It Has Become a Part of Me: Living With Low Anterior Resection Syndrome After Ostomy Reversal: A Phenomenological Study.

PURPOSE: The purpose of this study was to explore challenges of individuals living with low anterior resection syndrome (LARS) 1 year or more after ostomy reversal and formulate a greater understanding of their needs. DESIGN: Qualitative study with a phenomenological approach. SUBJECTS AND SETTING: The sample comprised 2 women and 5 men. All participants had undergone low anterior resection in the Comprehensive Cancer Center of a Swiss university hospital. The mean age of participants was 66 years (range, 61-71 years). METHODS: Interviews were conducted 12 to 42 months after ostomy reversal. Data were collected from one-on-one in-depth interviews using a standardized interview guide with open-ended questions. An interpretative phenomenological analysis was used to interpret data. RESULTS: Analysis revealed 3 central categories addressing the burden of living with LARS: "Internalizing new living conditions"; "Actively planning a new everyday life"; and "Knowing the body and controlling symptoms." "Unpredictability" emerged as the key challenge. Being informed in advance about the problems expected to arise, having the possibility to talk about problems, as well as receiving peer support and structured aftercare were identified as means to ease patients' challenges when living with LARS. CONCLUSIONS: Twelve to 42 months after stoma reversal, participants had internalized their new living conditions. Their level of acceptance of their situation was substantial. There are indications that a culture of open information before ostomy reversal contributed to being mentally prepared for the situation after surgery. Talking openly about their problems helped participants organize their everyday life.

Treatment of Peristomal granulomatosis with a Neem and Red Hypericum Oil application: Case studies.

BACKGROUND: Peristomal granulomatosis is a chronic inflammatory disease of uncertain aetiology, and a high recurrence rate. It frequently occurs in patients with enterostomy and urostomy. The most frequent type affects the mucocutaneous junction, causing bleeding and painful nodular lesions, which complicate management of the ostomy pouching system. Currently, only invasive treatments are available, consisting in cauterisation or surgical removal of the granuloma. Our objective was to evaluate efficacy of a topic mixture oil, composed by a 1:1 of extracts of Neem and Red Hypericum; amongst its many therapeutical properties, it is proven to inhibit the over-granulation process. METHOD: Two clinical cases presenting typical peristomal granulomatosis were selected. On first access after recruitment, the patients underwent an accurate nursing anamnesis, a global assessment was carried out according to the Toven Method and an assessment of peristomal sore skin according to SACS 2.0. Granulomatosis wounds were treated with the oil mixture, applied on a hydrofiber pad, secured over the wound site by means of a transparent film. This allowed the release of active ingredients while ensuring the pouching system secure adhesion. The chosen protocol consisted in 2 dressing changes per week, while monitoring the granulomatosis wound evolution by means of a TOR Form validated data form and documenting progress by taking photographs. RESULTS: Initially a regression of the inflammatory process was observed, with significant decrease of bleeding and pain. Gradually, the proliferating lesions reduced in size (both width and extent), and eventually healed completely. The product was very well tolerated, even when in contact with the stoma mucous membrane. No recurrence signs were observed either at the follow up visit 15 days from end of treatment, and in clinical case N.2 equally none were present two months after treatment. CONCLUSIONS: Compared to conventional methods which are invasive, not resolving, and not tolerated by patients, the product was demonstrated to be an innovative therapeutical solution, easy to apply, with no side effects and well-liked by patients. The excellent results obtained require further confirmation and validation through new studies on a statistically significant number of cases.

Factors Associated with 60-Day Readmission Following Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy.

INTRODUCTION: Readmission rates following surgery are subject to scrutiny in efforts to control health care costs. This study was designed to define the 60-day readmission rate following cytoreduction and HIPEC at a high-volume center and to identify factors associated with readmission. METHODS: Patients who underwent complete cytoreduction and HIPEC at a single institution from August 2007 through June 2014 were identified from a prospectively maintained database. Multiple preoperative and operative factors were analyzed for their ability to predict 60-day readmission following surgery. RESULTS: A total of 250 patients were identified. Forty patients (17%) experienced readmission within 60 days of surgery. The most common reasons for readmission were ileus/dehydration (12, 31%), deep space infection (8, 21%), and DVT/PE (6, 15%). Initial postoperative length of stay was longer for patients readmitted within 60 days (median 12 vs. 9 days, p = 0.013). Of categorical variables analyzed, including gender, histology, HIPEC agent, intraoperative transfusion, and individual procedures performed during cytoreduction, adjuvant systemic therapy, and postoperative morbidity, only Charlson comorbidity index CCI (odds ratio (OR) = 3.80 [1.68-8.60]) and stoma creation (OR = 6.04 [1.56-12.14]) were associated with 60-day readmission. CONCLUSIONS: Few measurable variables are associated with readmission following cytoreduction and HIPEC. Patients with high CCI and those with stomas created at the time of CRS/HIPEC may be at increased risk of readmission within 60 days. Earlier or more frequent follow-up for high-risk patients should be considered as a strategy to reduce readmissions.

