Ostomy creation

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J Wound Ostomy Continence Nurs. 2021;48(5):415-430.
Published by Lippincott Williams & Wilkins
Ostomy Care
ABSTRACT
PURPOSE: Ostomy creation is often an integral part of the surgical management of various diseases including colorectal
malignancies and inflammatory bowel disease. Stoma and peristomal complications may occur in up to 70% of patients
following ostomy surgery. The aim of this scoping literature review was to synthesize evidence on the risk factors for developing
complications following creation of a fecal ostomy.
DESIGN: Scoping literature review.
SEARCH STRATEGY: Two independent researchers completed a search of the online bibliographic databases PubMed,
MEDLINE, Cochrane, Google Scholar, and EMBASE for all articles published between January 1980 and December 2018. The
search comprised multiple elements including systematic literature reviews with meta-analysis of pooled fndings, randomized
controlled trials, cohort studies, observational studies, other types of review articles, and multiple case reports. We screened 307
unique titles and abstracts; 68 articles met our eligibility criteria for inclusion. The methodological rigor of study quality included
in our scoping review was variable.
FINDINGS/CONCLUSIONS: We identifed 6 risk factors associated with an increased likelihood of stoma or peristomal
complications (1) age more than 65 years; (2) female sex; (3) body mass index more than 25; (4) diabetes mellitus as a comorbid
condition; (5) abdominal malignancy as the underlying reason for ostomy surgery; and (6) lack of preoperative stoma site marking
and WOC/ostomy nurse specialist care prior to stoma surgery. We also found evidence that persons with a colostomy are at a
higher risk for prolapse and parastomal hernia.
IMPLICATIONS: Health care professionals should consider these risk factors when caring for patients undergoing fecal ostomy
surgery and manage modifable factors whenever possible. For example, preoperative stoma site marking by an ostomy nurse
or surgeon familiar with this task, along with careful perioperative ostomy care and education of the patient by an ostomy nurse
specialist, are essential to reduce the risk of modifable risk factors related to creation of a fecal ostomy.
KEY WORDS: Colostomy, Ileostomy, Ostomy, Parastomal hernia, Peristomal complications, Stomal complications.
INTRODUCTION
Creation of a fecal ostomy is an integral part of the surgical management of neoplastic lesions, inflammatory bowel
diseases (IBDs), congenital malformations, or trauma of the
intestinal tract.
1 Approximately 1 million new stomas are created annually, with the largest portion of stomas being created
in patients between 50 and 70 years of age.
2 In the United
States, approximately 100,000 to 150,000 intestinal stomas
(fecal diversions) are created annually.
3,4 Te most common
causes of fecal diversions include colorectal cancer (44.6%-
74.1%) and IBDs (12.1%-28.2%).
3,5-8 Other indications for
fecal diversions are complicated diverticulitis (12.7%) and
fecal incontinence (6.7%).
5 Fecal diversions are occasionally
created for the management of radiation proctitis, traumatic
injury, infectious colitis, chronic wounds, anastomotic leak,
and neurogenic bowel dysfunction following spinal cord injury. Ostomy creation can be permanent or temporary, as well
as elective or part of an urgent/emergent surgical procedure.
Stoma complications affect a signifcant proportion of persons living with a fecal ostomy.
9-12 Stoma complications include
mucocutaneous separation, stomal retraction, stenosis, necrosis, prolapse, fstula, trauma, and peristomal hernia. Peristomal
complications include peristomal moisture-associated skin
damage, allergic contact dermatitis, mechanical injury (both
Piotr Zelga, MD, PhD, Department of General and Colorectal Surgery,
Medical University of Lodz, Lodz, Poland.
Piotr Kluska, MD, Department of General and Colorectal Surgery, Medical
University of Lodz, Lodz, Poland.
Marta Zelga, MD, Department of Pediatric Surgery, Urology and Transplantology, Polish Mother’s Memorial Hospital Research Institute, Lodz, Poland.
Joanna Piasecka-Zelga, PhD, Research Laboratory for Medicine and
Veterinary Products in the GMP Quality System, Nofer Institute of Occupational
Medicine, Lodz, Poland.
Adam Dziki, MD, PhD, Department of General and Colorectal Surgery,
Medical University of Lodz, Lodz, Poland.
Piotr Zelga and Piotr Kluska contributed to this work equally.
The authors declare no conflicts of interests.
Correspondence: Piotr Zelga, MD, PhD, Department of General and
Colorectal Surgery, Medical University of Lodz, Plac Hallera 1, 90-647 Lodz,
Poland ([email protected] tel).
Patient-Related Factors Associated With Stoma and
Peristomal Complications Following Fecal Ostomy
Surgery
A Scoping Review
Piotr Zelga ¿ Piotr Kluska ¿ Marta Zelga ¿ Joanna Piasecka-Zelga ¿ Adam Dziki
DOI: 10.1097/WON.0000000000000796
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416 JWOCN ¿ September/October 2021 www.jwocnonline.com
pressure and adhesive-related), fungal infection/candidiasis,
varices, folliculitis, pyoderma gangrenosum, hyperplasia, and
suture granulomas.
13
While these complications may occur at any point following ostomy creation, evidence suggests that the majority of
complications develop within the frst 5 years following stoma
surgery.
4 Reported incidence rates of stomal and peristomal
complications vary from 2.9% to 81%.
1,4,11,14-17 Complications may prolong hospital stay, increase the risk of hospital
readmissions, and escalate the number of visits to outpatient
clinics, resulting in substantial costs related to ostomy care;
moreover, these complications negatively affect health-related
quality of life (HRQOL).
18-20
Due to the growing number of ostomies created on an annual basis, the prevalence of stoma-related complications is
expected to increase.
21-24 Determining factors that contribute
to the development of stoma complications could help identify patients at a greater risk for complications and possibly
guide interventions to decrease risk. Multiple risk factors have
been examined including body mass index (BMI), tobacco or
alcohol abuse, underlying disease leading to ostomy surgery
and treatments associated with the disease (chemotherapy,
radiation therapy, chronic steroid use), presence of comorbid
conditions such as diabetes mellitus, coronary heart disease,
hypertension, chronic obstructive pulmonary disease, and
surgery-related factors (type of stoma such as on the small or
the large intestine, loop, terminal, surgeon experience), position of the stoma on the abdomen and in relation to the
rectus sheath, preoperative marking of the stoma site, and the
setting in which the ostomy was created (urgent/emergent
vs planned).
6,25-35 However, studies vary and no consensus
around which modifable factors are most amenable to preventive interventions exists.
31,33,34,36-38 Terefore, the purpose
of our scoping review was to identify patient-related risk factors contributing to an increased risk of stoma and peristomal
complications in patients with fecal ostomies.
METHODS
Two reviewers (P.K. and P.Z.) searched the literature independently using the following online bibliographic databases: PubMed, MEDLINE, Cochrane, Google Scholar, and
EMBASE for studies published between January 1980 and
December 2018. Te search string used to search the databases is depicted in Table 1. We included the following types
of articles/elements: systematic reviews with or without metaanalysis of pooled analysis, randomized controlled trials
(RCTs) including reviews from the Cochrane Library, nonrandomized cohort studies, observational studies, and other
types of review articles. We included elements published in
the Dutch, English, French, German, and Spanish languages. Te search strategy is detailed in the Figure
. Studies were
originally screened in abstract format seeking additional inclusion criteria for study participants 18 years and older,
original research or review that primarily focused on fecal
stomal and parastomal complications, and original research/
reviews analyzing risk factors for the development of stomal
and parastomal complications in persons with fecal ostomies.
Additional articles were identifed through the examination of
reference lists (ancestry search). We excluded gray literature
sources (abstracts), clinical audits that did not provide detailed
quantitative measurements, editorials, letters to the editor, and
individual case reports.
SEARCH STRATEGIES
Two reviewers searched the literature (P.Z., P.K.) and screened
the abstract titles and study type. A second pair of reviewers (P.K., M.Z.) read selected elements in full and selected

