RING OF FIRE:
WALKING THE LINE BETWEEN SUCCESS
AND FAILURE IN OSTOMY MATURATION
http://www.youtube.com/watch?v=FhE6Izmkpx4
Joyce Pittman PhD, FNP-BC, ANP-BC, CWOCN
Indiana University Health
Indianapolis, IN
Paul Szotek, MD
Indiana University Health
Indianapolis, IN
• Physiologic vs Psychosocial
• Physiologic involve changes of the stoma and peristoma skin
• Psychosocial involve quality of life or adjustment to
having an ostomy
• Early vs late
• Early= within 30 days following surgery
• Late = greater than 30 days following surgery
• Stomal vs Peri-stomal
• Involving stoma
• Involving area around the stoma
Prevalence/Incidence:
• Several studies report complication rates
range from 10- 80% of individuals with an
ostomy.
• Study design differences, inconsistent
definitions and terminology, and timing of
measurements make it difficult to accurately
measure ostomy complication incidence
(Salvadalena, 2008).
June 22, 2014
1
Most common physiological complications include:
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peristomal irritant dermatitis
stoma pain
stoma mucocutaneous separation
stoma necrosis
stoma retraction
stoma stenosis
stoma prolapse
herniation around or beside the stoma
(J. Colwell, Goldberg, M., Carmel, J., 2001; Park, 1999; C. Ratliff,
Scarano, K., Donovan, A., 2005)
Stomal Complications
Peristomal Complications
Mucocutaneous separation (Early)
Irritant dermatitis (Early or Late)
Stomal necrosis (Early)
Candidiasis (Early or Late)
Stomal retraction (Early)
Folliculitis (Early or Late)
Stomal stenosis (Late)
Mucosal transplantation (Late)
Stomal prolapse (Late)
Pseudo verracous lesions (Late)
Stomal trauma (Early or Late)
Pyoderma gangrenosum (Late)
Parastomal hernia (Late)
Suture granulomas (Early)
Varices (Late)
Stomal Necrosis
• Death of the stomal tissue resulting from impaired blood
flow. (Colwell & Beitz)
• Most common early complication
• Caused by:
– tension on or inadequacy of the mesenteric vasculature to
the intestinal end
– trauma during creation
• Associated with obesity and higher BMI (Colwell &
Fichera)
• Severity varies- whole stoma, extending below the fascia,
or only a portion of the stoma and above skin level.
June 22, 2014
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Stomal necrosis
Stomal Necrosis Management
• Watch and wait
• Superficial - top layer may slough leaving red viable
stoma
• If above fascia but below skin level- stomal tissue
sloughs, malodorous, flaccid. Debridement needed
• MC Separation usually occurs
• With healing- stomal retraction and stenosis
• If stenosis below fascia- and output decreases or
stops- surgery likely indicated
Mucocutaneous Separation
• Detachment of stomal tissue from the surrounding
peristomal skin (J. Colwell, Beitz, J., 2007).
• Result of poor healing, tension, or infection.
• Incidence reported 4% to 24% (Park, Cottom).
• Varies in severity:
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–
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–
Partial- only a portion of the stomal circumference
Complete- entire circumference is involved.
Superficial- only the skin level,
Full thickness- extends to the fascia level (Franchini, 1983).
June 22, 2014
3
Mucocutaneous separation & retraction
MC Separation Management
• Depends on severity of separation
• The more severe the separation, the more likely
retraction will occur. With healing, the likelihood of
stenosis is high.
• Partial and superficial Separation- may be able to be
managed conservatively. Fill defect with skin barrier
powder, hydrofiber, or calcium alginate
• If separation is severe and involves the fascial layer,
stoma may drop into abdominal cavity and return to
surgery may be indicated
Stomal Retraction
• Disappearance of stoma tissue protrusion in line with
or below skin level (J. Colwell, Beitz, J., 2007).
• Caused by:
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Tension on stoma
Short mesentery
High BMI
Inadequate initial stoma length
Improper skin excision
Stomal necrosis
Mc separation
June 22, 2014
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Stomal Retraction
Stomal Retraction
• Prevalence ranges 4-40% (Ratliff, Pittman, Cottom)
• Incidence more than doubled between 1996 and 2004
(22% versus 51%) (Cottom).
