The Development and Use of Algorithms for Diagnosing and Choosing Treatment of Ostomy Complications: Results of a Prospective Evaluation
Stoma complications are classified and treated based on the etiology, pathology, location, and clinical presentation of the complication. Clinical assessments and descriptions of abdominal stomal topography differ among care providers, hampering interpretation and communication.
Using existing literature and clinical experience at the State Scientific Centre of Coloproctology in Russia, algorithms were developed to facilitate a uniform approach to the diagnosis and choice of treatment of ostomy complications. The algorithms consist of a definite sequence of explicit step-by-step procedures, including visual inspection, digital exploration, and instrumental exploration, for determining whether complications should be categorized and treated as a stoma problem or peristomal skin disorder. The algorithm was subsequently used by nonexpert nurses for all consecutive patients who visited the clinic during a 2-year period. Of the 1,427 patients seen, 553 (38.8%) had 742 complications. Of those, 387 were stoma complications and 355 were classified as peristomal skin disorders (eg, contact dermatitis, hypergranulation of the skin, allergic dermatitis, folliculitis, psoriasis and herpes). Of the 553 patients with complications, the most frequent complications were found to be contact dermatitis (184 patients, 33.3%), parastomal hernia (97, 17.5%), and mucocutaneous separation (72, 13.0%); 176 patients were referred to surgery and 377 received conservative treatment. Although the algorithms remain to be validated, the authors believe that studying the manifestation and causes of complications will help in the selection of justified treatments, which will eventually reduce the number of complications and improve the quality of stoma care.
Potential Conflicts of Interest: none disclosed
The observed frequency of stoma complications varies from 25% to 74%1-21 but the mechanisms for developing stoma complications have not been researched extensively and interpretations differ among authors.2,4,5,8,10-14,16-25 Variations in the descriptions of clinical, topographic, and anatomical features of ostomy complications make interpreting and applying data difficult and cloud treatment choice. In Russia, stoma care nurse is not a recognized specialty and all stoma care is provided by nonspecialty nurses. The purpose of this study was to develop a uniform approach to the diagnosis and treatment of ostomy complications that would help optimize rehabilitation of patients with a stoma and be easy for nonspecialty nurses to use.
Methods and Procedures
Literature search. Before the algorithms were developed, a literature search was conducted through the State Central Scientific Medical Library, Russia, using Reference Manager in PubMed (1994 to 2009) and the following search terms: ostomy complications, diagnostic and treatment algorithm, stoma complication, and skin disorders. Current textbooks and monographs on ostomy complications also were reviewed. The results of these searches confirmed the lack of uniformity both in classification of stoma complications and diagnosis of peristomal complication.
The literature5-8,10-14,16,17,19,20,23-33 and a retrospective analysis of the authors’ data indicate that stoma complications can be divided into two categories: 1) complications related to the stoma and 2) peristomal skin disorders. Stoma complications include bleeding, necrosis, eventration (ie, protrusion of the omentum or intestine through an opening in the abdominal wall), mucocutaneous separation, parastomal abscess, phlegmon, stoma retraction, prolapse, parastomal hernia, stenosis, fistula, granuloma, and malignancy. These complications usually are described according to changes of the bowel and location in relation to the abdominal wall. The main causes of these complications are related to stoma creation surgery11,12,27,29 and include incorrect stoma siting (which increases the risk of retraction and parastomal hernia); inadequate bowel mobilization (which may lead to retraction or stoma necrosis); excessive bowel mobilization (which may lead to prolapse, evagination, and parastomal herniation); inadequate diameter of the opening on the abdominal wall or aponeurosis (if it is too big, eventration/prolapse in the stoma area or herniation may occur. If it is too small, stoma necrosis or stenosis is a risk); inadequate blood supply of the mobilized bowel (creates the risk of necrosis); fistula formation and parastomal abscess from sewing through the bowel wall; and use of nonabsorbable sutures for affixing the bowel on the skin (which can cause suture issues, mucocutaneous separation, and infection and consequently parastomal abscess).
Peristomal skin disorders are characterized by changes of the peristomal skin. The most frequent peristomal skin disorders are contact dermatitis, allergic dermatitis, folliculitis, pyoderma gangrenosum, hyperkeratosis, granulomas, psoriasis, and fungal infection.15,25,28 Based on the literature13,16,28 and the authors’ experience, the main causes of these complications are assumed to be exacerbation of the patient’s pre-existing skin conditions combined with stoma complications such as retraction. When retraction is due to peristomal area deformation, it is difficult to ensure secure adhesion of the base plate of the ostomy appliance and consequently it is difficult to protect peristomal skin, making stoma care more difficult or impossible and resulting in peristomal dermatitis. Other complications from improper stoma care include unsuitable ostomy bags, cutting an inappropriately large hole on the base plate, and peculiarities of bowel function such as thin stools and profuse mucous discharge that affect the peristomal skin. Thus, special ostomy care products (convex products, rings, paste, and others) are required.