TABLE 1.
Scoping Review Search Strategy
Databases: PubMed, MEDLINE, EMBASE, Cochrane Database of Systematic
Review, Google Scholar
Search limits: Jan 1980-Dec 2018
Search terms
1 Ostomy type “loop ileostomy”
2 “end ileostomy”
3 “loop colostomy”
4 “end colostomy”
5 (1 OR 2 OR 3 OR 4)
AND
6 Ostomy
complications
“stomal complications” OR “parastomal
complications” OR “peristomal complications”
7 “early complications”
8 “late complications”
9 7 OR 8
10 6 OR 9
11 “peristomal hernia” OR “parastomal hernia”
12 “stoma retraction” OR “stomal retraction”
13 “stoma prolapse” or “stomal prolapse”
14 “stoma stricture” OR “stomal stricture”
15 “peristomal dermatitis”
16 “peristomal skin irritation”
17 “high output ileostomy” OR “dehydration”
18 (10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17)
AND
19 Risk factors age
20 gender OR sex
21 obesity
22 BMI OR “Body Mass Index”
23 “concomitant diseases” OR comorbidities
24 diabetes OR “Diabetes mellitus”
25 cancer
26 “Crohn disease”
27 elective
28 emergency
29 27 OR 28
30 “stoma nurse”
31 “WOC nurse”
32 “stoma marking”
33 (19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR
26 OR 29 OR 30 OR 31 OR 32)
Final search string
34 5 AND 18 AND 33

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JWOCN ¿ Volume 48 ¿ Number 5 Zelga et al 417
elements meeting inclusion and exclusion criteria. Any disagreements were resolved by discussion. Four investigators
(P.Z., P.K., J.P.Z., and J.M.-W.) extracted relevant data from
each element including authors, publication date, study design, number of participants, outcomes, overall complications
rates, complication rates related to stoma type and duration
of follow-up, conclusions, and study heterogeneity. Specifc
data related to potential risk factors for each stoma or parastomal complication and the rates of any complication in groups
based on sex, age, BMI, and the underlying cause of ostomy
were also extracted, when available. Discrepancies involving
lack of concordance in extracted data values were resolved by
discussion with the other investigators (A.D., M.M.).
Extracted data were then divided into 3 categories and
grouped into relevant tables. Table 2 summarizes details of
included elements (authors, number of participants, number
of studies included in systematic reviews, reported complication rates, and study or review design). Table 3 summarizes
complication rates for ostomy types and data regarding analysis of patient-related risk factors. Te conclusions drawn from
the selected studies/reviews in all 3 groups were ranked using
the Grades of Recommendation, Assessment, Development,
and Evaluation (GRADE) approach by 2 reviewers (M.Z.,
M.M.).
26,27 Two independent reviewers (J.P.Z. and A.D.) verifed the ratings, and any disagreements were reconciled by
discussion. Te rating for each study included in the review is
depicted in Table 2.
We selected the GRADE instrument to evaluate the quality of underlying evidence and generate strength of recommendations from the studies included in our review.
26,27 In
addition to examining study design, the GRADE approach
enabled ranking of evidence based on risk of bias, imprecision,
inconsistency, indirectness of results, and publication bias. Ultimately, the quality of evidence for each outcome was divided
into 4 categories ranked from high to very low.
39,40
FINDINGS
Te initial search produced 1266 potentially relevant articles
and another 30 identifed via ancestry search. Te flowchart
describing the process through which eligible studies were
selected is presented in detail in the Figure. After removing
the duplicate results from the different databases, 679 records remained. Tree hundred seventy-two records were
then removed after initial abstract title and study type were
Figure. PRISMA Flow Diagram: Patient-related risk factors associated with stomal and peristomal complications following fecal
ostomy surgery.

