Permanent stoma rates after anterior resection for rectal cancer: risk prediction scoring using preoperative variables.

BACKGROUND: A permanent stoma after anterior resection for rectal cancer is common. Preoperative counselling could be improved by providing individualized accurate prediction modelling. METHODS: Patients who underwent anterior resection between 2007 and 2015 were identified from the Swedish Colorectal Cancer Registry. National Patient Registry data were added to determine presence of a stoma 2 years after surgery. A training set based on the years 2007-2013 was employed in an ensemble of prediction models. Judged by the area under the receiving operating characteristic curve (AUROC), data from the years 2014-2015 were used to evaluate the predictive ability of all models. The best performing model was subsequently implemented in typical clinical scenarios and in an online calculator to predict the permanent stoma risk. RESULTS: Patients in the training set (n = 3512) and the test set (n = 1136) had similar permanent stoma rates (13.6 and 15.2 per cent). The logistic regression model with a forward/backward procedure was the most parsimonious among several similarly performing models (AUROC 0.67, 95 per cent c.i. 0.63 to 0.72). Key predictors included co-morbidity, local tumour category, presence of metastasis, neoadjuvant therapy, defunctioning stoma use, tumour height, and hospital volume; the interaction between age and metastasis was also predictive. CONCLUSION: Using routinely available preoperative data, the stoma outcome at 2 years after anterior resection for rectal cancer can be predicted fairly accurately.

Usually, the goal of rectal cancer surgery is to remove the tumour and construct a bowel join. Sometimes, it is necessary to construct a stoma, which may become permanent. Swedish registry data were used to develop and test a statistical model to forecast the risk of a stoma 2 years after surgery. In addition, an online calculator was developed. The model performed reasonably well, and can be used to inform the patient and surgeon before surgery of the risk of a permanent stoma.

The Quality of Life of Patients with Colorectal Cancer and a Stoma in China: A Quantitative Cross-sectional Study.

OBJECTIVE: To explore quality of life (QOL) in patients with colorectal cancer and a stoma and factors associated with their QOL. METHODS: A quantitative cross-sectional study was carried out in the stoma and wound care clinic of a cancer hospital in China. Participants were recruited from clinic patients. Investigators collected demographic data and clinical information; QOL was measured using a Chinese version of the stoma-QOL scale. RESULTS: In total, 359 participants took part; 161 (44.8%) had an ileostomy, whereas the others had a colostomy, and about half of the participants (46.5%) had a permanent stoma. The mean age was 57.86 ± 11.92 years. The QOL scores of most participants were poor, with a median value of 49.44. Participants whose stoma was cared for by others had a significantly lower QOL score than those who cared for their own stomas (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.05-2.38; P = .029). Participants with a temporary stoma had a lower QOL score than those with a permanent stoma (OR, 2.08; 95% CI, 1.275-3.40; P = .004). Further, participants with a complication had a lower QOL score than those without (OR, 1.62; 95% CI, 1.07-2.43; P = .022). CONCLUSIONS: These findings suggest a need for well-developed interventions to improve the QOL of these patients. This study provides valuable insights to inform the development of future clinical practice and research in this area in China and beyond.

Family Functioning, Perceived Social Support, and Adaptation to a Stoma: A Descriptive, Cross-sectional Survey.

