A Multicenter, Retrospective Study to Evaluate the Effect of Preoperative Stoma Site Marking on Stomal and Peristomal Complications

Even though preoperative marking of the stoma area is considered important for the prevention of postoperative complications, not all healthcare institutions have universally adopted this practice. A multicenter, retrospective, descriptive study was conducted to determine the effect of stoma site marking on stomal and peristomal complications.   The 1-year study included 748 patients (408 [54.5%] male, mean age 56.60 ± 16.73 years) from eight stomatherapy units in Turkey. Patient data, including age, gender, diagnosis, type of surgery, history of preoperative stoma site marking, person performing the marking, and postoperative complications, were obtained from patient records, abstracted, and analyzed. Cancer was the reason for the operation in 545 (72.9%) of the cases. In 287 patients (38.4%), the stoma and wound care nurse and/or surgeon marked the stoma area; this occurred 1 day before or on the day of surgery according to Wound Ostomy Continence Nurses Society and American Society of Colon and Rectal Surgeons recommendations. Stomal/peristomal complications developed in 248 (33.2%) persons; the most frequently observed complications in patients were parastomal skin problems (136, 48.7%), mucocutaneous separation (52, 18.6%), and retraction (31, 11.1%). The rate of complications was higher among patients whose stoma site was not marked than among those whose stoma site was marked (22.9% and 46%, respectively; P <0.001). The results of this study confirm the stoma area should be marked preoperatively in all planned surgical interventions in order to reduce the risk of postoperative complications. Additional prospective and experimental studies on effectiveness of preoperative stoma site marking should be conducted with larger sample groups.

Stoma creation is a procedure widely utilized in gastrointestinal and urinary system surgery. Stomas created for cancer, trauma, and inflammatory intestinal diseases are associated with complications that cause difficulties in the daily life of the individual.^1-3 According to the literature, the rate of complications in patients with stomas can vary from 10% to 70%^4-9; preoperative marking of the stoma site is effective in reducing the incidence of complications among individuals with stoma.^10,11

Stoma site marking is performed in patients who are scheduled to undergo ostomies and is considered the first stage of adaptation to the stoma.¹² The process of marking the stoma site allows individuals in the preoperative stage to obtain information on the stoma, stoma care, and products to be used; increases adaptation to the stoma and stoma care; reduces the risk of stomal/peristomal complications; and improves quality of life.^2,13-15 Therefore, the American Society of Colorectal Surgeons (ASCRS), the American Urologists Association (AUA), the Wound Ostomy Continence Nurses Society (WOCN), and the Turkish Wound Ostomy Incontinence Nurses Society (Yara Ostomi I•nkontinans Hems¸ireleri Derneg˘i [YOIHD]) recommend the stoma site should be determined in all patients with planned ostomies and marked preoperatively by a trained, experienced, authorized clinician.^12,16 Furthermore, a 2009 guide published by the World Health Organization¹⁷ emphasized the operation site had to be marked to ensure patient safety.

The first Turkish stomatherapy unit was established in 2000; currently, there are 16 units. However, stoma site marking is systematically performed in only a few centers. In Turkey, stoma areas are marked by stoma and wound care nurses in some centers and stoma and wound care nurses and/or surgeons in others. To create a stoma in the rectus muscle in an area easily visible and accessible by the individual, the individual should be evaluated in the standing, sitting, lying, bending, and walking positions, and the site should be marked.² In patients who have not had their stoma area marked preoperatively, the stoma area is marked while the patient is laying on the operating table; this is an undesired practice. In such positions, abdominal creases straighten out, and a stoma that appears to have been created on a flat site may be situated between abdominal creases when the patient is in the seated position. Creating a stoma between creases compromises pouch and skin barrier adherence and may cause leakage, which negatively affects the complication rate and patient quality of life.

Because preoperative stoma site marking involves consideration of the creases, edges, visible areas, incision lines, and bony edges, it prevents the development of numerous complications.^10,11 In addition to adversely affecting the quality of life and patient adaptation to their stomas, stomal and peristomal complications increase healthcare expenses.^2,12

No studies on the effect of stoma site marking on stomal/peristomal complications have been conducted in Turkey. Thus, YOIHD acknowledges stoma site marking to be a priority medical issue and planned this study to assess the status of stoma site marking in Turkey, increase interest in this issue, and emphasize its importance.

This purpose of this study was to evaluate and describe the effect of stoma site marking on stomal and peristomal complications.

