Principles of Ostomy Management in the Oncology Patient


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Principles of Ostomy Management in the Oncology Patient

  1. 1. 59VOLUME 3, NUMBER 1 ■ JANUARY/FEBRUARY 2005 J Support Oncol 2005;3:059–069 © 2005 Elsevier Inc. All rights reserved. R E V I E W Principles of Ostomy Management in the Oncology Patient Dorothy Doughty,MN,RN,CWOCN,FAAN Abstract Fecal and urinary diversions are fairly common among pa- tients diagnosed with abdominal and pelvic malignancies who have undergone removal of the bladder or rectum or who have suffered from obstruction caused by tumor invasion or radiation damage. Effective ostomy management is important in palliative care and involves estab- lishment of an effective pouching system,attention to diversion-specific alterations in dietary and fluid intake, and management of peristomal and stomal complications. Management of colostomy must include measures to prevent or manage constipation,management of ileostomy must include strategies for maintenance of fluid-electrolyte balance and prevention of food blockage,and management of urinary diversion must include options to be used at night and a focus on consistent adequate fluid intake. Common peristomal and stomal complications may neces- sitate use of barrier products, convex pouching systems to compensate for retraction, and/or binders. Surgery may be needed if incarcerated hernias, persistent prolapse, or stenosis severe enough to interfere with function occur. F ecal and urinary diversions are not un- common among patients diagnosed with abdominal or pelvic malignancies. Most commonly, an ostomy is performed in con- junction with removal of the bladder or rectum; however, an ostomy also may be required to re- lieve obstruction of the urinary or fecal stream, which may result from tumor infiltration or from radiation damage [1, 2]. Most patients undergo “standard” diversions, in which an opening is created between the intes- tinal or urinary tract and the abdominal wall with no continence mechanism. However, construc- tion of continent diversions is becoming more common, especially among patients undergoing radical cystectomy for bladder or cervical cancer. These “continent” diversions involve creation of an internal reservoir, which is anastomosed either to the patient’s own sphincter mechanism or to the abdominal wall. When the reservoir is anastomosed to the ab- dominal wall, a one-way “continence mechanism” is created and interposed between the reservoir and the opening on the abdominal wall. Continent diver- sions are managed either via spontaneous urination or defecation (when the reservoir is anastomosed to the patient’s own sphincter mechanism) or via rou- tine intubation and drainage (when the reservoir is anastomosed to the abdominal wall with an interven- ing continence mechanism) [1, 3]. Whatever the reason for the ostomy, effective management is important in comprehensive sup- portive care. For patients with “standard” diver- sions, this involves effective containment of ma- terial drained from the gastrointestinal tract and protection of the peristomal skin, prompt detec- tion and management of any peristomal or stomal complications, and maintenance of normal stomal function. For patients with continent diversions, management involves monitoring the individual’s ability to effectively empty the reservoir and to maintain continence, along with interventions to prevent common complications and to maintain normal urinary and/or fecal output. This article will review the principles underlying effective management of the patient with a standard or continent diversion. Management of the Patient With a Standard Diversion: Pouching Principles For the patient with a standard diversion, ef- fective containment of output and protection of the peristomal skin are essential to quality of life. A number of pouching systems now are available; the various systems commonly are classified as uri- nary or fecal, one- or two-piece, flexible or rigid, and flat or convex. In addition, pouches are avail- able with several different skin barriers and a va- riety of special features, such as tape borders, belt tabs, and flatus filters. Such choices can be over- Manuscript received September 7, 2004; accepted September 10, 2004. Correspondence to: Dorothy Doughty, RN, Emory University, Wound Ostomy Continence Nursing Education Center, Room AT 732, 1365 Clifton Road NE, Atlanta, GA 30322; phone: (404) 778-3541; fax: (404) 778-4778; e-mail: Ms. Doughty is Director of the Emory University Wound Ostomy Continence Nursing Education Center, Atlanta, Georgia.