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TABLE 2.
Summary of All Studies Included in the Scoping Review Assorted by Date of Publication
S No. First Author Year No of
Patients
Country Study Design Focus Grade
1 Pearl 1987 610 USA Retrospective observational study Rates and risk factors for stoma-related complications Low
2 Bagi 1992 50 Denmark Retrospective observational study Incidence of stoma-related complications Low
3 Leong 1994 150 UK Retrospective observational study Risk factors and complications rates for permanent end
ileostomies
Low
4 Bass 1997 1790 USA Retrospective observational study Effect of preoperative stoma site marking on stoma-related
complications
Low
5 Shellito 1998 USA Narrative review Complications after stoma surgery Moderate
6 Park 1999 1616 USA Retrospective observational study Nature and rate of stoma-related complications Moderate
7 Edwards 2001 70 UK Prospective randomized study Whether loop ileostomy or loop transverse colostomy is the
optimal method of defunctioning in such anastomoses
Moderate
8 Saghir 2001 121 UK Retrospective observational study Rates and risk factors for stoma-related complications Low
9 Duchesne 2002 164 USA Retrospective case-control study Rates and risk factors for stoma-related complications Low
10 Law 2002 70 China Prospective randomized study Ileostomy or colostomy for temporary decompression of
colorectal anastomosis
Low
11 Kairaluoma 2002 141 Finland Retrospective observational study Complications after temporary stoma creation Low
12 Arumugam 2003 97 UK Prospective observational study Nature and rate of stoma-related complications Moderate
13 García
Botello
2004 127 Spain Retrospective observational study Complications of ileostomy construction and takedown Low
14 Mahjoubi 2010 174 Iran Cross-sectional survey Quality of life of patients with an appropriate stoma site and of
patients with an inappropriate stoma site
Low
15 Harris 2005 345 UK Retrospective observational study Stoma-related complications Low
16 Ratliff 2005 161 USA Prospective observational study Frequency of peristomal complications Moderate
17 Robertson 2005 208 UK Prospective observational study Complication rates at different time points during the
postoperative follow-up period
Moderate
18 Scarpa 2005 24 Italy Retrospective observational study Outcomes of ostomy procedures in the treatment of
constipation
Low
19 Caricato 2007 132 Italy Retrospective observational study Long-term defunctioning stoma complications after colorectal
surgery
low
20 Thalheimer 2006 120 Germany Retrospective observational study Morbidity of temporary loop ileostomy in patients with
colorectal cancer
Low
21 Cottam 2007 3970 UK Prospective observational study Stoma complications within 3 wk of surgery Moderate
22 Kann 2008 3904 UK Narrative review Early stomal complication Moderate
23 Salvadalena 2008 USA Narrative review Ostomy-related complications Moderate
24 Takahashi 2008 102 Japan Retrospective observational study Stoma-related complications in inflammatory bowel disease Low
25 Güenaga 2007 334 Brazil Systematic review Ileostomy or colostomy for temporary decompression of
colorectal anastomosis
High
26 Pittman 2008 239 USA Cross-sectional survey and
retrospective observational study
Demographic, clinical, and quality-of-life variables related to
ostomy complications
Low
27 De Raet 2008 41 Belgium Retrospective observational study Risk factors of parastomal hernia after abdominoperineal rectal
amputation
Very low
28 Mala 2008 72 Norway Retrospective observational study Morbidity related to the use of a protective stoma in anterior
resection for rectal cancer
Low
29 Liu 2008 360 Taiwan Retrospective observational study Risk factors related to the parastomal infection after the
patients underwent emergent stoma creation
Very low
30 Nybæk 2009 199 Denmark Cross-sectional survey Peristomal skin complications Low
31 Rondelli 2009 1529 Italy Systematic review and
meta-analysis
Comparison of temporary loop ileostomy and loop colostomy
for temporary decompression of colorectal and/or coloanal
anastomoses
Moderate
(continues)

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TABLE 2.
Summary of All Studies Included in the Scoping Review Assorted by Date of Publication (Continued)
S No. First Author Year No of
Patients
Country Study Design Focus Grade
32 Sung 2010 1170 South
Korea
Retrospective observational study Rates and risk factors for stoma-related complications Low
33 Nastro 2010 1216 UK Retrospective observational study Rates and risk factors for stoma-related complications Low
34 Pilgrim 2010 90 Australia Prospective observational study Rate and risk factors for parastomal hernia Moderate
35 Parmar 2011 192 UK Prospective observational study Rates and risk factors for stoma-related complications Moderate
36 Krishnamurty 2017 USA Narrative review Overview of stoma complications Moderate
37 Persson 2010 209 Sweden Prospective observational study Evaluation of stoma-related complications and their
association with possible risk factors
Moderate
38 Jonkers 2012 100 The
Nether
lands
Prospective observational study Complication types and rates after stoma surgery Moderate
39 Messaris 2012 603 USA Retrospective observational study Identifcation of factors predictive of readmission after
colectomy/proctectomy and diverting loop ileostomy
Low
40 Person 2012 105 Israel Cross-sectional survey Impact of preoperative stoma site marking on the incidence of
complications, quality of life, and the patient’s independence
Moderate
41 Sohn 2012 165 South
Korea
Retrospective observational study Risk factors of parastomal hernia Low
42 Karaveli
Cakir
2018 60 Turkey Nonrandomized, quasi
experimental prospective study
Effect of preoperative stoma site marking on the health
related quality of life
Moderate
43 Arolfo 2018 1076 Italy Retrospective observational study Stoma-related complications Low
44 Wu 2013 60 USA Retrospective case-control study Risk factors for peristomal pyoderma gangrenosum Very low
45 Dumont 2005 85 France Retrospective observational study Complications after Hartmann’s procedure Low
46 Åkesson 2012 92 Sweden Retrospective observational study Morbidity related to defunctioning loop ileostomy in low
anterior resection
Low
47 Paquette 2013 201 USA Retrospective observational study Readmission for dehydration or renal failure after ileostomy
creation
Low
48 McKenna 2016 59 USA Prospective cohort study Impact of preoperative stoma marking on health-related quality
of life
Moderate
49 Lindholm 2013 144 Sweden Prospective observational study Ostomy-related complications after emergent abdominal
surgery
Moderate
50 Salvadalena 2013 96 USA Prospective observational study Incidence of peristomal and stoma complications during the
frst 3 mo after stoma creation
Moderate
51 Funahashi 2014 80 Japan Retrospective observational study Risk factors for parastomal hernia in patients with permanent
colostomy
Very low
52 Sheetz 2014 4250 USA Retrospective observational study Incidence of stoma-related complications Low
53 Geng 2015 1025 USA Meta-analysis Elective surgical complications related to defunctioning loop
ileostomy compared with loop colostomy after low anterior
resection for rectal carcinoma
High
54 Shabbir 2010 UK Narrative review Overview of stoma complications Moderate
55 Oliphant 2015 222 UK Retrospective observational study Colorectal cancer patients undergoing surgery with curative
intent who received adjuvant chemotherapy
Low
56 Hirsch 2015 115 USA Retrospective observational study Complications after ostomy surgery in Crohn’s disease patients Low
57 Jayarajah 2016 146 Sri Lanka Retrospective observational study Long-term complications of enteral ostomies Low
58 Harilingam 2017 202 UK Retrospective case-control study Prevalence of, and risk factors for, stomal complications Low
59 Carlsson 2016 207 Sweden Prospective observational study Prevalence of ostomy-related complications 1 y after ostomy
surgery
Moderate
60 Koc 2017 462 Turkey Retrospective observational study Factors affecting early stoma complications Low
61 Steinhagen 2017 USA Narrative review Peristomal skin complications Low
(continues)

