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Mechanical Management of the Ileostomy Stoma
Symposium on Diseases of the Colon and Anorectum
Mechanical Management of the Ileostomy Stoma
AlbertS. Lyons, M.D.,* and Marlene J. Brockmeier, R.N., M.A.**
Full rehabilitation of the patient with an ileostomy depends on a well constructed stoma, efficient mechanical management, and psychological adjustment. All three are related. Upon the construction of the stoma can depend the success or failure of the management, and while psychological adaptation depends on many factors, a poorly managed ileostomy can make adjustment difficult or impossible in even the most stable and accepting person. There is a necessity for the surgeon, as well as the nurses, the stomal therapist, or the visiting chairmen of ileostomy clubs, to be knowledgeable on the details of stomal management. The surgeon should not neglect his responsibilities in instructing and caring for the patient. Each member of the team has a role to play. This report is limited to management of the ileostomy appliance and accessories. It does not concern itself with complications or difficulties in management. These are separate subjects in themselves. Since there is a multiplicity of appliances, all cannot be mentioned, and therefore only a general classification is presented together with a discussion of the principles of each type. t Nor is the material intended to be comprehensive, as this would be both cumbersome and unwise. Published bulletins and manuals of the United Ostomy Association and local ileostomy clubs are sources of additional information. Location of the Stoma Although this article deals only with appliances, the location of the stoma is of prime importance in the adequate management of an ileostomy.2 The stoma should be placed in such a way that it will enable the tit should be understood that while some brand names are mentioned, this is done solely for the purpose of illustration, and there is no intent to suggest that one particular product is superior to or preferred over another. *Associate Clinical Professor of Surgery, Mount Sinai School of Medicine; Chief, Intestinal Rehabilitation Clinic, Mount Sinai Hospital, New York, New York **Nurse-Clinican, Department of Nursing, Mount Sinai Hospital, New York, New York Surgical Clinics of North America- Vol. 52, No.4, August 1972
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disk of an appliance to clear the anterior superior spine and also, if possible, to allow a belt to be worn, if it is so later desired by the patient, without its pulling up the appliance against the stoma. Thus the stoma should not be situated too low or too lateral. Other considerations have to be borne in mind, such as the scar of the main laparotomy incision, other scars and depressions, the navel, the rib margins, and the pubis. However, the anterior superior spine and the waist fold are the only landmarks that have to be avoided at all costs. The others can be overcome. Therefore, it is a wise practice to have the patient wear a sham appliance, if possible before the operative procedure. In this way, the optimum location can be best determined. Other surgeons prefer to use measurements by means of a circular disk. Some prefer to make the measurements in the operating room although this has the limitation of choosing the spot with the patient supine, and therefore may not allow for other requirements with the patient in different positions. The important point is that the location should be chosen before the operation no matter what method is used.
Length of the Stoma The second important requirement is that the ileostomy stoma project above the skin surface. Those surgeons who have written of their preference for a flush stoma, would find that such advocacy before a group ofileostomates would bring denunciation. A flush stoma makes the application of any appliance difficult and in some instances impossible. This is quite different from a sigmoid colostomy which can be managed well without an appliance or with only an adjunctive appliance. In the United States, most ileostomates consider a length of a half inch to three-quarters of an inch the optimum. On the continent of Europe and in England, stomas of an inch to two inches seem to be preferred.
CHOOSING THE APPLIANCE Surgeons are sometimes too dogmatic about the choice of an appliance, often considering one particular brand as the only suitable mechanism. Wide experience in attending both clinics and club meetings throughout the country discloses a great variety of preferences in different localities. Even in any one particular region, while a predominant type of appliance is used, there are always a substantial number of people who prefer different ones. In some geographic locations, particular appliances are more accessible than others and this fact can be a factor in choice. A good principle is to choose one or two types to start with and then to encourage the patient to learn of others, especially by attending local and national meetings and by receiving the United Ostomy Quarterly Bulletins.
When to Use an Appliance Some protective device should be placed over the skin surrounding an ileostomy immediately after completion of the procedure in the
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operating room. Often one of the flimsier but transparent pouches is most suitable for this maneuver. More sturdy appliances may be ordered from 5 days to 3 weeks or longer after the operation. The determining factors are the amount of swelling, the changing size or shape of the ileostomy, requiring changes in the tailoring of the appliance opening, and the need to observe the functioning of the stoma itself. Theoretically there is no reason not to use a permanent appliance immediately in the operating room, but in practice the postoperative types of pouches are more serviceable in the early days.