Management
•
•
•
•
Goal is to augment the level of stoma above the skin
Convex pouching system
Belt
Surgical revision- local revision or new stoma
Stomal Stenosis
• Impairment of effluent drainage due to narrowing or
contracting of the stoma tissue at the skin or fascial
level (J. Colwell, Beitz, J., 2007).
• Causes:
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–
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MC separation
Stoma necrosis
Stoma retraction
Chronic disease
Excessive scar formation (dilatation)
Chronic inflammation (peristomal irritant dermatitis or
hyperplasia
June 22, 2014
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Stomal stenosis
Stomal Stenosis
The incidence of stomal stenosis has been
reported between 2- 23%.
Typically, ribbon-like stool or projectile
evacuation, frequent UTIs, or flank pain.
Management:
– Low residue diet, stool softeners, liquids
– Dilation?
– Surgery
Stomal Prolapse
Stomal prolapse is the telescoping of the intestine
through the stoma (J. Colwell, Beitz, J., 2007).
Causes:
– Increased abdominal pressure
– Obesity
– Stomal opening is created too large
– Stoma outside of rectus muscle
– Double-barrelled loop ostomies
June 22, 2014
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Stomal Prolapse
Stomal prolapse
– Study of 322 stomas, 156 were end colostomies
and 6.8% (Cheung, 1995), developed prolapse.
• Management• Conservative management recommended
• Pouch needs to accommodate the length of the stoma
• Flexible pouching system (avoid rigid systems) to
minimize trauma
• To reduce prolapse- lie flat, apply gentle pressure, cool
compress/ice pack, sugar directly to stoma
• Hernia support belt with prolapse strap.
Stomal (parastomal) hernia
Parastomal (peristomal) hernia is defined as a defect in
abdominal fascia that allows the intestine to bulge into
the parastomal area (Colwell & Beitz, 2007).
Incidence- 30- 50% (Israelsson, 2008)
Causes of abdominal hernias:
• Natural anatomical openings in abdominal wall- inguinal ring,
umbilicus, esophageal hiatus.
• Previous surgical entry sites- incisional, stomal site
• Increased abdominal pressure- obesity, heavy lifting, coughing
with COPD, straining with BM or urination, ascites.
• Poor site selection or technical issues- fascial opening too large,
stoma in an incision, lateral to rectus(?)
June 22, 2014
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Parastomal Hernia
NuHope, 2014
Parastomal Hernia Management:
Nonsurgical:
– Hernia support belts
– Flexible pouching system• 1 pc or
• 2 pc with floating flange
– Irrigation – hold if difficulties encountered
– Regular diet/fluid to ensure soft stool/prevent constipation
– Routine follow-up with provider/WOC nurse
Parastomal Hernia Management
Surgical repair Indications: (depends on degree)
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Obstruction
Incarceration with/without strangulation
Prolapse
Stenosis
Intractable dermatitis
Difficulty with appliance management
Large size
Cosmesis
Pain
June 22, 2014
8
Walking the Line of Success using Fluorescence
Angiography
Paul P. Szotek, MD
Acute Care & Trauma Surgery
Indiana University Health
Indianapolis, IN
Most common physiological complications include:
◦ Stoma necrosis
Anatomical
◦ Stoma
MC separation
◦ Stoma retraction
◦ Stoma stenosis
◦ Stoma prolapse
◦ Parastomal Hernia
June 22, 2014
Vascular / Blood Flow
9
Clinical Judgment by Visual Inspection & Doppler
Calling Dr. Antelope ... we need your primitive “Gold Standards”
No problem …
I hear it coming but where’s it going?
(Doppler)
Does not look like a lion hiding in the
brush
(Looks ok…just a little beat up)
My years of judgment will save me….
I’ll get away with it..
or not…
Often Fail / insufficient/ unreliable…..
Run like #$%!
0hrs Op #1: Surgeon 1 – 25yrs experience + Doppler – Left Colon Resection – “Rest Prob OK”
14hrs Op #2: Surgeon 2 – 23yrs experience + Doppler – Remainder of Colon Resected – “SB Prob OK”
36hrs Op #3: Surgeon 3 – 5 yrs experience
Szotek parts ways with IU Health
Szotek, Paul P Stoplight Report
Service Dates From Aug 1, 2012 to Jul 31, 2013
https://catalyst.nrcpicker.com/iuhcg2012b/iuhealthp/iuhpadult/iuhpsca/providerb/PPSzotek/default.aspx
Picker Dimensions
Pay for Performance
Benchmarks
September 25, 2013
Fiscal Year-to-Date
Szotek, Paul P
Overall
NRC 75th
Percentile*
Current
YTD
Previous
Year
Qtr 3
FY2013‡
Qtr 2
FY2013
Using any number from 0 to 10, where
0 is the worst provider possible and 10
is the best provider possible, what
number would you use to rate this
provider?
