Speaker 1Okay, throughout this course we've talked a lot about how important it is to establish a secure pouching seal. We've talked some about the different products that are available, and we've talked about some basic principles of management. In this class, we're going to specifically focus on difficult stomas, situations where we're having a really hard time getting a secure seal. We're going to talk about some specific guidelines for getting the best pouching outcomes possible, and we'll also talk about when to refer for surgical intervention. So we'll talk about factors that impact the ability to obtain a secure seal. We'll talk about measures to promote positive outcomes, factors that contribute to difficult pouching situations, and strategies for management of difficult stomas. So you've heard a number of times that our goal always is to establish a secure pouch seal that provides predictable wear time for the individual, and we've said more than once, and ideally we want to give that person at least two to three days of predictable wear time. So most of the time we're teaching patients to plan to change their pouch twice a week. Some people can get by with once a week, but somewhere between once and twice a week. So that's a wear time of somewhere between three and seven days. That's what we hope for. What we know is that if we don't get a good seal, we're going to have to change it. If we don't get a good seal, if we can't provide this individual with predictable wear time, it has a very negative impact on their quality of life. They're anxious because they never know when their pouch is going to leak, when they're going to have a problem. They can get into a vicious cycle where they have leakage episodes, higher level anxiety, skin breakdown, more frequent leakage episodes, et cetera. What we know statistically is that pouching problems, issues with leakage, and peristomal skin breakdown are way more common than we want them to be. We have data that says, in some studies, over 50% of our patients have problems with leakage and with peristomal skin breakdown after they go home. We want to get those numbers right. We're going to talk in this class about strategies we can use to optimize outcomes, minimize anxiety, minimize leaks, minimize problems with peristomal skin complications. You have heard before, I'm going to review it one more time here as a basis for our discussion. Factors that impact on a secure seal. First of all, where is the seal? Where is the stoma located? Is it on a nice flat or slightly rounded surface? That's great. That's ideal. But what if it's in a crease? What if there are a lot of wrinkles? What if it's in a concave defect? Remember that our pouching system always has to match the abdominal contours. So peristomal skin contours are a critical consideration in getting a good seal. The second very important consideration is does the stoma protrude, and where is the os located? If we have a centrally located os or an os located on the superior aspect of the stoma, the drainage tends to project into the pouch. We have much better outcomes if the os is on the inferior aspect, if it tends to empty at skin level. It's much more difficult to get and maintain a secure seal. So we're very interested in identifying where the os is located, where it empties. We also have to think about volume and consistency of the output. The higher the volume, the thinner the consistency, the greater the risk for undermining and leakage. And finally, there are some patient factors. Our patients are on fixed incomes. They really try to stretch each pouch. They try to wear it as long as they can. Because even what seems to us like limited out-of-pocket cost can make a big difference to patients. So we have to ask our patient, "Okay, what kind of insurance coverage do you have? How much can you afford to pay for our pouching systems?" We're going to try really hard. To keep your out-of-patient cost and out-of-pocket cost at a minimum, while still maintaining optimal outcomes. And some patients don't do what we tell them to do. So we teach them how to size the opening in the pouch correctly, but they forget that when they get home and they just keep cutting it wide. Or we teach them the importance of very gentle peristomal skin care, but they still scrub or whatever. So we're always having to assess what's going on on the patient side and why. And how can we intervene in a positive way? So you know the measures that we want to take to assure positive patient outcomes. Number one, we want to see that patient pre-operatively. We want to get to talk to them, make sure they understand what's happening and why. We want to answer any questions. Any questions they have, but most importantly, we want to be able to assess their abdominal contours and mark them for the best stoma site. Because we cannot compensate effectively post-operatively for a poorly sited stoma. We're going to do everything we can, but if the stoma is poorly sited, that is a big uphill climb. So we want to get to mark the stoma site pre-op. Then post-op, we start out by assessing peristomal contours, location of the ice, and selecting a pouching system that gives us the very best match to abdominal contours and to the location of the ice. And then once we get a pouching system that