The creation of a stoma is a life-saving surgical procedure that requires major adjustments. PURPOSE: The aim of this study was to examine the relationships among family functioning, perceived social support, and adaptation to living with a stoma. METHOD: A descriptive, cross-sectional survey was conducted between October 2013 and June 2015 among consecutive patients who visited the stomatherapy unit of a university hospital in Ankara, Turkey, for regular follow-up visits. Eligibility criteria stipulated participants must be at least 18 years of age, literate, live with family, have their stoma for at least 2 months, and be willing to participate. Instruments included a demographic and stoma-related information form, the Multidimensional Scale of Perceived Social Support (MSPSS; subscale range 4-28, total score range 12-84; higher scores indicate better perceived support), the McMaster Family Assessment Scale (FAS; range 1.32-3.15; higher scores indicate deteriorating family function), and the Ostomy Adjustment Inventory Scale-23 (OAI-23; range 19-85; higher scores indicate increasing adaptation). Data were entered into statistical software for analysis that included descriptive statistics and Mann-Whitney U and Spearman correlation tests. RESULTS: Among the 75 participants (mean age 55.4 ± 12.96 years; average stoma duration 3.77 ± 4.97 years), 41 (54.7%) were male, 59 (78.7%) were married, and mean duration of living with a stoma was 3.77 ± 4.97 years. The average MSPSS score was 61.0 5 ± 15.00, the average FAS score was 1.98 ± 0.38, and the average OAI-23 score was 49.39 ± 14.62, all within the "moderate" range for their measures. Stoma complications, time since surgery, stoma self-care, marital status, whether the surgery was planned or an emergency, and employment status significantly affected MSPSS, FAS, and OAI-23 scores. As the FAS scores increased, the MSPSS (r = -.399; P = .001), and OAI-23 (r = -.300; P = .009) scores decreased. CONCLUSION: The results suggest wound, ostomy, continence nurses should assess and encourage familial and social support. Prospective studies examining the effect of familial and social support on stoma adjustment are warranted.

The Effect of Postoperative Telephone Counseling on the Sexual Life of Patients With a Bowel Stoma: A Randomized Controlled Trial.

Sexual problems following ileostomy or colostomy surgery are common. PURPOSE: The purpose of this study was to determine the effect of telephone counseling on the sexual lives of individuals with a bowel stoma. METHOD: Using a randomized, controlled, quasi-experimental study design, patients who were between 18 and 70 years old, had a sexual partner, and had undergone ileostomy or colostomy surgery were eligible to participate. Patients were randomized to telephone counseling as needed (intervention) or regular outpatient follow-up care only (control) for 12 weeks following surgery. Sociodemographic data were collected, and the Golombok-Rust Inventory of Sexual Satisfaction (GRISS) was completed on admission for surgery and 6 and 12 weeks postoperatively. Data were analyzed using descriptive statistics and the Mann-Whitney U, Kruskal-Wallis, Friedman, Wilcoxon signed ranks, and chi-squared tests and Yates's correction for continuity. RESULTS: Of the 70 participants (35 in each group), the average age of intervention group participants was 53.00 ± 11.18 years, and the average age of the control group was 50.74 ± 13.72 years; 19 (54.3%) in the intervention group and 18 (51.4%) in the control group were male. Neither the demographic data nor the GRISS scale scores were significantly different between groups at baseline. After discharge, patients in the intervention group called to receive counseling for their concerns regarding sexual life and challenges they experienced with their stoma an average of 3.57 ± 0.86 (range 2-5) times during the first 6 weeks and 6.52 ±.77 (range 5-8) times between weeks 6 and 12. Mean total and subscale GRISS scores improved significantly from 5.89 ± 1.33 to 7.33 ± 1.24 (P <.01). CONCLUSION: In this study, telephone counseling was effective in improving the sexual lives of patients with a colon- or ileostoma 12 weeks after surgery.

Relationships Among Spiritual Well-being, Adjustment, and Quality of Life in Patients With a Stoma: A Cross-sectional, Descriptive Study.