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reviewed. Abstracts of 307 elements were screened for those
meeting inclusion criteria, resulting in 142 possibly relevant
studies for which full-text articles were reviewed. Seventy-four
elements were excluded mostly due to lack of ability to retrieve
the data for fecal ostomies from cohorts that included both
fecal stomas and urostomies or those that reported fndings
from pediatric and adult patients. Articles were also removed
if full text were not available (at all or in inclusion languages)
or had issues with data reporting. Tis resulted in 68 studies
included in our review.
Descriptive features of elements included in our scoping
reviews are summarized in Table 1. Tey include 4 systematic reviews with meta-analysis of pooled fndings (one was a
Cochrane review), 7 narrative reviews, 2 prospective randomized studies, 13 prospective observational or cohort studies, 3
cross-sectional surveys, and 39 retrospective observational or
case-control studies.
More than 60% of elements included in the review were
of retrospective design, and their quality as per GRADE
ranking was assessed as low or very low. Tese studies were
mostly observational in nature and exposed the risk of bias
related to detecting and properly reporting stoma and peristomal complications without any intentional randomization
according to stoma type or risk factors. A limited number of
prospective or cross-sectional surveys are included in our scoping review; these elements were retained because the risk for
bias was reduced by providing regular assessment for the presence of complications by physicians or nurses during planned
follow-up visits or randomizing the patient to specifc subgroups. We assert that the comparatively small number of systematic reviews with meta-analysis illustrates the generally low
quality of data in this area of care.
Complication Rates
Te reported rates of stoma and peristomal complications are
presented in Table 3. A majority of articles reported stoma
and peristomal complication rates around 40%, though the
range of rates varied widely from 12% to 82%.
9,41,42 Te most
common early ostomy-related complication was peristomal
complications, whereas parastomal hernia was the most common late complication. Multiple studies focused exclusively
on these 2 types of complications.
27,43-50
Peristomal complications were reported in 6% to 74% of
patients.
6,51-53 Peristomal skin complications were reported in
0% to 74% of patients with ileostomies and from 3% to 20%
of patients with colostomies.
6,14,26,51,54,55 Te literature we reviewed also suggested that peristomal complications tend to
be underrecognized and underreported.
We also extracted data related to long-term complications
after ostomy surgery. Te rates of parastomal hernia were reported between 1% and 40%, with a median of 10%.
8,34,43-45,56-58
We found sparse research related to stoma or peristomal
complications occurring 5 years or more after ostomy surgery. Nevertheless, fndings from the literature suggest that
the rate may be as high as 58% for long-term complications
associated with colostomies
5 and as high as 76% for those
living with an ileostomy.
6
Our scoping review also identifed potential systemic complications that were more frequently observed in patients after
ostomy surgery such as the need for postoperative mechanical
ventilation (13.7%), the need for blood transfusion after surgery (8.9%), sepsis (7.9%), and pneumonia (7.1%).
35,59 Shellito60 found the risk of sepsis after surgery for intestinal stoma in
his narrative literature review study was between 1% and 15%,
whereas readmission rates following ostomy creation for dehydration were found in retrospective studies on 201 patients
by Paquette and colleagues
61 and on 603 patients by Messaris and colleagues62 to range from 17% to 43%. In addition,
Messaris and colleagues
62 reported the 60-day readmission rate
was 16.9% (n
= 102) for those with dehydration, the most
common systemic complications in their retrospective study
comprising of 603 patients with loop ileostomies (43.1%).
62
Age as a Risk Factor for Stoma and Peristomal
Complications
Age emerged as a potential risk factor for the development of
stoma and peristomal complications. Age was reported as an
independent risk factor for ostomy-related complications in
12 original studies and was identifed as a potential risk factor
in systematic reviews.
44,61,63-65 Most of the studies reported that
the risk of ostomy complications increases with patients 65 to
68 years and older. Moreover, studies reported that advanced
age was associated with a higher risk of systemic complications
described previously. Nevertheless, fndings from some studies
indicated that only certain complications are associated with
aging whereas others occur more frequently in younger adults.
For example, Sung and colleagues
66 reviewed medical records
in a single-center study and reported that stoma retraction is

TABLE 2.
Summary of All Studies Included in the Scoping Review Assorted by Date of Publication (Continued)
S No. First Author Year No of
Patients
Country Study Design Focus Grade
62 Amelung 2018 361 The
Nether
lands
Retrospective observational
study/systematic literature
research
Ileostomy or colostomy preference in patients requiring
temporary double-barrel stoma construction
Low
63 Qureshi 2018 195 UK Retrospective case-control study Stoma-specifc complications in patients having stoma surgery
in either an emergency or elective setting
Low
64 Ambe 2018 Germany Narrative review Overview of stoma complications Moderate
65 Malik 2018 1009 UK Systematic review Incidence of stoma-related complications High
66 Emmanuel 2018 203 UK Retrospective case-control study Complication rates according to the type of protective stoma in
anterior resection for rectal cancer
Low
67 Andersen 2018 5019 Denmark Retrospective observational study Incidence and risk factors for stoma bulging Low
68 Park 2018 71 Sweden Retrospective observational study Complications after loop ileostomy surgery in patients with
ulcerative colitis
Low

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TABLE 3.
Rates and Risk Factors for Ostomy-Related Complications From Original Investigative Reports Included in the Scoping Review
S.
No.
References Year Overall
Complications
Rate
Peristomal
Complications
Stomal Complications Other Complications Risk Factors for
Ostomy-Related
Complications
M-C
Separation
Parastomal
Hernia
Stoma
Retraction
Stoma
Prolapse
Stoma Stricture
1 Pearl 1987 25.9% 42.1% 13.7% 2.5% 13.2% 5.1% 6.6% Stoma necrosis: 13.7% Surgeon experience
2 Bagi 1992 72% 63% 2% Stoma necrosis: 6% No risk factor identifed
3 Leong 1994 57% 29% 11% 13% 8% 4% Obstruction: 18%
Fistula: 7%
Age
Female gender
4 Bass 1997 53% 28% 2% 7% 1% 2% Necrosis: 6%
Parastomal infection: 4%
Lack of preoperative
stoma marking
5 Park 1999 34% 12.3% early
5.7% late
3.96% 1.18% 4.5% early
1.1% late
1.73% 0.25% Stoma necrosis: 0.3% Age
Operating service
Stoma type
Lack of preoperative
stoma marking
6 Edwards 2001 15% 3% 3% High output: 1% Creation of loop
transverostomy
7 Saghir 2001 68% 36% 17% 13% 14% 3% Bleeding: 3%
Fistula: 2%
Age
8 Duchesne 2002 25% 17% 21% 5% 21% 17% Stoma necrosis: 0.3% Obesity
Inflammatory bowel
diseases
9 Law 2002 22% 14% 1% 0% 4% High output: 1% Creation of loop
ileostomy
10 Kairaluoma 2002 12% 1% 1% 4% 1% Necrosis: 4% No risk factor identifed
11 Arumugam 2003 50.5% 12.37% 12.37% 23.7% Stoma necrosis: 3% BMI
Diabetes
Emergency surgery
12 García-Botello 2004 39.4% 12.6% 3.1% 3.9% 3.1% High output: 0.8% No risk factor identifed
13 Robertson 2005 23.5% Elective: 15%-36%
Emergency:
13%-28%
Elective: 0%-40%
Emergency: 0%-20%
Elective: 16%-23%
Emergency: 0%-22%
Elective: 2%-6%
Emergency: 0%-4%
Elective: 2%-6%
Emergency: 0%-6%
Odor:
Elective: 2%-6%
Emergency: 0%-6%
Creation of ileostomy
14 Ratliff 2005 16% 21% 2% 4%
15 Harris 2005 25% Ileostomy: 6.7%
Colostomy: 7.5%
Ileostomy: 4.5%
Colostomy: 6.8%
Ileostomy: 1%
Colostomy: 3.4%
Fistula:
Ileostomy: 1%
Colostomy: 1.1%
Age
Emergency surgery
Underlying disease
(continues)