works, we want to teach the patient and the caregiver, okay, this is what's working for you. Right now, this is how often you need to change your pouch. These are the steps you need to follow. Your stoma is going to change sizes, so it's going to be critically important for you to continue to measure and to adjust the opening in the pouch accordingly. Also, we want to teach you how to manage minor skin irritation, because almost everyone with an ostomy occasionally has minor irritation. We want to be sure. It doesn't turn into anything major. Now, why is it, if we know what needs to be done, we know that patients need to be marked pre-operatively, we know that we need to match the pouch to the peristomal contours and ice location post-operatively, and we have a variety of products available to us to assure a good seal. Why do we have so many negative outcomes? Why are more than 50% of patients still reporting episodes with leakage? Why does up to 60% report issues with peristomal skin breakdown? So there are a number of factors that contribute to these problems at present. First of all, sometimes patients have to go to surgery on an emergency basis, and they don't get marked, or if they do get marked. It turns out not to be a great site because of pre-op abdominal distention. So definitely that's a contributing factor. Also the fact that we have a lot of individuals in our population who are obese or morbidly obese, and that has a very negative impact, specifically, what we know is that when we have abdominal obesity. We have a lot of people who are obese or morbidly obese, and we have a lot of people who are obese or morbidly obese, and we have a lot of people who are obese or morbidly obese, and we have a lot of people who are obese or morbidly obese, and we have a lot of people who are obese or morbidly obese, and we have a lot of people who are obese or morbidly obese, and we have a lot of people who are obese or morbidly obese, and we have a lot of people who are obese or morbidly obese, and we have a lot of people who are obese or morbidly obese, and we have a lot of people who are obese or morbidly obese, and we have a lot of people who are obese or morbidly obese, and we have a lot of people who are obese or morbidly obese. to go. So surgeons will tell you when you have a patient who is obese or morbidly obese, he or she may not be able to cite the stoma where you marked it because they may not be able to mobilize the bowel sufficiently to get it to that area. So you see the patient on bottom, seen that patient before, you see the X, that's where we wanted the stoma, and you see where it was. Because they could not mobilize the bowel sufficiently to bring it out to the marked site. So that's the first effect of obesity. The second is the effect of a thick abdominal wall. So look at the illustration mid-screen. And remember that when they're making a stoma, they trim the mesentery and all the mesenteric vessels away from the section of bowel that they're going to feed through the abdominal wall and use to make the stoma. The limitation on how much mesentery you can trim without causing some degree of stoma ischemia is about seven centimeters. So look again at that illustration mid-screen. Look at the layer that looks yellow. That's the fat. Now you can see in that illustration, the fat is less than two centimeters thick. And so the surgeon's going to be able to feed the bowel through, turn it back on itself, create a protruding stoma, just like you see on top. But what if you tripled the thickness of that yellow layer, of the fat layer? Then the bowel would barely reach the surface of the skin. And you would have a patient who came back from surgery with a retracted stoma and possibly with irregular peristomal contours like you see on the bottom. So anytime the thickness of the abdominal wall is greater than the length of bowel used to create the stoma, you're going to have retraction. You may very well have dimples. You're going to have a lot of redness in the abdominal wall. You'll have dimpling and irregularities. There's two other things that contribute to difficult pouching situations. One is the impact of our short-stay system. So you know that patients may go home as early as three days postoperatively, occasionally two days postoperatively. So what does this mean? Well, first of all, it means I don't have much time, you don't have much time to teach this patient self-care. So how much are they going to retain? And how much of it still needs to be taught when they go home? Because in the end, outcomes are going to depend on how well we taught this patient self-care. Secondly, it means that we make pouching decisions in the hospital when the stoma is still edematous, so protrusion is greater. When the stoma is less severe. When the abdomen is distended, so we have a better pouching surface. And when output is frequently lower volume because the patient's not yet eating or eating only small amounts. So we're making decisions when they're pretty low risk for leakage. And then they get home, everything changes. And so it's critically important that they have access to follow-up long-term care. Which is the next problem. When things change post-operatively, when the stoma shrinks, when the os angles at a different position, when abdominal contours