Algorithm development and use. The algorithms were developed in 2004 based on relevant literature, clinician opinion, and a retrospective analysis of the authors’ patient records. Subsequently, the algorithms were tested on the authors’ patient population.
Algorithms design. The algorithms consist of a sequence of well-defined instructions and explicit step-by-step procedures for solving a problem. The algorithm for diagnosis was based on two main principles: syndromic approach and optimal diagnostic appropriateness.34-36 A syndromic approach facilitates selection of the most general and significant (key) symptoms for the particular type of ostomy complications — ie, each particular type of complication is characterized by its own syndrome (symptom complex/symptom group) that distinguishes the complication from any other type of complication.
This algorithm was developed using the scheme in Figure 1.
The first step in diagnosing ostomy complications, and the first step in the algorithm, is to perform a visual inspection to determine if the changes are related to the stoma itself or to peristomal skin (localization of complications) (see Figure 2).
Stoma complications. Stoma complications are inspected visually to determine the location of the bowel in relation to the level of the abdominal wall, general contours of the abdominal wall in the peristomal area, diameter of the mobilized bowel and its condition, and changes of the parastomal wound (see Figure 3). Stoma size, defects in the aponeurosis, location of the bowel loop or the omentum in the fat layer around stoma, bowel wall defects, and infiltration in the parastomal area are explored digitally (see Figure 4). Revealing the level of changes (skin, fat layer, or aponeurosis) as well as the defect itself is essential because this will influence treatment choice.
Instrument and laboratory diagnostic methods can be used when exploration and verification are needed for diagnosis. These methods include x-ray, including irrigo (radio)scopy, fistulography, computer tomography (to diagnose parastomal hernias, fistulas, stenosis, malignancy); ultrasound of the parastomal area (diagnosis of parastomal abscesses, fistulas); pathomorphological investigations (differential diagnostics of hypergranulations of the mucosa, malignancies); and microbiological investigation of wound exudate (diagnosis of inflammatory complications) (see Figure 2).
Peristomal skin disorders. Peristomal skin disorders are diagnosed on the basis of clinical observations of skin changes (see Figure 5). Peristomal skin changes can be described using peristomal skin color changes and skin damage severity. According to severity of lesions, peristomal contact dermatitis is divided into three groups: 1) erythema, maceration, 2) vesicules, erosion, and 3) ulcers. This classification system, proposed as the algorithm was developed, is based on symptoms and severity of skin damage and affects the choice of treatment. The cause of peristomal skin changes must be established and can include leakage of intestinal output under the base plate, reactions to ostomy care products, skin infections or folliculitis, and pre-existing and current skin diseases/conditions. Pathological, morphological, and microbiological investigations may be used for differential diagnosis (see Figure 2).
Treatment choice. Once a stoma complication, peristomal skin disorder, or a combination of both is identified, the indications for surgical versus conservative treatment (ie, professional ostomy care) are assessed. Urgent surgical treatment is required if complications endanger the patient’s life; such complications include bleeding, deep necrosis of the stoma, retraction up to aponeurosis, high small intestinal fistula, abscess, phlegmon in the parastomal area, or acute bowel obstruction (see Figure 6). Complications affecting normal bowel function (in case of stenosis, hernia, or prolapse) and complications creating practical difficulties in managing the stoma, peristomal skin, and equipment (retraction, parastomal hernia, stenosis, prolapse) are subject to planned surgery. Indications for surgical treatment are defined by concomitant diseases and generalization of the underlying disease. Taking into consideration the above factors, the type of surgery is chosen — eg, surgery to refashion and/or reposition the stoma and eliminate complications in combination with restoration of bowel continuity.
Stoma complications are treated conservatively if surgical correction is impossible or the patient is at high risk for surgical complications secondary to an existing concomitant disease. Conservative treatment includes etiopathogenetic treatment (eg, treatment based on the cause and peculiarities of the development of complications), individual selection of ostomy and skin care products, and correction of intestinal dysfunctions and compromised organ function.
After developing the algorithms in 2004, nonspecialty nurses performing ostomy care were trained to use them. The training lasted 2 days and involved lectures, workshops, hands-on master classes, practical training sessions, and an algorithm skill assessment.