  2. 2. 60 THE JOURNAL OF SUPPORTIVE ONCOLOGY whelming to both the patient and the clinician; however, selection of an appropriate and effective system and maintenance of a secure seal can be facilitated by adhering to these principles [4]: 1) Select a pouching system that is appropriate to the type of diversion (ie, urinary, fecal drainable, or fecal closed-end). Urinary pouches are equipped with a narrow spout that facilitates emptying and permits connection to a night drainage system; most also provide an antireflux feature that mini- mizes urine contact with the peristomal skin. One potential disadvantage of urinary pouches is that they are odor-resistant as opposed to odor-proof; therefore, maintenance of dilute and acidic urine is important for patients using these devices. Fecal drainable pouches are equipped with a wide outlet to permit drainage of thick stool; the outlet is closed by a clamp or by an incorporated self-closure mechanism (eg, EasiClose, Coloplast Corp., Marietta, Georgia; Lock ‘n Roll, Hollister Inc., Libertyville, Illinois; or Invisiclose, Con- vaTec, Princeton, New Jersey). Drainable pouches are considered “standard” for patients with fecal diversions and are required for patients with high- volume output, such as those who have under- gone an ileostomy or transverse colostomy. Fecal closed-end pouches are designed for patients with Ostomy Management low-volume output who would rather remove and replace the pouch than empty it; these pouches, which are most appropriate for individuals with sigmoid colostomies, may be required for patients who lack the dexterity to manipulate a pouch clo- sure mechanism. All fecal pouches are completely odor-proof; odor occurs only if the pouch is leak- ing or if the exposed portion of the outlet is con- taminated by stool. Another consideration in primary pouch selec- tion is one-piece versus two-piece systems. One- piece systems include an adhesive barrier (with or without a tape border) that is fused to the pouch, whereas two-piece systems have an adhesive bar- rier baseplate with an attached flange or an adhe- sive “landing zone” to which the patient attaches a separate pouch. The simpler one-piece systems generally require less dexterity for application, whereas two-piece systems allow the patient to remove and replace the pouch without removing the skin barrier. 2) “Match”thepouchingsystemtothepatient’s abdominal contours and the height of the stoma. This principle is the most critical to effective main- tenance of a pouch seal. The patient should be as- sessed while both supine and sitting to determine whether the stoma is located on a flat surface, in a deep crease, or in a concave “valley.” A protruding stoma located on a flat surface can be managed effectively with almost any flat pouching system. However, stomas located in deep creases usually require all-flexible pouching systems, and those located in concave “valleys” typically require matching convexity. In addition, convexity may be helpful when the stoma is at skin level or retracted instead of protruding. 3) Size the pouch opening to minimize both ex- posed skin and the risk of undermining. In general, the opening in the pouch should be sized about 1/4" larger than the stoma and should permit a 1/8" clearance on each side. However, a skin-level or retracted stoma frequently requires at least a 1/4" clearance on each side to prevent undermining of the drainage; for these patients, the opening is typi- cally sized at least 1/2" larger than the stoma. 4) Use skin protective products appropriately. Plasticizing films (eg, Skin-Prep, Smith & Nephew Inc., Largo, FL; Allkare, ConvaTec; or Skin Gel, Hollister) effectively protect against tape damage and maceration, but they do not provide protec- tion against enzymatic drainage. Pectin-based paste, paste strips, and barrier rings are designed to Cleanse skin with tap water; pat dry Sprinkle pectin powder (eg, Stomahesive, ConvaTec, Princeton, New Jersey; Adapt, Hollister, Libertyville, Illinois) onto damaged skin. Dust off excess. “Blot” over powder with moistened finger or alcohol-free plasticizing wipe (eg, Cavilon, 3M, St. Paul, Minnesota; Skin-Prep No-Sting, Smith & Nephew, Largo, Florida) Repeat layers as needed to form “crust” Figure 1 Crusting Procedure
  3. 3. 61VOLUME 3, NUMBER 1 ■ JANUARY/FEBRUARY 2005 protect against enzymatic drainage and are benefi- cial in preventing undermining and in filling small defects to create a flat pouching surface. However, consider the following to use these products ap- propriately [4, 5]: • Plasticizing films are not required routinely but may be beneficial for patients with friable, dry, or oily skin. Counsel patients and caregivers to allow these products to dry completely before applying the pouch to allow evaporation of the solvent (usually, these preparations contain alcohol as the solvent). These films are available in alcohol-free forms (Cav- ilon, 3M Health Care, St. Paul, Minnesota; Skin- Prep No-Sting, Smith & Nephew), which may help when the skin is damaged; the alcohol-free forms, however, are considerably more expensive. • Use pectin-based paste or paste strips/rings routinely in the presence of enzymatic drainage to protect exposed peristomal skin and to act as a “caulk” around the stoma to minimize the risk of undermining. Ostomies that produce enzymatic drainage include ileostomies, cecostomies, ascend- ing colostomies, and transverse colostomies. Paste products generally are not required with descending or sigmoid colostomy stomas, but they may be beneficial in creating a flatter pouching surface and providing a more secure seal. Remem- ber, paste melts with urine; if additional protec- tion is needed for a urinary stoma, extended-wear barrier rings (eg, Eakin, ConvaTec; Adapt, Hol- lister) are the most appropriate products. 5) Apply the pouching system to clean, dry skin. This is a problem when the peristomal skin is denuded and weeping. In this case, first treat the damaged skin with a procedure known as “crust- ing” to create a dry surface. The crusting proce- dure is outlined in Figure 1. 6) Teach the patient or caregiver to empty the pouch when one third to one half full to prevent excessive tension on the pouch seal. Advise the patient to change the pouch once or twice weekly and any time there is evidence of leakage or skin irritation, which may include burning or itching under the pouch. See Figures 2 and 3 for sample instructions for emptying and changing the pouch. Management of the Patient With a Standard Diversion: Diversion-Specific Care Establishment of an effective pouching system and instruction in survival skills are essential el- ements of care for any patient with a standard diversion. In addition, there are aspects of care that are diversion-specific; instruct patients about any dietary or fluid modifications relevant to their ostomy and, if fecal diversions have been accom- plished, about strategies to minimize and manage gas and odor [6]. ILEOSTOMY An ileostomy is an opening into the distal small bowel (ileum); it typically involves removal of the entire colon and rectum because of chronic inflam- matory disease or familial adenomatous polyposis. A diverting ileostomy also may be performed to restore fecal drainage when there is an obstructing tumor mass in the colon or may be constructed to protect a distal anastomosis [2, 3]. The normal volume of output from an ileostomy is about 500–1,000 cc daily; drainage from the ileos- tomy occurs after meals and at other unpredictable times and typically is mushy in consistency. Most importantly, the drainage from an ileostomy stoma contains a large number of proteolytic enzymes that Doughty Hold end of pouch up and remove clamp Turn end of pouch back on itself to form a “cuff”(Pouches with self-closure mechanisms form a “funnel”when opened; cuffing is not required) Drain pouch into toilet (placing toilet paper into toilet prior to draining pouch contents reduces splash back and noise) Clean cuffed end of outlet with toilet paper and/or damp paper towel or disposable wipe (Rinsing is optional but not necessary,as long as exposed end of pouch is kept clean) Undo the cuff and reapply the clamp Figure 2 Pouch-Emptying Procedure Peer viewpoints on this article by Ms. Bridget O’Brien, Drs. Lisa Baddi and Al Benson III, and Ms. Janice Colwell appear on pages 71 and 72.