The Postoperative Pouches The postoperative pouches all have some type of adaptable face plate which can be modified, frequently if necessary, to fit the early stoma. Face plates of adhesive-backed pouches (e.g., Altantic, Marsan) are cut to fit the stoma, leaving approximately 1/16 inch between face plate and stoma. When removing this pouch, many prefer to use an adhesive solvent. It is important to use only a small amount as the solvent itself can be irritating to the skin. Others remove the pouch by lifting with one hand while the other gives counter pressure on the abdomen. Further skin protection can be provided by using washers or gaskets on the skin exposed around the stoma. One such gasket is the Karaya gum doughnut. Karaya gum stoma pouches, using the gasket as the main face plate (e.g., Hollister), are available in various sizes up to 3 inches. The Karaya gum can be molded to fit closely against the stoma. In as much as this material becomes jelly-like and soft, it can cause no harm to the ileum. This type of pouch is very easily removed from the skin, as Karaya gum is water soluble. The adhesive-backed and the Karaya gum pouches are both one-piece units, easily emptied from the bottom without removing the pouch from the patient. Adhesive-backed pouches may stay in place for at least 3 or 4 days without leakage. Karaya gum pouches usually will remain in place for at least 24 hours and sometimes longer, but this will vary, depending on perspiration, weather conditions and body temperature. Although these pouches are referred to as "postoperative" units, some patients have preferred to use them on a long term basis. This preference is related to the ease of application and of removal of the pouch, as well as to their disposable characteristics. Types of Appliances Appliances may be classified according to a variety of characteristics, each of which has advantages and disadvantages. Further more, there are so many different types of appliances that each has a number of properties which overlap different categories. One-Piece and Two-Piece Appliances ONE-PIECE DEVICES. These are relatively simple to use. They last from 3 to 8 months and sometimes longer, depending on the effect of the ileal emanations on the materials. Usually the patients have three appliances at the same time: one in place on the abdomen, one hanging and drying after being washed, and one put away ready for use. They require
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little dexterity to be applied, and since the attachment of bag to disk is part of the construction, no leakage is possible at that junction. The usual type (e.g., Permatype, Rutzen) is apt to lie flat against the abdomen and is therefore cosmetically agreeable. One does have to remove the entire appliance when it is changed. Of course, for emptying, one has only to open the spout at the bottom. In this respect, there is no difference between one-piece and two-piece appliances. The patient does have to practice centering the stoma through the hole in the disk. There are ways to get around this difficulty. For instance, Turnbull has advocated a .simple technique of wrapping a cylinder of dissolving paper about the stoma. The appliance hole is then slipped over this and placed properly under view. The paper is then either lifted out just before the disk is pressed against the skin or else is allowed to drop into the bag itself. Another method is to mark with indelible ink or silver nitrate stick a spot on the edge of the appliance to correspond with a similar spot at its edge on the skin. When the appliance is in proper place, the two spots coincide. Thus each time one applies the face plate, the patient has merely to line up the two indelible spots and know thereby that the stoma is properly centered. Two-PIECE DEVICES. These consist of a face plate and a removable pouch, usually made of latex or vinyl. The face plate can be cemented directly on the skin, or a Colly-Seel (to be described later) or a Karaya gum gasket can be placed around the stoma and the face plate cemented to it. The pouches are then fitted snugly over a ridge on the front of the face plate (e.g., Torbot, United Surgical, Marsan). The advantages of a two-piece appliance are: (a) if the patient has a new stoma, he and the staff can check it by simply removing the pouch, without removing the entire appliance; this characteristic is also advantageous when the patient visits his surgeon or is visited by a stomal therapist; (b) when the face plate is applied, it is possible to insure its proper position with ease since the stoma is at all times visible during the maneuver; (c) these appliances are usually of light weight. Some are quite flat and others are somewhat bulky. The major disadvantage of the two-piece device is the chance that the pouch may come loose from the face plate if it becomes too full. In our experience, this has not been a major problem. What has been a difficulty sometimes is the inability of the patient-especially the elderly, the unskillful, or the timid- to apply the pouch to the face plate. If time is taken to instruct patients, and they are allowed to practice under observation, most of them can manage well. · Another advantage is the ability to dispose of the bag attachment, if it is of disposable material, while leaving the face plate intact and still adherent. Some of the nondisposable pouches can last for several months if washed and cared for, while the face plate remains in use for much longer periods. Shape of Disk (Face plate). Most appliance disks are flat. This seems to be suitable for most abdomens. Some appliances (e.g., Permatype) also come with disks of different convexities. These are suitable for flatter stomas or for those which lie in a valley, especially on the obese abdomen.
