. A complication of this therapy, radiation proctitis, may be limited to the direct posttreatment period or it may appear as serious complications that occur months to years after therapy has been completed. Mucosal damage, present with both acute and chronic radiation proctitis, produces a variety of symptoms including mucoid diarrhea, pain upon defecation, serious rectal bleeding, stenosis, and fistula formation. The treatment of radiation proctitis is symptom related, and the goals of therapy include the prevention or correction of mucosal changes and eradication of rectal bleeding. This article will review the pathophysiology of radiation proctitis and its treatment.

A comparison of the efficacy and cost-effectiveness of two methods of managing pressure ulcers

To compare the efficacy and the cost-effectiveness of moist gauze dressings and a hydrocolloid wafer dressing (DuoDERM CGF), 70 patients with 97 pressure ulcers that were stage II and/or stage III were randomly assigned to one of two treatment methods: moist gauze dressings or hydrocolloid dressings. Efficacy was defined as the number of ulcers that completely healed. In this debilitated, poorly nourished group of patients, one ulcer completely healed in the moist gauze dressing group, and 11 healed in the hydrocolloid group. The per diem cost of the moist gauze dressing was $12.26; the per diem cost of the hydrocolloid dressing was $3.55.