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TABLE 3.
Rates and Risk Factors for Ostomy-Related Complications From Original Investigative Reports Included in the Scoping Review (Continued)
S.
No.
References Year Overall
Complications
Rate
Peristomal
Complications
Stomal Complications Other Complications Risk Factors for
Ostomy-Related
Complications
M-C
Separation
Parastomal
Hernia
Stoma
Retraction
Stoma
Prolapse
Stoma Stricture
16 Scarpa 2005 46%2 0% 0% 8.1% 0% 25% 0% Peristomal sepsis: 12.5% Age
End ileostomy
17 Caricato 2007 60% 32% 22% 6% 5% 15% Peristomal abscess: 4% Age > 68 y
18 Thalheimer 2006 13.3% 6.7% 3.3% 1.7% High-output stoma: 1.7% Adjuvant oncologic
treatment
19 Cottam 2007 34% 24% 40% 1.7% Stoma necrosis: 8.7% Stoma height
Stoma type
Age
Female gender
Ulcerative colitis
BMI
Emergency procedure
20 Takahashi 2008 Crohn’s disease:
36.8%
Ulcerative colitis:
17.4%
Crohn’s disease:
1.3%
Ulcerative colitis:
8.7%
Crohn’s disease:
6.6%
Ulcerative colitis:
2.2%
Crohn’s disease:
2.6%
Ulcerative colitis:
4.3%
Crohn’s disease:
5.3%
Ulcerative colitis:
2.2%
Fistula:
Crohn’s disease: 19.7%
Ulcerative colitis: 0%
Crohn’s disease
21 Mala 2008 26% 5% 1% Subileus: 8%
22 Sung 2010 22.1% 15.5% 3.7% 5.8% 7.4% 4.4% 1.4% Stoma necrosis: 2.3% Female gender
BMI
23 Nastro 2010 56% 14.1% 5.9% 5.4% 4.3% Fistula: 6.1% Comorbidity
High ASA score
Cancer as the
underlying disease
24 Parmar 2011 27.1% 5.7% 25.3% 2.3% 32.2% 4.6% Stoma necrosis: 6.9% Colostomy
Short stoma length
(higher BMI)
Emergency surgery
Lack of preoperative site
marking
25 Persson 2010 Loop ileostomy:
79%
End ileostomy:
70%
Colostomy: 53%
Loop ileostomy:
74%
End ileostomy:
60%
Colostomy: 4%
Loop ileostomy:
3%
End ileostomy:
10%
Colostomy: 4%
Loop ileostomy: 0%
End ileostomy: 60%
Colostomy: 24%
Loop ileostomy: 0%
End ileostomy: 0%
Colostomy: 24%
Loop ileostomy: 0%
End ileostomy:
0.5%
Colostomy: 4%
Stoma necrosis:
Loop ileostomy: 5%
End ileostomy: 10%
Colostomy: 20%
Stoma height
(continues)

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JWOCN ¿ Volume 48 ¿ Number 5 Zelga et al 423

TABLE 3.
Rates and Risk Factors for Ostomy-Related Complications From Original Investigative Reports Included in the Scoping Review (Continued)
S.
No.
References Year Overall
Complications
Rate
Peristomal
Complications
Stomal Complications Other Complications Risk Factors for
Ostomy-Related
Complications
M-C
Separation
Parastomal
Hernia
Stoma
Retraction
Stoma
Prolapse
Stoma Stricture
26 Jonkers 2012 82% 55% 15% 6% 9% 6% 3% High output: 5% Inappropriate stoma
siting
27 Arolfo 2018 46% 55% 8.2% 0.3% 3.8% 3.9% Bleeding: 1.3%
Fistula: 1%
Male gender
Ileostomy creation
Lack of preoperative
stoma marking
28 Åkesson 2012 71% 55% 13% 4% High-output stoma: 27%
Obstruction: 13%
Age
29 Dumont 2005 19% ASA score
30 Salvadalena 2013 72% 63% 2% 5% 2% 2% No risk factor identifed
31 Lindholm 2013 55% 13.7%-57% 7.2%-21% 10% 4% 4% 0%-9% Necrosis: 4.5%-7.5% Stoma type
32 Sheetz 2014 43.9% Sepsis: 7.9%
Superfcial SSI: 6.8%
Deep SSI: 2.3%
Emergency surgery
33 Hirsch 2015 38% 4% 3% 0.5% 0% 0.5% 2% Penetrating disease
Use of narcotics before
surgery
Loop ostomies
34 Carlson 2016 35% 11% 20%a 2.4% 1% 1.4% Lack of preoperative
stoma marking
Stoma height
35 Jayarajah 2016 34.2% 15.1% 9.6% 1.4% 16.4% 0.7% …… End ostomies
Lack of preoperative
stoma marking
36 Harilingam 2017 34.2% 8.7% 11.6% 4.3% 30.4% 5.8% 2.9% Performance status
BMI
37 Koc 2017 28.4% 1.1% 19.5 % 0.2% 3.2% Stoma location
38 Amelung 2018 Overall: 37%
Ileostomy: 37.9%
Colostomy: 37.4%
Ileostomy: 0%
Colostomy: 3.4%
Ileostomy: 6.7%
Colostomy: 8.5%
Ileostomy: 0%
Colostomy: 3.4%
Ileostomy: 4.7%
Colostomy: 13%
Ileostomy: 7.9%
Colostomy: 5.9%
High-output ileostomy:
Ileostomy: 16%
Colostomy: 5%
Formation of colostomy
39 Qureshi 2018 30.77% Emergency: 15%
Elective: 5%
Emergency: 23%
Elective: 13%
Emergency: 5%
Elective: 3.7%
Emergency: 5%
Elective: 2.9%
Emergency surgery
Surgeon experience
(continues)