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Consistency of Disk (Face plate). The firm types predominate in popularity. They seem to adhere better than the others in most cases. Those disks which have relatively thin edges usually have the plate absent at the rim in order to avoid injuring the projection stoma if it should impinge against the edge. The firmness is usually dependent on a metal or plastic ring, bound between two layers of the material of which the appliance is made. In some two-piece appliances, the disk is of firm plastic but with smooth, rounded, and thick edges that will not cut into the sides of a projecting stoma. Malleable disks can be molded to the contour of the abdomen and are sometimes useful in conforming to a valley resulting from a scar surrounding the stoma. Soft disks are not commonly used, as many people find that they do not adhere as securely. Nevertheless, a few prefer this type to all others. In pressure ulcerations of the skin, the soft disk is quite useful. In one particular appliance (Nova, originally devised by Orowan) the hole is bounded by a soft, foam-like cushion into which the stoma fits snugly. Materials Most appliances are made of combinations of rubber, latex, rubber-substitutes like neoprene, and plastic materials, both transparent and opaque. Some of the heavier materials are usually more odor-proof than the lighter plastics. But those who have no odor problems often prefer the lighter types to the heavier. Colors also vary (e.g., white, black, pink, tan). Adherents Some prefer to use a type of adhesive substance in the cement category and others prefer materials that are not a type of glue. CEMENTS. Regular tubes or bottles (with brush) of liquid latex cement are the most popular. Of prime importance in the use of cements is the necessity for allowing them to dry completely on both appliance and skin before pasting them together. An imperfectly dried layer of cement will tend to loosen the appliance and to cause skin irritation by the entrapment of its solvent. Another popular method is to use double-faced adhesive rings of thin plastic material (e.g., by Minnesota Mining). The hole in the ring may be cut to size by either the patient or the manufacturer. It is applied either to the face plate first or to the skin, and then simply and quickly the appliance is fixed to the skin surface. This does away with the need to await the drying of the cement when using liquid adherents. When the appliance is removed, patches of cement may stick to the skin. These may be removed by an adhesive solvent but large amounts of the solven't and excessive rubbing are to be avoided. Often the patches can be peeled off with the fingers. Actually, there is no urgency in removing all the adhesive film. It can be left on the skin while the fresh application of cement is put on. Even the cement on the face plate can be allowed to remain. Many have found that the adhesive quality of the disk is thereby enchanced. Others prefer to remove all cement layers from the disk at each removal.
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NoN-CEMENT ADHERENTS. Large gaskets containing Karaya gum (e.g., Karayaseal) can be used to cover the entire skin area over which the appliance disk is placed. This has a certain amount of adhesive quality which is found to be satisfactory especially with the addition of a belt. It does wash away with water and is therefore not usually employed by those who wish to go swimining. Also in the hot weather, the heat of the body and the atmosphere can cause this material to run. Colly-Seel is a relatively new product with a Karaya gum and a plastic material base which is exceptionally effective as an adhering substance without the use of cements. It is often healing as well as protective. Our patients refer to it as "liverwurst," an apt description of what the Colly-Seel wafer looks like. They come in 3lf2 and 6 inch sizes in packages of 10. A hole is cut in the middle of the wafer to fit the stoma. It has a certain amount of resiliency which permits it to fit around the projecting ileostomy fairly closely but it has enough resistance to make actually snug abutment on the stoma harmful. Therefore, a tiny rim of skin at the base is best left uncovered. The smooth side of the Colly-Seel is placed against the patient's skin. It adheres more effectively if a bit of water or an antacid gel (e.g., Maalox, Gelusil) is rubbed on the smooth side before the application. Body heat and moisture actually aid the adhesive property. It has several outstanding special uses. For instance, those who seem to develop skin irritation when either cement or adhesive disks are applied prefer placing the Colly-Seel on the skin and then cementing the appliance to the Colly-Seel. Often, the Colly-Seel wafer will adhere to the face plate without the use of an adhesive. People with extremely loose drainage sometimes find that the Colly-Seel keeps the appliance on more securely than any other substance. A few who have problems caused by scars near the stoma, or who are extremely obese or thin, have been able to mold the wafer to fill in and adapt to the irregularities. We instruct both the staff and the patient to use it like a round flat piece of clay and to be creative in employing the material to solve difficulties. The edges of the Colly-Seel can be vulnerable to water, and the wafer can itself deteriorate, dripping its decomposition to the skin below. This can be prevented by using waterproof tapings all around the edges of the appliance. Some patients have been able to keep the appliance in position by this means for a week or more, even when swimming and showering daily. Neutral nail polish on the Colly-Seel rim edge also waterproofs. Ointments of many kinds, together with a belt, have been used in the past for those who could tolerate none of the adhering substances. However, this method usually leads to slipping of the appliance and to curling of the material covering the face plate. If one has to do without any of the adherent materials, it is better to do without the ointments, we believe, and to use gauze or linen, plus a lotion (e.g., Tincture of Benzoin, Cherry Resin, etc.). It is also to be noted here that the "post-op" sheaths applied in the operating room are also of two types-one using adhesive backing (such as the Atlantic or Marsan pouch) and others (such as the Hollister) using Karaya gum doughnuts for adherence.
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Belts For many years, a belt was wom with every type of appliance. In recent years, the cement on devices has been used without belts by many, with the employment of reinforcing adhesive tapes instead. Some surgeons avoid the use of belts and do not even allow for the belt position in choosing a location for the stoma. However, a belt is frequently needed for the non-cement appliances, and many patients feel insecure without its presence on any appliance. At some of the club meetings in various sections of the country, we have discovered that the majority of people employ belts. This is particularly true for men. Many women who do not use belts wear girdles over the appliance. If one uses a belt, it is wise to have several so that if one becomes wet, a dry one is available. For those who go swimming, having a second belt in reserve is a great convenience. Some of the belts are rubberized; others are of nonelastic materials. They attach to the appliance either by fastening to a flange or by means of hooks which fit into an opening. Another kind of belting attaches to a metal ring which fits over the face plate.
