Speaker 1In this class, we're going to continue our discussion of prevention and management of stoma complications. This time, we're going to focus on prolapse and hernia. We'll talk about signs of stoma prolapse and management, and signs and management of peristomal hernia. So, just as a quick review, looking at stoma complications, big picture, incidence is high, up to 50% across the board. Risk factors are pretty well known, obesity, which of course is a risk factor for most post-operative complications, also advanced age because it affects healing, inflammatory bowel disease or ischemic colitis because of the ongoing inflammation. We're going to talk a little bit more about what the risk factors are for post-operative complications, and then we'll talk a little bit more about what the risk factors are for post-operative complications. So, first of all, we're going to talk a little bit about what the risk factors are for post-operative complications, and we're going to talk a little bit more about what the risk factors are for post-operative complications, and then we're going to talk a little bit more about what the risk factors are for post-operative complications, and then we're going to talk a little bit about what the risk factors are for post-operative complications. So, we're going to talk a little bit more about what the risk factors are for post-operative complications. failure to involve the ostomy nurse preoperatively, failure to assure pre-op teaching, but more importantly, failure to assure stoma site marking during the pre-op phase. Now, early versus late complications, by definition, 30 days is kind of the cutoff. Within the first 30 days is considered early, after that point considered late. And prolapse and hernia are very common types of late complications. So prolapse, what is that? Well, when you have stoma prolapse, basically the stoma is telescoping, or the bowel is telescoping through the stoma. So the stoma is kind of turning inside out, and you end up with a very, very long, at-risk stoma that is very distressing to patients. Because, as you can see, if you woke up and you look down and that's what your stoma looked like, that would be very upsetting. I had one patient who's like, it looks like I had a sex change during the night, and I want it fixed, and I want it fixed now. We understand. Okay, we're on it. We're going to be working on that. It can occur in any stoma, but statistically, it's more common in people who have a loop colostomy. And it typically involves the distal limb, which to me seems counterintuitive. It seems like all the peristaltic push would be against the proximal end. So it seems like if you were going to have prolapse, it would be more likely to involve the proximal end of that loop. But no, statistically, it's much more likely to involve the distal end. What causes prolapse? That's what patients want to know. We know some of the risk factors. We know that if you have to create a large opening in the fascia muscle layer, like if you're creating a stoma and the bowel is very distended, then you have to create a large opening to bring that distended bowel through. But then you're going to be left with a large opening, and instead of having to do a large opening, you're going to have to do a large opening. And that's what patients want to know. Having snug support for the stoma, now you have a large opening that makes prolapse more likely. Statistically, it's more likely to occur if the stoma is sited outside the rectus muscle. So as we've discussed in previous classes, it is standard of care to locate the stoma within the rectus muscle to reduce the risk of complications. Understandably, anything that increases intra-abdominal pressure in babies, constant crying, people who have lung disease and they cough a lot, people who have a urinary stoma and they're chronically constipated and they're straining, they can get prolapse. And obesity, which again affects the constituents. The constituents of the tissue, when you have abdominal wall obesity, you have a disproportionate amount of fat as compared to muscle, so you end up with less support for the stoma. Now, as ostomy nurses, when we see prolapse, we need to be assessing for the severity of prolapse for any complications associated with prolapse. So we definitely want to assess the length and the severity because when you have extensive prolapse, complications are more likely. But the length is not the most important assessment parameter. It's important in terms of increasing risk for complications. It's important in terms of increasing risk for distress to the patient. But as you can see, the length is not the most important assessment parameter. It's important in terms of increasing risk for prolapse. A more important assessment parameter is stoma viability and stoma function. You're looking to see, is there any evidence of ischemic changes? Is there any evidence that this prolapse is interfering with normal function of this stoma? So you look at stoma color, any evidence of congestion or ischemia. So when you look at the slide on top, yes, you have extensive prolapse. But what you're more concerned about is how all of those ischemic changes involving the distal stoma. So clearly you have ulcerations and you have dusky color in areas where the stoma appears almost black. So that's going to require urgent intervention, possibly surgery. The other thing you're alert to is stoma output. Do you have a reduction in output? Is there an absence of output? Do you have abdominal distention? Is there cramping pain? So if you see evidence of stoma ischemia, if you see evidence of obstructive changes, that requires urgent surgeon notification. That patient's probably. You're going to require surgical intervention. The other thing you want to be alert to is trauma to the stoma itself. Because when you have prolapse, that telescoping pushes the stoma past