Individual spiritual preferences and adjustment to a stoma may affect quality of life. PURPOSE: This study aimed to investigate the relationship among and the factors that influence spiritual well-being, adjustment to a stoma, and quality of life in patients with a stoma. METHODS: A cross-sectional, descriptive study was conducted over 6 months among outpatients with a stoma recruited from general surgery and enterostomal therapy clinics of a university hospital in Turkey. Turkish-speaking patients who were at least 18 years of age and had a colostomy or ileostomy for at least 2 months were eligible to participate. Participants independently (or with researcher help if necessary) completed the Sociodemographic Characteristics Form; the 12-item Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp) that utilized 5-point, Likert-style responses to items regarding meaning, peace, and faith (score range 0-48; higher scores indicate more spiritual well-being); the 23-item Ostomy Adjustment Scale that utilized 5-point, Likert-style responses to items regarding acceptance worry, social adjustment, and anger (score range 0-92; higher scores indicate better adjustment); and the 21-item Stoma Quality of Life Scale that used a combination of scoring methods (score range 0-100; higher scores imply better quality of life) and Likert-style questions. Data were transferred without patient names from the questionnaires directly into a software program for analysis. Descriptive statistics, correlation, and hierarchical regression analyses were applied. RESULTS: Of the 95 participants (52 [54.7%] men; mean participant age 56.54 ± 13.74 years), mean scores were 31.66 ± 7.39 for spiritual well-being, 51.73 ± 12.28 for adjustment to a stoma, and 55.27 ± 16.45 for quality of life. A statistically significant difference was found between the mean spiritual well-being and quality-of-life (r = 0.525, P <.001) and adjustment to a stoma (r = .549, P <.001) scores, and a significant relationship was noted between the mean quality-of-life and adjustment scores (r = 0.698, P <.001). Stoma adjustment and quality of life significantly correlated with the meaning and peace subscales of FACIT-Sp (P <.001). No correlation was found between faith or stoma adjustment and quality of life. Hierarchical regression analysis showed the most significant factors affecting quality of life were adjustment to a stoma (ß = .541) and spiritual well-being (ß = .190). CONCLUSION: Adjustment and spirituality are important quality-of-life factors in patients with a stoma. Clinical assessments and practices should include the meaning and peace aspects of spiritual well-being and how well the patient is adjusting to the stoma. Well-designed randomized controlled studies that evaluate the impact of the spiritual dimension of nursing care on patient outcomes as well as the effect of spiritual well-being on adjustment to stoma are suggested.

Development of a New Incontinence Containment Product and an Investigation of Its Effect on Perineal Dermatitis in Patients With Fecal Incontinence: A Pilot Study in Women.

Research related to the design and development of new incontinence containment products for women is scarce. PURPOSE: The purpose of this 2-part study was to 1) develop a new incontinence containment product for fecal incontinence and 2) examine the effect of this new product on the occurrence of incontinence-associated dermatitis (IAD). METHODS: In part 1, a new incontinence containment product was designed, developed, and trialed among 10 healthy female volunteers. The product was comprised of a double layer of polypropylene nonwoven fabric and 100% cotton interlock fabric with a 3-ply 100% cotton interlock fabric added into the perianal section. Participants wore the product for 8 hours and were asked to defecate into the product and evaluate its comfort, ability to contain liquids and protect privacy, any personal allergic reaction, and air permeability. In part 2, after any product modifications, 12 bedridden women treated in the neurology unit of a hospital in western Turkey who had an indwelling urinary catheter and fecal incontinence and who did not have diabetes mellitus, a darkly pigmented area in the perianal area, pressure injury, or erythema were randomized to 2 groups (study product and control, a premium adult diaper) and monitored for 8 days for the development and severity of perineal dermatitis (scored from 0 [no erythema] to 4 [broken, abraded skin]) using a skin assessment tool. Any type of erythema was considered IAD. Skin care (cleansing with a washcloth and water) was provided daily and after each defecation to all study participants. Data were collected via paper-and-pencil completion of the perineal skin integrity assessment and patient observation forms and entered into and analyzed by a computerized statistical program. Fisher's exact test and the chi-squared test were used to analyze the difference in IAD incidence and severity between the 2 groups, and the Mann Whitney U test was used to detect differences in the number and consistency of defecations. RESULTS: No statistically significant differences were noted among the characteristics of the 12 participants (6 in each group) except for age; patients in the study product group were significantly older (70.66 ± 10.36 vs 52.20 ± 16.78 years; P <.05. Four (4) patients in the study group exhibited 13 areas of perineal dermatitis (degree 1 = 6 areas; degree 2 = 6 areas; degree 3 = 1 area; and degree 4 = 0); 1 patient in the control group had 4 areas with degree 1. CONCLUSION: This prototype product is not sufficient to be used in clinical practice in patients with fecal incontinence, but further study in a larger population is warranted..