  4. 4. 62 THE JOURNAL OF SUPPORTIVE ONCOLOGY may damage skin rapidly and severely if the mate- rial remains in contact with the skin. Thus, meticulous protection of the peristomal skin is one of the most critical elements of care for an ileostomy patient [4, 6]. Specifically, the pa- tient must be taught to use paste or barrier rings routinely to prevent exposure of the peristomal skin to the irritating drainage and to change the pouch immediately for any indicators of leakage. On a daily basis, patients with ileostomies lose at least 250–500 cc of fluid that ordinarily would be absorbed by an individual with an intact colon; thus, Gently remove old pouch and discard (save clamp if pouch has external clamp) Gently clean peristomal skin with warm water; pat dry (cleansing with water only is best—if soap is used,avoid those with oils and rinse thoroughly) Size the opening in the pouch correctly For protruding stoma,ensure that opening is ¼”larger than stoma For skin-level or retracted stoma, ensure that opening is at least ½” larger than stoma Remove paper and plastic backings from pouch to expose barrier and tape surfaces Apply skin protective products as needed: For dry,oily,or fragile skin: Apply plasticizing wipe (eg,Skin-Prep),and allow to dry For enzymatic or liquid stool:Apply ring of paste* directly around stoma;as an alternate approach, apply paste to back of pouch right around opening. Note:Wetting a finger helps to smooth paste into place; when stoma is skin level,paste should be applied as flat layer so there is no interference to drainage. Use paste,rings,or barrier strips to fill in any defects and create a flat surface Center pouch and press firmly into place. Encourage patient or caregiver to hold hand over newly applied pouch for 5–10 minutes (warmth of hand helps to “mold”barrier into place) If a 2-piece system used:Attach pouch and check security of attachment Close spout or outlet *Tube paste contains alcohol and causes burning when the skin is damaged; use of alcohol-free paste strips are preferable in patients without intact skin Figure 3 Pouch-Change Procedure Ostomy Management
  5. 5. 63VOLUME 3, NUMBER 1 ■ JANUARY/FEBRUARY 2005 these patients must increase their daily fluid intake by at least 1–2 glasses and must remember that they are at high risk for rapid dehydration during periods of increased output or reduced fluid intake. These patients also must drink more fluids during episodes of diarrhea or diaphoresis; patients who are unable to replace lost fluids because of nausea or vomiting require intravenous fluid replacement [6]. Dietary counseling for the individual with an ileostomy should include guidelines for preventing food blockage, a complication unique to ileostomy patients. “Food blockage” occurs when a mass of insoluble fiber becomes lodged just proximally to the stoma at the point where the bowel is brought through the fascia-muscle layer, a point of poten- tial narrowing. Patients must eat foods high in in- soluble fiber one at a time and in small amounts, chew thoroughly before swallowing, and maintain adequate fluid intake. Patients also must recognize and promptly report the signs of food blockage, which include no output or high-volume liquid malodorous output, cramping pain, distention, and, possibly, nausea and vomiting. Food blockage is managed by ileal lavage, which can be performed by either the nurse or the physi- cian. In this maneuver, a 14–16 French catheter is inserted to the point of the obstruction, and 30–50 cc of warm saline is instilled forcefully. The cath- eter then is removed to permit drainage. This is re- peated until the blockage is relieved [5, 6]. Management of gas and odor is a common concern for any patient with a fecal diversion. Be- cause the small bowel has low bacterial levels, the individual with an ileostomy typically experiences less gas and less odor than does the patient with a colostomy. Patients learn to limit activities that increase the volume of swallowed air (eg, smoking, drinking through straws, and chewing gum) and to “muffle” the sounds of flatus by exerting pressure against the stoma with their arm or hand [5]. The last major concern for the patient with an ileostomy is medication absorption. Because the colon and ileocecal valve have been removed or by- passed, the patient becomes unable to completely absorb a number of drugs (eg, large pills, sustained- release medications, and enteric-coated medica- tions). Thus, whenever possible, these patients should receive medications in liquid form [5]. CECOSTOMY OR ASCENDING COLOSTOMY Cecostomies and ascending colostomies are not common but may be required occasionally to relieve obstruction in the ascending or right trans- verse colon. In particular, cecostomies are difficult to manage due to their location in the right groin and the mushy consistency of the drainage mate- rial; fortunately, they generally are intended only for temporary diversion. In many ways, when considering skin care, fluid intake, and medication adjustments, management of the patient with a cecostomy or ascending colos- tomy essentially is the same as that of an individual with an ileostomy. However, these patients typically are not at risk for food blockage; because the larger diameter of the colon offsets the potential narrow- ing at the fascia-muscle layer, these patients do not need to restrict their intake of high-fiber foods. Pa- tients with a cecostomy/ascending colostomy also must manage gas and odor differently, since the colon has high bacterial counts; these patients usu- ally need to limit intake of gas-producing foods, and they may need pouch deodorants or oral deodor- ants to minimize odor with pouch emptying. TRANSVERSE COLOSTOMY An opening into the