The high rate of ostomy complications is a challenge.11,15 The current study found that 56.5% of patients had at least 1 complication in the early period, whereas 36.2% of patients had at least 1 complication > 30 days after surgery, which is similar to results of previously published retrospective8 and prospective7,10,11,27 studies conducted in other parts of the world. Compared to the retrospective studies conducted in Turkey, while the complication incidence rate in the late period was similar to the rate determined by Baykara et al,9 the complication rate in this study during the early period was higher than the rate reported by Koc et al.3 However, a clear and direct comparison cannot be made as a result of the many different definitions of ostomy-related complications used in the literature. The results of studies conducted on ostomy complications may vary due to differences in inclusion criteria and methodology, the definitions of the complications not being expressed clearly, and differences in surgical techniques.
In this study, the most common complication in both the early and late periods was PICD, which was observed most often in patients with an ileostomy. These results are similar to the literature.7,9,10,12,14,15 Other important results are that PICD most commonly developed in the second or third week in the early period and that the rate of PICD decreased over time. Similarly, a prospective study (n = 180) conducted by Persson et al7 determined that peristomal skin problems developed most commonly in patients with ileostomy 2 weeks after surgery. The decrease in the frequency of PICD may be explained by the ostomy reaching its actual size after edema decreases, the correct cutting of the flange, patients adapting to ostomy care, and the closure of the temporary ostomy. Considering the results of this study and those in the literature, patient follow-up after discharge is important.
In this study, mucocutaneous separation was the second most common complication. It occurred in 23.6% of patients and most commonly within the first 2 weeks postoperatively. This finding is similar to results of a retrospective study conducted in Turkey9 and prospective studies conducted in other parts of the world.10,12 A prospective study conducted by Cottam et al12 found that mucocutaneous separation occurred in 24% of patients within 3 weeks after ostomy surgery. Lindholm et al10 conducted a prospective study in patients with ostomy who underwent emergency surgery and reported that mucocutaneous separation developed within the first 2 weeks after ostomy creation. Other prospective7 and retrospective8 studies have found lower rates of mucocutaneous separation. Thus, considering other studies in the literature, mucocutaneous separation varies between 3.7% and 24%.3,8,9,12
In the current study, the rate of peristomal suture granuloma in the early (5.1%) and late (4.2%) period was low and similar to that reported in the literature.7,8 In this study, granuloma developed more commonly between the first and second month after surgery. A prospective study of patients (n = 180) who underwent elective ostomy surgery reported that granuloma occurred between the third and sixth month,7 whereas results of a prospective study among patients (n = 144) who underwent emergency surgery showed that granuloma developed in 12th month postoperatively.10 The occurrence of granuloma in the early period could be the result of poor ostomy care skills and the incorrect cutting of the flange. Because granuloma causes bleeding and pain, it may increase anxiety in patients, making it difficult for them to change the pouch system.10
The rate of retraction in the early (3.3%) and late (1%) periods in this study was found to be similar to previously published prospective11 and retrospective3 studies. However, other retrospective8 and prospective6,12 studies have shown retraction rates of 7.4% to 40.1%. Shellito28 determined that retraction is usually caused by previous stomal necrosis or tension on the bowel when ostomy creation was performed.
In this study, the rate of peristomal hernias was 9.4%, which was lower than the rates reported by Arumugam et al27 and Robertson et al.29 Arumugam et al27 reported that among 97 patients, parastomal hernia developed in 12 patients. Robertson et al29 reported that the proportion of patients who had parastomal hernias increased with time (from 0 to 40% in the colostomy and 0 to 22% in the ileostomy groups). However, in Sung et al’s retrospective work (N = 1170),8 the rate (5.8%) was lower than in this study. In this study, peristomal hernias occurred more commonly in patients with end ostomy. This result is in agreement with a study conducted by Persson et al.7
Several variables affect the development rate of peristomal hernias, including age, ostomy creation outside of the rectus abdominis muscle, suboptimal operative techniques, and the fascia tissue being excessively damaged.8,26,28,30 Based on an advanced analysis, the current study determined that age > than 65 years and left quadrant ostomy affected the development of hernia. Peristomal hernias present multiple challenges for patients including cosmetic issues, local discomfort, pain, the sensation of a mass in the abdomen, and flange application problems.8,10
In the present study, having a BMI > 24.9 kg/m2, an ileostomy, or a temporary ostomy increased the rate of PICD. The literature relevant to PICD reports that the output of more liquid stool may damage skin integrity on various levels.14,15,31,32 Other research, similar to this study, showed that obesity was related to a higher frequency of peristomal complications.8,12,27 Based on the literature and the results of this study, it can be concluded that weight control may be an important factor in preventing PICD in patients with an ostomy.
End ostomy, obstacles to ostomy care, and ostomy height < 10 mm influenced the likelihood of mucocutaneous separation in this study. The result that end ostomy increases the risk of the development of mucocutaneous separation was in accordance with the results of previous studies.9,10,12 Similarly, Lindholm et al10 reported that mucocutaneous separation developed more commonly in patients with an end colostomy. Cottam et al12 concluded that the likelihood of stoma complications can be predicted based on ostomy height.12 Parmar et al6 reported that the ostomy was more “problematic” in patients with short ostomy length. In that study,6 a problematic stoma was “one which needs one or more accessories to keep the patient clean and dry for a minimal period of 24 h[ours].”
In the current study, 67.5% of patients received care for the complications they encountered and were taught how to prevent future complications. The application of powder and barrier sprays to areas with rashes and the use of ostomy equipment are suggested in managing patients with PICD.23,32–35 In this study, powder and barrier sprays were used in 95.6% of patients with PICD. Colwell et al34 stated that WOC nurses most commonly use powder and barrier wipe layers (81.4%) for patients with PICD. A cross-sectional descriptive study was conducted by Beitz and Colwell25 with WOC nurses (n = 281) to evaluate which optimal interventions WOC nurses used the most for complications. They found that nurses used powder and barrier sprays more commonly for patients with peristomal irritant dermatitis after determining the etiology of the complication by evaluating the peristomal skin. In the same study, WOC nurses stated that they applied silver nitrate to remove excess tissue. Silver nitrate was also applied to the majority of patients with peristomal suture granuloma (71.7%) in the current study.
Optimal management of mucocutaneous separation, including filling the site with absorbent materials, paste, or powder depending on its extent, is very important to prevent additional complications until the area has healed.20 In this study, powder and barrier sprays were used on 93.3% of patients with mucocutaneous separation, whereas absorbent materials were used on 57.8%.
Patients with a peristomal hernia are advised to avoid heavy lifting and wear supportive clothing/hernia belts. Surgery is performed only if the bowel is obstructed.20,25,35,36 In this, and previous studies, patients with peristomal hernias were advised to use hernia belts and flexible products.25,33 In cases in which prolapse, observed in the late period, decreases patients’ quality of life or when the ostomy is under too much tension, surgical treatment is advised. In other cases, interventions such as applying a cool compress to the ostomy to reduce ostomy size and choosing an appropriate pouch system were found to be similar to those previously reported.25,33
Previous studies have recommended the use of convex flanges and belts to patients with retraction.7,20,34 Colwell et al34 stated that 46.8% of WOC and enterostomal therapy nurses reported that 26% to 50% of their patients required convexity. In the current study, new products were also recommended.
All patients with an ostomy deserve to be cared for by health professionals who possess sufficient knowledge to assess and recommend optimal ostomy care strategies and help prevent complications.23 Nursing interventions in this study were congruent with those described in the literature.