88.1%
(n=576,428)
100.0%µ
PR=100
(n=11)
--
100.0%µ
(n=7)
100.0%µ
(n=4)
--
--
Key Drivers
NRC 75th
Percentile*
Current
YTD
Previous
Year
Qtr 3
FY2013‡
Qtr 2
FY2013
Qtr 1
FY2013
Qtr 1
FY2013
Qtr 4
FY2012
Qtr 4
FY2012
In the last 12 months, when you made
an appointment for a check-up or
routine care with this provider, how
often did you get an appointment as
soon as you needed?
75.0%µ
PR=52
(n=4)
50.0%µ
(n=2)
--
--
Access to Care
81.4%
(n=403,581)
--
100.0%µ
(n=2)
During your most recent visit, were
clerks and receptionists at this
provider's office as helpful as you
thought they should be?
Emotional Support
94.1%
(n=574,978)
90.9%µ
PR=54
(n=11)
--
100.0%µ
(n=7)
75.0%µ
(n=4)
--
Does this provider involve you in
decisions about your care as much as
you want?
Respect for Patient
Preferences
92.7%
(n=447,483)
81.8%µ
PR=23
(n=11)
--
85.7%µ
(n=7)
75.0%µ
(n=4)
--
--
NRC 75th
Percentile*
Current
YTD
Previous
Year
Qtr 3
FY2013‡
Qtr 2
FY2013
Qtr 1
FY2013
Qtr 4
FY2012
--
63.6%µ
(n=11)
--
71.4%µ
(n=7)
50.0%µ
(n=4)
--
--
--
50.0%µ
(n=10)
--
57.1%µ
(n=7)
33.3%µ
(n=3)
--
--
72.7%µ
(n=11)
--
85.7%µ
(n=7)
50.0%µ
(n=4)
--
--
NRC 75th
Percentile*
Current
YTD
Previous
Year
Qtr 3
FY2013‡
Qtr 2
FY2013
Qtr 1
FY2013
Qtr 4
FY2012
Respect for Patient
Preferences
95.7%
(n=579,515)
100.0%µ
PR=100
(n=11)
--
100.0%µ
(n=7)
100.0%µ
(n=4)
--
--
Would you recommend this provider's
office to your family and friends?
Would Recommend
Provider's Office
94.4%
(n=575,064)
100.0%µ
PR=100
(n=11)
--
100.0%µ
(n=7)
100.0%µ
(n=4)
--
--
During your most recent visit, did this
provider seem to know the important
information about your medical history?
Coordination of Care
91.4%
(n=576,686)
90.9%µ
PR=73
(n=11)
--
100.0%µ
(n=7)
75.0%µ
(n=4)
--
--
Focus
During your most recent visit, did this
provider's staff introduce themselves to
you and explain their role in your visit?
During your most recent visit, did this
provider's staff keep you updated on
your wait time while in the waiting area
and the exam room?
When you last called our office, did this
provider's staff demonstrate a
courteous and caring attitude over the
telephone?
Highest Scores
During your most recent visit, did this
provider spend enough time with you?
--
--
Green - score is equal to or greater than the NRC 75th Percentile
Yellow - score is less than the NRC 75th Percentile, but may not be significantly
µ - Warning: n-size is low!
‡ - Data is not final and subject to change.
©2013 National Research Corporation
June 22, 2014
Red - score is significantly less than the NRC 75th Percentile
* - Benchmark that is used to determine the color on each line.
PR=Percentile Rank
Page 1 of 1
10
of intra-operative
perfusion assessment
as we know it ?