the barrier of the pouching system. And you can get trauma to the stoma from rubbing against, pushing past the pouching system. Especially if there are rigid components. You can also get trauma from rubbing against the surface of the pouch. So you're alert to the extent of prolapse, you're actively assessing for ischemic changes or evidence of obstruction. You're also actively assessing for any trauma to the stoma itself. Now, how do we manage trauma to the stoma itself? How do we manage trauma to the stoma itself? How do we manage prolapse? Well, first of all, we need to modify the pouching system. So we're going to get called or the patient's going to come into clinic to say, "What do I do? You know, do I need a different pouch?" And many times, they do need a different pouch to accommodate the prolapse and to prevent trauma. Typically, you want a pouching system that's all flexible. So usually, you want a one-piece instead of a two-piece. Because a two-piece has that ring, and if the bowel rubs against the ring when it telescopes out, then you're going to end up with ulcerations of the stoma. So usually, an all-flexible system is best. You frequently need a larger pouch, a post-op pouch, or even occasionally an irrigation sleeve if you have extensive prolapse. Because you have to accommodate. The length of the prolapse and the width of the prolapse and still provide room for output. So most of the time, we have to change the pouching system. We want a flexible pouch. We want adequate capacity. If I'm getting any trauma from the prolapse bowel rubbing against the surface of the pouch, I can add lubrication to the inside of the pouch. Most of the time, what we try to do is reduce the prolapse and then maintain the bowel the reduced state. So how do we do that? First of all we have to eliminate swelling because I want to push the bowel back into the abdominal cavity and if the bowel is edematous it's not going to want to go through the stoma opening. So the first thing I need to do is eliminate the edema from the bowel wall and the best way to do that is to sprinkle sugar on the prolapsed bowel and I put that slide there so you can see I mean just what I said. You take table sugar and you sprinkle it all along the prolapsed bowel and you're thinking I'm doing this why? Well remember that sugar is an osmotic agent. It attracts fluid so when you put sugar on that prolapsed stoma it's going to pull fluid out of the edematous bowel and the bowel is going to go back to normal size. So the best analogy I can give you is think about the times that you have sliced strawberries and the strawberries start out firm with really good turgor and then you sprinkle sugar all over the strawberries and what happens? Now you get all of this fluid out of the strawberries so you end up with this syrup all around your wilted kind of strawberries so they're not firm. Now they're soft and kind of puckered and you've got all this fluid. That's exactly what happens at the level of the bowel. You're pulling the fluid out of the bowel. You're reducing the diameter of the prolapsed bowel so that now you can take your gloved finger and you can literally push at the os and start pushing the bowel back inside, back inside the abdominal cavity. So that's very helpful. Sometimes people will use ice but sugar works the best. Now if I can get the prolapsed bowel back in the abdominal cavity a lot of times I can use a hernia belt with a prolapsed over belt. So you have to think ahead, which I didn't the first few times I did this. I would get it reduced and then I would sit the patient up to put the support binder behind them and of course what would happen the stoma would re-prolapse. So I learned before I reduced the prolapsed stoma, position my support belt, then reduce the stoma, then apply my pouch and close the binder around the patient before he or she ever sits up. Now if there are ischemic changes, if there are obstructive changes, almost always the patient's going to require surgery to resect the ischemic bowel to manage the obstruction. And the surgeon's going to try to make sure that the opening in the abdominal wall and in the fascia muscle layer provides snug support. He's going to tack the bowel against the abdominal wall to try to minimize the risk of recurrent prolapse. What we know is that any patient who's had prolapse is fairly high risk for recurrence. So now we're going to talk about peristomal hernias. So what is a peristomal hernia? Well you know what a hernia is. It's a defect in the fascia muscle layer. It allows loops of bowel to slip through and it can occur at different points. It can occur along an incision line. It can occur at the groin level. It can occur at the peristomal site. So we of course are talking about peristomal hernias. Look at the slide on top and you can see that in creating the stoma, we created a defect in the fascia muscle layer. And if a loop of bowel herniates through that defect, it can create a bulge in the soft tissue around the stoma. This is the most common stoma complication. Incidence depends on what the study population is. Reported incidence ranges from a low of 14% to a high of 80%. It's more common in patients with a colostomy, possibly because in general those individuals are older. So their tissue turgor is not as strong. But maybe for other reasons that we really haven't explored. Maybe because we see more obesity in people who are undergoing colostomy than people who are undergoing ileostomy. The specific risk factors have yet to be clearly identified. But looking at the peristomal hernia population as a whole, we do know this about risk factors. Obesity across the board is a risk factor for hernia formation. Because again, obesity alters the ratio between fatty tissue and muscle tissue. The stronger your muscle, the better your protection against hernia. The weaker your muscle, the less protection you have. So