Obesity is a significant risk factor for ileostomy site incisional hernia following reversal.

BACKGROUND: Incisional hernia following ileostomy reversal can cause significant morbidity, impaired quality of life, and burden on the healthcare system. This study aimed to determine the prevalence of ileostomy site incisional hernia following reversal and to identify possible risk factors for its development. METHODS: This was a retrospective cohort study involving consecutive patients who underwent ileostomy reversal between November 1999 to February 2015 by a single surgeon. Primary outcome analysed was incisional hernia occurrence at the previous stoma site. RESULTS: Two hundred and twenty-four ileostomy reversals were identified. The most common indication for ileostomy construction was colorectal cancer, followed by inflammatory bowel disease and diverticulosis. The stomas were either a loop (75%), end-loop (24%) or end ileostomy (1%). The mean time interval from the stoma creation to reversal was 6.1 months (range 2-69, SD 7.1). After a mean follow-up of 30.7 months (range 10-89, SD 15.1), 12 patients (5%) developed a hernia at the previous stoma. The mean time for hernia occurrence was 25.2 months (range 3-126, SD 32). Patients who developed ileostomy site incisional hernia were more likely to have a higher body mass index (28.1 versus 26.3, P = 0.007). CONCLUSION: Although we found a lower rate of incisional hernias after reversal of ileostomies than reported elsewhere in the literature, it remains a significant clinical problem. Obesity is a significant risk factor for ileostomy-site incisional hernia.

Islam and the Urinary Stoma: A Contemporary Theological and Urological Dilemma.

BACKGROUND: The prayer ritual is an essential component of Islam that requires entry into a state of physical purity (wudhu) through ablution, which is invalidated by voiding. An important dilemma for patients and surgeons may arise when a Muslim patient is counselled on cystectomy because of the belief by some that an incontinent urinary diversion will automatically invalidate their wudhu. OBJECTIVE: To determine if there are any religious barriers and implications for Muslim patients undergoing an incontinent urinary diversion. DESIGN, SETTING, AND PARTICIPANTS: A questionnaire was distributed to all UK mosques, addressed to the imam (n=804). RESULTS AND LIMITATIONS: A total of 134 imams (response rate 16.7%) responded. There was general agreement among imams, with >90% answering that it is possible for a Muslim to perform ablution, pray, and enter a mosque with a urinary stoma. The majority of imams (86.6%) also stated that refusal of a urinary stoma was not justified by religious teachings. When asked if patients should choose the option of a neobladder despite this surgery having greater risk, 57.5% of respondents stated that they were either unsure or agreed with this alternative. CONCLUSIONS: The majority of imams agreed that Muslims with a urinary stoma are able to maintain their ablution, allowing them to conduct their daily prayers, and that this form of surgery should not be refused on religious grounds. Our study suggests that the consensus view is that a urinary stoma is not contraindicated with regard to the practice of Islamic prayer rituals. PATIENT SUMMARY: In this study we investigated if having a urinary stoma would be a religious barrier for Muslim patients in performing their obligatory prayer rituals. The overwhelming majority of imams stated that having a urinary stoma should not stop Muslim patients practising important aspects of their faith.

A Descriptive, Qualitative Study to Assess Patient Experiences Following Stoma Reversal After Rectal Cancer Surgery.