transverse colon occasion- ally may be created to relieve distal obstruction or to protect a distal anastomosis, although the trend is to perform an ileostomy in these situations [7, 8]. The output from a transverse colostomy typi- cally is of a mushy or soft-stool consistency, with drainage occurring after meals and at other unpre- dictable intervals. Management issues for these patients primar- ily focus on strategies to minimize gas and odor; this is accomplished by identifying and restricting gas-forming foods, such as beans, broccoli, and cabbage. In addition, these patients should use pouching systems with charcoal filters to vent and deodorize gas if needed, as well as pouch deodor- ants or oral deodorants to minimize stool odor with pouch emptying [6]. Routine use of oral de- odorants, such as bismuth subgallate (Devrom) and chlorophyllin copper complex (Derifil), also may reduce fecal odor significantly. Patients with transverse colostomies also need information on strategies for concealing the sto- ma, since these stomas typically are located in the upper quadrants. Effective options include use of a camisole or undershirt worn beneath a loose blouse or shirt and a vest or jacket. Patients with transverse colostomies also need to learn the importance of adequate fluid intake and fluid re- placement during episodes of diarrhea [6]. Doughty
  6. 6. 64 THE JOURNAL OF SUPPORTIVE ONCOLOGY Importantly, patients with transverse colos- tomies are not candidates for routine irrigation to control fecal output because peristalsis in the ascending colon is continuous. Irrigation may be necessary before a diagnostic study or operative procedure, but it should not be performed routine- ly unless the patient has atypical constipation. DESCENDING/SIGMOID COLOSTOMY The descending/sigmoid colostomy, a fairly common diversion, typically is performed when the rectum is removed [2]. Stool consistency and patterns of elimination typically are similar to those seen before surgery; most patients have one to two formed stools daily. Major issues for patients undergoing this procedure include measures to re- duce gas and odor, prevention of constipation, and decisions regarding management approach [6]. Measures to reduce gas and odor include restricted intake of gas-forming foods and use of pouch or oral deodorants, as noted above. Prevention of constipation is very important for individuals having a descending or sigmoid colostomy [6]. These patients must maintain adequate intake of fluids and fiber (ie, 30 cc of fluid/kg body weight per day and approximately 30 gm of fiber per day). Instruct patients unable or unwilling to maintain a high-fiber diet to be- gin routine use of a bulk laxative (eg, methylcel- lulose, partially hydrolyzed guar gum, or psyllium hydrophilic mucilloid) or a bran mixture (1 cup unprocessed miller’s bran plus 1 cup applesauce plus ¼ cup prune juice). Teach patients to initi- ate therapy with the recommended daily dose of a bulk laxative or with 2 tbsp of the bran mix- ture and to increase the daily dose by 1 tbsp each week until they produce a soft, formed stool. In- struct patients about the critical importance of adequate fluid intake along with the bulk agent or bran, since failure to assure adequate fluid in- take may result in a bowel obstruction. Manage patients with a tendency toward constipation and who are unable to maintain sufficient fluid intake with a softener-stimulant combination (eg, casan- thranol/docusate sodium) as opposed to a bulking agent or bran. Finally, counsel acutely constipated patients to use an oral laxative. Unlike other patients with a fecal diversion, patients with a descending or sigmoid colostomy may manage it with routine irrigation [6], which involves daily or every other day instillation of 500–1,000 cc of lukewarm tap water into the co- lon via a cone tip irrigator; the cone tip both pre- vents bowel injury and prevents backflow of the irrigant. The instilled water distends the left co- lon, and the resulting peristalsis empties this area. Because peristaltic activity in the left colon is in- termittent and infrequent, this maneuver typically provides a “stool-free” period of 24–48 hours. Routine irrigation on a regular schedule tends to regulate bowel function so that fecal spill- age between irrigations is unlikely. Once fecal output is regulated effectively, the patient can discontinue use of a drainable pouch and can wear a simple “stoma cap” between irrigations; the stoma cap absorbs mucus and deodorizes and vents flatus [4, 6]. UROSTOMY Individuals needing bladder removal due to cancer of the bladder or cervix also require cre- ation of an alternate path for urine elimination; the most commonly performed procedure in this patient population is an ileal conduit [1]. This procedure involves resection of a small segment of ileum; the bowel then is reconnected, causing no change in bowel function. The ileal segment is used to create a pathway for urinary elimina- tion—the proximal end is sewn closed, the ureters are connected, and the distal end is brought to the abdominal wall as a stoma. Urine flows via the ureters into the ileal segment and out of the body. Patients undergoing this procedure pass clear urine with mucous strands that is normally almost continuous [6]. Management for patients with an ileal conduit is focused on maintenance of adequate fluid in- take, nighttime management of the conduit, and strategies to minimize urinary odor. Adequate fluid intake is critical to prevention of infection; since an ileal conduit lacks any type of antireflux mechanism, the best barrier to ascending bacteria is almost constant urinary flow [1, 6]. Thus, pa- tients must be taught both to drink enough fluid (30 cc/kg/day) and to consume these liquids at regular intervals throughout the day. Nighttime management of the conduit fre- quently is a challenge. Most individuals who require an ileal conduit are older, meaning that much of their urine is produced at night; the pa- tient either will need to get up at regular inter- vals to empty the pouch or to connect the pouch to a night drainage system [6]. Instruct patients choosing to use a night drainage system to run the Ostomy Management
