Speaker 1In this class, we're going to follow up on management of patients with difficult stomas. And specifically, we're going to look at clinical slides and look at a decision-making pathway and give you some practice in problem solving. So describe critical strategies for management of difficult stomas, and mainly we're going to practice using a problem-solving pathway. So these are the strategies we talked about in the previous class. We said it was critical to assess peristomal contours and the location of the os in both sitting and standing positions. A lot of times we'll assess supine as well and twisting. But sitting and standing are usually the problematic positions. Then we're going to use assessment data and our knowledge of general strategies to come up with an initial management plan, which we're going to outline in just a minute. And then we're going to sit and talk to the patient. And we're going to tell them, "Look, we know you're having a really hard time. We hate this. You've already been through enough. You shouldn't be struggling to get a secure pouching system. But here's what we're going to do. And I guarantee you, we have many different products out there. I'm going to keep working until we find the best solution for you. So hang in there. Don't give up. We'll solve this together. So here's our specific pathway. First of all, we're going to assess the position of the os. We're going to assess the peristomal contours. As we've said. In multiple positions, sitting, supine, standing. We'll also look at the back of the pouch when we take it off to see what our leakage patterns are. Then we're going to look at the pouches available to us and we're going to select the pouch that provides the very best match to the pouching surface and the position of the os. And basically we're choosing between flat, all flexible, and convex. And the reason convex and flexible are in bold is because typically if we're having a problem, we're going to need to use either convexity or an all-flexible pouch. Flat pouches work great when we have a relatively flat surface and a protruding stoma with a centrally located os, but typically if we have a pouching issue, we're going to need an all-flexible or a convex pouching system. We're going to use some combination of filler products. Squeezable paste, paste rings, paste strips to fill defects in the pouching surface to create the flattest surface possible. And we're always going to be thinking as we apply our filler products, I want a ramp. I want the drainage to flow up and over and in. We're going to be thinking about adding a belt or a binder to provide mechanical support. Belts work great if the stoma is in a belt plane. If the stoma is not in the belt plane, binders are usually more effective. We will use additional adhesive if the skin is very dry, if there's a specific dermatologic process. Or if we're just having to use a belt. We're going to be having trouble getting a good bond between the pouch and the skin. We're going to tweak. And our last resort, if we cannot solve the problem, is to do a surgical consult, have that patient assessed for either a stoma revision or to have it relocated altogether. So now we're going to practice. So I'm going to show you the clinical slide. And we're going to walk our way through the decision making pathway. We're going to decide for each patient, what's the best choice in terms of a pouching system? Should we be going with flat, flexible, or convex? Do we need filler products? Do we need a belt or a binder? And should we add adhesive products? So here, should we use a flat, flexible, or convex? Well, flat's not going to work, because we don't have flat contours, and we don't have a protruding stoma. So flat's off the table. Flexible won't work. It's not going to contour to that concave defect. So what we need is an oval, convex pouching system, because our stoma is in an oval, concave defect. And our ass empties at skin level. Yes, especially when you look at the bottom. You can see clearly, we need strip paste, right where the arrow points, that little crease there. And we would benefit from a barrier ring stretched and fitted in place right around the stoma, because you clearly have an irregular surface right around the stoma. So we need strip paste, and we need a barrier ring. What about a belt or a binder? Well, our stoma's nowhere close to a belt plane. So if we add a belt, it's just going to pull on the pouching system and pull it up toward the waistline, toward the belt plane. And it's going to be hard to get a binder that gives a good fit there. If we were going to use an abdominal binder support, it's going to have to be form-fitting, nice and stretchy. Or we could suggest that this patient get support underwear or biking shorts to give more support to the pouching system. What about adhesive products? Yes, if adhesion is an issue, otherwise it's probably not necessary. So the two most critical things would be our filler products to create a flatter pouching surface and an oval convex pouching system. Along with supportive underwear or a form-fitting binder or wrap. Here we have a stoma with a wound. This is pyoderma. So we have to address options for wound management. We have to select the best pouching system. We have to think about whether we need filler products, whether or not we need a belt or a binder, and whether we need adhesive agents. So what about for wound management? Well this is pyoderma gangrenosum, so we know that if we have access to an antimicrobial anti-inflammatory foam, such as Hydrafera Blue, that would probably be best. So we could cut that to fit the wound and then put a barrier ring or a hydrocolloid on top. If we did not have access to that antimicrobial anti-inflammatory foam, that would probably be best. We could use an alginate or a hydrofiber. And again, we could add a barrier ring or a hydrocolloid. Then our pouching system. So what would be the best choice in terms of a pouching system? Flat, flexible, convex, well we don't need convexity. We have a pretty flat surface once we address the wound. And our os is centrally located. Convexity. We could potentially add pressure and trauma and trigger pathology. We don't want that. So we would use a flat or a flexible pouch. Well we're going to use filler products for