This multicenter, retrospective, descriptive study among patients in eight (out of 16) participating stomatherapy units in Turkey was conducted between January and December 2012. Data were examined for 1 year and included computerized patient records extracted and recorded on a data collection form developed by the researchers based on clinical experience and current literature. Data abstraction for each patient was completed by a nurse at each stomatherapy unit. The data collection forms comprised 10 questions and included patient age, gender, diagnosis, type of operation, status of stoma site marking, person performing the marking, and history of complications since procedure. The forms were exchanged by mail.

Data were evaluated using IBM SPSS for Windows 20.0 software. Figures, percentile calculations, chi-square test, Fisher’s exact test, and the likelihood-ratio (LR) test were used for data evaluation. Because patient data were complete, no data extractions were performed.

Ethical consideration. This study was planned by YOIHD. Nurses were provided information on the purpose and method of the study at the IV Stoma and Wound Care Nurses Meeting (September 10–11, 2012). Written informed consent was obtained from the participating institutions.

Data were extracted from the records of 748 patients (408, 54.5% male; mean age 56.60 ± 16.73 years; 72.2% >50 years of age) at eight stomatherapy units in Turkey. Stoma types included ileostomy (363, 48.5%), colostomy (354, 47.3%), and urostomy (21, 2.8%) and were temporary in 556 (74.3%) patients. The majority of patients (545, 72.9%) had been diagnosed with cancer. The stoma was created during an emergency procedure in 221 patients (29.5%) (see Table 1).

In patients whose stoma area was marked preoperatively, a stoma and wound care nurse and/or a surgeon had marked the site 1 day before or on the day of the operation in accordance with recommendations of the Wound Ostomy Continence Nurses Society and American Society of Colon and Rectal Surgeons.¹² The stoma site was marked preoperatively in 287 (38.4%) study participants; of those, the site was marked by a stoma and wound care nurse in 258 patients (89.9%). The preoperative stoma site marking was unknown in 97 patients (13.0%) (see Table 1).

Stomal/peristomal complications had developed in 248 study participants (35.2%); the three most frequently observed complications were peristomal skin problems (136, 48.7%), mucocutaneous separation (52, 18.6%), and stomal retraction (31, 11.1%) (see Table 1).

The rate of complication development was 46% among patients who did not have their stoma sites marked preoperatively and 22.9% among patients who had their stoma sites marked (c² = 46.408, P <0.001) (see Table 2). In individuals who underwent stoma site marking, the rates of peristomal skin problems, mucocutaneous separation, and stomal retraction were significantly lower than in individuals with no preoperative stoma site marking (P <0.05) (see Table 3).

Age, stoma type, and person marking the stoma were not found to affect the rate of stomal and peristomal complication development (P > 0.05). The rate of stoma retraction was significantly higher in women than in men (5.9% versus 2.7%, c² = 4.739, P = 0.029).

Stomal and peristomal complications developed in 60% of individuals with more than one stoma, 38.9% of individuals with an ileostomy, 28.9% of individuals with a colostomy, and 14.3% of individuals with a urostomy. The higher rates of complications among patients with an ileostomy or with more than one stoma were found to be statistically significant (c² = 14.421, P = 0.002) (see Figure 1). When the complication rate was examined according to stoma type, peristomal skin problems were found to develop at a higher rate in individuals with an ileostomy and in those with more than one stoma (c² = 26.651, P <0.001).

The stoma site was not preoperatively marked in 80% of individuals with more than one stoma, 49.7% of colostomy patients, 47.7% of ileostomy patients, and 33.3% of urostomy patients. A statistically significant relationship was noted between stoma type and the stoma site marking status (LR = 26.574, P <0.001). In the statistical evaluation using the LR test, stomal and peristomal complications were found to develop in 67.3% of colostomy patients and in 64.5% of ileostomy patients whose stomal sites were not marked, a statistically significant difference (P <0.05) (colostomy: LR = 21.910, P <0.001; ileostomy: LR = 31.714, P <0.001).

Stomal and peristomal complications developed in 40% of stoma patients who underwent emergency surgical interventions and in 31.1% of stoma patients who underwent planned surgical interventions, a statistically significant difference (P = 0.019) (see Figure 2). Mucocutaneous separation was observed at a higher rate among stoma patients who underwent an emergency surgical intervention (P = 0.002), whereas stomal retraction was observed at a higher rate among patients who underwent planned surgical interventions (P = 0.038) (see Table 3). Statistical analysis showed the higher rate of mucocutaneous separation observed in patients who underwent emergency surgical interventions and the higher rate of stomal retraction observed in patients who underwent planned surgical interventions are associated with the preoperative marking of the stomal region. The incidence of peristomal skin problems, mucocutaneous separation, and retraction in patients who underwent preoperative stoma site marking did not vary according to the type of surgery (P >0.05) (see Table 4).