  7. 7. 65VOLUME 3, NUMBER 1 ■ JANUARY/FEBRUARY 2005 tubing down their pajama legs to minimize twist- ing and to connect the pouch to the night drain- age unit with about 1–2 oz of urine in the pouch to prevent a vacuum effect; also, teach them to rinse the night drainage unit daily and to cleanse it thoroughly at weekly intervals. As noted previously, urinary pouches are odor- resistant, not odor-proof; thus, odor control is a major concern for many patients. Adequate fluid intake helps to maintain dilute acidic urine, es- pecially if water is the predominant liquid con- sumed. To reduce odor, other strategies may include avoiding foods and fluids that increase urinary odor, such as asparagus; placing patients in a two-piece pouching system, if possible; and instructing patients to “swap” pouches if any odor is noticed. The ureterostomy is a much less common urinary diversion, in which the ureter is brought directly to the skin surface [1]. Output from a ureterostomy differs from an ileal conduit in that mucus is absent; management for a ureterostomy is the same as that for an ileal conduit. Prevention and Management of Peristomal and Stomal Complications Effective management of the ostomy patient also must include monitoring for and management of peristomal and stomal complications (Figure 4). PERISTOMAL COMPLICATIONS Common peristomal complications include epithelial denudation, yeast dermatitis, and al- lergic dermatitis. Epithelial denudation occurs when enzymatic damage pools on the skin; it typically is caused by a poorly fitting or incorrectly sized pouch that per- mits contact between the skin and the drainage [5, 9, 10]. The enzymes within the drained material lit- erally digest the epithelial layer, producing an area that is red, wet, and painful. The damaged skin area corresponds to the path taken by the drainage and generally is inferior to and lateral to the stoma. Management of epithelial denudation primar- ily focuses on modification of the pouching system to eliminate contact between the drainage and the skin. The damaged skin is treated with “crusting” (see Figure 1) before application of the pouch. Yeast dermatitis occurs when yeast penetrates the peristomal skin; this is most commonly seen among patients experiencing yeast overgrowth as a complication of antibiotic therapy, but it also can occur in areas exposed to moisture. Yeast der- matitis typically presents as a circumferential rash that appears solid in the center and that features distinct “satellite” lesions at the edges; most pa- tients describe the rash as “itchy and tender.” Management of yeast dermatitis typically in- volves “crusting” with use of an antifungal pow- der, such as nystatin. Systemic therapy with fluco- nazole (Diflucan) may be indicated if the patient also suffers from oral thrush and/or candidiasis in multiple body folds [10, 11]. Although products designed for ostomy man- agement generally are described as “hypoaller- genic” in nature, any product can elicit an allergic Figure 4 Peristomal and Stomal Complications Left: Mechanical damage from pouch removal in patient receiving radiation therapy. Right: Yeast dermatitis in patient with ileal conduit. Doughty
  8. 8. 66 THE JOURNAL OF SUPPORTIVE ONCOLOGY reaction in sensitive patients. Allergic dermatitis is characterized by an area of erythema, pruritus, and/or blistering that “matches” the area of skin that touches the allergen. Management of allergic dermatitis primarily depends on eliminating the offending substance; if the area involved has been exposed to several substances, patch testing may be required to de- termine the specific allergen. Secondary manage- ment includes minimizing product use until the dermatitis resolves and topical treatment with antihistamines (eg, diphenhydramine gel) or low- dose steroids [5, 9, 10]. In selecting topical prod- ucts, it is important to choose gels or vanishing creams instead of ointments, which may prevent pouch adherence. STOMAL COMPLICATIONS Common stomal complications include retrac- tion, hernia formation, prolapse, and stenosis; al- though it is uncommon, excessive bleeding may occur as well. Stomal retraction to skin level or below is com- mon and is a frequent contributor to difficult pouch- ing situations. Retraction may occur early after sur- gery due to difficulty mobilizing the bowel, presence of a thick abdominal wall, or breakdown of the mucocutaneous suture line. Late retraction may be caused by postoperative weight gain, ascites, or ten- sion on the mesentery produced by intraperitoneal tumor growth. Management of retraction involves modification of the pouching system to “match” the change in peristomal contours and typically requires convexity [9, 10]. Peristomal hernia describes herniation of a loop or loops of bowel into the subcutaneous tissue and through the muscle defect created by the stoma. Typically, the hernia is most pronounced under conditions of increased abdominal pressure, such as sitting, standing, coughing, or straining; in a su- pine position at rest, the hernia frequently reduces spontaneously [10]. Peristomal hernias may progress to incarcera- tion and strangulation, although this is uncom- mon. The “usual” problems associated with her- nias are difficulty in maintaining a pouch seal or