Park et al24 performed a retrospective analysis of all gastrointestinal stomas (N = 1616) performed at their hospital over a period of almost 20 years that examined early and late complications. Early complications were defined as occurring within 1 month of surgery and included skin irritation, poor location, partial necrosis, retraction, parastomal separation, parastomal abscess, bleeding, complete necrosis, evisceration, stenosis, pseudoepithelial hyperplasia, protruding sigmoid, and allergy. Late complications occurred 1 month or more after surgery and included skin irritation, prolapse, stenosis, parastomal hernia, pseudoepithelial hyperplasia, retraction, allergy, and perforation. The authors presented evidence that 553 individuals (34%) had 807 complications. Of these, 448 had 600 early complications, 105 had 207 late complications, and 30 experienced both early and late complications. Of the late complications, 93% occurred within the first 6 months.
By ostomy type, the highest percentage of complications in Park et al’s study24 occurred with ileostomy (49%), followed by ascending colostomy (35%), sigmoid colostomy (34%), descending colostomy (31%), and transverse colostomy (22%). Loop ileostomy had the highest overall rate of complications, and end colostomy had the lowest rate. Although “skin irritation” was not clearly defined, this was the most common early complication and was attributed or secondary to stoma neglect, leakage, improper fit, or frequent changing of the pouching system. Less frequent late complications were predominantly related to skin irritation, prolapse, and stenosis.24
Ratliff et al26 assessed a cohort of individuals with a new ostomy during a postoperative visit for the presence of peristomal complications including mechanical injury, chemical damage (irritant dermatitis, pseudoverrucous lesions, hyperplasia), infection (Candida, bacterial, folliculitis), and allergic response. Over the course of 1 year, 220 individuals with an ostomy were seen 2 months after surgery by the wound ostomy continence (WOC) nurse during a routine examination. The frequency of peristomal complications was 13%; complications included chemical (irritant) damage (n = 24), mechanical damage (n = 7), and Candida infection (n = 3). The WOC nurses who examined each patient reported the complications were related to stomas that were flush or retracted, peristomal hernias in which the opening of the pouch was cut too large, or due to an injury caused by the pouch itself. Citing a wide variation regarding how peristomal complications are reported in the literature, the authors emphasized the importance of using universal definitions for peristomal complications for reporting and tracking.
Herlufsen et al20 reported the frequency, severity, and diversity of peristomal skin disorders among 202 individuals with a permanent stoma in Denmark as part of a 2-phase, cross-sectional study. In the first phase, an anonymous questionnaire was used to collect data; in the second phase, participants completed a questionnaire and a stoma care nurse filled out a registration form and performed a clinical examination of the peristomal skin. Healthy peristomal skin was defined as the complete absence of any visible skin change of the peristomal area. Peristomal skin disorders were classified as mild (slight skin involving only a small portion of the skin, usually 0.1 cm to 0.5 cm requiring minor adjustment), moderate (definite skin changes — eg, ulcers in the peristomal region involving an area of at least 2 cm2, adjustment of the pouching system, and/or a suggestion of treatment), or severe (conditions requiring immediate medical attention or substantial involvement of the skin beneath the ostomy appliance interfering with appliance adhesion). The number of peristomal skin disorders was higher for permanent ileostomy (57%) and urostomy (48%) than colostomy (33%). In persons with skin disorders, 77% were related to stoma effluent. However, 38% of participants failed to recognize they had a skin disorder before clinical examination confirming the disorder, and more than 80% did not seek professional care. These findings suggested a need for education and regular evaluation of the peristomal skin by a professional.
Pittman et al18 conducted a secondary analysis of data collected from veterans by Krouse et al.13 The authors examined the relationships among City of Hope-Quality of Life-Ostomy Questionnaire (COH-QOL-OQ) scores and ostomy complications. Ostomy complications were defined as “skin problems,” “leakage,” and “difficulty adjusting.” The instrument has 4 domains (physiological, psychological, social, and spiritual) which are scored on a scale of 1 to 10 with 10 being the highest or best QoL score.10 The mean total QoL score was 7.67 ± 1.47 for individuals with mild and 5.06 ± 1.78 for persons with severe skin problems. Mean total QoL scores for study participants with mild leakage was 7.46 ± 1.58 compared to 5.02 ± 1.81 for persons with severe leakage problems and 7.99 ± 1.27 for persons with mild difficulty adjusting compared to 4.39 ± 1.41 for persons with severe difficulty adjusting. Although QoL scores were lower for persons with severe skin problems, leakage, and difficulty adjusting, no significant differences were noted in the severity of complications when the researchers examined race/ethnicity, gender, or education.
In a systematic literature review regarding the incidence of complications related to the stoma and peristomal skin, Salvadalena30 concluded the exact incidence and prevalence of complications are unknown due to differences in the way data are collected and stomal and peristomal complications are defined. Few studies report the use of measurement instruments and many fail to provide descriptions of the reliability or validity of methods used for evaluation. Due to inconsistencies in data collection, operational definitions, and study design, it is difficult to pool data; Salvadalena recommended the development of instruments to investigate stomal and peristomal complications.