Standard surgical treatment for patients operated for rectal cancer is abdominoperineal excision of the tumor result- ing in a permanent colostomy or an anterior resection, often with construction of a temporary loop ileostomy. Both options impact bowel function. Living with a permanent colostomy has been studied in depth, but knowledge is limited about patients' experiences living with a resected rectum after stoma reversal and how it affects daily life. A qualitative study was conducted to describe the rst 4 to 6 weeks after reversal of a temporary loop ileostomy due to rectal cancer. Patients from 1 university hospital and 1 county hospital in Sweden were recruited by telephone and were eligible to participate in the study if they: 1) had been operated for rectal cancer with an anterior resection and a temporary loop ileostomy that had been reversed; 2) were >18 years of age, fully oriented, and understood the Swedish language; and 3) had a postoperative course without complications. Interviews were conducted be- tween December 2013 and June 2015 either at the hospital or at the participants' homes. Participants were asked to narrate their experiences since stoma reversal. Probing open-ended questions were used to stimulate narration and clarify and enhance understanding. The interviews were recorded, transcribed verbatim, and analyzed us- ing thematic content analysis. The 16 participants included 9 women and 7 men (median age 67 years). Three (3) main themes emerged: Life being controlled by the altered bowel function, with the subthemes loss of control over bowel function, uncertainty regarding bowel function, and being limited in social life; Striving to regain control over the bowel, with the subthemes using ability and knowledge, social support, and being grateful and hopeful; and A desire to be normal, with subthemes getting rid of the stoma and restoration of body image. Patients experienced severe bowel function problems, including increased bowel movement frequency and inability to anticipate or trust bowel function after stoma reversal. Outwardly, patients experienced a signi cant improvement in body image but continued to struggle with suboptimal bowel function. Patients needed reassurance that their bowel symptoms were normal. Participants strove to regain control over bowel function using various strategies, including what they had learned about diet and medication before stoma reversal and by trying to defy the restrictions of their new normal. They felt they were ghting to regain bowel control without help from health care professionals. In order to cope with altered bowel function, they needed the support of family and friends. The results suggest that, following stoma reversal, patients need information about available treatments to address their symptoms and require regular follow- up visits to evaluate and address functional results.

Using a Bedside Video-assisted Test Tube Test to Assess Stoma Viability: A Report of 4 Cases.

Mucosal discoloration of an intestinal stoma may indicate self-limited venous congestion or necrosis necessitating operative revision. A common bedside technique to assess stoma viability is the "test tube test". A clear tube is inserted into the stoma and a hand-held light is used to assess the color of the stoma. A technique (video-assisted test tube test [VATTT]) developed by the authors utilizes a standard video bronchoscope inserted into a clear plastic blood collection tube to visually inspect and assess the mucosa. This technique was evaluated in 4 patients (age range 49-72 years, all critically ill) with a discolored stoma after emergency surgery. In each case, physical exam revealed ischemic mucosa at the surface either immediately after surgery or after worsening hypotension weeks later. Serial test tube test assessments were ambiguous when trying to assess deeper mucosa. The VATTT assessment showed viable pink mucosa beneath the surface and until the fascia was revealed in 3 patients. One (1) patient had mucosal ischemia down to the fascia, which prompted operative revision of the stoma. The new stoma was assessed with a VATTT and was viable for the entire length of the stoma. VATTT provided an enhanced, magnified, and clearer way to visually assess stoma viability in the postoperative period that can be performed at the bedside with no adverse events. It may prevent unnecessary relaparotomy or enable earlier diagnosis of deep ostomy necrosis. Validity and reliability studies are warranted.

A Descriptive Study Assessing Quality of Life for Adults With a Permanent Ostomy and the Influence of Preoperative Stoma Site Marking.

