Risk factors associated with the development of elimination stoma and peristomal skin complications

Background: Stoma formation leads to changes that are influenced by several factors, namely the presence of stoma and/or peristomal skin complications. It is estimated that 80% of ostomy patients have at least one stoma-related complication throughout their life. Objectives: To identify the risk factors associated with the development of elimination stoma and peristomal skin complications. Methodology: Literature review, based on the methodological strategy of the Joanna Briggs Institute for scoping reviews. A total of 1,492 articles were identified, of which 22 were included for analysis. Results: Most of the risk factors for the development of complications are non-modifiable. Pre and postoperative education, stoma site marking, and follow-up after hospital discharge are some of the nursing-sensitive factors. Conclusion: The identification of risk factors associated with the development of stoma complications allows nurses to early identify patients’ vulnerability indicators and intervene more effectively.


Introduction
In recent years, the number of people with colorectal cancer has increased and, consequently, so has the number of ostomy surgeries (Vonk-Klaassen, de Vocht, den Ouden, Eddes, & Schuurmans, 2016).Stoma formation is a life-changing event that can be both physically and psychologically agonizing (Di Gesaro, 2012;Slater, 2010), and have a strong impact on patients' quality of life (Jayarajah, Samarasekara, & Samarasekera, 2016).One of nurses' objectives is to help ostomy patients by minimizing the impact of this event on their lives, thus it is essential to analyze the factors influencing patients' quality of life, namely stoma-related complications (Jayarajah et al., 2016;Pittman, Kozell, & Gray, 2009).A significant number of ostomy patients have at least one stoma-related complication throughout their life, which affects the person's ability to care for the stoma, and, consequently, leads to psychosocial problems, increased morbidity, and increased healthcare-related costs (Sung, Kwon, Jo, & Park, 2010).Indeed, the management of complications requires frequent visits of health professionals, hospital admissions, and possibly new surgeries that have a negative economic impact on the patient and the healthcare system (Jayarajah et al., 2016).Given that the reported incidence of stoma and peristomal skin complications can reach up to 84% (Formijne Jonkers et al., 2012;Pittman, 2011), the identification of the factors that contribute to the development of these complications will help identifying those patients who are at higher risk of developing them.In this review, the following peristomal skin complications were considered: dermatitis, erythema, ulcers, and granulomas.The following stoma complications were also considered: poor positioning (which requires, at least, one effluent collection device during 24 hours), retraction (stoma lumen below skin level), mucocutaneous dehiscence, necrosis, peristomal hernia, prolapse, stenosis, stoma mucositis, fistula, hemorrhage, and ischemia.A preliminary literature search in the CI-NAHL database using the terms ostomy and complications revealed that some research studies suggest the existence of factors associated with a higher incidence of complications.However, no literature review was found that specifically identified the risk factors for the development of stoma and peristomal skin complications.Thus, the development of this review emerged from the lack of formal nursing knowledge about the risk factors associated with the development of stoma and peristomal skin complications, as well as their importance in the planning of interventions for this population.The main objective of this review was to identify risk factors associated with the development of elimination stoma and peristomal skin complications.To this end, the following research question was formulated based on the mnemonic PCC (Population, Concept, and Context): What are the risk factors associated with a greater development of elimination stoma and/or peristomal skin complications in adults aged over 18 years in hospital settings or after hospital discharge?Methodological procedures were described in a previously established protocol (unpublished for lack of time), including the objectives, the inclusion criteria, and the methods to be used.

Methodological procedures of integrative review
A scoping review of the literature was conducted on the risk factors associated with the development of stoma and peristomal skin complications, following the Joanna Briggs Institute methodology (Peters et al., 2015) and the guidelines established by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) model.Studies were identified through a search conducted on 24 March 2017 in the MEDLINE Complete, Cochrane Library Plus, and CI-NAHL Plus With Full Text databases, using a combination of several MeSH terms and natural language.The following inclusion criteria were applied: studies that included patients aged over 18 years; with an elimination ostomy; who had developed stoma or peristomal skin complications; in the postoperative period (hospital or community); primary or secondary studies, qualitative or quantitative, published in Portuguese, English, or Spanish, between 1 September 2010 and 28 February 2017.This publication timeframe was set because there was already a literature review on this topic that integrated the existing evidence until 2010 (Pittman, 2011).
A relevance test (Pereira & Bachion, 2008) was designed using a list of direct questions to evaluate the relevance of the studies for the purpose of this review.Studies were initially evaluated after reading their title and abstract, resulting in affirmative or negative answers.Articles with at least one negative answer were excluded from the analysis.The application of the relevance tests and the selection of articles were independently performed by two researchers.In case of disagreement about the inclusion of an article, a third researcher was consulted.
All articles included through the application of the relevance test in the first phase were then subjected to the same process in the phase of full-text article reading.