Laparoscopic Appendicostomy Low-Profile Balloon Button for Antegrade Enemas in Children.

INTRODUCTION: The Malone appendicostomy is a continent channel used for antegrade enemas. It requires daily cannulation and is susceptible to stenosis. We use an indwelling low-profile balloon button tube inserted through the appendix into the cecum for antegrade enemas. We hypothesized that this method is effective at managing constipation or fecal incontinence and is associated with a low rate of stenosis. METHODS: Children who underwent laparoscopic appendicostomy balloon button placement at our institution from January 2011 to April 2017 were identified. The primary outcome was success in managing constipation or fecal continence as measured by the Malone continence scale. Postoperative complications were analyzed. RESULTS: Thirty-six children underwent the procedure, 35 of which met the inclusion criteria. Thirty-one patients (88.5%) underwent the operation for idiopathic constipation, 3 patients (8.6%) for anorectal malformation, and 1 patient (2.9%) for hypermobility. Rate of open conversion was 3%. A full response was obtained in 24 patients (68.6%), partial response in 9 patients (25.7%), and 2 patients failed (5.7%). One patient developed an internal hernia requiring laparotomy and later developed mucosal prolapse. One patient developed a stricture noted at button change. Seven patients (20%) underwent reversal of their appendicostomy tube: 5 due to return of normal bowel function and 2 due to discomfort with flushes. CONCLUSION: A laparoscopic appendicostomy with a balloon button tube is an effective means of addressing chronic constipation or fecal incontinence. The stenosis rate associated with tube appendicostomy may be lower than those reported for Malone antegrade continence enema procedures.

An Evaluation of Parastomal Hernia Repair Using the Americas Hernia Society Quality Collaborative.

The purpose of this review was to evaluate outcomes relating to parastomal hernia repair. Data from the Americas Hernia Society Quality Collaborative were used to identify patients undergoing parastomal hernia repair from 2013 to 2016. Parastomal hernia repairs were compared with other repairs using Pearson's test and Wilcoxon test with a P value <0.05 considered significant. Parastomal hernia repairs were performed in 311 patients. Techniques of repair include open in 85 per cent and laparoscopic in 15 per cent. Mesh was used in 92 per cent with keyhole in 34 per cent, flat mesh in 33 per cent, and Sugarbaker in 25 per cent. Mesh types were permanent synthetic in 79 per cent, biologic in 13 per cent, absorbable synthetic in 6 per cent, and hybrid synthetic/biologic in 2 per cent. Most common location for mesh was sublay in 84 per cent followed by onlay in 14 per cent and inlay in 2 per cent with 59 per cent of patients undergoing a myofascial release. Ostomy disposition included ostomy left in situ (47%), moved to a new site (18%), taken down (22%), and rematured in same location in (13%). Outcomes related to parastomal hernia repair included 10 per cent surgical site infection, 24 per cent surgical site occurrence, and 12 per cent surgical site occurrences requiring procedural interventions with a 13 per cent readmission rate and 6 per cent reoperation rate. When comparing parastomal hernias with other ventral hernia repairs, parastomal hernias had a significantly higher surgical site infection, surgical site occurrence, surgical site occurrences requiring procedural intervention, readmission, reoperation rate, and length of stay, and were less commonly performed laparoscopically (P < 0.05). Most parastomal hernias are being repaired open with synthetic mesh in the sublay position. Less favorable outcomes of parastomal hernia repair when compared with other ventral hernia repairs are likely related to the complexity of parastomal hernia repair.

Clinical and Economic Burden of Peristomal Skin Complications in Patients With Recent Ostomies.

