|
|
|
Keywords: Assessment, colostomy, stoma-siting
Surg J R Coll Surg Edinb Irel., 1 December 2003, 347-349
Aims:
The ability of surgeons to site a colostomy is assessed in a clinical model. In addition, the tuition
received by surgical trainees in stoma siting is also reviewed. Materials and Methods:
Eleven surgeons
(trainees - six, colorectal subspeciality interest - two) were asked to site an end colostomy on nine
patients using an adhesive disc (diameter - 1cm). The position of the stoma was then measured on
the ‘x’ and ‘y’ axis of a 2cm box grid, (maximum error - 1cm) which was placed on the abdomen and
centred on the umbilicus. The positions were then compared with that chosen by the stoma nurse who
was taken as the gold standard. Results were compared using ANOVA and the Mann Whitney - U test.
A telephone questionnaire was then undertaken to review the training of junior surgeons.
Results: There was variance present within the group of surgeons studied (p<0.01).Trainees and consultants
had a similar accuracy in stoma-siting (p<0.2). Consultants with a colorectal subspeciality interest
were better at placing stomas than those with a general interest (p<0.002). Badly placed stomas were
three times more likely to be too low than too high (p<0.002). Thirty of 37 trainees reported receiving
no undergraduate training from a specialist stoma nurse. Ninety per cent received postgraduate
training from another surgeon while a specialist nurse trained only 35%. Conclusion:
There was no
difference between trainees and consultants in their ability to site a colostomy. However, surgeons
with a subspeciality interest chose stoma sites that were more consistent with the specialist nurse
than general surgeons. Training is haphazard and ability is frequently assumed rather than proven
INTRODUCTION
The formation of a colostomy is one of the easiest of bowel procedures for a surgeon to
perform and one that they are often shown how to do early in their training. It is also one
of the easiest operations to perform badly, and patients can be left with the legacy of leakage,
prolapse, parastomal hernia, retraction and stenosis.1-4 In addition, a badly placed stoma
can be difficult for the patient to manage personally, and demands may then have to
be made of relatives or district nurse services. The plethora of consumables (barrier creams,
fillers, convex bags, etc.) that are available, and used by stoma nurse specialists on a
regular basis, is testimony to the cumulative lifelong complication rate.5-8
While many elective stomas will be sited by a specialist nurse, siting for colorectal emergencies will be done by the surgeon either pre- or intra-operatively. The choice of traditional landmarks, i.e. umbilicus and anterior superior iliac spine may not be reliable in all patients, and failure to take into account obesity, abdominal contours, skin creases, pendulous breasts and planned and existing scars may result in a sub-optimal site being chosen.
Ability to accurately site a stoma is often assumed rather than proven and formal training may have been limited. The aim of this study was to compare the stoma siting ability of surgeons with that of a specialist stoma nurse. The nature and extent of undergraduate and postgraduate training is also considered.
MATERIALS AND METHODS
Eleven surgeons (trainees - six, colorectal subspeciality interest - two) were asked to
site an end colostomy on nine patients (five males) using an adhesive disc (diameter
- 1cm). Of the trainees, two were involved in basic training (less than six months
general surgical experience, three were at SHOIII level and one was a year five specialist registrar with a vascular
interest). Patients who volunteered to take part were either routine admissions for minor surgical procedures, or longer
stay patients undergoing investigation. Three patients had previous midline laparotomy wounds (upper - one, lower
one, full length - one). Patients were of varying body mass index (BMI); one patient was below normal weight; three
were within the normal range; three were classed as overweight; two were considered obese. The position of the
stoma was then measured on the ‘x’ and ‘y’ axis of a 2cm box grid, (maximum
error - 1cm) which was placed on the abdomen and centred on the umbilicus, xyphisternum and symphysis pubis.
Each consultant surgeon and trainee in turn sited the stomas, blinded to the position chosen by their colleagues and the specialist nurse. The patients could be questioned by those siting the stomas. Prior instruction was not given to the members of the study group but they were allowed to alter the position of the patient by getting them to sit or stand. The positions were then compared with those chosen by the stoma nurse, who was taken as the gold standard. Results, which were compared using ANOVA and the Mann Whitney - U test, were tabulated and anonymous feedback was given to each individual taking part.
In the second part of the study, a telephone questionnaire was undertaken to review the training of 37 junior surgeons working within the West of Scotland. They were asked specifically if they had had any undergraduate training in stomas given by a specialist nurse. The contribution of a stoma nurse to their postgraduate training was also assessed.
RESULTS
There was variance present within the group of surgeons studied (p<0.01)
(Figure 1). The median distance (all surgeons) from the site chosen by the stoma nurse was 2.0(1.2)cm-median
(inter-quartile range) (Table 1). Seniority had no effect on the results, as trainees
and consultants had a similar accuracy in stoma siting (p<0.2). Consultants with a
colorectal subspeciality interest were more likely to chose the same site as the
stoma nurse than those with a general interest (p<0.002). Badly placed stomas
were three times more likely to be too low than too high (p<0.002). Stomas were considered to be too close to a
midline laparotomy wound if the flange would have covered the latter, and this occurred in 33% of cases.
Thirty of the 37 trainees reported receiving no undergraduate training from a specialist stoma nurse. Of those, 12 had received no formal postgraduate training either. Of the 25 who were trained , 90% received postgraduate training from another more senior surgeon while a specialist nurse contributed in only 35% of cases.