difficulty with colostomy irrigation. Hernias typically are managed conservatively in patients with advanced disease, with surgical repair usually limited to hernias complicated by incarcera- tion. Conservative management may involve use of a “hernia belt” (NuHope, Pacoima, California), an abdominal binder with a cutout sized to fit the stoma and pouch that keeps the hernia reduced. The patient applies the binder while in a supine po- sition, reducing the hernia. Pouching modifications are made as needed to accommodate the change in peristomal contours, and patients who manage their colostomies with irrigation are instructed to discontinue irrigation if they encounter difficulty with water instillation or return [10]. Stomal prolapse represents a telescoping effect of the bowel that results in significant elongation of the stoma; it may be caused primarily by inad- equate intra-abdominal fixation of the bowel and by conditions resulting in increased abdominal pressure. Prolapse frequently is very upsetting to the patient, but it represents a surgical emergency only when it is associated with stomal ischemia. Conservative management of stomal prolapse includes application of a hypertonic substance (eg, sugar or salt) to reduce bowel wall edema, followed by attempts to manually reduce the pro- lapsed bowel. When this technique is successful, reduction sometimes may be maintained by ap- plying a binder or a hernia binder with prolapse overbelt. Persistent or recurrent prolapse typically requires surgical repair [9, 10]. Stomal stenosis refers to a narrowing of the sto- ma at either the fascia level or the skin level that is sufficient to interfere with normal stomal function. Indicators of stenosis include visible narrowing of the stomal opening, cramping pain, or a sense of fullness followed by explosive output. Patients with urinary diversions also may report flank pain and increased incidence of infections. Stenosis may be confirmed easily by a digital exam. If the stenosis is mild, it may be managed, at least temporarily, by gentle routine stomal dila- tations. Significant stenosis, however, generally requires surgical revision [9, 10]. Management of the Patient With a Continent Diversion As explained previously, continent diversions involve creation of an aperistaltic internal reser- voir fashioned from detubularized bowel loops. Two approaches may be used to provide con- tinence and drainage. First, the reservoir may be placed in the pelvis and anastomosed to the patient’s native sphincter mechanism; urination or defecation then occurs via voluntary sphinc- ter relaxation and abdominal muscle contraction. Second, the reservoir may be placed in the abdo- Ostomy Management
  9. 9. 67VOLUME 3, NUMBER 1 ■ JANUARY/FEBRUARY 2005 men and anastomosed to the abdominal wall with a one-way continence mechanism interposed be- tween the reservoir and the abdominal opening; in this case, drainage requires routine intubation of the reservoir. FASHIONING THE PELVIC RESERVOIR Pelvic reservoirs include ileal-anal reservoirs and orthotopic neobladders. Ileal-anal reservoirs generally are constructed in patients diagnosed with benign diseases requiring total colectomy. The reservoir is fashioned from loops of ileum, so patients typically have frequent stools that are mushy in consistency and that contain proteolytic enzymes [3]. Individuals who are given ileal-anal reservoirs must practice meticulous skin care, especially dur- ing episodes of diarrhea. In addition, they must be alert to the occurrence of pouchitis, an inflamma- tion of the reservoir that may be caused by bacterial overgrowth or an imbalance in the mix of aerobic and anaerobic organisms. Pouchitis is manifested by increased stool frequency and urgency, cramp- ing abdominal pain, and, possibly, blood and mucus in the stools; this complication generally is treated either with use of oral antibiotics (eg, metronidazole or ciprofloxacin [Cipro]) or by administration of sol- uble fiber plus probiotics, such as VSL#3 [12, 13]. Construction of an orthotopic neobladder now represents a fairly common option for patients who require cystectomy for bladder cancer, espe- cially when patients are treated in major medical centers. This procedure involves formation of a “neobladder” from loops of bowel and anastomo- sis of this structure to the urethral stump. This surgery represents an option only for patients in whom curative resection does not involve the stri- ated urethral sphincter [1, 14]. Because the neobladder is noncontractile, ef- fective emptying requires relaxation of the vol- untary sphincter coupled with abdominal muscle contraction. Patients who are unable to empty the neobladder effectively must accompany voluntary voiding with clean intermittent catheterization. A more common problem is urinary leakage, es- pecially at night, when the voluntary pelvic floor muscles are relaxed; patients with significant leak- age may require absorbent garments or external collection devices [14]. STRUCTURE OF ABDOMINAL RESERVOIRS Abdominal reservoirs include ileal reservoirs (eg, Kock ileostomy or Barnett Continent Ileal Reservoir), which are uncommon, and continent urinary diversions (eg, Indiana Reservoir, Florida Pouch, or Miami Pouch), which are becoming more common, especially in leading medical centers. Surgeons fashioning ileal reservoirs use detu- bularized loops of bowel to create an aperistaltic structure; continence is provided by intussuscept- ing the segment of bowel that lies between the res- ervoir and the abdominal stoma [3]. The patient learns to intubate the reservoir with a large-bore catheter 3–4 times daily; since ileal contents are thick and sometimes difficult to drain, the patient must instill lukewarm water, as