Accessories WASHERS. In order to cover the rim of skin exposed at the base of the stoma, a washer of some kind is necessary to protect against the ileal contents. A popular kind of protector, long in use, is a rubber dam square with a center hole which is approximately the size of the stoma. The hole has several slits put in the rim in order to adapt to the stomal diameter. The dam is cemented to the appliance and then -to the skin. Another old fashioned washer is the half-moon of double-backed adhesive which is usually placed on the skin at the base of the stoma before the appliance is put in place. Still another makeshift washer which some find superior to others consists of a doughnut of absorbent cotton which is saturated with a simple protective ointment or Karaya powder. The most popular and useful protector at the present time is the Karaya gum gasket. It is easy to apply and can be stretched or cut to make a snug fit. On the body it becomes soft and jelly-like, serving to protect the skin and the stoma from abrasion against the edge of the hole in the face plate. A foam rubber disk of the same diameter as the face plate can be cemented to the face plate. A hole is cut (either by the patient or the manufacturer) in the foam rubber so that it can fit snugly against the stoma. When the face plate together with its foam rubber pad is cemented to the abdomen, the rim of skin which would have been left uncovered is thus completely covered by the foam rubber. If the stoma later shrinks in diameter over a period of time, only the hole size in a new foam rubber pad has to be made smaller, while the old face plate can continue to be used~ The Colly-Seel wafer has been described under "Adherents." SKIN PROTECTORS. Tincture of Benzoin as a first application on the skin dries the surface and allows better adhesion. Some have advised against the use of Compound Tincture of Benzoin lest it cause reaction in
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people who are hypersensitive but we have found allergic response rare. However, if one has misgivings, the plain Tinture of Benzoin may be used. Some find that the Colly-Seel and Karaya gum washers do better without underlying Tincture of Benzoin. Karaya gum powder is sometimes dusted over the entire surface of the skin that is to be occupied by the face plate. Of course, when the Colly-Seel is used, the entire skin surface is also protected. A method used in the past, and now also sometimes effective for people who cannot tolerate Colly-Seel, cement, or adhesives, is to place tissue paper on the skin, wet it with water, and then impregnate with Karaya powder by dusting heavily. Sometimes several layers of the wetted paper and the powder may be applied. The appliance is then fitted over these layers and held with a belt. Another type of crusting has also been produced, especially in those with irritated skin, by a mixture of cod liver oil powder (e.g., Desitin Powder) and Tincture of Benzoin. In fact, many different kinds and combinations of Karaya, powders, and antacid gels have been used as bases on the skin beneath the face plate for those who have acute irritative problems. Although the management of skin and appliance difficulties is not the subject of this paper, it should be mentioned that some people regularly use hydrocortisone, antifungal and antibiotic powders, lotions, and ointments because of past skin rashes resulting from bacterial and fungal infections. ADHESIVE TAPES. Many ileostomates use reinforcement tapes along the circumference of the face plate after the appliance is in place. Virtually every kind of adhesive tape has been found useful but it would appear that those which at the present time cause the least skin reaction are the Micropore, Cleartape, and waterproof adhesives. An adhesive tape manufactured in England (Downs) also has marked adhering and water-protective qualities. However, a few people have developed sensitivities and this possibility should be kept in mind. CovERS. Because the bag portion of the appliance may rub against the lower portion of the abdominal wall, causing skin rashes and macerations, cloth or felt coverings can be worn over the bag. These not only serve as protectors of the skin but also have a cosmetic value when brightly colored or flowered cloth is used. Many women wear panties over the appliance and some have even split the lower portion of the panties for use during sexual activity. The bikini type of panty also protects against rubbing by the pouch of the appliance.
APPLIANCE MAINTENANCE After the bag is emptied, while still in place on the abdomen, the inside may be rinsed by pouring water into the spout at the bottom of the appliance. For this purpose, some people carry a folded pint carton, a collapsible cup, or other kind of container so that this procedure can be accomplished easily in public as well as in private facilities. When the entire one-piece appliance or the bag portion from a two-piece appliance has been removed, some type of cleansing process is in order. Numerous tablets and solutions are sold by appliance dealers for
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this purpose. Some people prefer a dilute Clorox solution. Others use detergents and hexachlorophene soaps. Usually the one-piece appliance or the bag of the two-piece device is first rinsed in cool water (some think that warm or hot water promotes bacterial growth), and then is scrubbed with a bottle brush and a cleansing agent. The applicance or the pouch is allowed to soak in the solution for a period of time (for 1 hour to several hours). It is patted dry and then usually hung on a hook or a coat hanger, with the walls held apart either by tissue paper or by a spreader at the mouth of the spout to allow free circulation of air. With the appliance in place on the abdomen, there are a variety of closures used for the spout. Among the more popular are the thick rubber band, the barrette, and the solid plug. A small binder clip as used on a clip board and purchasable at a stationery store also has become popular. Deodorants In general, odor is not a major problem with most ileostomates. The contents of the small intestine have a bacterial population that is different from that of the colon, and usually does not contain malodorous end-products. But foods, medicines, and lack of cleanliness of the appliance can lead to odors. Moreover, some people do seem to produce odors in their ileal emanations no matter what their diets are. Local deodorants that have been in use are many in number. For instance, several kinds of deodorant tablets sold by appliance dealers are related to the quarternary amines. Aspirin tablets placed in the appliance have been reported to be effective, as have chlorophyl concentrations. Masking perfumes are used as well as sprays and liquids which claim to be neutralizing in their effects. Several new deodorizing products show promise of being effective (e.g., Pettibone Powder). Among the deodorants taken by mouth are bismuth compounds, especially bismuth subgallate and bismuth subcarbonate. They may be taken as tablets or powders. Although the dosage varies widely, effectiveness has been reported with teaspoonful doses several times a day. Chlorophyl tablets have also found supporters (e.g., Derifil). The avoidance of specific foods (e.g., fish, garlic, some condiments, egg yolk) has sometimes been effective. Only trial and error can determine the usefulness of a deodorizing method in any one person.