This study found stomas were created in patients mostly due to cancer, which is supported by the literature.^4,18-20 Among the most widespread types of cancer in Turkey, colorectal cancers rank second for women (12.5%) and fourth for men (18.2%), and bladder cancer ranks third for men (21.1%). As these data indicate, the types of cancer that necessitate the creation of ostomies are currently in the top five most common types of cancer in Turkey,²¹ increasing the likelihood of regularly encountering patients with a stoma in clinical practice.

The results of this study show complications developed in one third of stoma patients and that peristomal skin complications were the most common. This finding is similar to results reported in the literature. In the study conducted by Karadag˘⁵ in a similar group of patients, the complication rate was 32.8% and the most widespread complication was peristomal skin irritation (17.9%). In a prospective, descriptive study conducted among 220 patients with fecal and urinary stomas and in their second postoperative month, Ratliff et al²² found complications developed in 35 individuals (16%) with a stoma and that more than half (24, 68.6%) of these complications were described as irritant dermatitis. Akçam et al⁶ observed a complication rate of 24.1%; the most frequent complication was dermatitis (5.8%). Other published studies have found higher rates of complications. In a prevalence study conducted on stoma complications and factors affecting the development of stoma (n = 330), Mahjoubi et al²³ found a relatively high rate of complications (69.4%) in colostomy patients, whereas Özaydın et al⁹ reported the rate of developing complications was 48%, and the most frequently encountered complication was skin irritation (63%). Overall, rates of stoma complications reported in the literature vary between 10% and 70%.⁴

Complications reduce the self-care ability of stoma patients, leading to a variety of psychosocial problems.¹³ The type of stoma, type of operation, surgical technique, preoperative marking of the stoma site, and general health of the individual — in addition to preoperative and postoperative follow-up care, appropriate peristomal skin care, and patient education — influence the development of complications. The current study was conducted in stomatherapy units, where follow-up and patient care were performed regularly. This may explain a lower rate of complications than what has been reported in the literature.

Although this study was conducted at institutions with stomatherapy units, half of the patients were not marked preoperatively. In individuals without stoma site marking, the rate of complications was nearly twice as high as the rate in those with marking. Likewise, Person et al²⁴ reported a lower complication rate among patients who underwent stoma site marking than in those without stoma site marking. In a jointly published practice manual from the ASCRS and WOCN,¹² marking of the stoma site was accepted as a proven benefit. Furthermore, in the systematic review study conducted by Colwell and Gray,¹⁰ the positive impact of preoperative education and stoma site marking on postoperative patient outcomes was accepted as evidence. The same study found preoperatively determining the stoma region reduced complication development, a statement supported by Level 4 evidence (ie, specialist committee reports and expert opinions).

In the current study, the rates of peristomal skin problems, mucocutaneous separation, and retraction complications were significantly higher in individuals whose stoma sites were not marked than in patients whose stoma sites were marked. In patients who do not undergo preoperative marking, the stoma can be created in between skin creases, near bony edges, and near incision lines, causing difficulties with pouching systems. Peristomal urine and stool leakage onto the skin are the main causes of chemical irritant dermatitis in ileostomy and urostomy patients.²⁵ Furthermore, retraction can develop in stomas not created properly or in the appropriate region. Stomal retraction generally causes mucocutaneous separation. Stomal retraction and mucocutaneous separation make obtaining a secure seal between the skin and the pouch system difficult and increase the risk of leakage and skin problems.²⁶ This, in turn, creates more problems, because it is difficult to place a pouch system on skin with deteriorated integrity. This vicious cycle not only leads to physiological problems, but also to psychosocial problems, adversely affecting patient quality of life.