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TABLE 3.
Rates and Risk Factors for Ostomy-Related Complications From Original Investigative Reports Included in the Scoping Review (Continued)
S.
No.
References Year Overall
Complications
Rate
Peristomal
Complications
Stomal Complications Other Complications Risk Factors for
Ostomy-Related
Complications
M-C
Separation
Parastomal
Hernia
Stoma
Retraction
Stoma
Prolapse
Stoma Stricture
40 Emmanuel 2018 57.1% High-output stoma: 12%
Stoma-related bowel
obstruction: 2%
ASA score >3
Laparoscopic surgery
41 Park 2018 49% 23% 6% 1% 4% High output: 18%
Ostomy-Related Complications Focused Studies
Parastomal hernia
42 De Raet 2008 Rate of complication: 46% Other complications: … Risk factors:
Waist circumference
>100 cm
43 Sohn 2012 Rate of complication: 30.3% Other complications: … Risk factors:
Female gender
Age
>60 y
BMI
>25 kg/m2
Hypertension
44 Pilgrim 2010 Rate of complication: 33% Other complications: … Risk factors:
Aperture size
Patient age
45 Funahashi 2014 Rate of complication: 22 (27.5%) Other complications:
Wound infections: 10%
Risk factors:
BMI
Laparoscopic approach
Creation of transperitoneal colostomy
High-Output Ostomy and Readmission
46 Messaris 2012 Rate of readmission: 43% 60-d readmission rate Dehydration rates:
Dehydration: 43.1%
Genitourinary comorbidities: 2%
Risk factors:
Laparoscopic approach
Lack of epidural anesthesia
Preoperative use of steroids and postoperative use
of diuretics
47 Paquette 2013 Rate of readmission: 17% 30-d readmission rate Dehydration rates:
Dehydration: 8.1%
Renal failure with dehydration: 8.9%
Risk factors:
Age
>50 y
Performing ileal pouch anal anastomosis
(continues)

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JWOCN ¿ Volume 48 ¿ Number 5 Zelga et al 425

TABLE 3.
Rates and Risk Factors for Ostomy-Related Complications From Original Investigative Reports Included in the Scoping Review (Continued)
S.
No.
References Year Overall
Complications
Rate
Peristomal
Complications
Stomal Complications Other Complications Risk Factors for
Ostomy-Related
Complications
M-C
Separation
Parastomal
Hernia
Stoma
Retraction
Stoma
Prolapse
Stoma Stricture
Peristomal Skin Complications
48 Liu 2008 Rate of peristomal skin complications: 5.6% Other complications:
Wound infection:
With peristomal infection: 65%
Without peristomal infection: 10.3%
Risk factors:
Obstruction period
Obesity
Operative time
Serum albumin
Serum CRP
Abdominal surgical wound infection laparoscopy
49 Nybæk 2009 Rate of peristomal skin complications: 44.8% Other complications:
Fecal dermatitis: 47.7%
Mechanical dermatitis: 38.8%
Folliculitis: 5.5%
Psoriasis: 2.2%
Nummular eczema: 2.2%
Pyoderma gangrenosum: 1.1%
Risk factors:
Leaking ostomy
BMI
>30
50 Pittman 2008 Rate of peristomal skin complications: 41% Other complications:
Mucocutaneous separation: 70%
Diffculty adjusting the stoma bag: 66%
Stoma leakage: 72%
Fissure: 1.1%
Risk factors:
Age
<60 y
Lack of preoperative stoma marking
Ostomy type
Colon cancer
Rectal cancer as the reason for the ostomy
51 Wu 2013 15 consecutive cases of pyoderma gangrenosum: … Other complications: … Risk factors:
Female gender
Presence of concurrent autoimmune disorders
High BMI
52 Andersen 2018 Rate of peristomal skin complications: 36.2% Other complications: … Risk factors:
Age
Colostomy
Male gender
Alcohol consumption
Impact of Oncologic Treatment on Ostomy Function and Complications
53 Oliphant 2015 At 3 mo, the mean loop ileostomy stoma function score was poorer among the chemotherapy group when compared to the surgery-only group (4.55
vs 1.53). No differences were found when colostomy (2.00 vs 2.62;
P = .411) or end ileostomy (1.00 vs 2.00; P = .170)
Risk factors:
Adjuvant chemotherapy
Loop colostomy
(continues)

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426 JWOCN ¿ September/October 2021 www.jwocnonline.com
more common in patients older than 65 years than in younger
groups (
χ2 = 5.4, df = 1, P = .021) but the risk of stoma
hyperplasia was higher in younger patients (
χ2 = 12.2, df =
1, P = .001).
A minority of researchers found that younger age may increase the overall risk for stoma and peristomal complications.
For example, in a prospective observational study of 3970
patients, Cottam and colleagues
33 reported the risk of stoma
complications decreases with age. Tey found that patients
aged 26 to 40 years had a signifcantly higher rate of stoma
and peristomal complications when compared to participants
aged 71 to 85 years (38.5% vs 31.1%;
P = .009).33 Similarly,
Jayarajah and colleagues
67 retrospectively studied medical records of 192 patients and reported a higher risk of complications in patients younger than 60 years old, though this
difference was not statistically signifcant (
P = .063). Specifcally, participants younger than 60 years developed more
parastomal hernias (3% vs 12%;
P = .06) and hyperplasia
of the peristomal skin (38% vs 23%;
P = .06). Several factors may have influenced these fndings: (1) more than 70%
of participants were younger than 60 years, and younger patients were more likely to undergo ileostomy surgery (50%
vs 14%;
P = .02).
Sex
Sex was identifed as an independent risk factor for ostomyrelated complications in 7 original studies.28,33,44,49,50,66,68 In 5 of
the 7 studies, female sex increased the risk for complications.
Our review also found that some authors reported that female
sex was associated with a higher likelihood of specifc types of
stoma and peristomal complications and that women with ostomies may suffer more frequently from specifc ostomy complications. In a prospective multicenter study conducted in the
United Kingdom of 3970 participants with ostomies, female
sex was associated with overall higher rates of ostomy complications (38% vs 30%;
P < .001).33 Te most frequent complication was ostomy retraction (occurring in 40% of all patients),
followed by mucocutaneous separation. Te same trend was
observed in a large retrospective study in Korea (1170 patients),
in which rates of stoma retraction (11.6% vs 4.2%;
P < .001),
flat stoma (12.4% vs 5.7%;
P < .001), and parastomal hernia (8% vs 4.2%; P < .005) were higher in female patients.
Tere are several possible explanations for these outcomes. In
the single-center retrospective study of 199 patients conducted
by Qureshi and colleagues,
16 a stoma was more often created in
females in an emergent settings whereas males were more likely
to undergo planned stoma creation. Moreover, in prospective
observational studies by Carlsson and colleagues
57 (n = 207)
and Cottam’s group
33 (n = 3970), the researchers postulated
that females may be at a higher risk of developing ostomy-related complications due to having lower stoma height (
P =
.002 and P < .001, respectively) when compared to males.
Tis difference may be related to a higher percentage of females
undoing surgery in emergency settings without preoperative
stoma siting, along with technical difculties during surgery,
precluding creation of proper stoma height. Te authors of this
study and other reports in the literature concluded that lower
stoma height was also influenced by female preference related
to body image.
16,29,33
Male sex was identifed as a signifcant risk factor in
2 studies.
50,68 One was a retrospective single-center study of
1076 patients and the other of 5019 patients and focused on
parastomal hernia/parastomal bulging.