MEASURING AND FITTING THE APPLIANCE Measuring Devices One may measure the diameter of a stoma with an ordinary ruler or estimate its width by eye reckoning, but it is easier to use one of the measuring devices obtainable from the appliance dealer. Some of the catalogues (e.g., Atlantic) have a variety of holes on the back cover which can be tested on the stoma until the proper sized opening is found. Other companies (e.g., United Surgical, Marsan) have separate cards with different hole widths. Also available are plastic measurers with different size rings.
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Postoperative Pouches The adhesive-backed pouches should have a hole cut to fit before the paper or other backing is removed. This tailoring should be done in the operating room at the completion of the operation. The hole should be large enough to accommodate the stoma together with a rim of skin of about 1/16 inch showing (i.e., a diameter 1/8 inch larger than the stoma). This allows for good adherence. If the hole is too small, in addition to its chance of rubbing against the ileostomy limb, it will also lead to inadequate adherence at the base of the stoma and allow seepage beneath. If the hole is too large, too much skin will be exposed and a washer of some kind will have to be applied. If there is to be any error in cutting the hole size, or in ordering from the manufacturer, the error should be in the direction of largeness rather than tightness-in any type of appliance, temporary or permanent. The Karaya gum gasket pouches (e.g., Hollister) can hug the stoma without harm because the Karaya doughnut is soft and becomes jelly-like when in contact with body heat. Permanent Appliances Any time between 5 days and 3 weeks after operation, the permanent appliance can be ordered. Generally, the earlier this is done the better. But if the stoma is edematous, or one wants to-observe it, the postoperative pouch can be worn for long periods. However, whenever possible the patient should leave the hospital with the appliance in place that he is to wear permanently. The size of the opening in the face plate will depend somewhat on the type of appliance chosen. The same general principles prevail for the more permanent as for the temporary postoperative pouches. The width of the face plate can also be chosen. For the average patient, a diameter of 3 to 5 inches is usually suitable. Children and patients with small abdomens require smaller face plate disks. This can be determined by measuring in the same way that one measures for the location of the stoma in the preoperative period. Here too it is principally the anterior superior spine and the level of the waist fold which are the most important landmarks to consider. Some people indicate preference for the wider face plates in the belief that a wide application adheres best. Others use a relatively small disk and find it adequate. The total diameter of the face plate desired should be reported to the manufacturer or dealer when ordering the permanent appliance.
TEACHING THE PATIENT The statement of a few basic principles may be in order. It is well to start the instruction of the patient as early as possible. Let him watch all the manipulations so that he becomes accustomed to them. Get some one to visit him in the early postoperative period who knows how to manage a stoma-an enterostomal therapist, an ileostomy club member, or a knowledgeable nurse or house staff member. Urge him to participate in all the procedures, even if he is only ready enough to give mild assistance. The
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earlier he is willing to consider the stoma as a part of himself, rather than as some distant, strange and disgusting mechanism, the quicker he is apt to adjust to its presence. Keep the instruction simple. Do not try to inform him of all the varieties of appliances or of the many possibilities in management until he has learned to master one. It can also be mentioned here that while the skin and appliance are being prepared, a wick of cotton or gauze can be applied to the tip of the stoma or can be wound around the ileostomy to absorb interfering emanations. Most people can learn to choose a time for changing the appliance which coincides with the period when their ileostomy function is least active. The application may be performed in any position. Some prefer standing before a mirror; others like to be semi-reclining; and still others find sitting the most comfortable. The patient may shower or bathe with the appliance in place or removed. Preferences vary. Explicit directions are given to each of our patients, emphasizing the logical sequence of applying the unit. Some, but not all require written reinforcement.