that's what I'm going to talk about today. Thank you. Interestingly, waist circumference greater than 100 cm has been identified as a specific risk factor. So we're going to talk about weight control and waist control as being an important component of hernia prevention. So obesity, morbid obesity, specifically waist circumference greater than 100 cm. Greater than 40 inches. Also, if they had to create a large opening in the fascia muscle layer. Again, if your bowel was very edematous. If you have to do a loop stoma, you're going to end up with a larger defect in the fascia muscle layer. If the stoma is located outside the rectus muscle. Now, that has been challenged during more recent studies. But still, citing the stoma within the rectus muscle, it's a risk factor. So we're going to talk about weight the rectus muscle is considered standard of care. Anything that increases intra-abdominal pressure, just like it increases the risk for prolapse, it increases the risk for hernia. So heavy lifting, chronic coughing, chronic straining, crying in an infant, and then anything that compromises healing or tissue strength, malnutrition, advanced age, being on steroids, any baseline collagen abnormality, even sepsis is a risk factor. Now we want to prevent hernias because management is much less effective than prevention. So let's focus on what can be done intraoperatively and postoperatively. To prevent peristomal hernia formation. So first of all, they're going to minimize the opening in the fascia muscle layer. There's even been some discussion about the size of the surgeon's finger and how much of a hole they're creating in the fascia muscle layer. So they're going to minimize the opening in the fascia muscle layer to minimize the risk that loops about the fascia muscle layer. that loops of bowel will slip past the stoma. We want a snug fit for the stoma. We know that mesh can be used to strengthen the abdominal wall and it can help to prevent hernia formation, but of course the use of mesh is controversial because if the mesh gets infected that's a huge issue. We know that mesh can sometimes erode the bowel wall, so the big discussion is when do the positive benefits of mesh outweigh the potential complications? Which mesh is best? So there's a lot of focus now on identifying biologic meshes that are less likely to cause problems while still providing support. So ongoing research, emerging answers. And again, citing within the rectus muscle. So intraoperatively, keep the defect in the fascia muscle layer to a minimum. Think about mesh biologics probably better than synthetics and cite the stoma within the rectus muscle. What about postoperatively? Well, this is where we get involved. So we do want to talk to patients about the negative impact of weight gain and obesity. So we want our patients to maintain a healthy weight. We want them to keep their waist circumference less than 40 inches. So we do want to talk to them about maintaining a healthy diet, remaining active, avoiding weight gain. We want to make sure that they adhere to their surgeon's restrictions on weight lifting because that can cause a hernia right there. If people do heavy lifting during the early post-op period while the muscles are still healing, major risk factor for hernia development. So the surgeon is going to determine what the limits are on weight lifting. He'll tell the patient no more than 10 pounds for the first six weeks and after that no more than this much. We want to reinforce that. That's critically important. Adhere to surgical restrictions. That's what studies have found is a key element of hernia prevention. Abdominal supports should be worn when the patient is up and active. So a lot of patients are in abdominal binders during the post-op period in the hospital. But what happens when they go home? And even in the hospital, are they in the right binder? Is it correctly sized? Is it correctly positioned? Because many times I'll walk in and the binder is not in the right place. It's in the wrong place. So we want to make sure that the abdominal support is sized and fitted just like you see on the bottom right. So it should be giving effective support for the patient. From just above the umbilicus to just above the symphysis. You want to teach the patient abdominal strengthening exercises. Now they don't begin these immediately post-op. They should have phased involvement of abdominal strengthening exercises. So they should start limited exercise about one week to 10 days post-operatively. And this should be done once a week. And then they should gradually advance once their surgeon clears them. We'll talk more about that. And finally, just staying active and healthy. So get out there. Walk. Do the things you did before surgery that you enjoy. But don't just sit on the couch because that tremendously increases your risk. So let's talk about abdominal support belts and garments. These are very helpful when people are up and around the room. I'm going to show you a few of them in just a moment. and active because they provide additional support to the abdominal wall and they counter any increase in intra-abdominal pressure and they reduce the risk of peristomal hernia formation. So the good thing is that there are now increasing numbers of garments available on the market and people can get something that is comfortable and that actually helps flatten and secure the pouch. So it helps to conceal and secure the pouch and also provides support. Most people tell me that they actually feel better when they're wearing the garment because it provides support to their muscles. So you can see some of the products that are on the market that are widely used. Coloplast has something that is very easy to use. Coloplast has some of the products that are on the market that are widely used. Coloplast has something called a brava wrap. New Hope has a complete line of binders so they