Algorithm testing commenced in January 2005 in all patients who visited the clinic and had their original surgical procedure in the State Scientific and Research Centre of Coloproctology (SSCC, Moscow, Russia), as well as in patients who underwent surgery in other clinics who were provided follow-up care and consultations in the authors’ center between January 2005 and December 2007. The algorithms were tested in practice by one nurse under supervision of two physicians. Although the algorithm was used to train nurses from other clinics for use in their daily work, this study presents how one nurse in the authors’ clinic used the algorithms.
The nurse used the algorithm to diagnose existing ostomy complications and recorded them in the database; the physicians confirmed all diagnoses. The nurse then used the algorithm to determine and initiate a conservative treatment choice for peristomal skin disorders and stoma complications without physician assistance. If surgical treatment was needed, patients were referred to the surgeon. Treatment plans and care progress also were recorded in the database.
Data. Data were collected during a 24-month period (January 2005 through December 2007). Microsoft Access/ Microsoft Excel (Reading, Berkshire, UK) was used for the collection and descriptive analysis of the data.
During the 24-month data collection phase, 1,427 patients with a stoma (655 men, 772 women; mean age 59.1 SD 15.2 years, range 16 to 86 years) were registered at the Ostomy Rehabilitation Centre of the SSCC. The majority of patients (956, 66.9%) had surgery at the SSCC; 471 patients (33.1%) underwent stoma surgery at other clinics. More than half (507, 53.1%) of the patients who had surgery in the SSCC had a temporary stoma (preventive proximal stoma to be closed by reconstructive operations); 449 (46.9%) patients had a permanent stoma. The ratio of temporary versus permanent stomas was similar for patients from other clinics; 255 (54.1%) temporary and 216 (45.9%) permanent stomas (see Table 1). Most permanent and temporary stomas were sigmoid colostomies (see Table 2).
Of the 1,427 patients, 553 (38.8%) had 742 ostomy complications, observed for the first time in the ostomy rehabilitation center, irrespective of the number of visits or type of examination. On average, patients made three visits. Stoma complications were observed in 158 patients (28.6%), peristomal disorders in 202 (36.5%), and 193 (34.9%) had two or more complications. Of the 742 ostomy complications, 387 (52.2%) were stoma-related and 355 (47.8%) were peristomal skin disorders. Table 3 shows the structure of the number complications of two groups.
The most frequent stoma-related complications were parastomal hernia (97, 25.1%), mucocutaneous separation (72, 18.6%), retraction (55, 14.2%), prolapse (65, 16.8%), and stenosis (39, 10.1%) (see Table 3). The most frequent peristomal skin disorder was contact dermatitis of differing severity. This complication was registered in 317 (89.3%) of 355 patients with skin disorders (see Table 3). Hypergranulation of the skin was seen in 24 patients (6.8%), followed by allergic dermatitis (seven, 2.0%) and folliculitis (four, 1.1%). Other specific peristomal disorders were very rare: psoriasis was diagnosed in two (0.6%) patients and herpes in one (0.2%) patient.
Among patients who underwent surgery at different clinics, the rate of complications occurring more than 1 month post surgery was high (hernia: 29.2%, prolapse: 22.3%, retraction: 16.2%, stenosis: 11.4%, hypergranulation of the mucosa: 9.1% but these patients typically visited the Ostomy Rehabilitation Centre of the SSCC for the first time between 6 months to 5 years after their operation (average time between surgery and first visit was 7 months). Because patients who underwent surgery at SSCC also visited the centre during the early postoperative period, early complications such as mucocutaneous separation, necrosis, and bleeding were seen more frequently in this group (see Table 4).
With the exception of hypergranulation, the frequency of peristomal skin disorders was similar in both clinic groups. Peristomal dermatitis was the most commonly observed peristomal complication and documented in 317 patients. Of those, 188 (59.3%) had dermatitis only and 129 patients (40.7%) had dermatitis in addition to other complications. Most patients with dermatitis (178, 56.2%) had superficial skin damage (erythema, maceration) (see Table 5). One third of all patients with an ostomy complication (n = 533) (176, 31.8%) required surgical treatment, including 101 patients with stoma complications and 75 who had several complications (see Table 6). Ostomy reconstruction was performed in 53 patients, eliminating ostomy complications, and bowel continuity was surgically restored in 123 out of 176 patients (69.9%).
