Mark Cheetham, Shrewsbury and Carol Catte, Chertsey
Presented at ACPGBI Liverpool 2013, 1 July
In the ideal world all stomas would be sited on a flat surface of the abdomen, and protrude above the level of skin (colostomy slightly, ileostomy and urostomy by about an inch). Unfortunately some stomas are not perfect: there may be problems at the time of surgery – adequate bowel and mesentery are not able to be mobilised enough to create a ‘spout’, or in an emergency situation the patient’s abdomen has not been marked pre-operatively to select an appropriate site for the stoma; post-operatively there may be weight gain, or scar tissue from infection, or muco-cutaneous separation.
These are possible causes of a retracted stoma – the resultant stoma sits either flush or below skin level, or in a skin crease, and is at risk of allowing faeces or urine onto the skin surface. This results in leakage from the bag and sore skin, and causes distress and discomfort for the patient. The use of accessory products in addition to a normal stoma bag will be required in order to ensure that there is a good seal around the stoma and the bag adheres well to the skin.
Some of the additional products that may be required are paste, powder, seals, washers, belts, convex or soft-convex flanges, flange-extenders, skin protection wipes or sprays, thickeners.
It is necessary to consider the ability of the patient to change his bag as well as the most cost-effective system when drawing up a care plan, and a certain element of ‘trial and error’ may be necessary to find the most efficient way of dealing with the problem.
A bag with a convex or soft-convex flange may be used to enable the stoma to protrude more or for a superficial crease. A thin elastic belt can be attached to the bag for added security. This type of flange may be too rigid if there is a deep crease, and would be forced off when the patient bends e.g. when sitting. In these circumstances, a bag with a flexible flange is used, and paste or a seal (or a combination of both) is applied to fill the crease. The edges of a sunken stoma need to be built up to form a seal to prevent stool or urine leaking and causing erosion of the skin.
It will be necessary to treat sore skin if faeces or urine has leaked around the stoma – output from an ileostomy will cause excoriation in a very short time; output from a colostomy or urostomy is less irritant to the skin. If the skin is macerated (moist and weeping) a powder form of adhesive will be applied first to absorb any exudate on the skin to give a dry surface on which to apply the next layer of paste or seal. It may be beneficial to use a skin protector wipe or spray to prevent any leakage causing further soreness.
There are many products available to assist with managing a retracted stoma, and an experienced Stoma Care Nurse will be able to recommend an appropriate method that will allow the patient to lead as normal a life as possible without the fear of leakage and sore skin.