have many many options. Ostomy Secrets has wraps that are for both men and women. Stealth belts, that's what you see on top. And if they don't want something that's intended just for ostomy patients, they can wear, they can just order supportive underwear. That's fine. Or biking shorts, that's a great option. So yes, they should be wearing some kind of support garment when they're up and active. But we need to be aware that support garments are not a substitute for abdominal exercises. Nothing substitutes for a strong sheath of abdominal muscles that provides excellent support for the stoma and that resist loops of bowel telescoping through. So let's talk about exercises. Patients are encouraged to begin with isometric core exercises about a week to 10 days post-operatively. They're encouraged to do these exercises two to three times a day. The first one is just lie on your back with your knees bent. Contract your abdominal muscles, but do it while exhaling. So you're tightening for three to five seconds. You do about five reps. So just exhale while tightening your muscles. Then you can do pelvic tilts. So you lie on your back, your knees are bent, you're pressing your lower back onto the floor while tightening your abdominal muscles. Hold it two to three seconds, do about five reps. And then knee roll. So again, lying on your back with your knees bent, your feet together, tighten your abdominal muscles, allow your knees to roll to the side. And then come back to the center and repeat on the other side. So these are just isometrics. You're not doing anything aggressive, but you're starting to strengthen the muscles that support your stoma and the muscles that prevent peristomal hernia formation. Active abdominal exercises should gradually be added, but only after healing is complete and you have surgeon approval. So typically somewhere between six and eight weeks post-op. And this is going to include crunches, planking, sit-ups, all of that kind of stuff. Ideally, you work with a trainer to assure appropriate technique. One of the most important things is to get in the habit of when you're contracting the muscles, when you're using the muscles, don't hold your breath, exhale. And there's a great online resource for graduated abdominal exercise program. It's www.meplus.convatec.com. So I'd encourage you to go there, review that program, and share this link with your patients so that they see what's recommended for them for hernia prevention. They need to know hernias are really common, that they can cause a lot of problems, and that they can almost always be prevented. Okay, so now let's move away from prevention. Let's move into detection and management. So how do hernias present? Well, you know this. Sometimes there's abdominal pain and discomfort. Sometimes that's the first clue. So we've had patients who come in and they're not complaining of a bulge. They're not saying, "I think I have a hernia." They're saying, "I have pain." It comes and goes. We've had patients admitted to the hospital with pain that comes and goes. But then if you have them sit up, if you have them stand and strain, if you have them cough, many times then you see the bulge right around the stomach. So they may come in with pain. They may come in complaining of a bulge. They might say the bulge comes and goes. It's worse when I'm sitting or standing. It tends to go flat when I lie down. That's great. That means the hernia is reducible. Sometimes they'll come in and they'll say, "I've got this bulge. It's there all the time." Sometimes it hurts. Sometimes it doesn't. Some people come in complaining of pouching. Sometimes they'll say, "I've got this bulge." Sometimes they'll say, "I've got this bulge." defect and sometimes you can feel the loop of bowel extending into the subcute tissue when the patient bears down. But definitive diagnosis typically involves a CT scan or some other imaging study so that you can literally see the defect in the fascia muscle layer and you might be able to see the loop of bowel extending through that defect. Now, what are the potential complications? Well, we've already said it can cause problems with pouching because your peristomal contours keep changing. Your peristomal surface looks one way when the hernia is reduced looks totally different when that loop of bowel is extending into the subcute tissue. For some people it causes chronic pain and discomfort. I remember one lady we had in the hospital not too long ago that was her number one complaint was pain and discomfort. That's actually how we found the hernia was because of her complaints of persistent pain. For some people it's distressing because they constantly have this bulge, their clothes don't fit right, they look asymmetrical and they're very acutely aware. And you see the most serious complication is that that loop of bowel can get caught out in the subcute tissue. If it gets caught then you can get obstruction and you can get gangrene of the bowel so you can end up with incarceration of that loop. It can't get back into the abdominal cavity and then that loop of bowel can become strangulated where there's interference with perfusion and the bowel becomes aggressively ischemic and you can end up with perforation. So how are we going to manage? Well ideally we manage non-surgically because we know that if we do surgery recurrence is common and surgery always carries its own set of adverse results. So if we can manage non- surgically we will. So we are going to ensure a flexible pouching system if at all possible. We try to avoid a firm pouch, we try to avoid convexity because we've already talked about the fact that that can result in peristomal pressure injury formation. So in general you look at the slide on the top left. There's a patient with the hernia out with the loop of bowel out in the subcute tissue. You see that patient's going to do best with an all flexible pouching