The majority of patients with ostomy complications (377, 68.2%) received conservative treatment. Of these, 57 patients with stoma complications and 118 patients with combined complications were not eligible for surgical correction (see Table 6). Treatment of combined complications depends on prevalence of complications. All 193 patients with combined complications had stoma complications. Among them, 153 had stoma complications and skin disorders (eg, retraction with dermatitis); the rest (40 patients) had two or more stoma complications (eg, necrosis plus retraction plus mucocutaneous separation). If stoma complications prevail, surgical intervention is recommended. Contraindications to surgical correction should be taken into consideration.
All 202 patients with peristomal skin disorders were treated conservatively — ie, by protecting the peristomal skin using two-piece appliances and modern wound and skin care products. Patient and caregiver instruction is imperative for the successful treatment and prevention of peristomal skin disorders.
Although relevant literature was replete with descriptions and clinical pictures of ostomy complications, a systematic approach for the diagnosis and treatment of these complications based on simple classification of key symptoms was lacking. Lyon13 published algorithms for the diagnosis of peristomal skin disorders; algorithms for wound treatment also have been developed.34 The current investigation proposes algorithms for diagnosis of both stoma complications and peristomal skin disorders and uses general symptoms (level of damage) important for the choice of treatment along with pictograms to illustrate complications. The algorithms described in this study contain well-defined steps and instructions for the assessment and management of patients with a stoma. They facilitate a uniform approach to patient care but are not an independent diagnostic instrument.
Lack of a precise terminology and universal assessment and treatment often led to misunderstanding and negatively affected continuity of care and communication between the nurse and the physician at the authors’ facility. During the algorithm evaluation, no diagnostic discrepancies were registered between the nurse and the physicians.
The importance of using a systematic approach to the treatment of ostomy complication has been documented,31,32 and Colwell and Beitz27 described general and systematic stomal and parastomal definitions and interventions. Results of the data analysis from the patient registry suggest the algorithms can be used to diagnose both stomal complications and peristomal skin disorders. The algorithm studied enabled the authors to assess the nature of ostomy complications, which is important for the organization of stoma care.
The study results support findings37,38 that algorithms with face, content, and construct validity can facilitate the provision of optimal care and also confirm that wound education for nurses needs to be improved. The algorithm also allowed the nurse to determine the type of treatment needed and manage peristomal skin disorders and stoma complications conservatively without physician assistance. Patients requiring surgical treatment were referred to the surgeon. The observed frequency of stoma complications varies from 25% to 74%.1,2 Study data showed that complications in ostomy patients occurred in 38.8% of the population studied. These data are the subject of further investigation.
One third of patients required surgical intervention, but in the vast majority of patients (68.2%) conservative treatment — ie, professional ostomy care — was the obvious choice of treatment. These data showed that the nurse can treat the majority of patients with complications without the physician’s assistance. That was important for the organization of stoma care in this clinic.
The most important limitation of the study is the level of assessment subjectivity. Even though the algorithms provide step-by-step instructions, assessments remain subject to individual interpretation. The interpretation of additional diagnostic tests such as x-rays also depends on some level of subjectivity. Studies to validate these algorithms are needed and will be conducted.
Stoma complications are classified and treatment is based on the etiology, pathology, location, and clinical presentation of the complication. An instrument to facilitate a uniform approach to the diagnosis and treatment of these complications was developed. To test its use in clinical practice, the algorithms were used by a nonspecialty nurse to guide the assessment, care, and referral of 1,427 outpatients. Analysis of data showed that complications in ostomy patients are rather frequent and occurred in 38.8% of the study population. Of the 742 patients, complications were identified in 553, with stoma complications observed in 158 patients and peristomal disorders in 202 patients; 193 patients had more than one complication; 387 (52.2%) of a total of 742 complications were stoma complications; and 355 (47.8%) were peristomal skin disorders.
One third of patients required surgical intervention, but in the vast majority of patients (68.2%), conservative treatment, including professional ostomy care, was the most appropriate treatment choice. Results of this study suggest that the algorithms facilitate rapid categorization of complications and treatment selection using a minimum number of key symptoms. Additional studies to validate these algorithms will be conducted.
Dr. Kalashnikova is Chief, Ostomy Rehabilitation Centre, and Head of the Outpatients’ Clinic; Dr. Achkasov is Senior Researcher; Ms. Fadeeva is a stoma care nurse, Ostomy Rehabilitation Centre; and Dr. Vorobiev is a Professor and Academician of the Russian Academy of Medical Sciences and Director, State Scientific Centre of Coloproctology, Moscow, Russia. Please address correspondence to: I. Kalashnikova, MD, Chief of Ostomy Rehabilitation Centre, Head of the Outpatients’ Clinic, State Scientific Centre of Coloproctology, 2, Salyam Adilya Str., Moscow, 123423, Russia; email: email@example.com or firstname.lastname@example.org.