needed, to thin the ileal contents and facilitate drainage. Patients typi- cally are taught to irrigate the reservoir until re- turns are clear once or twice daily; this maneuver may help to prevent pouchitis. Dietary modifica- tions include avoidance of foods that are likely to clog the drainage catheter, such as foods that are high in insoluble fiber. Medication modifications include avoidance of formulations that are likely to be absorbed incompletely and of products that fea- ture a wax matrix, since the wax shells are retained in the reservoir and eventually cause obstruction. Continent urinary diversions most commonly involve use of the cecum and ascending colon to create a reservoir; the contractile fibers of the ce- cum usually are interrupted with an ileal “patch” to prevent peristaltic activity [1]. The continence mechanism involved with this structure varies. In one common approach, the surgeon constructs the stoma from the ileum and uses the one-way ileal cecal valve as the continence mechanism; this mechanism is reinforced further by plicating the ileal segment around the ileal cecal valve to provide increased resistance. In another approach, the surgeon harvests the appendix, reverses it, and anastomoses one end to the reservoir and the oth- er to the abdominal wall; the appendiceal reversal creates an effective continence mechanism [1]. Management of a continent urinary diversion involves routine intubation using clean technique. In many medical centers, patients learn to irrigate the reservoir until the drainage is clear once or twice daily to help reduce the risk of pouchitis. In addition, patients are taught the importance of adequate fluid intake and of close adherence to the catheterization schedule. Patients with continent reservoirs typically do not require pouching and suffer peristomal com- plications rarely, because there usually is no out- Doughty
  10. 10. 68 THE JOURNAL OF SUPPORTIVE ONCOLOGY put between intubations. Patients commonly are taught to cover the stoma with a simple pad to absorb mucus and protect the stoma. Issues Unique to Oncology Patients In addition to the “usual” issues outlined previ- ously, cancer patients with ostomies have unique issues related to their disease process and its treat- ment. They include management of a stoma in the radiation field, therapy for stomatitis, treatment of severe constipation, and the impact of advanced disease on their self-care status. STOMAL MANAGEMENT IN THE RADIATION FIELD When an ostomy patient requires irradia- tion and the stoma is in the radiation field, care must be modified to minimize the risk of peristomal skin damage [15, 16]. If the radia- tion oncologist elects to remove the pouch for each treatment, the patient should be managed with a minimally adhesive or nonadhesive sys- tem until irradiation is complete; good choices include a Hollister Karaya Ring Pouch with belt tabs (Libertyville, Illinois) or a Cook nonadhe- sive pouch (Spencer, Indiana). If the radiation oncologist chooses to leave the pouch intact during radiation treatments, the pouching sys- tem must be evaluated carefully to ensure that there are no metallic components or ingredi- ents, such as tapes containing zinc oxide [16]. Synthetic barriers, plastic pouches, and paper tape all are safe for peristomal use; however, a plasticizing wipe must be used beneath the tape to minimize the risk of tape damage. Instruct patients who take oral deodorants, such as bis- muth subgallate or chlorophyllin copper com- plex, to discontinue these medications during irradiation and to clear all medications with the radiation oncologist. MANAGEMENT OF STOMATITIS Stomatitis is a common complication of both radiation therapy and chemotherapy and is mani- fested by stomal edema and friability. Instruct pa- tients to use extremely gentle technique in caring for their ostomy during chemotherapy and irradia- tion. In addition, colostomy patients who irrigate should discontinue irrigation until therapy is com- plete and bowel function has returned to normal. Patients also should report marked stomal friabil- ity to the radiation oncologist, since therapy may need to be interrupted temporarily [16]. MANAGEMENT OF SEVERE CONSTIPATION Severe constipation commonly occurs in pa- tients with advanced cancer because of their reduced activity, reduced fluid and fiber intake, and use of opioid analgesics. Initial management should include adequate fiber and fluid intake; place patients unable to ingest sufficient fiber and fluids on a softener-stimulant combination. Give patients with persistent constipation additional laxatives, as needed, to maintain nor- mal bowel function [17, 18]. Osmotic agents, such as saline cathartics, lactulose, sorbitol, and polyethylene glycol formulas, all are safe for the colostomy patient, as are stimulant laxatives that may include bisacodyl and senna. Irriga- tion also can be beneficial as adjunct therapy for these individuals. When managing constipation in the colos- tomy patient, remember that the ostomy has not changed any aspect of bowel motility. Bowel man- agement for these patients must compensate for Table 1 Major Manufacturers of Ostomy Products COMPANY CONTACT INFORMATION PRODUCT LINE Coloplast Marietta,GA One- and two-piece pouches, (800) 533-0464 fecal and urinary (flat,flexible, and varying levels convexity) Skin protective products ConvaTec Princeton,NJ One- and two-piece pouches, (800) 325-8005 fecal and urinary (flat,flexible, and shallow convexity) Skin protective products Hollister Libertyville,IL One- and two-piece pouches, (800) 323-4060 fecal and urinary (flat,flexible, and shallow convexity plus convex rings) Skin protective products Marlen Bedford,OH One-piece pouches,fecal and (216) 292-7060 urinary; two-piece adhesive systems fecal only (flat,flexible, and varying levels of convexity) Skin protective products NuHope Pacoima,CA One-piece pouches,fecal and (800) 899-5017 urinary (flat,flexible,and varying levels convexity) Customized pouches,belts and binders,skin protection Ostomy Management