system. If for some reason I need to use convexity I'm going to use soft convexity and I'm going to monitor that patient very very closely. If I have a colostomy patient and they've been managing with irrigation I want to tell them it's not safe to irrigate when the hernia is out. I'm going to show them the diagram on the right. I'm going to say see what's happening when you've got the bulge. It means a loop of bowel is caught out in the tissue and if you distend that loop of bowel with your irrigating fluid it might not be able to get back in the abdominal cavity. You might cause a complication that forces you to have surgery. So you should either stop irrigating, manage with a pouch, take a mild laxative as needed, or if you're going to irrigate you should do it only when the hernia is reduced when that loop of bowel is in the abdominal cavity. We want to prevent constipation because that increases peristaltic force and that can contribute to that loop of bowel getting caught out in the subcute tissue. So we want to use fiber, fluids, softeners, low-dose polyethylene glycol, whatever is necessary to prevent constipation. And we want to use abdominal support. Now if this hernia is reducible that's best-case scenario. So if the hernia is reducible I want to teach the patient put your abdominal support underneath you, your whatever kind of wrap you're using, and in this case they would be best off with some kind of wrap. So put that underneath you then lie down so that the hernia goes back in, then close the wrap around you. Or if they want to use biking shorts or support undergarment, they need to lie down so that the hernia is reduced and then pull on their biking shorts or their support undergarment. If the hernia is irreducible, a support garment can still be helpful, a wrap can still be helpful, a binder just to give support and to reduce muscle strain and discomfort. What about surgery? Well typically surgery is limited to situations where the hernia is very symptomatic. For example, my patient who has so much pain that it was really debilitating for her. It interfered with every aspect of her life. So they're like okay we're going to take you back to surgery. Definitely for any patient who develops incarceration, strangulation, so they have a loop of bowel caught that can't get back and they're having pain, there's evidence of ischemic changes, there is evidence of impending perforation, so maybe they have a hernia that's non-reducible so they have persistent bulge, persistent pain, absence of output, increasing abdominal pain. That's evidence of partial or complete blockage. That patient has to go back to surgery. What about a patient who has constant problems with peristomal skin irritation? They can't keep a pouch on. Yes, they're probably going to require surgical intervention. So only for symptomatic peristomal hernias. And what we know statistically is the majority of patients can be managed conservatively without surgery. Only about twenty to thirty percent will require surgery. We've already said the reason they don't like to take people back to surgery is because recurrence is way too common. Now what are the repair options? Well sometimes they'll try to just stitch up the defect around the stoma. They'll just do a fashion repair. Sometimes they'll try to do a fascial repair with mesh. Both of those are pretty high risk for recurrence and complications. The recommended approach is remark the patient for a new stoma on the other side and move the stoma. So in summary, this class is focused on two late complications: prolapse and hernia formation, with prolapse you've got the bowel telescoping through the stoma to create a very difficult situation. So here we focus on pouching modifications to prevent trauma to the stoma. We monitor very closely for ischemic changes or obstruction which almost always mandate surgery. We provide a lot of support to the patient because this is a very distressing complication. If possible we'll reduce the prolapse and maintain it in the reduced state with a binder, with a hernia belt and an over belt. Hernia formation, the most common post-op complication, can occur in up to 80% of patients. More common in individuals with a colostomy. Also more common in people who are obese. More common when they had to create a large opening in the fascia muscle layer to begin with. More common in people who have very weak abdominal musculature. What we want to do is prevent hernia formation. We want to minimize the defect in the abdominal wall. That's what the surgeon tries to do. We want to make sure that the patient adheres to restrictions on lifting. We want to recommend support garments when people are up and active. And we want to teach patients the importance of abdominal strengthening exercises. Beginning with core exercises seven to ten days post-op and then moving into more aggressive abdominal exercises once the abdominal muscles are very well healed and surgeon approval has been obtained. For a patient who develops a hernia, ideally we will manage them conservatively. If it's reducible, We're going to teach them how to reduce the hernia and how to apply their support garment with the hernia reduced. We're going to tell them to omit irrigations or do irrigations when the hernia is reduced. If the hernia is not reducible, we're going to use a support garment just to reduce discomfort. And we're going to tell the patient, "Call immediately if you develop worsening pain. If anything changes with your output, if there's anything that concerns you because you're at risk, that your bowel could become starved for blood and surgery could become an emergency situation." At this time, because recurrence is so common, surgery is recommended only for people who are symptomatic and for people with evidence of acute strangulation. And that's it for this class.
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