MULTIPLE SCLEROSIS

CHOOSING THE RIGHT POUCHING SYSTEM

  In certain cases, when severe inflammatory bowel disease (IBD) affects the colon, ostomy surgery may be required. Although this procedure has been the passport to a healthier, more active life for thousands of people, its initial impact often is emotionally and physically traumatic. Choosing a pouching system (also known as an ostomy appliance) that is right for you can make your adjustment to an ostomy considerably easier.

People with IBD may undergo two types of ostomy surgery. If all or most of the colon must be removed, the surgeon will create an ileostomy by bringing the end of the small intestine up to an opening (a stoma) made on the abdomen. If only part of the colon is removed, the end of the large intestine is used to create a stoma. Fecal matter (known as effluent or output) drains into a pouch that is worn over the stoma. Today, many people can opt for an ostomy alternative (e.g., pull-through surgery), which eliminates the need to wear the external pouch. But some patients are not suitable candidates for these procedures, while others prefer a standard ostomy.

For the healthcare professional who is caring for a person who has just undergone ostomy surgery, the biggest challenge is selecting an appropriate pouching system. As an Enterostomal Therapy (ET) nurse with 18 years of experience, I can honestly tell you that I really don't know which pouching system is right for a person. Oh yes, I know what type of wafer is indicated for various types of output, and whether additional skin protection should be provided by utilizing skin barrier pastes or strips. But only you--the person with the ileostomy or colostomy--know for sure what pouching system is right for your needs.

Why do I say this? Because my years of experience have shown me that the right pouch for the patient is the pouch the patient says is the right pouch. After all, living day in and day out with a pouching system is the only true test of how the system affects a person's daily life. There are many options and factors to be considered. For example, a person whose output is frequent may prefer a pouch that can be emptied without being removed from the abdomen. On the other hand, people with irrigating colostomies, who are able to regulate their bowel movements by giving themselves an enema through the stoma, may need only a security pouch, or even a gauze pad. The key questions that must be answered are: Does a person feel secure when wearing a particular pouching system? Does it help her feel confident when interacting with family, friends, and co-workers? Does the way the pouch appears on the body or under clothing positively or negatively affect how one feels regarding sexuality? Do these feelings affect the ability to interact sexually?

I believe that my role as an ET nurse is to recommend a pouching system that meets the person's individual clinical needs. The appliance should provide a sustained and reliable wear time, prevent leakage, contain stool and gas, and protect the skin around the stoma. It also must be compatible with the patient's self-care ability and lifestyle, while providing a sense of physical and psychological security and well-being.

One or Two-Piece?
To make an informed decision, it is important to understand the differences between a one-piece and a two-piece pouching system. A two-piece system consists of a body side skin barrier (a pad that covers and protects the area around the stoma) with flange (a rim that holds the pouch in place on the skin barrier), and a detachable pouch. Such systems are versatile and allow the pouch to be positioned on the flange according to individual preference. They permit access to the stoma because the pouch can be removed from the flange without removing the entire system from the abdomen.

One-piece systems are pouches in which the skin barrier, faceplate (the disk-shaped section that sticks to the skin around the stoma), and pouch are manufactured as one unit. These systems are flexible, lightweight, and, depending upon manufacturer, usually have a low profile under clothing. No assembly is required, and they can be applied to the abdomen in one step. If you wish to examine the stoma or the skin around it, however, the entire system must be removed from the abdomen.

Which Pouch?
For IBD patients who have ostomies, two types of pouching systems are available: drainable and closed-end. Drainable pouches have a wide spout at the bottom that is closed with a plastic tail closure. To empty the appliance, the tail closure is removed and stool is drained directly into the toilet. Closed-end pouches have no opening at the bottom and must be removed for disposal or emptying.

Each type of pouch is available in a variety of sizes and lengths to accommodate the quantity of output, short torsos, clothing, lifestyle, activity, self-care ability, or personal preference. There even are pouching systems designed especially for children.

Ostomy appliances are also available in a variety of fabrics. Some people prefer an opaque material that conceals the pouch contents, while others prefer transparent material so that they can see the stoma and its output.

For years, ET nurses in the U.S. have been taught that people with ileostomies, non-irrigating colostomies, or colostomies created in the transverse or ascending colon should be fitted with drainable pouching systems. It was almost "taboo" to fit one of these patients with a closed-end pouch. Perhaps this rule, once "carved in stone," needs to be re-evaluated in the '90s. Interestingly, in Europe and other countries, people regularly use closed-end pouches to manage these types of ostomies. Indeed, some persons find these pouches easier to use than drainable systems. It has been my experience that closed-end pouching systems can have a dramatic affect on the quality of life for some people, regardless of the type of surgery they have.

Which is the Best Skin Barrier for Me?
Skin barriers protect the skin around the stoma from the acids and enzymes in the stool. They also can help create a level pouching surface if there are folds, creases, scars, or wrinkles in the skin around the stoma. Some skin barriers are used to treat skin problems associated with pouch leakage or allergic reactions to products. Skin barriers are available in a variety of forms: rings, wafers, flanges, paste, powder, and strips.

Skin barriers vary with regard to durability and resistance to erosion. Basically, there are three types: karaya (a polysaccharide gum), pectin-based, and extended-wear. The most recently developed are the extended-wear. These skin barriers have improved the condition of the skin around the stoma and have more than doubled pouch wear time for some patients.

Adapting to "Difficult" Stomas
Sometimes, the stoma may not protrude enough. There may be skin surface irregularities around it, or it may be at or below skin level. This also can occur when a person who has undergone ostomy surgery regains the weight lost due to IBD. In these cases, an outward curving on the back of a flange, which "mirrors" the uneven skin surface (called convexity) can improve the pouch seal and protect the skin around the stoma from leakage and damage. The outward curving is manufactured into the faceplate or flange or is created by adding rings or skin barriers to a flat flange.
If you are unable to maintain the seal on your pouching system for a minimum of 24 hours, or if you are plagued with persistent skin problems, you should visit an ET nurse for an evaluation of your management system. Once the ET nurse solves the clinical problems, you may search among the variety of pouches and accessories available today, to find the pouching system that is right for you.

Gwen B. Turnbull, RN, BS, CETN