Diseases or anomalies of the genitourinary or gastrointestinal tract often require removal of organs and creation of an artificial opening (stoma) to allow for elimination of urine or stool. Preoperative stoma site marking can affect quality of life (QoL). A descriptive study was conducted to assess the relationship between QoL and preoperative stoma site marking in adults with a permanent ostomy. Using convenience sampling methods, 230 eligible participants attending a United Ostomy Association of America conference were invited to complete a survey of demographics regarding age, gender, time since surgeries, and ostomy type and the City of Hope National Medical Center Quality of Life Ostomy Questionnaire. The latter contains 2 sections of 30 and 43 items each that address life impact and quality of life, respectively. The researcher explained the study and provided a study packet to volunteers who were interested in participating. Volunteers were to complete the surveys over a 4-day period while at the conference; the investigator collected all study materials. Inclusion criteria stipulated study participants must be English writing/reading persons at least 18 years of age with a colostomy, ileostomy, or urostomy. All descriptive statistics (means, standard deviation, frequency, and percents) used to describe demographic and surgical history and quantitative data (logistic regression, cross-tabulation, Pearson product moment correlations, and analysis of covariance) used to determine relationships among factors were entered and analyzed using a computer software program. Of the 140 participants who met inclusion criteria and provided data, the majority (85, 60.7%) had their stoma site marked by a wound, ostomy, continence (WOC) nurse. WOC nurse marking was more likely in recent years, and WOC nurse marking was 1.03 times more likely for each year since stoma surgery (M = 13.44, SD = 13.48). Mean QoL was 7.56 (SD = 1.59, range 3.84-10.00) and was positively correlated with age (r [137] = 0.27, P = 0.001), years since first surgery (r (138) = 0.25, P = 0.003), and years since most recent surgery (r [137] =0.28, P = 0.001). The total number of surgeries was unrelated to QoL. More than 75% of the participants received preoperative marking, with a significant difference in QoL for persons marked by a surgeon (M = 7.71, SE = 0.16) or a WOC nurse (M = 8.82, SE = 0.37) versus another professional (M = 4.83, SE = 1.05) (F [3.118] = 3.44, P = 0.19). The increasing prevalence of preoperative stoma site marking by a WOC nurse over time serves as a benchmark for this centerpiece of WOC nursing practice. The findings confirm the need for stoma site marking and validate the impact of stoma site marking by the WOC nurse.

The Effect of Colostomy and Ileostomy on Acts of Worship in the Islamic Faith.

PURPOSE: The aim of this study was to determine the impact of colostomy and ileostomy on Muslim patients' acts of worship. DESIGN: This was a cross-sectional, descriptive study. SUBJECTS AND SETTING: The research setting was a stoma therapy unit of a 500-bed capacity training and research hospital in Ankara, Turkey. The study sample comprised 150 patients with colostomies (40.7%) or ileostomies (59.3%); their mean age was 51.6 ± 12.9 (mean ± standard deviation), more than half (60.7%) were men, and 84.7% were married. METHODS: Participants were queried about specific religious practices following ostomy surgery including those related to salat, fasting, and pilgrimage. Data were collected using forms specifically designed for this study; respondents were interviewed either face-to-face or via telephone. Descriptive statistics were used to characterize the influence of a fecal ostomy on specific religious activities. RESULTS: Participants reported decreasing the frequency of daily and Friday prayers (25.2% and 22.7%, respectively) or stopped practicing these activities all together (12.0% and 14.0%, respectively). Respondents tended to increase the frequency of acts of absolution while reducing acts of fasting. Perceptions of cleanliness, central to performance of salat within the Islamic faith, emerged as a central concern. CONCLUSIONS: Ostomy surgery influences multiple religious acts practiced by Muslims. Awareness of the potential impact of a fecal ostomy on religious acts within the Islamic faith, combined with specialized education about spiritual practices delivered by the WOC nurse or a knowledgeable resource person, is strongly recommended for all persons following ostomy surgery.

Exploring the Relationship Between Resilience and Ostomy Adjustment in Adults With a Permanent Ostomy.

PURPOSE: The aims of this study were to describe the relationship between resilience and ostomy adjustment in adults with permanent stomas and to determine if participants who report higher levels of resilience also report higher levels of adjustment to a permanent ostomy. DESIGN: Descriptive, correlational research design utilizing the Roy Adaptation Model as the theoretical framework was used. SUBJECTS AND SETTING: Persons with permanent stomas were recruited from ostomy support groups on the East Coast of the United States. The study sample included 48 respondents. Their mean age was 66 ± 12.7 years (mean ± SD); the majority (60.4%) were women, had an ileostomy (62.5%), and had a history of inflammatory bowel disease (62.5%). METHODS: Respondents completed a questionnaire that queried demographic and pertinent clinical data, along with 2 previously validated instruments, the Resilience Scale and Ostomy Adjustment Inventory-23. The relationships between levels of resilience, levels of adjustment to an ostomy, and demographic characteristics were examined. RESULTS: Participants with higher levels of ostomy adjustment had higher levels of resilience than respondents who reported lower levels of ostomy adjustment (r = 0.65, P ≤ .01). CONCLUSIONS: Findings from this study suggest that higher levels of resilience facilitate adjustment to a permanent ostomy.