change, when output changes, when activity level changes. We need to have that patient in contact with an ostomy nurse who can reassess and who can identify the pouching system to meet the current status. And who can re-teach the patient so that they continue to be successful. But what we know is that many home health agencies do not have an ostomy nurse. And many patients never get referred to an ostomy clinic long-term. So you really have to think about what's happening in your area. Are patients going home three, four, five days post-operatively? Who's seeing them at home? And what access do they have to an ostomy clinic long-term? Those are very important considerations. So these are the challenges we commonly face. All of these are common problems. Sometimes we have a stoma that's in or adjacent to a deep crease. So look mid-screen on your right. There you have a deep crease. Sometimes you have a stoma that's in or adjacent to a deep crease. Sometimes you have a stoma in a shallow crease. Sometimes you have very irregular contours. So look at the bottom left. Very irregular contours. You've got creases. You've got dimples. Sometimes you have an ost that empties at or below skin surface. So that's what you see on the left in the middle. And then you might have a stoma-wound combination like you see on the bottom right. You might have a stoma that goes just as you want it to go. You'll end up with a situation on top where you have a flat pouching surface, a protruding stoma, a centrally located ost. That's the best thing that could happen for that patient. So you're going to assess the patient post-operatively. Your goal and your challenge is to select a pouching system that provides the best match to peristomal contours. The pouching system has to adhere effectively to the abdominal skin. You're only going to get good adhesion if there's a good match between the contours. So you basically have three contours to select among. Some of your pouches are flat. Some of them are convex. And some of them are completely flexible. They will fold in two. If you have a flat or a rounded surface, like you see on top, then you can use a flat pouch, unless the ost empties at or below skin level, in which case you'll have to go to convexity. If the stoma is in or adjacent to a deep crease, you will always, always need a completely flexible pouch. One that will fold in two and will fit into that deep crease. If the stoma is in a concave valley, like you see at mid-point on the bottom, you will need a pouch with convexity. That's the only thing that will match that contour and give you good adhesion. Whenever you have an irregular surface, you have, you don't want to have a little bit of creases, little defects. You're going to need to use filler products to create a flatter surface. If you look at the slide on the top left, look at all those irregularities. Look at those little dimples and grooves. How is the pouch going to adhere securely? You can't get a good match between the contours of the pouch and the appearance of the pouch. abdominal surface. But what if I take either squeezable paste or a very soft moldable barrier ring and press it into place over that surface to create a flat pouching surface? Now my pouch can adhere. I can get a secure seal. So anytime I have irregularities in my pouching surface, I have to use some combination of filler products. My squeezable paste, my paste strips, my barrier rings, any of those can be used to help me create a flat surface. Now remember if I have an Oss that empties at skin level, which is what you see on the top left and the middle right, any protective products I use, any products I use to create a flat surface have to be flattened out. Right next to the Oss. At the Oss, they have to be skin level so that the drainage will flow up and over. I want to create a ramp and not a retaining wall. When should I use convexity? Convexity helps us solve a lot of problems and those problems fall into two general categories. So I should be thinking about using convexity anytime my Oss empties at or below skin level. What convexity does in that situation, it pushes in around the stoma. Pushes in around the Oss, which helps to force the drainage to project into the pouch. Gives added support all the way around the stoma. So if you have a skin level Oss like you have on top of top and in the middle. You have to use convex anytime your stoma sits in a concave valley because that's the only thing that's going to give you a match between the pouching surface and the abdominal surface. So you look at the slide in the middle and you're like yeah a flat pouch wouldn't work, an all flexible pouch wouldn't work, but that convex pouch yes if I've picked the right level of convexity I can create a good match between my abdominal surface and my pouching surface. I'm going to add belts or binders as needed for additional support. Belts and binders provide mechanical support. They help to hold the pouch firmly against the abdominal wall so they contribute to adhesion. And then if I have skin that's dry and very resistant to adhesion I can add either spray-on adhesive or paint-on adhesive. But I need to follow the manufacturer's guidelines for application and for drying time. So now we're going to put it all together everything you've heard