The Ostomy Files: When Surgical Revision Is Not an Option

    The stoma is poorly cited and lies deep in a fat fold near the groin. A double-barrel colostomy is placed through an incision. An appropriately cited stoma is now retracted due to massive postoperative weight gain.

    Most clinicians who care for patients with an ostomy have encountered situations like this sometime during their practice. Such scenarios create major management problems for the clinician as well as the patient and can consume inordinate amounts of time, effort, and money. They also have a major negative affect on the quality of the patient’s life. Often, problems are so severe that surgical repair of the stoma or surgical relocation of the stoma to a more optimal site on the abdomen is required.¹ In some cases, however, the patient is a poor surgical candidate due to advanced age, poor prognosis, or other medical complications. In these situations, the challenge and responsibility of finding a suitable pouching system solution arrive back in the hands of the clinician.

    When stomal problems occur, healthcare providers should seek the expertise of ostomy experts, such as Wound Ostomy Continence Nurses (WOCNs). If the service of a WOCN is not available, non-specialized nurses may want to contact local medical supply distributors or call manufacturers’ Customer Service or Professional Services departments to request guidance or suggestions for ostomy products that may be appropriate for the patient.

    Modern ostomy products easily lend themselves to customization to meet a myriad needs and solve challenging management problems. Usually, a patient with a difficult-to-manage stoma has a history of frequent leakage and subsequent chronic peristomal skin irritation. Leakage is often secondary to an improperly sized stomal opening in the skin barrier, the inability of the pouching system to adhere to uneven skin surfaces during routine activities, or the failure of the skin barrier to manage the type and/or quantity of stomal output.

    The selection of an appropriate skin barrier is just as important, if not more important, as selecting an appropriate pouch.² Skin barriers differ in their composition but most are hydrocolloids and are categorized as standard skin barriers and extended-wear skin barriers. Extended-wear skin barriers have delayed absorption, generally provide longer wear time, and maintain shape in the presence of moisture. They protect peristomal skin, contribute to healing of existing skin irritation, and extend wear time in many difficult-to-manage situations. A patient who has experienced daily or twice-daily leakage would welcome a secure 24-hour wear time even though the wear time is less than ideal or average. This would represent a definite improvement in the patient’s quality of life.

    Cut-to-fit skin barrier wafers allow the stomal opening to be placed off-center or cut into irregular stoma shapes and sizes — measures that often help solve problems and improve the skin-to-skin barrier seal. Solid skin barriers without flanges can be cut into strips or rings and used to create a level skin surface on which the pouching system can adhere. Skin barrier pastes serve as excellent fillers or as caulking to level uneven skin surfaces, such as old scars or fat folds. Moldable cohesive seals can be configured into almost any shape and used as fillers and rings and to increase the depth of convexity.

    The use of convexity is one of the most common interventions involved in managing a “difficult” stoma. Convexity is available in one- and two-piece systems, as precut and cut-to-fit, as well as a newer two-piece moldable configuration. Moldable convexity provides the ability to create the size and shape of the stomal opening. These alternatives are ideal, especially when the challenges are substantial.

    The goal of ostomy rehabilitation is integrating the stoma into the patient’s everyday life. Ideally, this includes self-care. However, with more difficult-to-manage or poorly cited stomas, family members or caregivers may need to assist the patient with ostomy care. The goal, then — when surgical revision is not an option — is to identify a system that 1) will provide a predictable, sustained wear time (even if that time is 24 or 48 hours); 2) is as easy as possible to learn and/or teach; 3) protects the peristomal skin; and 4) contributes to a sense of security and confidence for the wearer. 

The Ostomy Files is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ

1. Katz J. Stoma relocation. Ostomy Quarterly. 2004;41(3):58-60.

2. Turnbull GB, Colwell J, Erwin-Toth P. Quality of life: pre, post, and beyond ostomy surgery. Ostomy/Wound Management. 2004;50(7A Suppl):1S-12S.