  11. 11. 69VOLUME 3, NUMBER 1 ■ JANUARY/FEBRUARY 2005 the loss of sphincter function but otherwise fol- lows standard principles. ADVANCED DISEASE AND PATIENT INDEPENDENCE One of the most common problems encoun- tered in patients with advanced cancer is the loss of their ability to take care of themselves. In this case, caregivers must be taught to empty and change the pouch or to intubate the continent di- version. Sometimes, it is necessary to modify the care routine to simplify management for both the patient and caregiver. For example, the colostomy patient who previously managed with irrigation but is no longer able to do so may be managed with a drainable pouch. If patients are consti- pated, they may use laxatives to maintain bowel function. Similarly, the caregiver may find it easier to manage a continent urinary diversion or or- thotopic neobladder with an indwelling catheter rather than with intermittent catheterization. RESOURCES In managing the cancer patient with an os- tomy, two resource groups are of particular ben- efit. The United Ostomy Association [Irvine, California, (800) 826-0826;] pro- vides patient support and general information. The Wound Ostomy Continence Nurses Society [Glenview, Illinois, (888) 224-9626; www.wocn. org] provides access to nurses specializing in os- tomy patient management. In addition, major product manufacturers offer patient education materials and specific instruc- tions for use of their products. For further infor- mation regarding the major manufacturers, see Table 1. Summary Effective management of any ostomy patient requires establishment of an effective pouching system, education regarding the basics of ostomy management and complication prevention, and prompt management of any peristomal or stomal complications. The patient with advanced cancer may require additional modifications related to the disease itself or to therapy. Finally, patients and caregivers may benefit from access to such or- ganizations as the United Ostomy Association or the Wound Ostomy Continence Nurses Society. References 1. Tomaselli N, McGinnis D. Urinary diversions: surgicalinterventions.In:ColwellJ,GoldbergM,Carmel J, eds. Fecal and Urinary Diversions: Management Principles.St.Louis,Mo:Mosby; 2004:184–206. 2. Vasilevsky CA, Gordon P. Gastrointestinal cancers:surgical management.In:Colwell J,Goldberg M, Carmel J, eds. Fecal and Urinary Diversions: Management Principles. St. Louis, Mo: Mosby; 2004:126–135. 3. Kiran R, Fazio V. Inflammatory bowel disease: surgical management. In: Colwell J, Goldberg M, Carmel J, eds. Fecal and Urinary Diversions: Management Principles. St. Louis, Mo: Mosby; 2004:80–101. 4. Colwell J. Principles of stoma management. In: ColwellJ,GoldbergM,CarmelJ,eds.FecalandUrinary Diversions: Management Principles. St. Louis, Mo: Mosby; 2004:240–262. 5. Erwin-TothP,DoughtyD.Principlesandprocedures of stomal management. In: Hampton B, Bryant R, eds. Ostomies and Continent Diversions: Nursing Management.St.Louis,Mo:Mosby;1992:29–103. 6. Carmel J, Goldberg M. Preoperative and postoperative management. In: Colwell J, Goldberg M, Carmel J, eds. Fecal and Urinary Diversions: Management Principles. St. Louis, Mo: Mosby; 2004:207–239. 7. Rullier E, Letoux N, Laurent C, et al. Loop ileostomy versus loop colostomy for defunctioning low anastomoses during colorectal surgery.World J Surg 2001;25:274. 8. Sakai Y, Nelson H, Larson D, et al. Temporary transverse colostomy versus loop ileostomy in diversion: a case-matched study. Arch Surg 2001;136:338. 9. Colwell J, Goldberg M, Carmel J. The state of the standard diversion.JWound Ostomy Continence Nurs 2001;28:6–17. 10. ColwellJ.Stomalandperistomalcomplications. In: Colwell J, Goldberg M, Carmel J, eds. Fecal and Urinary Diversions:Management Principles.St.Louis, Mo:Mosby; 2004:308–325. 11. Erwin-Toth P.Prevention and management of peristomal skin complications.Adv SkinWound Care 2000;13:175–180. 12. Cohen Z.What are the continuing challenges and issues related to restorative proctocolectomy? In: Boulos P, Wexner S, eds. Current Challenges in Colorectal Surgery. Philadelphia, Pa: WB Saunders Co; 2000:129–143. 13. Crentsil V, Hanauer S. Inflammatory bowel disease:medical management.In:Colwell J,Goldberg M, Carmel J, eds. Fecal and Urinary Diversions: Management Principles. St. Louis, Mo: Mosby; 2004:63–79. 14. Krupski T, Theodorescu D. Orthotopic neobladder following cystectomy: indications, management, and outcomes. J Wound Ostomy Continence Nurs 2001;28:37–46. 15. FlorutaC,BerschornerJ,HullT.Gastrointestinal cancers:medicalmanagement.In:ColwellJ,Goldberg M, Carmel J, eds. Fecal and Urinary Diversions: Management Principles. St. Louis, Mo: Mosby; 2004:102–125. 16. Ratliff C. Principles of cancer therapy. In: Hampton B, Bryant R, eds. Ostomies and Continent Diversions: Nursing Management. St. Louis, Mo: Mosby; 1992:163–194. 17. Jensen L. Assessment and management of patientswithboweldysfunctionorfecalincontinence. In: Doughty D, ed. Urinary and Fecal Incontinence: Nursing Management, 2nd ed. St. Louis, Mo: Mosby; 2000:353–384. 18. Mercadante S. Diarrhea, malabsorption, and constipation.In:BergerA,PortenoyR,WeissmanD,eds. Principles and Practice of Palliative Care & Supportive Oncology,2nded.Philadelphia,Pa:LippincottWilliams & Wilkins,2002:233–249. Doughty Peer viewpoints on this article by Ms. Bridget O’Brien, Drs. Lisa Baddi and Al Benson III, and Ms. Janice Colwell appear on pages 71 and 72.