PURPOSE: The purpose of this study was to estimate the risk and economic burden of peristomal skin complications (PSCs) in a large integrated healthcare system in the Midwestern United States. DESIGN: Retrospective cohort study. SUBJECTS AND SETTING: The sample comprised 128 patients; 40% (n = 51) underwent colostomy, 50% (n = 64) underwent ileostomy, and 10% (n = 13) underwent urostomy. Their average age was 60.6 ± 15.6 years at the time of ostomy surgery. METHODS: Using administrative data, we retrospectively identified all patients who underwent colostomy, ileostomy, or urostomy between January 1, 2008, and November 30, 2012. Trained medical abstractors then reviewed the clinical records of these persons to identify those with evidence of PSC within 90 days of ostomy surgery. We then examined levels of healthcare utilization and costs over a 120-day period, beginning with date of surgery, for patients with and without PSC, respectively. Our analyses were principally descriptive in nature. RESULTS: The study cohort comprised 128 patients who underwent ostomy surgery (colostomy, n = 51 [40%]; ileostomy, n = 64 [50%]; urostomy, n = 13 [10%]). Approximately one-third (36.7%) had evidence of a PSC in the 90-day period following surgery (urinary diversion, 7.7%; colostomy, 35.3%; ileostomy, 43.8%). The average time from surgery to PSC was 23.7 ± 20.5 days (mean ± SD). Patients with PSC had index admissions that averaged 21.5 days versus 13.9 days for those without these complications. Corresponding rates of hospital readmission within the 120-day period following surgery were 47% versus 33%, respectively. Total healthcare costs over 120 days were almost $80,000 higher for patients with PSCs. CONCLUSIONS: Approximately one-third of ostomy patients over a 5-year study period had evidence of PSCs within 90 days of surgery. Costs of care were substantially higher for patients with these complications.

An electronic approach to minimising moisture-associated skin damage in ostomy patients.

Marked developments in the design of ostomy appliances in recent years have revolutionised stoma care and management but the prevalence of peristomal skin complications continues to be problematic with incidence rates ranging from 10% to 70%. Despite requisite pre and post-operative education for new patients, complications continue to arise - even under the close supervision of specialist nurses. Prolonged exposure of the skin to high pH stoma effluent is widely accepted as a key contributor to the onset of moisture-associated skin disease and it is our hypothesis that a "smart wafer", employing electrochemical manipulation of local pH, could mitigate some of the issues currently plaguing ostomy management. Current electrochemical research strategies translatable to stoma care are presented and their possible implementations critically appraised.

Frequency, risk factors, and adverse sequelae of bone loss in patients with ostomy for inflammatory bowel diseases.

BACKGROUND: Bone loss in patients with inflammatory bowel disease (IBD) with ostomy has not been systemically studied. The aims of the study were to evaluate the frequency, risk factors, and sequelae of bone loss in patients with IBD and stomas and to monitor the change in bone mineral density (BMD) over time after ostomy. METHODS: A total of 126 patients met the inclusion criteria (i.e., those with IBD diagnosis and stoma), including ileostomy (N = 120), colostomy (N = 3), and jejunostomy (N = 3). BMD was measured on dual-energy X-ray absorptiometry (DEXA). Patients were classified as having normal or low BMD based on the International Society for Clinical Densitometry criteria. Thirty-two demographic and clinical variables were evaluated with logistic regression models. RESULTS: At a median of 6.6 years (interquartile range, 2-18.7 yr) after stoma, 37 (29.4%) patients had a low BMD. On univariate analysis, there were no significant differences between the normal and low BMD groups in the following variables: gender, race, age at diagnosis of IBD, prevalence of Crohn's disease and ulcerative colitis, age at ostomy, duration from diagnosis to DEXA and from ostomy to DEXA, menopausal age, diabetes, hypothyroidism, renal stones, short bowel syndrome, history of smoking or excessive alcohol use, family history of IBD or osteoporosis, daily calcium and vitamin D supplement, estrogen replacement, and steroid use. Body mass index was significantly lower in the low BMD group than the normal BMD group (23.3 ± 5.5 versus 26.0 ± 5.2, P = 0.013). Fragility fracture occurred in 8 (21.6%) patients in low BMD group and 4 (4.5%) patients in normal BMD group (P = 0.006). In a multivariate analysis, low body mass index was the only covariate-adjusted factor associated with low BMD. In patients with multiple DEXA scans available over time after ostomy, hip BMD was found to improve marginally, and the lumbar and femoral BMD remained stable. CONCLUSIONS: Low BMD was common in patients with IBD after ostomy, largely based on the findings in patients with CD with ileostomy. Fragility fracture was 5 times more frequent in patients with ostomy with low BMD compared with those with normal BMD. The low BMD was associated with a low body mass index. Screening and surveillance of BMD should routinely be performed, particularly in these patients at risk. Bone mass tends to stabilize over time after stoma.