Ratliff 25 prospectively investigated peristomal complications as reported by WOC nurses who completed a peristomal skin complication form for 89 patients with an ostomy regardless of whether they had a complication. Patients were seen within the first 2 months of ostomy surgery in hospital, home health, or outpatient clinic settings. Of the 42 (47%) patients who had peristomal complications, 31 had irritant dermatitis, 5 had mechanical injury, 4 had Candida infections, 1 had an allergic reaction, and 1 had pyoderma gangrenosum. Because studies are limited, the author suggested a central repository for peristomal complications data collected over time and in multiple settings.
Erwin-Toth et al8 evaluated skin condition and health-related QoL (HRQOL) in 743 persons in North America with a colostomy, ileostomy, or urostomy present for at least 6 months. Volunteers solicited via mail and advertisements, as well as patients who sought care from clinicians serving as data collectors, completed self-report surveys including the Ostomy Skin Tool (OST)34 and the Stoma Quality of Life questionnaire.35 The OST evaluates the presence and severity of 3 conditions (domain): discoloration (D), erosion or ulceration (E), and tissue overgrowth (T); each domain score ranges from 0 (normal skin) to 15 (indicating severe discoloration, ulcerations, denuded skin, and extensive overgrowth). The instruments were self-administered at baseline and again after 6 to 8 weeks, at which times a WOC nurse evaluated the peristomal skin using the OST.34 Interestingly, many participants did not recognize their peristomal skin was not considered “normal.” During the first visit, 29% of the participants reported a peristomal skin disorder; however, visual assessment by a WOC nurse revealed 61% of patients had objective signs of a peristomal skin disorder. In essence, a skin disorder was twice as likely to be detected by a WOC nurse; 32% of patients were unaware they had a peristomal skin disorder. Similarly, on the second visit, 30% of patients did not report any peristomal skin disorder, which was then subsequently noted by the WOC nurse. After the first visit, a double-faced adhesive pouching system was initiated; upon follow-up, participants reported improvement of skin condition and overall significant improvement (P <.0001) in mean QoL scores also was noted. The greatest change in QoL was observed in the quartile of participants with the lowest QoL at baseline. The researchers concluded regular contact with a WOC nurse combined with the use of an appliance with double-layer adhesive led to significant reduction in leakage and accessory use, improved skin condition, and significant improvement in HRQOL.8
Meisner et al21 used a population-based, cost modeling study to investigate peristomal skin complications using the OST and concluded peristomal skin complications are common, expensive, and difficult to manage. Their work further supported the premise peristomal complications are common and their frequency and severity are underrecognized and underreported.21
Gray et al36 performed a comprehensive review of the literature and summarized consensus-based statements outlining best practice for assessment, prevention, and management of peristomal moisture-associated dermatitis among patients with fecal ostomies. The authors concluded peristomal moisture-associated skin damage (MASD) is a prevalent and clinically relevant complication.
Salvadalena30 also examined stomal and peristomal complications as well as related variables among adults with ostomies. Data collection occurred in 2 university hospital-based outpatient ostomy clinics and included 43 adults with newly created colostomy, ileostomy, or urostomy stomas. Patients were examined by a specialized nurse for the presence of complications up to 4 times during a 3-month period (within first 7 days and at 2, 6, and 12 weeks postoperatively). Peristomal complications were found in 27 (63%) of the participants, with onset most frequently occurring within 21 to 40 days. Of the 18 participants observed 70 days or longer, 7 (38%) remained free of complications and 6 developed 1 or more complications. The most common complication was irritation (MASD) and infection.
Although stomal and peristomal complications are receiving increased attention in the literature and it is generally agreed QoL is affected, research shows inconsistencies in the way clinicians report stomal and peristomal complications. Valid and reliable definitions have been lacking. In 2007, Colwell and Beitz32 surveyed a group of ostomy nurses to ascertain consensus for common terminology. The survey revealed most nurses considered peristomal complications to include peristomal varices, peristomal candidiasis, peristomal folliculitis, mucosal transplantation, pseudoverrucous lesions, peristomal pyoderma gangrenosum, peristomal suture granulomas, peristomal irritant contact dermatitis, peristomal allergic contact dermatitis, and peristomal trauma. Respondents considered stomal complications to include parastomal hernia, stomal prolapse, stomal necrosis, mucocutaneous separation, stomal retraction, stomal stenosis, stomal fistula, and stomal trauma. As a result of the study, the authors validated definitions and interventions for both stomal and peristomal complications and promoted use of this terminology for ostomy-related research endeavors.32
The purpose of this descriptive study was to explore the relationship among QoL scores and 6 peristomal complications: peristomal candidiasis, peristomal folliculitis, pseudoverrucous lesions, peristomal irritant contact dermatitis, peristomal allergic contact dermatitis, and peristomal trauma as validated by Colwell and Beitz.32