In the current study, among individuals with more than one stoma or an ileostomy, the rate of developing complications was significantly higher, confirming previously reported study results. In a retrospective study (N = 1,616 stoma patients), Park et al²⁷ found the highest rate of complications was associated with loop ileostomy (75%), and the most frequent postoperative early stage complication was skin eruption (12%). Özaydın et al⁹ found the rate of developing complications was 19.3% in individuals with ileostomy. The literature on peristomal skin problems indicates in ileostomy patients, fecal output with a more liquid texture damages skin integrity at various levels.^8,28

One of the most seemingly obvious observations in the current study was the rate of developing complications in patients with emergently created stomas (40.0%) was higher than in those with planned ostomies (31.1%). However, advanced analyses, which found the stoma site is marked at a lower rate in emergency operations, have shown this observation was related to the failure to mark the stoma site rather than to the emergent nature of the operation. In both emergency and planned operations, the complication rates in patients whose stoma region was not marked were very similar. Likewise, in a prospective study conducted on stomal complications, Arumugam et al¹⁸ found no significant difference in the rates of developed complications between planned and emergency operations. In prospective study conducted by Robertson et al,⁴ the rate of developing stomal complications in planned operations was similar to that in unplanned operations. Marking the stomal site, which is one of the rights of patients undergoing stoma creation, is part of the listed job duties of certified stoma and wound care nurses working in stomatherapy units in Turkey.^29,30 Nurses marked most stoma sites in the current study. In planned ostomy surgeries, stoma and wound care nurses mark the stoma site in cooperation with the surgical team. However, stoma and wound care nurses at stomatherapy units serving as outpatient clinics are unable to mark stoma sites in emergency operations performed on weekends or during night shifts. Furthermore, it is frequently impossible to perform preoperative preparations in emergencies. In addition, in emergency operations, the decision of whether a stoma will be created can be made during the actual operation. Thus, the stoma site is not marked in emergency operations, which is considered an important contributing factor to the higher rate of stoma complications associated with emergency operations.

This study did not include all stomatherapy units in Turkey; the study sample is limited to institutions agreeing to participate in the study. In addition, the study is retrospective and as such limited to the patient records and record accuracy at the units where the study was conducted.

In this study, the site of stomas created during emergency surgical procedures were generally not marked, and the rate of complications in this patient sample was higher than in patients who underwent a planned procedure and had their stoma site marked preoperatively. In accordance with these results, the following recommendations have been made for the purpose of decreasing stomal and peristomal complications: in addition to meeting all other preoperative medical requirements, the stoma site should be marked on all patients who will undergo an operation. The number of stomatherapy units that provide patients with preoperative and postoperative follow-up and training, care, and consultancy should be increased, along with the number of certified stoma and wound care nurses with the requisite knowledge and skills for preoperative marking of the stoma site. Training materials on stoma site marking, such as training programs and CDs, to increase awareness, knowledge, and skills of clinicians should be readily available. The results of this study confirm previous reports that the stoma site should be identified and marked preoperatively in all surgical interventions that may result in the creation of a stoma. Additional prospective and experimental studies on effectiveness of preoperative stoma site marking to underscore these recommendations should be conducted with larger sample groups.

Statistical analyses were conducted by Associate Professor Dr. Erdem Karabulut, faculty member at the Department of Biostatistics at the Faculty of Medicine in Hacettepe University, Ankara, Turkey.

Dr. Baykara and Dr. Demir are instructors; and Dr. Karadag is a professor, Gazi University, Faculty of Health Sciences, Department of Nursing, Ankara, Turkey. Dr. Harputlu is an enterostomal therapy nurse, Dokuz Eylul University Hospital Stomatherapy Unit, Izmir, Turkey. Ms. Kahraman is an enterostomal therapy nurse, Ege University Hospital Stomatherapy Unit, Izmir, Turkey. Ms. Karadag is an enterostomal therapy nurse, Turkey High Specialization Education and Research Hospital Stomatherapy Unit, Ankara, Turkey. Ms. Hin is an enterostomal therapy nurse, Gazi University Hospital Stomatherapy Unit. Ms. Togluk is an enterostomal therapy nurse, Istanbul University Cerrahpasa Hospital Stomatherapy Unit, Istanbul, Turkey. Ms. Altinsoy is an enterostomal therapy nurse, Istanbul University Capa Hospital Stomatherapy Unit, Istanbul, Turkey. Ms. Erdem is an enterostomal therapy nurse, Uludag University Hospital Stomatherapy Unit, Bursa, Turkey. Ms. Cihan is an enterostomal therapy nurse, Cukurova University Hospital Stomatherapy Unit, Adana, Turkey.

Please address correspondence to: Sevil Guler Demir, PhD, Gazi University Faculty of Health Sciences Department of Nursing, Emniyet Mah, Muammer Yasar Bostanci Cad. No: 16 Postal Code 06500 Besevler/Ankara, Turkey; email: sevilgulerdemir@yahoo.com.