TABLE 3.
Rates and Risk Factors for Ostomy-Related Complications From Original Investigative Reports Included in the Scoping Review (Continued)
S.
No.
References Year Overall
Complications
Rate
Peristomal
Complications
Stomal Complications Other Complications Risk Factors for
Ostomy-Related
Complications
M-C
Separation
Parastomal
Hernia
Stoma
Retraction
Stoma
Prolapse
Stoma Stricture
Impact of Preoperative Stoma Marking on the QOL
54 Mahjoubi 2010 From a total of 9 functional scales, 3 scales in patients with an appropriate stoma site were signifcantly higher than in patients with an inappropriate
stoma site: sexual enjoyment (71.2% vs 63.2%;
P = .02), physical functioning (74.3% vs 68.2%; P = .005), and role functioning (74.3% vs
64.4%;
P = .0001)
Risk factors: Lack of preoperative stoma marking
55 Person 2012 QOL of patients whose stoma sites were preoperatively marked was signifcantly better than that of the unmarked patients (P < .05 in 18 of 20 items) Risk factors: Lack of preoperative stoma marking
56 McKenna 2016 Analysis demonstrated signifcantly higher HRQOL in the marked group compared to the unmarked group (F = 4.9, P = .031) Risk factors: Lack of preoperative stoma marking
57 Karaveli Cakir 2018 Increase in COHQOL-OQ score at the 6-mo period following the frst month interval was signifcantly greater in the marked group than in the unmarked
group (
U = 304; P = .031)
Risk factors: Lack of preoperative stoma marking
Abbreviations: ASA, American Society of Anesthesiologists Physical Status Classifcation System; BMI, body mass index; COHQOL-OQ, City of Hope Quality of Life-Ostomy Questionnaire; CRP, C-reactive protein; HRQOL, health-related quality of life; M-C separation, mucocu
taneous separation; QOL, quality of life.
acolostomy.

