PREVENTION & TREATMENT

The most vulnerable skin of all: managing early peristomal skin complications.

By Cynthia Ann Fleck, RN, BSN, MBA, CWS, DNC, CFCN, DAPWCA, FACCWS

When caring for skin and wounds, sometimes it’s easy to forget the most vulnerable skin of all – the epidermis surrounding an ostomy. Peristomal skin complications are a common problem for patients with stomas, and can have a negative impact on quality of life.

Often the situation is due to creases in the abdominal skin, bony structures, irregular anatomy or inappropriately placed stoma. Patients’ bodies changing with the aging process, gaining or losing weight and changes in muscle-to-adipose ratio are just a few known issues.

Complications are commonly attributed to a variety of reasons, including:

  • Flush or retracted stoma
  • Peristomal hernia
  • Barrier or flange is cut too large
  • A pouch that is heavy and needs to be emptied
  • Sensitivity and/or a true allergy to the appliance

Identifying potential early complications that may occur post-operatively is key to preventing more severe problems later. Stomal complications that occur usually within the first 30 days after surgery include the following:

  • Mucocutaneous Separation
  • Stomal Necrosis
  • Stomal Retraction

For each complication, it’s important to understand the risk factors involved, proper identification and assessment techniques, as well as treatment goals in order to produce positive outcomes.

Mucocutaneous Separation

Mucocutaneous Separation

Mucocutaneous separation is the detachment of the stomal tissue from the surrounding skin and can occur from a surgical site infection, tension on the suture line and performance of the surgery on a patient who has poor healing potential. This can occur as soon as 24 hours after surgery.

Risk factors:

    • Infection
    • Suture line tension
    • Patient has poor healing potential

Identification and assessment:

To visualize the peristomal area, gently remove the pouching system and cleanse the area with warm water using a soft washcloth.

Gently, using a cotton tip applicator, assess any open areas around the stoma exit site for depth. Be aware that it may be circumferential.

Treatment goal:

Promote healing and prevent fecal contamination, stenosis and/or stomal retraction. If this is detected in the immediate post-operative period, the surgeon should be notified.

Wound care to the separation should address depth and degree of separation using an absorbent filler dressing to promote granulation tissue in the areas of separation. Once that is addressed, use techniques to support a dry pouching surface and protect the open areas from fecal contamination.

Stomal Necrosis

Stomal Necrosis

Stomal necrosis represents the death of the stomal tissue due to an inadequate blood supply. Obesity, hypotension, hypovolemia, bowel wall edema, and tension or stripping of the mesentery can cause an inadequate blood supply with the resulting necrosis post-operatively.

Risk Factors:

    • Obesity
    • Hypotension
    • Hypovolemia
    • Edema of the bowel wall
    • Mesenteric stripping or tension

Identification and assessment:

    • You may be able to visualize the stoma by just removing the pouch of a two-piece ostomy product. If you’re unable to quickly identify it this way, gently remove the pouching system and cleanse the area with warm water and a washcloth.
    • Examine the stoma looking for any dusky, dry and black post- operative color changes. A lubricated test tube with pen light can be inserted into the stomal operation site to determine depth of the necrosis.

Treatment goals:

    • Early detection and then monitoring for any progression. The management of this condition depends on level of ischemia.
    • If there is superficial necrosis, observation is required. You can expect superficial sloughing of stoma, which will leave a viable stoma.
    • If the necrosis extends below the skin level and above fascial layer, debridement may be needed to remove any malodorous and flaccid stomal tissue.
    • If there is debridement, mucocutaneous separation is likely, stenosis may occur, and the stomal height may be diminished.
    • If the necrosis extends deeper than fascial layer, surgical intervention may be required.
Stomal Retraction

Stomal Retraction

Stomal retraction is when the stoma retreats into the abdominal wall to at or below the skin level.

Risk factors:

    • Tension on stoma
    • Thick abdominal wall
    • Adhesions or scar formation
    • Stomal necrosis
    • Mucocutaneous separation

Identification and assessment:

    • Remove the pouching system and cleanse the area with warm water and a soft washcloth.
    • Look at the wafer of the ostomy product to see where it has washed, or melted away, indicating areas of stomal effluent leakage.
    • Have the patient/resident stand, lie down and sit while observing stoma level and surrounding skin.

Treatment goals:

    • Create a flat pouching surface fill, or build up any abdominal creases or valleys in the peristomal area with stoma paste and/or barrier strips to fill in and bring these areas to skin level.
    • Bring the stoma level above the skin you can use a convex pouching system around the stoma.
    • Keep in mind that the depth of convexity will vary according to the amount of the stomal retraction.
    • Once the ostomy product is applied, the addition of an ostomy product belt may add additional augmentation by securing the pouching system close to the body.
Routsi Lee

Cynthia Ann Fleck, RN, BSN, MBA, CWS, DNC, CFCN, DAPWCA, FACCWS, is a certified wound specialist, dermatology advanced practice nurse, certified foot and nail care nurse, writer, speaker, past president and chairman of the board, The American Academy of Wound Management (AAWM), Past Director, the Association for the Advancement of Wound Care (AAWC), and Vice President, Clinical Marketing for Medline Industries, Inc. Advanced Skin and Wound Care.

Wound photos: Core Curriculum Ostomy Management 2016, WOCN Society