Appendicostomy in preschool children with anorectal malformation: successful early bowel management with a high frequency of minor complications.

AIM: The aim of this study is to evaluate postoperatively bowel symptoms of antegrade colon enema through appendicostomies in preschool children with anorectal malformation (ARM). METHOD: 164 children with ARM operated on with posterior sagittal anorectal plasty were included. The malformations were classified according to Krickenbeck classification. Seventeen children in preschool age had an appendicostomy. The bowel symptoms according to the Krickenbeck follow-up were analysed pre- and postoperatively. All complications were registered. A questionnaire on the use of the appendicostomy was answered. RESULTS: The median age (range) at the time of the appendicostomy was 4 (1-6) years. The observation time was 5 (0.5-14) years. The main indications for appendicostomy were incontinence and noncompliance to rectal enemas. Postoperatively there was a significant decrease in soiling and constipation (P < 0.001). The total complication rate was 43% with infections (29%), stenosis (12%), and retrograde leakage (0). The median time required for giving enema in the appendicostomy was 45 minutes (range: 15-120) once a day varying from 2 times/week to 3 times/day. And: complications are less frequent than in older children. CONCLUSION: Appendicostomy in preschool children with ARM is a way to achieve fecal cleanness before school start. The infection rate was high, but other complications are less frequent than in older children.

Letter: Pseudoverrucous papules and nodules: a case report.

Pseudoverrucous papules and nodules (PPN) is an uncommon complication, mainly reported in the diaper area. It is thought to be a manifestation of chronic irritant contact dermatitis that develops as a result of prolonged exposure to liquid stool and/or urine. We describe a case of a peristomal PPN in a patient who had a urostomy after treatment of bladder carcinoma with radical cystectomy.

Early and late complications among long-term colorectal cancer survivors with ostomy or anastomosis.

PURPOSE: Among long-term (>or=5 y) colorectal cancer survivors with permanent ostomy or anastomosis, we compared the incidence of medical and surgical complications and examined the relationship of complications with health-related quality of life. BACKGROUND: The incidence and effects of complications on long-term health-related quality of life among colorectal cancer survivors are not adequately understood. METHODS: Participants (284 survivors with ostomies and 395 survivors with anastomoses) were long-term colorectal cancer survivors enrolled in an integrated health plan. Health-related quality of life was assessed via mailed survey questionnaires from 2002 to 2005. Information on colorectal cancer, surgery, comorbidities, and complications was obtained from computerized data and analyzed by use of survival analysis and logistic regression. RESULTS: Ostomy and anastomosis survivors were followed up for an average of 12.1 and 11.2 years, respectively. Within 30 days of surgery, 19% of ostomy survivors and 10% of anastomosis survivors experienced complications (P < .01). From 31 days on, the percentages were 69% and 67% (after adjustment, P < .001). Bleeding and postoperative infection were common early complications. Common long-term complications included hernia, urinary retention, hemorrhage, skin conditions, and intestinal obstruction. Ostomy was associated with long-term fistula (odds ratio, 5.4; 95% CI 1.4-21.2), and among ostomy survivors, fistula was associated with reduced health-related quality of life (P < .05). CONCLUSIONS: Complication rates remain high despite recent advances in methods of surgical treatment. Survivors with ostomy have more complications early in their survivorship period, but complications among anastomosis survivors catch up after 20 years, when the 2 groups have convergent complication rates. Among colorectal cancer survivors with ostomy, fistula has especially important implications for health-related quality of life.

Quality of life and coping of persons with temporary and permanent stomas.

PURPOSE: To evaluate and compare the use of coping strategies and quality of life (QoL) among individuals with temporary and permanent stomas. DESIGN: Descriptive, cross-sectional. METHODS: After consideration of ethical issues, 42 subjects with temporary stomas and 72 subjects with permanent stomas were interviewed. The Coping Strategies Inventory of Folkman and Lazarus, and Ferrans and Powers QoL Index, both validated for the Brazilian culture, were administered. RESULTS: Subjects from both groups used all coping strategies queried in the Coping Strategies Index and QoL index, but significant differences (P<0.05) were found in use of confrontive, escape-avoidance, and positive reappraisal factors, which were more frequently employed by patients with temporary stoma. QoL scores did not differ between the groups. Significant correlations (P<.001) among subjects with temporary stomas were observed between the family QoL subscale and (a) distancing, (b) self-control, (c) accepting responsibility, (d) escape-avoidance, and (e) positive reappraisal coping factors. Significant correlations were also found between the psychological/spiritual QoL subscale and positive reappraisal factor; between the health/functioning QoL subscale and planful problem solving and positive reappraisal for patients with temporary stomas. Among subjects with permanent stomas, only significant correlations existed between the psychological/spiritual QoL subscale and self-control and social support coping factors. CONCLUSION: Individuals with stomas tend to show positive QoL scores. However, different coping strategies were used by persons with temporary versus permanent stomas.