•
Be Cost-effective
•
Be easy and efficient to use intra-operatively
•
Allow for real-time tissue perfusion analysis
•
Allow for multiple opportunities to assess tissue during procedure
•
Allow for more informed intraoperative decision making and planning
•
Be accurate
•
Be safe for patients
The Spy Perfusion System utilizes a fluorescence imaging agent,
indocyanine green (ICG), to enable visualization
ICG has a 50 year record of safe clinical use
First used as a fluorescence imaging agent for ophthalmic angiography
Tightly binds with plasma protein in blood1
Stays within the vasculature – does not leak out1
Not nephrotoxic
Excreted by the liver into bile1
Half-life of 2.5-3 minutes1
Contraindicated in patients allergic to iodide1
SPY
1. IC-Green™ (indocyanine green for injection, USP) [package insert]. Akorn Inc., Buffalo Grove, IL; November 2008. http://www.akorn.com/documents/catalog/package_inserts/17478-701-02.pdf. Accessed
January 5, 2011.
32
Trauma
Mesenteric Hematoma /Missed Bowel
Injury
Observation Vs Laparoscopy
June 22, 2014
Acute Care Surgery
Ischemic Bowel Consult
Observation Vs Laparoscopy
11
Case #3: Embolic Small Bowel Ischemia
Where would you resect ?
A. White
B. Blue
C. Black
www.autosuture.com
Case #1: POD#2 – “Dusky but viable end colostomy”
- Morbidy obese – 140kg , DM, CAD
- Admitted for Nec Fasciitis of Perineum, Debrided, Floating Rectum
- Elective Diverting End Colostomy
4:59 PM
EGS Partner
1. Nec Fasciitis
2. Perforated Diverticulitis
June 22, 2014
12
Spy uses in this case that Changed Management
1. Objective data to return patient to OR
2. Objective data to determine resection site
of colon and possibly prevent identical
complication
3. Improve mobilization of colon and identify
colon site to make ostomy after pull through
4. Confirm ostomy perfusion after Brooke
5. Identify poorly perfused anterior abd wall
blood flow and act on it intraoperatively
Case #2: Perforated Diverticulitis s/p Proximal Diverting Loop & “Dusky but Viable Ostomy
POD #2 , 140 KG, DM
Revision Costs: ~ 20-60k
Revision Costs: 40k
Revision Rate: 5%
Cost to Spy all 91pts
= 91k
5/91 pts x 40k = 200k
Savings = 108k
E
Estimated Charges > 1 Million
Death
Early stoma Vascular Compromise Rates Requiring Revision: 2.3-17%
www.health.ny.gov/health.../potentially_preventable_complications.pdf
Early Stomal Complications: Kann, Brian. Clin Colon Rectal Surg. 2008 February; 21(1): 23–30.
June 22, 2014
13
Dr.inAntelope
ICG FA (SPY)
Acute Care Surgery
No problem …
I hear it coming but where’s it going?
(Doppler)
Does not look like a lion hiding in the
brush
(Looks ok…just a little beat up)
My years of judgment will save me….
I’ll get away with it..
or not…
Run like #$%!
End organ microvascular perfusion
Summary
• Anatomical or Vascular or Both
• Costly to the healthcare system
• Never events….are they nuts?
• Fluorescence Angiography may
predict ischemia and help prevent
early complications at the time of
index surgery
• “Dusky but viable”
Special Thanks
Questions ?
Dr. Szotek’s Lab
Naveed Nosrati, MD
June 22, 2014
Lindsey Peters, MD
14
G
L
A
S
S
IU Health first in Indiana to use Google
Glass in surgery
To Collaborate:
Surgery goes sci-fi as Indiana hospital performs the nation’s first abdominal wall
reconstruction using Google Glass
google.com/+PaulSzotekMD
@glasstestdummie
@indyhernia
INDIANAPOLIS—A sci-fi way of seeing things offers a new way of performing lifesaving surgery.
Recently, physicians at Indiana University Health Methodist Hospital became the first in Indiana to
perform a surgery using Google Glass, a wearable mini-computer and camera disguised as a pair of
futuristic-style eyeglasses. IU Health Methodist Hospital is the first hospital in the United States to use this
technology to both remove a tumor and reconstruct an abdominal wall.
pszotek@iuhealth.org
References
Fitzgibbons, R., Cemaj, S., Quinn, T. 2011. Abdominal Wall Hernias. In Greenfield's Surgery Scientific Principles and Practice, 5th EditionEditors: Mulholland, Michael
W.; Lillemoe, Keith D.; Doherty, Gerard M.; Maier, Ronald V.; Simeone, Diane M.; Upchurch, Gilbert R..Lippincott Williams & Wilkins.