Ileostomy Clubs1 Much of what surgeons, nurses, and stomal therapists have learned, has been obtained from the ileostomy clubs'~-either by attendance at meetings or by watching visiting committees at work. Anyone who performs operations that lead to ileostomy should have knowledge of the presence of ileostomy groups in his area, and would do well to attend some of the meetings. The membership is always delighted and flattered to receive members of the medical profession either as observers or as speakers. One of the reasons that a single article on the management of ileostomy is of limited usefulness is that information on management is ever changing. A number of manuals (e.g., Boston Q.T. Ileostomy Club Manual) are more comprehensive. To keep abreast of the changing methods and ideas, subscription to the United Ostomy Quarterly'~'' is strongly suggested. This journal and other manuals are published by the United Ostomy Association,''** a loose federation of approximately a hundred affiliated local stoma groups. Enterostomal Therapists For many years the visiting committees of the ileostomy clubs were the only expert assistance available. A few nurses were also knowledgeable, but only in a few institutions, and they were relatively scarce. In recent years, the enterostomal therapist has come upon the scene. Lay people, nurses, and ileostomates trained in stomal care have become invaluable additions to the teamwork. The first reported clinic organized for training of stomal therapists was begun in Cleveland under the direc*Earliest reported club-QT Ileostomy Association of New York, 152 West 42nd Street, Suite 536, New York, New York 10001 *''Each Ostomy Quarterly contains a directory of all clubs in the United States and abroad. ''*''United Ostomy Association, 1111 Wilshire Boulevard, Los Angeles, California 90017
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tion of Tumbull. Others (e.g., in Harrisburg, Pennsylvania) are now in operation and more are in the process of formation. In our institution, we make use of a specially trained nurse-clinician. Therefore, the patient now has available for aid and instruction on ileostomy management, his surgeon, the nurse-clinician or enterostomal therapist, and the ileostomy club with its visiting committee. In some regions, the distributor and manufacturers representatives have been quite helpful in the fitting of appliances and even in helping to solve problems in management. Some of them charge for this aid. Others consider the assistance as part of their service. A few go beyond what could be expected of them in a spirit of dedication. The wise surgeon will make use of assistance wherever he can find it and will include himself actively in helping the patient to achieve rehabilitation.
REFERENCES 1. An Ileostomy club. J.A.M.A., 150:812, 1952. 2. Lyons, A. S.: Technique of ileostomy. Surg. Clin. N. Amer., 45:1211-1223, 1965.
Dr. Albert S. Lyons 1050 Park Ave. New York, N.Y. 10028
Mechanical Management of the Ileostomy Stoma
AlbertS. Lyons, M.D.,* and Marlene J. Brockmeier, R.N., M.A.**
Full rehabilitation of the patient with an ileostomy depends on a well constructed stoma, efficient mechanical management, and psychological adjustment. All three are related. Upon the construction of the stoma can depend the success or failure of the management, and while psychological adaptation depends on many factors, a poorly managed ileostomy can make adjustment difficult or impossible in even the most stable and accepting person. There is a necessity for the surgeon, as well as the nurses, the stomal therapist, or the visiting chairmen of ileostomy clubs, to be knowledgeable on the details of stomal management. The surgeon should not neglect his responsibilities in instructing and caring for the patient. Each member of the team has a role to play. This report is limited to management of the ileostomy appliance and accessories. It does not concern itself with complications or difficulties in management. These are separate subjects in themselves. Since there is a multiplicity of appliances, all cannot be mentioned, and therefore only a general classification is presented together with a discussion of the principles of each type. t Nor is the material intended to be comprehensive, as this would be both cumbersome and unwise. Published bulletins and manuals of the United Ostomy Association and local ileostomy clubs are sources of additional information. Location of the Stoma Although this article deals only with appliances, the location of the stoma is of prime importance in the adequate management of an ileostomy.2 The stoma should be placed in such a way that it will enable the tit should be understood that while some brand names are mentioned, this is done solely for the purpose of illustration, and there is no intent to suggest that one particular product is superior to or preferred over another. *Associate Clinical Professor of Surgery, Mount Sinai School of Medicine; Chief, Intestinal Rehabilitation Clinic, Mount Sinai Hospital, New York, New York **Nurse-Clinican, Department of Nursing, Mount Sinai Hospital, New York, New York Surgical Clinics of North America- Vol. 52, No.4, August 1972
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disk of an appliance to clear the anterior superior spine and also, if possible, to allow a belt to be worn, if it is so later desired by the patient, without its pulling up the appliance against the stoma. Thus the stoma should not be situated too low or too lateral. Other considerations have to be borne in mind, such as the scar of the main laparotomy incision, other scars and depressions, the navel, the rib margins, and the pubis. However, the anterior superior spine and the waist fold are the only landmarks that have to be avoided at all costs. The others can be overcome. Therefore, it is a wise practice to have the patient wear a sham appliance, if possible before the operative procedure. In this way, the optimum location can be best determined. Other surgeons prefer to use measurements by means of a circular disk. Some prefer to make the measurements in the operating room although this has the limitation of choosing the spot with the patient supine, and therefore may not allow for other requirements with the patient in different positions. The important point is that the location should be chosen before the operation no matter what method is used.
Length of the Stoma The second important requirement is that the ileostomy stoma project above the skin surface. Those surgeons who have written of their preference for a flush stoma, would find that such advocacy before a group ofileostomates would bring denunciation. A flush stoma makes the application of any appliance difficult and in some instances impossible. This is quite different from a sigmoid colostomy which can be managed well without an appliance or with only an adjunctive appliance. In the United States, most ileostomates consider a length of a half inch to three-quarters of an inch the optimum. On the continent of Europe and in England, stomas of an inch to two inches seem to be preferred.