Interpretation of results
Stomal and peristomal skin complications have a significant impact at personal, social, and economic levels (Pittman et al., 2009), which translates into a lower perceived quality of life, social isolation, longer hospital lengthof-stay (S13), increased use of primary health care services (S13), and more follow-up visits (S17).The following treatment-related factors were identified: stoma type and positioning, namely ileostomy, colostomies with <5 mm in height, ileostomies with <20mm in height, positioning in the left side or in the abdominal wall, the presence of more than one stoma, the longer distance from the navel, high output stomas, presence of liquid effluents, and oval stomas.Factors related to the surgical approach were also identified, namely emergency surgery, retention sutures, abdominal wall defect bigger than 25mm in diameter, and the use of laparoscopic or transperitoneal approach.Stoma height, shape, and size may influence the se-lection and adaptation of collection systems to the skin, leading to skin complications resulting from the contact with effluents.The type of ostomy, namely ileostomy, can also contribute to peristomal skin complications due to the characteristics of the effluents.Stoma positioning may also hinder the adaptation of collection systems.
The following sociodemographic factors were highlighted: age, female gender, and body mass index (BMI) over 25kg/m 2 .The latter factor is associated with intraoperative difficulties related to the surgical technique, as well as with the subsequent selection and adaptation of collection systems in large abdomens.
Old age emerges as a condition that may be associated with the risk of complications, namely peristomal skin complications, as a result from the increased skin's sensitivity to collection systems, effluents, and friction of devices due to the patient's thinner keratin (Hellman & Lago, 1990).The higher prevalence of complications in women may be associated with a greater abdominal muscle weakness and, possibly, with obesity.It should also be noted that the literature is sometimes inconsistent given the fact that some articles identify age and gender as risk factors (S13, S4, and S21), while others contradict it (S10, S15, S16).Therefore, both factors should be included as potential risk factors for the development of complications and analyzed individually.
The factors related to health resources included the lack of preoperative stoma site marking, of preoperative information, of perioperative monitoring by a stoma therapy nurse, and of follow-up after hospital discharge.The type of device was also identified as a risk factor for peristomal complications.
In fact, preoperative marking facilitates the selection of the stoma site in order to improve the adaptation of the collection system and the patient's comfort in the postoperative period.On the other hand, the characteristics of each type of stoma may require the use of different types of devices to ensure its effectiveness.The change in the shape and size of the stoma during the first days after surgery may also require a readjustment of the device to prevent leaks and skin problems.Therefore, patients should be followed-up by nurses with experience and knowledge in this specific area and materials.
In view of these results, it is clear that there are many factors and that several of them can be present simultaneously.Thus, since a comprehensive analysis of the identified factors is essential, they were divided into modifiable and non-modifiable factors.
The identification of non-modifiable risk factors is important because it enables nurses to profile patients who have higher risk of who have higher risk of developing complications.The early identification of sociodemographic and clinical indicators of vulnerability will enable nurses to establish an intervention plan that takes into account these factors and contributes to the prevention or early detection of complications.
In relation to modifiable factors, given the type of research, only nursing-sensitive factors were analyzed.Therefore, it should be noted that there are several key factors for the development of complications which are associated with nurses' performance.First, the impact of stoma devices on the development of complications should be highlighted.Since nurses are capable of influencing the choice of devices, they play a key role in the selection of the most adequate devices for the stoma.Therefore, nurses should be aware of all the available devices to be able to choose the most appropriate ones to the specificities of each stoma.It is also important that teams caring for this group of patients include experienced nurses with differentiated knowledge, such as stoma therapy nurses.Teams to make the right choice based on these professionals' knowledge about the available resources and experience in their use.Stoma site marking and pre and postoperative information emerge as protective factors in the development of complications.People who had the stoma site marked and received preoperative education by a nurse had lower anxiety levels (Millan, Tegido, Biondo, & García-Granero, 2010), a significantly better quality of life, improved confidence and independence in stoma care, and fewer postoperative complications, regardless of the stoma type (Person et al., 2012).
Patients who are more informed, know how to identify the causes of complications, monitor their stoma, and care for it properly are less likely to develop complications, not only because they are more competent in self-care, but also because they are able to early identify indicators of potential complications.Indeed, prevention and detection of complications is a key aspect of the self-care competence of patients with an intestinal elimination ostomy (Pinto, Santos, Brito, & Queirós, 2016).
With regard to the methods used for assessment and measurement of complications, most studies only reported the presence or absence of complications rather than using validated instruments.The use of validated instruments for the assessment and report of complications allows health professionals to elaborate better and more consistent clinical descriptions.However, the development of forms to report the presence of complications seems to be a simple, intuitive, easy to apply, and useful tool to standardize and ensure continuity of care in the data collection process (Nybaek, Knudsen, Laursen, Karlsmark, & Jemec, 2010).
Results should be interpreted with caution, given the limitations identified in the studies, particularly the fact that most of the included studies were retrospective, descriptive, and cohort studies using nonprobability sampling.Other limitations of this review included the lack of grey literature, the publication timeframe, and the number of searched databases.

Conclusion
This article contributes to the identification of risk factors for the development of stoma and peristomal skin complications, which allows nurses to early identify patients who are more vulnerable to these complications.Most of the identified factors are non-modifiable factors.However, some aspects are sensitive to nursing care and contribute to reducing the incidence of complications or early identifying their presence, thus promoting a better quality of life for patients with an elimination stoma.Two factors should be highlighted: pre and postoperative education, with the purpose of maximizing stoma self-care skills, and systematic follow-up after clinical discharge.
Most of the complications associated with the presence of an elimination stoma are peristomal skin lesions.Therefore, a significant number of complications can be prevented through the promotion of stoma self-care skills among patients or family caregivers.

Implications for nursing research and practice
From a research perspective, the authors suggest the development of studies on the association between risk factors and the development of complications, as well as of systematic literature reviews on the effectiveness of nursing interventions in reducing stoma and peristomal skin complications among adults with elimination stomas.
The scientific community should also operationalize the concept of stoma and peristomal skin complications and determine the most appropriate instrument for their identification and measurement.
Based on the modifiable and non-modifiable risk factors for the development of stoma and peristomal skin complications, it is essential to implement nursing intervention programs that can lead to better outcomes in patients with an elimination stoma, namely training for self-care, surveillance, and follow-up in order to prevent and/or early identify the presence of complications.
It is also essential to increase the number of nurses who are able to mark stoma sites in emergency and inpatient units, because only then will this intervention be possible for every patient selected for ostomy surgery. Fig Table 1 describes the search strategies used for each database.