A systematic review and meta-analysis of randomized controlled trials comparing interventions for peristomal skin care

Standard skin care procedures for percutaneous endoscopic gastrostomy (PEG) tubes and peristomal skin care for colostomy and ileostomy patients are not always sufficient to prevent peristomal skin problems. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to compare the effectiveness of standard peristomal skin care to adjunctive techniques or barriers (including glycogel dressings, gelatin- and pectin-based skin barriers, glycerin hydrogel wound dressing, Acacia senegal fiber pockets, hydrocolloid powder crusting, and German chamomile) to manage or treat patients with a stoma. Using systematic literature search techniques, all healthcare databases were searched up through September 2014. No language restrictions were applied. Studies were included if they met criteria for published RCTs or quasi-RCTs that evaluated the outcome of standardized peristomal skin care and other adjunctive techniques or barriers used among patients with a stoma or PEG tube. A meta-analysis was performed to calculate a pooled effect size by using random-effect models for the primary (skin irritation/reaction) and secondary (length of pouch wear time) outcomes. Six RCTs comprising 418 total patients were identified. Four evaluated the outcome of colostomy or ileostomy peristomal skin care, and no significant differences were detected in the incidence of skin problems (RR 0.67; 95% CI: 0.31-1.41). In the two studies that included length of pouch wear time, no significant differences were observed (RR 0.48; 95% CI: 0.03-7.97). No significant differences were seen in the rate of skin irritations of gastrostomy patients (RR 0.56; 95% CI: 0.20-1.59), but the difference in treatment outcomes of peristomal damage in patients with a colostomy was significant (P = 0.01). The limited number of studies, study quality, heterogeneity of variability in peristomal care strategies and techniques, clinical factors, and nonuniform reporting of clinical parameters contributed to the heterogeneity among the trials. Well-designed RCTs are needed to investigate the efficacy of various barriers and techniques for peristomal skin care and to help develop evidence-based standards of caring for the skin of patients with a colostomy, ileostomy, or gastrostomy.

The ileal pouch anal anastomosis: past, present, and future

The modern era of ileal pouch anal anastomosis began just over 20 years ago. Several areas remain controversial, including patient selection, surgical technique, use of a temporary diverting ileostomy, aging sphincters, complications, and postoperative management. This article reviews current controversies concerning ileal pouch anal anastomoses and our approach to managing patients who undergo this complicated procedure.

The state of the standard diversion

A fecal or urinary diversion is frequently recommended for a variety of patient conditions. This article will review some of the history of stoma creation, discuss current practices in stoma care, and summarize the current literature regarding stomal complications. Outcomes of fecal and urinary diversion procedures will be depicted, and postoperative quality of life will be described. An update of current ostomy equipment will be presented, along with the crucial role of the WOC nurse in stoma care rehabilitation. Areas for future research in the ongoing drive for evidence-based practice will be highlighted.

[Changes in colitis surgery. II: Corrective interventions and conversion operations]

Over a period of 9 years in 48 patients already operated on for ulcerative colitis secondary surgical interventions had to be planned. 25 patients had an ileostomy (IS), 10 a Kock-pouch (KP), 11 an ileoanal pouch (IAP) and 2 an ileorectal anastomosis (IRA). Whereas in 4 patients only the subjective wish for another procedure with better quality of life predominated, in 44 patients (91.7%) also objective, sometimes multiple indications for reoperation existed. In 37 patients main indications were complications or dysfunctions of the preexisting procedures, combined with the need for further resection of the colitis in 6 of them. Resection of the residual colitis was the main indication in the remaining 7 patients. The aim of the reoperation in all patients was both complete elimination of the eventually persisting colitis and restoration of quality of life in the best way wished or possible. Our of 25 IS 3 remained, 3 were reconstructed, 17 were converted to KP and 2 to IAP. Out of 10 KP one remained and in 9 corrective surgery of the nipple valve was performed. Out of 11 IAP 2 had to be resected with construction of IS, 5 were converted to KP and 4 were corrected. Two IRA were converted to IAP. The rate of early complications was 8.3% (n = 4), lethality was zero. Late complications occurred in 13 cases (27.1%) and were associated ten times with KP. Complications of KP decreased with time to zero due to technical modifications. They could always be corrected restoring function. Since only one KP had to be resected due to severe pouchitis, KP was an important secondary procedure for 31 out of 48 patients also in the long-term course ensuring both complete elimination of colitis and good quality of life owing to voluntary fecal control.

[Changes in colitis surgery. I: Is there a standard in primary surgical treatment?]

In a 15 years period surgery of ulcerative colitis expanded from ileostomy (IS) via Kock's pouch (KP) and ileoanal pouch (IAP) to ileorectal anastomosis (IRA). Interactions between availability of methods and frequency of operations are investigated retrospectively in order to establish an optimal primary procedure. With an overall amount of 80 operations the yearly operative frequency raised in correlation to the introduction of continence reconstructive procedures. As a consequence of this fact history of disease was shortened to less than 8 year and global colitis-associated morbidity markedly decreased. For patients readiness to undergo operation Kock's pouch was only important at the beginning (n = 9/11.3%). Most decisive was IAP (n = 49/61.3%) which could be realized last even in an one-stage-procedure with better early results due to improved patients conditions and simplified technical modifications. IRA (n = 7/8.8%) played only a limited role in the last years for selected patients, whereas IS (n = 15/18.8%) kept reserved for contraindications to reconstructive surgery. For all procedures operative complications decreased from 46.1% (12/26) to 11.0% (6/54) and lethality to 0%. Late complications were related to proctectomy (nerve damage) and construction of IAP (pouchitis in 34.8% and defunctioning of the pouch in 10.4%), whereas IRA was free of specific morbidity so far. Surgery of ulcerative colitis is characterized today by restoration of anal continence. The advantage of the changed surgical concept lies within the ability to perform colectomy at an earlier stage of the disease. Safe construction of IAP is the most important technical progress. Early operation of colitis and late morbidity of pouch justify (preliminary) IRA. Thus, surgical standard in colitis-surgery is defined more individually.

Evolution of ileostomy surgery

Ileostomy in association with proctocolectomy in one or two stages is the accepted treatment for ulcerative colitis. There are many difficulties in managing the permanent ileostomy in spite of improvements in design and construction, in availability of stomal appliances and in better skin protection and adhesive materials. The collection and storage of excrement in a bag outside the body imposes severe difficulties. To eliminate these problems an alternative ileostomy method, the continent ileostomy, was devised and the clinical results achieved in 314 patients are reported. There was a 2.2% overall operative mortality but no operative deaths in the last consecutive series of 152 patients. The nonfatal complication rate has decreased from 24% to 7% and revision because of a malfunctioning outlet valve has decreased from 54% to 6%. At follow-up 94% of the patients were continent. Except for a slightly increased loss of bile salts and a potential risk of decreased vitamin B12 absorption no harmful effects of the reservoir procedure have been found after observation times up to 12 years.