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.