our wound, but beyond that, no, not really. We don't need a belt or a binder and we don't need adhesive products. We don't want to add adhesive because then it could make removal more difficult and that could potentially trigger pathology. So here's our stoma in a shallow crease. This patient has an ileostomy in a shallow crease, so we have to determine the best pouching system. We have to determine the need for filler products. We have to decide whether a belt or a binder is needed and whether we need additional adhesive. So what would be the best pouching system? Definitely not flat. Flat will not contour to a shallow crease. So we either need convexity or we need flexibility. And in this case, we're going to take our lead from the abdominal wall. So if we have a soft abdominal wall, which we do, the abdomen here was very soft, then it's likely that convexity would give the level of support we need. would select a shallow convex pouch to begin with. If that did not work we would come back and we would try an all flexible pouch. But in general if you have a very soft abdomen convexity works well. What about filler products? Well we would probably benefit from a barrier ring right around the stoma or we could do paste strips at 9 o'clock and 3 o'clock and that would give a flatter surface. If we did the barrier ring it would also give us superior protection against the ileostomy output. Well this stoma is in a belt plane so a belt would be great if we ended up using convexity. So maybe a barrier ring, a convex pouch, and a belt. Or possibly a barrier ring and paste strips at 9 o'clock and 3 o'clock and then my convex pouch and a belt. Adhesive would be indicated only if I was having issues with adhesion. This is a urinary diversion. You can see that there's a lot of dimpling and creasing, a very irregular surface. So we have to again decide: flat, flexible, convex, yes or no to filler products, yes or no to belt or binder, yes or no to adhesive products. So what's the best pouching system? Flat's not going to work because we have an us that empties at skin level and we have a very irregular surface. So a convex pouch is going to give us the best outcomes. It's going to give us support all the way around the stoma. So we would need oval convexity, but our convexity needs to run from top to bottom, from 12 to 6. So most likely we would need to get a cut to fit convex pouch. Absolutely. We need a much flatter pouching surface because we have all of those wrinkles and divots and defects. So we could either use a flattened barrier ring or we could use tube paste to create a flat surface. Then we'll put on our convex pouch. Anytime we're using convexity, in general, a belt is helpful because it gives you additional mechanical support. So if the stoma is in the belt plane and his was, he would benefit from a belt. Do we need adhesive products? Only if that's an issue. Only if his skin is dry and we're having trouble getting things to stick. And this is an ileostomy and what I want you to notice is that there's a fistula opening right around four o'clock. And we have exactly the same list of menu items or choices. What's the best pouching system? Flat, flexible, or convex? Well, that fistula empties at skin level. So a convex pouching system would be best because it would provide support right around that skin level fistula opening so everything projected into the pouch. Now you might need a cut-to-fit convexity because we do have to accommodate that fistula opening. The alternative would be to use barrier ring and paste to create a flat surface and to protect the peristomal skin. And then size the opening in the convex pouch to come outside that fistula opening. But definitely we need convexity and definitely we need to make sure that the opening in the pouch accommodates that fistula opening. Yes, we have a very irregular surface. So after we clean the skin, we're going to use crusting to address the irritant dermatitis. We might need to use silver nitrate on the granulomas. And then we'll take either a flattened skin barrier or tube paste to protect all the exposed skin and to create a drainage ramp. That ramp for the drainage to follow into the pouch. Always when we use convexity, a belt is helpful so long as the stoma is in a belt plane. The stoma was in a belt plane, so yes, we would use that. And again, we would use adhesive products only if adhesion was an issue. So in summary, when you're dealing with a difficult stoma, start with thorough assessment. Evaluate the patient in as many positions as possible, ideally lying, sitting, standing, twisting. The problem positions are typically sitting and standing. Pay particular attention to the level of the os and the peristomal contours. Then select the pouch that gives you the best match to the peristomal contours and the location of the os. If you've got a flat surface, a protruding stoma, then a flat pouch is fine. If you have deep creases, you will have to use an all-flexible pouch. If you have a skin-level os or you have a concave defect, you will need convexity. You're going to use filler products as needed to create the flattest pouching surface possible. You'll think about adding mechanical support. Is the stoma in a belt plane? Could I add a belt? Is it away from the belt plane, but I need support and I should think about a binder or support underwear or biking shorts? What about the skin? Am I getting good adhesion between the skin and the pouching surface, or is the skin abnormally dry or flaking due to some kind of dermatologic process? Maybe I need to add adhesive. I'm going to do the best I can, and then I'm going to tweak. Every time there's a problem, I'm going to come back. I'm going to try to figure out what the product, what the problem is, and how we can solve it. And I'm going to remember that if I can't come up with a manageable situation, I need to involve the surgeon. Also, I never want to get so involved in how frustrated I am with patients that I forget how awful it is for the patient. Throughout this whole process, I've got to be supporting the patient, giving them hope, assuring them we're not going to give up, and that even if it requires a minor surgical procedure, we will fix this problem. Okay, thank you very much.
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