Evidence-based nursing care management for the pregnant woman with an ostomy.

Pregnancy presents many problems without working through additional problems in coping with an ostomy. Yet many women with an ostomy do get pregnant and do deliver healthy babies. Evidence-based nursing is of the utmost importance, as there is little published information on this topic. Because of the scarcity of pregnant subjects within the ostomy category, most studies, by necessity, select a purposive subject base. Therefore, other information sources regarding nursing management of the pregnant woman with an ostomy take on considerably more importance. This article explores other forms of evidence that can be used in managing the care of pregnant ostomy patients and specifically how nurses can integrate various sources of information in designing an evidence-based nursing care plan. Nonpharmacologic forms of relaxation therapy, easily used by nurses, such as mindfulness-based stress reduction, guided imagery, and hypnosis, are also identified as some ways nurses can relieve anxiety and experiential stress associated with pregnancy in women who have an ostomy.

Professional holistic care of the person with a stoma: online learning.

Stoma care nurse specialists are valued for their diverse expertise, but it is essential that all practitioners who regularly care for people with stomas have the opportunity to develop professionally and influence this important area of practice. The vision of a clinical and educational team from Suffolk and south Norfolk led to the development of innovative web-based learning material. The aim is to inspire nurses to engage actively with people who have a stoma. 'Professional care of the person with a stoma' is about caring for the whole person, physically and emotionally, from the period before surgery, to their continuing care in the community. An overview of four aspects of stoma care is presented here as a way of sharing with a wider audience the expert practice harnessed during the development of this web-based module.

Collaborative care management for a pregnant woman with an ostomy.

Pregnant women with an ostomy face many challenges during the prenatal period. Although these challenges may be present, pregnancy in the ostomate is presented as a continuum of health and wellness in this article. Collaborative care professionals, especially nurses and midwives, are often the most accessible professional sources for health care information, but current research and information on this topic is sparse. Ostomy-related problems that may occur during pregnancy, include: intestinal obstruction, peristomal hernia, pouching problems, including the effect of nausea and vomiting on pouch hydration, stomal retraction, stenosis, or laceration, and stomal prolapse. Three types of ostomies are discussed: continent ileostomies, urostomies and colostomies. A description of the normal characteristic appearance of each is also included. Collaborative care from pre-conception through the post partum period is described with emphasis on teaching self-help techniques such as: special nutritional considerations, how to recognize potential problems, and how to fit and adapt appliances to the changing body form of the patient as the pregnancy progresses. Phenomenologic information about the pregnant ostomate's perceptions about her pregnancy experience is also presented. Psycho-prophylaxis methods of complementary therapy alternatives alleviating nausea and vomiting within pregnancy, as well as the pain of childbirth are also presented. Although nursing/midwifery management of a pregnant ostomy patient is a challenge, those challenges are surmountable and outcomes resemble those found in the general population.

Neurogenic colorectal dysfunction - use of new antegrade and retrograde colonic wash-out methods.

OBJECTIVES: To evaluate results of the Enema Continence Catheter (ECC) and the Malone Antegrade Continence Enema (MACE) applied in patients with severe neurogenic colorectal dysfunction. METHODS: The ECC was offered to 21 patients (mean age 39.9, range 7 - 72 years). The MACE was used in eight patients (mean age 32.8 years, range 15 - 66 years). All patients still using the ECC or the MACE at follow-up were interviewed. Results from patients not available for follow-up were drawn from hospital records. RESULTS: Overall success with the ECC was found in 12 of 21 patients (57%). In patients with faecal incontinence, the ECC was successful in eight out of eleven patients (73%), while four out of ten patients (40%) with constipation were successfully treated. Overall success with the MACE was found in seven out of eight patients (87%). Successful treatment with the ECC or the MACE was followed by significant improvement in quality of life. CONCLUSION: The ECC is a simple therapeutic method in severe neurogenic colorectal dysfunction. If the ECC fails the MACE, as a minor and reversible operation, is a suitable alternative to more extensive procedures.