CHOOSING THE APPLIANCE Surgeons are sometimes too dogmatic about the choice of an appliance, often considering one particular brand as the only suitable mechanism. Wide experience in attending both clinics and club meetings throughout the country discloses a great variety of preferences in different localities. Even in any one particular region, while a predominant type of appliance is used, there are always a substantial number of people who prefer different ones. In some geographic locations, particular appliances are more accessible than others and this fact can be a factor in choice. A good principle is to choose one or two types to start with and then to encourage the patient to learn of others, especially by attending local and national meetings and by receiving the United Ostomy Quarterly Bulletins.
When to Use an Appliance Some protective device should be placed over the skin surrounding an ileostomy immediately after completion of the procedure in the
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operating room. Often one of the flimsier but transparent pouches is most suitable for this maneuver. More sturdy appliances may be ordered from 5 days to 3 weeks or longer after the operation. The determining factors are the amount of swelling, the changing size or shape of the ileostomy, requiring changes in the tailoring of the appliance opening, and the need to observe the functioning of the stoma itself. Theoretically there is no reason not to use a permanent appliance immediately in the operating room, but in practice the postoperative types of pouches are more serviceable in the early days.
The Postoperative Pouches The postoperative pouches all have some type of adaptable face plate which can be modified, frequently if necessary, to fit the early stoma. Face plates of adhesive-backed pouches (e.g., Altantic, Marsan) are cut to fit the stoma, leaving approximately 1/16 inch between face plate and stoma. When removing this pouch, many prefer to use an adhesive solvent. It is important to use only a small amount as the solvent itself can be irritating to the skin. Others remove the pouch by lifting with one hand while the other gives counter pressure on the abdomen. Further skin protection can be provided by using washers or gaskets on the skin exposed around the stoma. One such gasket is the Karaya gum doughnut. Karaya gum stoma pouches, using the gasket as the main face plate (e.g., Hollister), are available in various sizes up to 3 inches. The Karaya gum can be molded to fit closely against the stoma. In as much as this material becomes jelly-like and soft, it can cause no harm to the ileum. This type of pouch is very easily removed from the skin, as Karaya gum is water soluble. The adhesive-backed and the Karaya gum pouches are both one-piece units, easily emptied from the bottom without removing the pouch from the patient. Adhesive-backed pouches may stay in place for at least 3 or 4 days without leakage. Karaya gum pouches usually will remain in place for at least 24 hours and sometimes longer, but this will vary, depending on perspiration, weather conditions and body temperature. Although these pouches are referred to as "postoperative" units, some patients have preferred to use them on a long term basis. This preference is related to the ease of application and of removal of the pouch, as well as to their disposable characteristics. Types of Appliances Appliances may be classified according to a variety of characteristics, each of which has advantages and disadvantages. Further more, there are so many different types of appliances that each has a number of properties which overlap different categories. One-Piece and Two-Piece Appliances ONE-PIECE DEVICES. These are relatively simple to use. They last from 3 to 8 months and sometimes longer, depending on the effect of the ileal emanations on the materials. Usually the patients have three appliances at the same time: one in place on the abdomen, one hanging and drying after being washed, and one put away ready for use. They require
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little dexterity to be applied, and since the attachment of bag to disk is part of the construction, no leakage is possible at that junction. The usual type (e.g., Permatype, Rutzen) is apt to lie flat against the abdomen and is therefore cosmetically agreeable. One does have to remove the entire appliance when it is changed. Of course, for emptying, one has only to open the spout at the bottom. In this respect, there is no difference between one-piece and two-piece appliances. The patient does have to practice centering the stoma through the hole in the disk. There are ways to get around this difficulty. For instance, Turnbull has advocated a .simple technique of wrapping a cylinder of dissolving paper about the stoma. The appliance hole is then slipped over this and placed properly under view. The paper is then either lifted out just before the disk is pressed against the skin or else is allowed to drop into the bag itself. Another method is to mark with indelible ink or silver nitrate stick a spot on the edge of the appliance to correspond with a similar spot at its edge on the skin. When the appliance is in proper place, the two spots coincide. Thus each time one applies the face plate, the patient has merely to line up the two indelible spots and know thereby that the stoma is properly centered. Two-PIECE DEVICES. These consist of a face plate and a removable pouch, usually made of latex or vinyl. The face plate can be cemented directly on the skin, or a Colly-Seel (to be described later) or a Karaya gum gasket can be placed around the stoma and the face plate cemented to it. The pouches are then fitted snugly over a ridge on the front of the face plate (e.g., Torbot, United Surgical, Marsan). The advantages of a two-piece appliance are: (a) if the patient has a new stoma, he and the staff can check it by simply removing the pouch, without removing the entire appliance; this characteristic is also advantageous when the patient visits his surgeon or is visited by a stomal therapist; (b) when the face plate is applied, it is possible to insure its proper position with ease since the stoma is at all times visible during the maneuver; (c) these appliances are usually of light weight. Some are quite flat and others are somewhat bulky. The major disadvantage of the two-piece device is the chance that the pouch may come loose from the face plate if it becomes too full. In our experience, this has not been a major problem. What has been a difficulty sometimes is the inability of the patient-especially the elderly, the unskillful, or the timid- to apply the pouch to the face plate. If time is taken to instruct patients, and they are allowed to practice under observation, most of them can manage well. · Another advantage is the ability to dispose of the bag attachment, if it is of disposable material, while leaving the face plate intact and still adherent. Some of the nondisposable pouches can last for several months if washed and cared for, while the face plate remains in use for much longer periods. Shape of Disk (Face plate). Most appliance disks are flat. This seems to be suitable for most abdomens. Some appliances (e.g., Permatype) also come with disks of different convexities. These are suitable for flatter stomas or for those which lie in a valley, especially on the obese abdomen.