Cheung, M. T. (1995). Complications of an abdominal stoma: an analysis of 322 stomas. Australian & New Zealand Journal of Surgery, 65(11), 808-811.
Colwell, J. (2004). Principles of stoma management. In J. Colwell, Goldberg, M., Carmel, J. (Ed.), Fecal and Urinary Diversions (pp. 240-262). St. Louis: Mosby
Colwell, J., Beitz, J. (2007). Survey of wound, ostomy and Continence (WOC) Nurse Clinicians on stomal and peristomal complications: A content validation study.
Journal of Wound, Osotmy, Continence Nursing, 34(1), 57-69.
Colwell, J., Goldberg, M., Carmel, J. (2001). The state of the standard diversion. Journal of Wound, Ostomy, Continence Nursing, 28, 6-17.
Colwell, J. C., & Fichera, A. (2005). Care of the obese patient with an ostomy. Journal of Wound, Ostomy and Continence Nursing, 32(6), 378-385.
Colwell, J. C., Goldberg, M., & Carmel, J. (2001). The state of the standard diversion.[see comment]. Journal of Wound, Ostomy, & Continence Nursing, 28(1), 6-17.
Cottam, J. (2005). Audit of stoma complications within three weeks of surgery. Gastrointestinal Nursing, 3(1), 19-23.
Cottam, J., Richards, K., Hasted, A., Blackman, A. (2007). Results of a nationwide prospective audit of stoma complications within 3 weeks of surgery. The Association
of Coloproctology of Great Britian and Ireland. Colorectal Disease, 9, 834-838.
Duchesne, J., Wang, Y., Weintraub, S., Boyle, M., Hunt, J. (2002). Stoma Complications: A Multivariate Analysis. American Surgeon, 66(11), 961.
Franchini, A., Cola, B., Stevens, P.J. d'E. (1983). Atlas of stomal pathology. New York: Raven Press.
Hampton, B. (1992). Peristomal and stomal complications. In B. Hampton, Bryant, R. (Ed.), Ostomies and continent diversions: Nursing management. St. Louis: Mosby
Year Book
Leong, A., Londono-Schimmer, E., Phillips, R. (1994). Life-table analysis of stomal complications following ileostomy. British Journal of Surgery, 81, 727-729.
Park, J., Del Pino, A., Orsay, C., Nelson, R., Pearl, R., Cintron, J., Abcarian, H. (1999). Stoma Complications. Diseases of the Colon & Rectum, 42(12), 1575-1580.
Pittman, J. (2011). OSTOMY COMPLICATIONS AND ASSOCIATED RISK FACTORS: DEVELOPMENT AND TESTING OF TWO INSTRUMENTS. [Dissertation PhD]. Indiana
University Purdue University Indianapolis Library.
Pittman, J., Bakas, T., Ellett, M., Sloan, R., Rawl, S. (2014). Pschometric evaluation of the Ostomy Complication Severity Index. Journal of Wound Ostomy Continence
Nurses Society, 41(2), 1-11.
Pittman, J., Rawl, S. M., Schmidt, C. M., Grant, M., Ko, C. Y., Wendel, C., & Krouse, R. S. (2008). Demographic and Clinical Factors Related to Ostomy Complications and
Quality of Life in Veterans With an Ostomy. Journal of Wound, Ostomy and Continence Nursing, 35 (5), 493-503.
Porter, J., Salvati, E., Rubin, R., Eisenstat, T. (1989). Complications of colostomies. Disease Volon & Rectum, 32(4), 299-303.
Ratliff, C., Donovan, A. (2001). Frequency of peristomal complications. Ostomy/Wound Management, 47(8), 26-29.
Ratliff, C., Scarano, K., Donovan, A. (2005). Descriptive study of peristomal complications. Journal of Wound, Ostomy, Continence Nursing, 32(1), 33-37.
Salvadalena, G. (2008). Incidence of complications of the stoma and peristomal skin among individuals with colosty, ileostomy, and urostomy: A systematic review.
Journal of Wound, Ostomy, & Continence Nursing, 35(6), 596-607.
Steel, M., Wu, J. (2002). Late stomal complications. Clinics in Colon and Rectal Surgery, 15(3), 199- 207.
Weideman, Y., Dunn, D., Culleiton, A. (2012). Ostomy Management. Brockton, MA: Western Schools Inc.
June 22, 2014
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