Key:
-
Stoma sitings selected by stoma nurse
o Stoma sitings selected by surgeons
Figure 1: Stoma sitings selected by surgeons and by the specialist stoma nurse on a representative abdomen
| TABLE 1. DISTRIBUTION OF STOMA SITINGS EXPRESSED AS 1CM INTERVALS FROM THE SITE CHOSEN BY THE SPECIALIST STOMA NURSE | |
| Distance | Number of stomas |
| >1cm | 11 |
| 1-2cm | 35 |
| 2-3cm | 18 |
| 3-4cm | 11 |
| >4cm | 24 |
DISCUSSION
In current surgical practice, temporary
and permanent end colostomies,
fashioned as part of the treatment of
low rectal cancer, will have been sited
pre-operatively by a specialist stoma
nurse. Emergency end colostomies
will not routinely have been sited by
an experienced nurse and siting will be
performed immediately pre-operatively,
or worse, intra-operatively. In cases
of intestinal obstruction, this task is
made more difficult by abdominal
distension. While some of these stomas
are temporary, a proportion are not
reversed.
Many factors are important in forming a stoma, which is least problematic for the patient or their primary carer. Traditional teaching points to the midpoint between the umbilicus and the anterior superior iliac spine as the most appropriate site. In patients of above average build, these reference points become less reliable. It is important to make sure that the flange does not encroach on the midline wound as this can cause problems in the short-term with wound infection and in the long-term where patients have hypertrophic scars. Perhaps the single most important factor is avoiding natural or surgically created skin creases and the colostomy should be sited in the lying, sitting and standing positions. Even in emergency cases, most patients can be encouraged to sit up to identify skin creases. It does not require much specialist training to site a stoma and it is wrong to assume that the only person capable of doing this is the stoma nurse. If a few basic rules are followed, then ward nurses, basic and higher surgical trainees, and consultants can site a stoma in an appropriate position. A poor attempt pre-operatively is better than a guess intra-operatively. While the range of appliances and accessories available assists the stoma nurse in dealing with retraction (the main clinical problem), there is little that can be done to improve on the morbidity associated with a poorly sited stoma.
Preventing leakage is the major concern and appropriate siting is one factor in achieving this. If the stoma is sited below the patient’s abdominal pannus, accurate cleansing of the skin is hampered and subsequent re-fitting of the appliance unsatisfactory. Placement of the colostomy in a natural skin crease will also make it difficult to maintain a tight seal between skin and stoma bag. Avoiding retraction by adequate mobilisation of the left colon and if necessary, the splenic flexure, is also important and will help the surgeon locate the stoma in the pre-determined optimum site.
In this study, surgeons showed a variable ability at siting stomas, when compared with a specialist nurse. We have made the assumption that the nurse has chosen the optimum site in each case and this may not be valid. However, it is reassuring that the two surgeons with a colorectal subspeciality interest mirrored exactly (<1cm away) the site chosen by the stoma nurse in 8 of 18 cases and chose sites that were below the median distance in nine cases : in only one case was the siting considered inappropriate (4.5cm). This occurred in the most obese patient.
To follow this study through logically, each site chosen by each surgeon would need to have been produced operatively and the subsequent complication rate recorded. Clearly this was not possible, but we have made a ‘best attempt’ to deal scientifically with a hitherto unreported problem. Similarly, in some patients, there may be more than one suitable site for the stoma and this study takes no account of patient preference which would contribute to the decision in clinical practice.
Textbooks of operative surgery vary on the instructions given to the surgeon on where to site a stoma.1-4 Some refer exclusively to placement just above the midpoint between the anterior superior iliac spine and the umbilicus.1 Goligher (1980) chose the same site but, in addition, stressed the importance of making sure that the appliance bag did not encroach on the laparotomy wound.2 Considerably more attention is paid to the formation of an ileostomy than to a colostomy and little additional advice is given to assist in the placement of the latter. Moving the colostomy cephalad in patients with a lower abdominal corpulence is mentioned infrequently, while naturally occurring skin creases are seldom considered.4 The umbilicus and anterior superior iliac spine are easily recognised reference points and while the midpoint may be appropriate to the patient of average build, these anatomical landmarks become less helpful in individuals who are overweight or where natural skin creases occur.
While this study cannot prove that each patient has their own individual ‘best stoma site’, we have highlighted a clinical problem and identified an important gap in surgical training. No amount of barrier cream, fillers or convexity (special appliances) can compensate for poor technique or poor siting at the time of stoma formation. Fashioning of the colostomy after an emergency laparotomy is frequently left to the most junior surgeon in theatre, as it is the easiest part to do. If the wrong site has been chosen, it has become the easiest part to do badly and the patient frequently has to live with the consequences.
REFERENCES
1. Rintoul RF. Farquarson’s textbook of
operative surgery. Seventh edition. Churchill Livingstone. Edinburgh, London, Melbourne, New York 1986: 449,
450, 466.
2. Goligher JC. Surgery of the anus rectum and colon. Fourth edition. Bailliere and
Tindall, London 1980.
3. Dudley HAF. Hamilton Bailey’s emergency
surgery. Tenth edition. John Wright & Sons Ltd, Bristol 1997: 463,489.
4. Fielding LP, Goldberg SM. Rob & Smith’s operative surgery. Surgery of the
colon, rectum and anus. Fifth edition. Butterworth-Heinemann Ltd 1993: 244,
278, 491,562.
5. Leenan L, Kuypers J. Some factors influencing the outcome of stoma surgery. Dos Colon Rectum 1989; 32: 500-4.
6. Hawley PR, Ritchie JK. Complications of ileostomy and colostomy following excisional surgery.
Clin Gastroenterol
1979; 8: 403-14.
7. Kodner IJ. Stoma complications. In: Fazio V, ed. Current therapy in colon and rectal surgery.
Toronto BC Decker, 1990: 420-25.
8. Schimmer EE, Leong APK, Philips RKS.
Life table analysis of stoma complications
following colostomy. Dis Col Rectum
1994; 37: 916-20.
Copyright: 22 October 2003