so far in this class and in previous classes. We're going to talk about common pouching scenarios and some challenges and guidelines. So this is your best case scenario. You have a flat or a rounded pouching surface for both of these patients. You have a stoma that protrudes. You have a centrally or superiorly located os. That's perfect. And you know what? Your options are wide open. You could use a one-piece flat pouch. You could use a two-piece flat pouch. In general convexity would not be needed. If you had high output liquid stool you would add a barrier ring or paste. But other than that it's just the pouch. And the patient's going to get great outcomes and you can focus on rehabilitative care. But now look let's look at a major challenge and that is a stoma in or adjacent to a deep crease. So this patient on top was my patient. You can see you can't even see the stoma. The crease was actually two inches deep. So I couldn't see the stoma when this patient was sitting but I could see evidence because I could see peristomal skin damage. When you have a deep crease like you see in both of these slides, you have to have an all flexible pouch. You cannot use convexity. Convexity will not contour to a deep crease. You can't use anything with rigid components. You have to have a one-piece flat pouch that will fold on itself. Now how you size the opening depends on the location of the os. If your stoma protrudes and your os is above skin level then you're going to size the opening in the pouch to fit closely around the stoma. It's going to be an all flexible pouch sized to fit closely around the stoma. But if your os is at or below skin level, which was the case and that with this patient, then you've got to size with a little bit of clearance around the stoma opening to prevent undermining and leakage. If you size the opening in the pouch so it comes right up to the edge of a skin level stoma, the problem is with peristalsis that skin level stoma will expand. It will wet the barrier and you will get leakage. So if I have a skin level stoma and I cannot use convexity, and in this case I cannot use convexity because I have to have a completely flexible pouch, so I have to compensate by creating the opening in the pouch so that it's at least 1/8 inch larger all the way around. So that I help to prevent underbrush. And then if this is a fecal ostomy, and this was, I want to protect that exposed skin with a flat layer of paste or a flattened out barrier ring. So let me summarize again. Deep crease, you always have to use a completely flexible pouch. So it's going to be a one-piece, flat, all flexible pouch. If the stoma protrudes, you size the opening to fit snugly around the stoma. You add a barrier ring if necessary. If the stoma is skin level, you have to enlarge the opening in the pouch to give clearance. You want at least an 1/8 inch clearance all the way around, which means you have to add a quarter inch to the size of the stoma. In other words, if my stoma was 1-1/2 inches wide at the widest point, in order to give at least an 1/8 inch clearance on each side, I would have to cut the opening so that it was 1-3/4 inch at the widest point. So always provide clearance if you have a skin level stoma and a deep crease. What about shallow crease? A shallow crease can be particularly challenging because the path forward is not clearly defined. There's actually two different pathways you can take. One is to use a convex pouch. So you could teach this patient to stretch out their abdomen, apply a convex pouch with the opening size to fit closely around the stoma. If the stoma is in the belt, then you can use a convex pouch. And if the stoma is in the belt, then you can use a convex pouch. And that may be all you need to do. Just use a convex pouch with a belt. That's particularly likely to work if the abdomen is very soft, because then the abdomen tends to contour to the convex pouch. It's also a good choice if the osse is at skin level, because then the concave and the convexity provide support right around the stoma, helps the drainage project into the pouch. But sometimes when you have a shallow crease, the patient actually does better with a flexible pouch that will fold in and contour to the creases. That's usually a better option if you have a firm abdomen, because a firm abdomen can resist convexity. And especially if the osse is above skin level. So if you have a firm belly, osse above skin level, and it's located in a shallow crease, you're probably going to be better off using an all-flexible pouch. And you may need to add either a barrier ring or paste strips to fill the gaps at 9:00 and 3:00. So when I have a stoma in a shallow crease, I tell the patient right up front, there's many different things we can try. I'm going to try option number one. I'm going to see what kind of wear time you get with that. Then I'm going to do option number two, see what kind of wear time we get with that. We're going to pick the best of those two and tweak from there. What about a stoma in a concave valley? When the abdominal contours are concave, the pouch contours have to be convex. Now, you're going to have to match the level of convexity on the pouching system with the level of concavity at the level of the abdomen. So look at the top left. That stoma protrudes, and