To explore preferences and willingness to pay for attributes regarding stoma appliances amongst patients in the UK, France and Germany.

OBJECTIVES: To explore patient preferences regarding stoma appliances in the UK, France and Germany and to estimate willingness to pay (WTP) for attributes of stoma appliances. RESEARCH DESIGN AND METHODS: A discrete choice (DCE) survey was developed based on published literature, attributes of current available appliances and qualitative interviews with patients from the UK (N = 3), France (N = 2) and Germany (N = 2). Members from a patient panel in the UK, France and Germany were asked to participate in the DCE survey and to fill out two quality of life (QoL) questionnaires. Data were analyzed using the conditional logit model whereby the coefficients obtained from the model provided an estimate of the (log) odds ratios (ORs) of preference for attributes. WTP was estimated for each level of a given identified attribute. RESULTS: Seven key attributes were identified for the DCE survey: comfort and elastic flexibility, skin problems, early detection of leakage, leakage, filter performance, service/help after hospital discharge and out-of-pocket cost. A total of 415 participants (166 patients in UK, 99 in France, and 150 in Germany) completed the questionnaires. All attributes were significant predictors of choice. The two most important drivers of preference were the attributes comfort and elastic flexibility and skin problems which resulted in high WTP values. Appliances which were able to detect episodes of leakage were also of high importance to participants' appliances. CONCLUSIONS: The results show the importance of different attributes of stoma appliances for patients. Improving comfort and elastic flexibility, and risk of skin problems were the most important aspects of appliances. The WTP values indicate the value people place on improvement in each attribute of appliances.

Methods for siting emergency stomas in the absence of a stoma therapist.

INTRODUCTION: Stomas often have to be sited in emergencies by trainees who may have had little training in this. Emergency stomas and stomas where the site has not been marked preoperatively by a stoma therapist are more prone to complications. These complications may severely affect a patient's quality of life. Advice in the literature on how to best site stomas is conflicting. We compared two easy anatomical methods of siting stomas to sites chosen by a stoma therapist and looked at how this site was affected by the patients' body mass index (BMI). METHODS: Patients undergoing elective colorectal surgery were seen either pre or postoperatively. Each patient's BMI was recorded and the positions of three different potential stoma positions (site G: the gold standard, marked by a stoma therapist; site S: marked using a pair of scissors against the umbilicus; site H: halfway between the umbilicus and anterior superior iliac spine) were compared. RESULTS: The two fixed anatomical methods described (method S and method H) both gave poor results. The most common reason for poor siting was the proximity of a skin crease. There was a statistically significant correlation between the patient's BMI and the laterality of the gold standard site. CONCLUSIONS: The two simple anatomical methods described here do not provide a shortcut to effective siting. A more effective method may be calculating the laterality of the site using the patient's BMI, and then moving up/down to avoid a skin crease and improve the patient's view for changing the bag. This deserves further study.

Ostomy options for clients with ileostomies.

Quality of life with an external appliance has a significant impact on decision making when considering an incontinent or continent ostomy. A majority of clients with external pouches are content with their pouches and enjoy a good quality of life. For others, not having to deal with an external appliance is reason enough to consider surgery. Major physical and psychological lifestyle changes occur with the ileostomy, particularly with body image and self-concept (Reynaud & Meeker, 2002). Having an external appliance can lead to depression for the client because of skin irritation, leakage of stool, and difficulty securing the appliance. Other issues include moving wrong while sleeping, which can create an uncomfortable feeling of warmth across the abdomen, and putting on a seatbelt can be a challenge.