The Ostomy Files: The Position on Preoperative Stoma Site Positioning

   In a world of outcomes, a surprisingly scant amount of literature is available regarding the clinical and financial outcomes of preoperative stoma site marking, a totally controllable and essential component of quality ostomy care. In fact, it could reasonably be considered preventive medicine - the first step and cheapest alternative toward reducing complications and overall ostomy management costs and improving quality of life for the patient.

What is in the literature, however, substantiates what we have long recognized in clinical practice: The procedure positively influences clinical and financial outcomes for patients with stomas. A poorly placed stoma can result in failure of the pouching system, skin and leakage problems, and may require either local revision or relocation of the stoma. These complications also increase resource utilization and costs associated with patient care and negatively impact the quality of a patient's life (for which the cost is incalculable). Putting a price on a patient's emotional suffering, sense of well being, or security is virtually impossible. Follick et al1 examined the range of postoperative adjustment difficulties in a survey of 131 ostomy patients. The most frequently encountered problem was associated with "technical management problems" (eg, problems with the pouching system, irrigation, leakage, gas, odor, damage to the stoma, and skin problems) that were negatively correlated with psychosocial adjustment associated with poorer emotional, social, family, and marital adjustment. Eighty-four percent of the respondents admitted they had one or more of these technical management problems. Forty-nine years ago, Turnbull2 determined that a preoperative abdominal assessment should be conducted to locate a flat surface for stomal placement to ensure that the postoperative pouching system could adhere adequately. This preoperative "stoma siting" procedure consisted of cementing an appliance ring on the abdomen for 24 hours to see how it "rode" on the patient's abdomen. Three years later, Dr. Turnbull refined the approach by defining the optimal stomal placement as "medially, below the umbilicus."3 By 1964, Turnbull and Weakley4 further distilled the optimal stomal placement so that "the ileum transverses the belly of the rectus muscle and the stoma will be located at the summit of the infra-umbilical fat roll." In 2002, this technique is still accepted as the standard of practice.5 We know how to do it and why it should be done, but the nagging concerns linger: Is it being done on all patients and if not, why not? Where and what patients fall through the cracks? What can be done to prevent this from happening? In their 1991 publication of a review of the United Ostomy Association Registry (16,470 patients), Fleshman and Lewis6 reported no decrease in the number of poorly placed stomas from the previous 10 years. Another retrospective study7 compared complication rates between two groups of 593 patients who underwent elective ostomy surgery and were followed for postoperative complications. One group of patients had preoperative stoma site marking and another group did not. The groups had complication rates of 32.5% and 43.5%, respectively. This and another study8 help demonstrate that preoperative stoma site marking and education can reduce adverse outcomes. Payers and regulators need to have more evidence than this on which to base policy and evaluate costs. Not only are maladaptive behaviors exacerbated when a stoma is poorly sited or constructed, but also additional costs are incurred when the stoma requires a customized and complex pouching system9 or additional healthcare resources such as home health, outpatient clinic and emergency room visits, or extraordinary quantities of ostomy supplies. Where are the clinical and cost-effectiveness outcome studies to support this? What is the difference in wear-time and peristomal skin status of patients who receive preoperative stoma site marking and those who don't? In a world of prospective payment, where is the most cost-effective clinical setting where this crucial service can be provided? Who will pay for it? What will motivate surgeons to write orders for preoperative stoma site marking for all of their patients? When will surveyors, attorneys, and payers start looking at failure to preoperatively mark patients as a liability? The preoperative determination of stomal positioning on the abdomen is a controllable factor that must be performed correctly on virtually all patients. Not only can it enhance quality of life, but it can also serve to reduce the overall management costs and resource utilization required to care for the thousands of Americans who already have a stoma and those who will in the future. 

1. Follick MJ, Smith TW, Turk DC. Psychosocial adjustment following ostomy. Health Psychology. 1984;3(6):505-517.2

. Turnbull RB. Management of the ileostomy. Am J Surg. 1953;86:617-624.

3. Turnbull RB. Mucosal grafted ileostomy. Surg Clin North Am. 1956;Aug:841-847.

4. Turnbull RB, Weakley F. Ileostomy. In: Cooper, ed. The Craft of Surgery. Little Brown and Company, New York, NY. 1964;1065-1073.

5. Erwin-Toth P. Stoma site marking: a primer. Ostomy/Wound Management. 1997;43(4):18-25.

6. Fleshman JW, Lewis MG. Complications and quality of life after stoma surgery: a review of 16,470 patients in the UOA data registry. Seminars in Colon and Rectal Surgery. 1991;2(2):66-72.

7. Bass EM, Del Pino A, Tan A, Pearl RK, Orsay CP, Abcarian H. Does preoperative stoma marking and education by the enterostomal therapist affect outcome? Dis Colon Rectum. 1997;40(4):440-442.

8. Park JJ, Del Pino A, Orsay CP, Nelson RL, Pearl RK, Cintron JR, Abcarian H. Dis Colon Rectum. 1999;42(12):1575-1580.

9. Rozen BL. The value of a well-placed stoma. Cancer Practice. 1997;5(6):347-352.