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JWOCN ¿ Volume 48 ¿ Number 5 Zelga et al 427
Body Mass Index
Body mass index was associated with an increased likelihood
of stoma and peristomal complications in multiple studies.
10,31,33,37,44,46,47,49,66 Development of peristomal complications (allergic dermatitis, pyoderma gangrenosum) and stomal
complications (parastomal hernia, stoma retraction) occurred
more frequently in participants classifed as overweight and
obese (BMI
25).10,33,37,44,47 For example, in a retrospective
case-control study of 202 patients conducted by Harilingam
and colleagues
37 and a prospective multicenter observational
study of 192 patients by Parmar and colleagues,
10 patients with
BMI 30 or more had a 3 times higher risk of developing ostomy-related complications compared with individuals with
BMI less than 30 (OR
= 3.30; 95% CI, 1.61-6.78).
Underlying Indication for Ostomy Surgery
We found 4 studies that reported early stoma complications
were signifcantly more frequent in patients with malignant
disease as compared to benign disease.
8,17,32,69 In addition,
Malik and colleagues
17 reported higher complication rates
among those with end colostomies due to malignancies in a
systematic review of RCTs with a pooled enrollment of 1009
patients. Talheimer and associates
32 retrospectively evaluated
120 patients in a single-center retrospective study and reported
a higher rate of complications in patients undergoing adjuvant
chemotherapy or combined radio- and chemotherapy than
in patients receiving no additional therapy (25.5% vs 9.2%).
Oliphant and coworkers
69 reviewed the medical records of 222
patients and reported that 3 months after surgery, patients
with a loop ileostomy who received adjuvant chemotherapy
had signifcantly poorer ostomy function scores compared to
those who underwent surgery alone (4.55 vs 1.53;
P = .041).
In contrast, they found there were no differences in ostomy
function scores at 3 months in patients who underwent colostomy (2.00 vs 2.62;
P = .411) or end ileostomy (1.00 vs 2.00;
P = .170).69 Distinct from these fndings, we retrieved a study
that found stoma prolapse occurred less frequently in patients
diagnosed with malignant disease versus benign disease (OR
=
0.330; 95% CI, 0.106-1.027; P = .047).67
Despite a potentially higher risk of stoma and peristomal
complications in patients with underlying malignancies, we
found that clinically relevant rates of stoma and peristomal
complications are observed in patients with IBD, particularly Crohn’s disease, where surgical stoma creation may be a
necessary treatment in the course of the disease.
14,33,34,36,48,70,71
In a retrospective case-control study of 164 patients conducted by Duchesne and colleagues,36 11 (55%) of 20 patients
with IBD were noted to have ostomy complications. Moreover, IBD was a signifcant predictor of ostomy malfunction
(OR
= 4.49; 95% CI, 1.16-17.36).36 Similar results were
obtained by Pittman and colleagues
48 in their cross-sectional,
descriptive case-control study of 239 patients in which they
observed less serious skin complications and ostomy pouch
leakage in patients with colorectal cancer compared to patients with IBD (13.6% vs 30.3%;
P = .003) or intestinal
diverticulitis (18.2 vs 43.6;
P = .0001). In a single-center
retrospective cohort study conducted by Takahashi and associates
34 of 43 patients with ulcerative colitis and 59 patients
with Crohn’s disease, stoma-related complications (fstula,
retraction, and stenosis) occurred more frequently in patients
with Crohn’s disease versus those with ulcerative colitis
(36.8% vs 17.4%;
P < .05).
Comorbid Conditions
Although it is widely known that the presence of signifcant
comorbid conditions may negatively affect the postoperative
course, there is little evidence regarding the development of
ostomy-related complications and which conditions are most
likely to influence the risk for stoma and peristomal complications. In a retrospective study that examined 1216 patients
up to 10 years following creation of a fecal ostomy, Nastro
and colleagues
5 reported 807 complications that developed in
564 patients (46.4%). Comorbid conditions associated with
occurrences of stoma and peristomal complications were heart
disease (OR
= 1.69; 95% CI, 1.18-2.42; P = .004), musculoskeletal disorders (OR = 2.56; 95% CI, 1.61-4.04; P <
.001), cigarette smoking (OR = 1.14; 95% CI, 1.01-1.29;
P = .032), diabetes mellitus (OR = 1.73; 95% CI, 1.13-2.65;
P = .011), and ASA (American Society of Anesthesiologists)
physical status III or IV (OR
= 4.33; 95% CI, 2.60-7.23;
P < .001). An ASA score of more than 3 was also independently associated with the presence of postoperative complications, including stoma and peristomal complications, in a
retrospective case-control study of 203 patients conducted by
Emmanuel and colleagues
72 and a multicenter retrospective
study of 85 patients reported by Dumont and coworkers.
73
Type 2 diabetes mellitus was found to have an independent
association with late peristomal skin complications (
P = .045)
and ostomy located in a crease (
P = .028) in a prospective study
of 97 patients conducted by Arumugam and colleagues.
31 Diabetes mellitus emerged as the only signifcant patient-related
factor for high-output ileostomy (
P = .034) in a retrospective case-control study of 164 patients reported by Takeda and
coworkers.
74 Nevertheless, it is important to remember that
ileostomy is more likely to result in a higher-volume output
than colostomies with subsequent dehydration, electrolyte abnormalities, vitamin defciencies, and malnutrition.
75
Preoperative Stoma Site Marking as a Protective Factor
We found multiple and numerous reports of reductions in frequency of stoma and peristomal complications, along with improved HRQOL in patients receiving perioperative stoma site
marking and education/counseling from a WOC or ostomy
nurse specialist.
8,10,11,16,29,57,76-78 While results from individual
studies differ, fndings from most studies suggest that preoperative stoma site marking by a WOC nurse is protective against
complications. For example, in a prospective, nonrandomized
case-control study of 60 patients conducted by Karaveli Cakir
and Ozbayir
78 fndings showed that preoperative stoma site
marking increased quality of life at the 6-month period following
stoma creation. Tese fndings were similar to those reported by
Mahjoubi and colleagues,
79 Person and colleagues,80 Maydick,81 and McKenna and colleagues,82 who reported that
patients receiving preoperative stoma site marking have signifcantly higher HRQOL scores than unmarked patients.
Mahjoubi and colleagues
79 in a cross-sectional, case-control
study of 348 patients reported that patients with appropriate
stoma sites achieved better results on several functional scores
measured with the European Organization for Research and
Treatment of Cancer Quality of Life Questionnaire EORTC
QLQ-C30 and colorectal-specifc QLQ-CR38 questionnaires.
In the single-center study of 105 patients, Person and colleagues
80 reported that improved HRQOL occurred irrespective of permanent versus temporary stoma surgery or underlying cancer diagnosis. McKenna and colleagues82 reported
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similar fndings in a study of 59 patients who underwent ostomy surgery for the management of an underlying malignancy.
Maydick
81 conducted a survey among 230 participants attending a conference of the United Ostomy Associations of
America. Of the 140 participants who met inclusion criteria
and provided data, the majority (n
= 85; 60.7%) had their
stoma site marked by a WOC nurse. More than 75% of the
participants received preoperative marking, with a signifcant
difference in quality of life for patients whose stoma site was
marked by a surgeon (mean difference in quality-of-life scores
(
M) = 7.71, standard error (SE) = 0.16) or a WOC nurse
(
M = 8.82, SE = 0.37) versus another professional (M =
4.83, SE = 1.05) (P = .19).
SUMMARY OF EVIDENCE
Our review indicates that approximately 40% of patients with
an ostomy will experience 1 or more stoma or peristomalrelated complications.
29,35,37 Peristomal complications were
prevalent and occurred in nearly 80% of all patients experiencing complications. Patients developing these complications
had substantially higher costs of postsurgical care and suffered
from considerable difculty and distress and negative effects
on HRQOL.
20 Most peristomal complications appeared within frst month after the surgery.67 Te most frequent stoma
complications were parastomal hernia, stoma prolapse, and
mucocutaneous separation. With the exception of mucocutaneous separation, stoma complications were more likely to
occur later than peristomal complications.
We found evidence suggesting a number of patient-related
risk factors. Tey included nonmodifable factors: age more
than 65 years; female sex; concurrent diabetes mellitus; and
IBD or cancer as the underlying cause for ostomy creation.
Emergency surgery also emerged as an identifed independent risk factor associated with ostomy-related complications,
but we did not classify this factor as patient related.
83,84 Evidence further suggests that a combination of factors present
the greater risk of complications.
33 For example, higher BMI
is associated with a higher incidence of multiple stoma- and
peristomal-related complications and in such patients it is of
importance to properly mark the stoma site and have a stoma
height above the level of the skin.
66 Evidence concerning differences in specifc complications based on fecal ostomy type was
weak. Limited evidence suggests that colostomy, and especially
loop colostomy, is associated with an increased risk of prolapse
and parastomal hernia.
10,11,17 Te strongest evidence supports
creation of a loop ileostomy versus a loop colostomy because
it is associated with a reduced likelihood of stoma-related and
systemic complications.
38,85,86 Finally, we found evidence suggesting preoperative stoma site marking by a WOC or ostomy
nurse specialist acts as a protective factor reducing the likelihood of peristomal complications and impaired HRQOL.
GAPS IN EVIDENCE
Although the presence of comorbid conditions such as diabetes mellitus was found to be associated with an increased
likelihood of stoma and peristomal complications, we found
no studies that provided the direct evidence regarding association between the presence and grade of comorbid conditions based on a cumulative risk scale such as the Charlson
Comorbidity Index and development of the stoma or peristomal complications. We also observed lack of a unifed grading
system for reporting severity of stoma or peristomal complications.
LIMITATIONS
Although 4 RCTs, Cochrane systematic reviews, and systematic reviews were included in this analysis, most evidence in
our review was retrieved from observational studies or uncontrolled case series with a high risk of bias, limited follow-up,
and small sample sizes. Use of the GRADE instrument for
study bias revealed that the majority were graded as low or
very low, supporting our conclusions regarding a paucity of
high-quality studies of stoma and peristomal complications
among patients living with a fecal ostomy.
CONCLUSION
We completed a scoping review and found research related
to 5 factors associated with an increased likelihood of stoma or peristomal complications: (1) age more than 65 years;
(2) female sex; (3) BMI more than 25; (4) diabetes mellitus
as a comorbid condition; and (5) abdominal malignancy as
the underlying reason for ostomy surgery. We found a single
protective factor: stoma site marking and care by a WOC or
ostomy nurse specialist. Research indicates that up to 93%
of all ostomy surgical services incorporate a WOC or ostomy
nurse specialist as part of their health care team.
87 Follow-up
of the patient by a WOC nurse and a physician should include both the immediate postoperative period and over
time because ostomy complications that may need surgical
intervention develop in the late postoperative period, mostly
within the frst 6 months after stoma creation. Further research is needed to improve the evidence-based surgical decision-making regarding the type of stoma and its placement as
well as prevention and management of stoma and peristomal
complications.
ACKNOWLEDGMENT
Te authors wish to thank Michal Mik for comments when
preparing the manuscript. Tis research is partially supported by the European Social Fund (ESF) funded by the
National Center for Research and Development (grant no.
POIR.04.01.01-00-0066/18).
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