you have a stoma that's in a shallow concave defect. So that patient is going to do very well with shallow convexity. It's just what they need for the pouch to fit right into the stoma. If you have a deep defect like you see on the bottom right, you're going to need a deeply concave pouching system. So again, look at the system on the bottom left. That would be a good match to the stoma on the bottom right. So yes, fortunately we now have different levels of convexity, so we can pick the best match. Now let's look at it from a different perspective. Let's look at it from the perspective of where does the stoma empty? Where is the os? So let's say that our stoma is on a flat surface or in a concave defect, or maybe in a shallow crease, and the os is at level. So look at the stoma top left, top right, and midpoint. All of those empty at skin level, those stomas are all sitting either on a flat surface, a very mild concave defect, or in a significant concave defect. So with every one of those, you're going to use convexity. You're going to select the level of convexity that's the best match for the abdominal contour. So on the top two, you're going to use shallow convexity. Add a belt if the stoma is in a belt plane. The stoma in the mid illustration, middle illustration, that's in a deep concave defect. So you're going to use a deeply convex pouch to fit into the defect to provide support right around the os, and you're going to add a belt. If you can. But when your os empties at skin level and your stoma is in or adjacent to a deep crease, we've already said this, I'm just flipping it around for you. So skin level os, deep crease, now we have to use an all flexible pouching system. We cannot use convexity. And so we will compensate by enlarging the opening in our pouching system so it clears the stoma by 1/8 to 1/4 inch and will protect the skin. So if I summarize this whole slide, I would say if your os empties at skin level, almost always you use convexity. That's what you think. Skin level os use convexity. But there is one exception, and the one exception is when the stoma is located in a deep crease and you cannot use convexity. In that case, you compensate with a larger opening and skin level paste. Wrinkles we've talked about, you're going to create the flattest pouching surface you can. So when you have little defects, when you have creases, when you have irregularities, you have three types of filler products you can use, and they're all included on this slide. So you have your barrier rings, and you can use them as a ring. You can stretch them. You can flatten them out on the inside edge so that you can fit them into place around a stoma. You can also pinch off pieces of that barrier ring and roll it into like a little strip. Or you can use strip paste, which you see on the far left, which is great for linear defects. Or if you have extremely irregular contours, sometimes your squeezable paste does the best job because you can put it on there, use a wet finger, smooth it out to create a flat surface. Always, if your os is at skin level, your protective products have to be flattened or smoothed at skin level so that you create that ramp so that you do not create a retaining wall. And then you'll select your pouch based on the os. If it protrudes, you can use a flat pouch. If it's skin level, you would use convexity. If you have a stoma and a wound, typically you start with the wound. So you select a dressing that would be appropriate, that would manage exudate, that would maintain a moist wound surface, that would provide antimicrobial effects if needed. And most often, we end up with an alginate or a hydrofiber because it will absorb or maintain a moist surface and we can tuck it in around the stoma, help it contour. Then we will typically cover our dressing with a barrier ring or paste or a syringe so that now we have a pouching surface. And then we'll select our pouch based on whether or not the stoma protrudes and the location of the os. So if you look at the one on top, after we dress it and cover it with a barrier ring or a hydrocolloid, we're going to have to have a convex system because it's in a concave defect, empties at skin level. But if you look at the one on bottom, our stoma protrudes. Our os is centrally located. So after we dress the wound and put down a barrier ring or a hydrocolloid, we can just use a flat pouch. So last thing we wanted to talk about is convexity. Convexity helps solve so many problems. And today we have many, many options in the world of convexity. So I just wanted to summarize for you what's out there. If you've been doing ostomy care for a while, you probably know this. But if ostomy care is new to you, then some of this information will be new to you. So the first thing is to realize that we have products that provide shallow convexity and products that provide deep convexity. Shallow convexity is usually all we need if we have a skin level. So if you have a concave surface, we will need deep convexity. If we have a concave surface, we will need deep convexity. We also have convexity in both soft and firm versions. And in general, we pick soft versus firm based on the abdomen itself. So if my abdomen is very firm, I'm going to do better with soft convexity because I need to be willing to contour to the abdomen. If I have a soft abdomen, I can use firm convexity. There's another time that we need soft convexity, and that's when I'm using convexity early post-op. There are concerns that if we use rigid convexity early post-op, we can be putting tension on the mucocutaneous suture line. We can increase the risk. We can increase the risk of mucocutaneous separation, stoma prolapse, eventual stenosis. In contrast, if we use soft convexity early post-op, we are very unlikely to create any problems. So in general, you would use soft convexity in the early post-op period. You can get convex products, rings, pouches, and rings. You can also get round or an oval. You will select round versus oval depending on the shape of the stoma and also the shape of the peristomal defect. So if you look at the stoma on top, it's got kind of an oval contour. So that patient's going to do better with oval deep convexity. And finally, you can get convexity as an integral. It's an integrated feature so that the pouching system comes already convex. But you can also get convex barrier rings that can be added onto a flat pouch or to a shallow convex pouch to increase the level of convexity. Does it matter? Yes, sometimes it does. In general, you're integrated convex systems. These are better when you're dealing with a skin-level us. So look at this slide on top. That's when you would want integrated convexity. And this is why. When you have integrated convexity, it means it's created during the manufacturing process. They shape the barrier into a convex mold. So it's going to provide a very flat convex ramp that promotes drainage. If you have add-on convexity, you need a protruding stoma. So I want you to look at the barrier ring in the center of the slide. That is a convex barrier ring. But they create the convexity by making that barrier ring very thick in the center and thin at the periphery. So that creates that convex contour. That's absolutely fine if you have a concave defect in a protruding stoma. You could use that convex barrier ring. You could add it to whatever pouch, put it on, and you would get a great seal because that convex ring would contour to the concave defect. It would fit right around the stoma. It would be just what you needed. Now, I remember way back, having a patient just like the one on the bottom left. And we had tried flat, we had tried flexible, nothing was working. I knew we needed convexity, but we didn't have many options in the world of convexity. But then I called one of my reps and she said, hey, we have some new convex barrier rings. You can use them to make any system convex. I'm like, that's what I need. So she dropped them by I grabbed that convex ring, went to the patient's bedside, added that convex ring to the pouch, and it was a perfect fit. And the patient immediately went from changing the pouch several times a day to a three to four day pouch seal. I'm like, wow, this is awesome. Now we can solve all kinds of problems. And I was partially right. So two weeks after that, I got the patient on the topper right. Again, remember, we didn't have a lot of options in convexity. Flat didn't work. Flexible didn't work. But I thought, hey, I know exactly what to do. I'm going to go get that convex barrier ring. I'm going to add it to my flat pouch. It will fit right there in that concave defect. And I think it'll solve this patient's problem. So I did that. But notice that in the slide on the top right, the ice empties at skin level. So even though it looked like a perfect fit because the convex ring fit the concave defect, I failed to consider the fact that I was adding a retaining wall. And I had a call in two hours that the patient was leaking. I'm like, why? Why is this not working? Now I understand. So you always have to think about the impact of add-on convexity because add-on convexity adds thickness. And it's fine if you have a protruding stoma and a protruding os, but it's not a good choice if the os empties at skin level. So in summary, always, always, we're trying to establish a secure pouching system. Our two most critical assessment factors, where is the os located? And how would you describe the peristomal skin contours? If you have a stoma in a deep crease, you absolutely always have to use an all-flexible pouch. If you have a stoma in a concave defect, you have to use a convex pouch. If you have a stoma in a shallow crease, you're going to try two different approaches. You're going to try a convex pouch, especially if the abdomen's soft. And you're going to try an all-flexible pouch, especially if the abdominal surface is firm. If you have wrinkles and defects, you're going to use all of your filler products to create the flattest surface possible. In general, if your os is skin level, you need convexity. Bounce and binders are great for adding mechanical support. And if the problem is things aren't sticking well because the skin is very dry or I had one patient with psoriasis, nothing wanting to stick because of the flaking skin due to psoriasis, think about adding adhesion and possibly adding about. Okay, in a later class, we'll actually do some problem-solving slides so you can kind of practice matching challenges to solutions. Okay, that's it for this one. Thank you.
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