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Consistency of Disk (Face plate). The firm types predominate in popularity. They seem to adhere better than the others in most cases. Those disks which have relatively thin edges usually have the plate absent at the rim in order to avoid injuring the projection stoma if it should impinge against the edge. The firmness is usually dependent on a metal or plastic ring, bound between two layers of the material of which the appliance is made. In some two-piece appliances, the disk is of firm plastic but with smooth, rounded, and thick edges that will not cut into the sides of a projecting stoma. Malleable disks can be molded to the contour of the abdomen and are sometimes useful in conforming to a valley resulting from a scar surrounding the stoma. Soft disks are not commonly used, as many people find that they do not adhere as securely. Nevertheless, a few prefer this type to all others. In pressure ulcerations of the skin, the soft disk is quite useful. In one particular appliance (Nova, originally devised by Orowan) the hole is bounded by a soft, foam-like cushion into which the stoma fits snugly. Materials Most appliances are made of combinations of rubber, latex, rubber-substitutes like neoprene, and plastic materials, both transparent and opaque. Some of the heavier materials are usually more odor-proof than the lighter plastics. But those who have no odor problems often prefer the lighter types to the heavier. Colors also vary (e.g., white, black, pink, tan). Adherents Some prefer to use a type of adhesive substance in the cement category and others prefer materials that are not a type of glue. CEMENTS. Regular tubes or bottles (with brush) of liquid latex cement are the most popular. Of prime importance in the use of cements is the necessity for allowing them to dry completely on both appliance and skin before pasting them together. An imperfectly dried layer of cement will tend to loosen the appliance and to cause skin irritation by the entrapment of its solvent. Another popular method is to use double-faced adhesive rings of thin plastic material (e.g., by Minnesota Mining). The hole in the ring may be cut to size by either the patient or the manufacturer. It is applied either to the face plate first or to the skin, and then simply and quickly the appliance is fixed to the skin surface. This does away with the need to await the drying of the cement when using liquid adherents. When the appliance is removed, patches of cement may stick to the skin. These may be removed by an adhesive solvent but large amounts of the solven't and excessive rubbing are to be avoided. Often the patches can be peeled off with the fingers. Actually, there is no urgency in removing all the adhesive film. It can be left on the skin while the fresh application of cement is put on. Even the cement on the face plate can be allowed to remain. Many have found that the adhesive quality of the disk is thereby enchanced. Others prefer to remove all cement layers from the disk at each removal.
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NoN-CEMENT ADHERENTS. Large gaskets containing Karaya gum (e.g., Karayaseal) can be used to cover the entire skin area over which the appliance disk is placed. This has a certain amount of adhesive quality which is found to be satisfactory especially with the addition of a belt. It does wash away with water and is therefore not usually employed by those who wish to go swimining. Also in the hot weather, the heat of the body and the atmosphere can cause this material to run. Colly-Seel is a relatively new product with a Karaya gum and a plastic material base which is exceptionally effective as an adhering substance without the use of cements. It is often healing as well as protective. Our patients refer to it as "liverwurst," an apt description of what the Colly-Seel wafer looks like. They come in 3lf2 and 6 inch sizes in packages of 10. A hole is cut in the middle of the wafer to fit the stoma. It has a certain amount of resiliency which permits it to fit around the projecting ileostomy fairly closely but it has enough resistance to make actually snug abutment on the stoma harmful. Therefore, a tiny rim of skin at the base is best left uncovered. The smooth side of the Colly-Seel is placed against the patient's skin. It adheres more effectively if a bit of water or an antacid gel (e.g., Maalox, Gelusil) is rubbed on the smooth side before the application. Body heat and moisture actually aid the adhesive property. It has several outstanding special uses. For instance, those who seem to develop skin irritation when either cement or adhesive disks are applied prefer placing the Colly-Seel on the skin and then cementing the appliance to the Colly-Seel. Often, the Colly-Seel wafer will adhere to the face plate without the use of an adhesive. People with extremely loose drainage sometimes find that the Colly-Seel keeps the appliance on more securely than any other substance. A few who have problems caused by scars near the stoma, or who are extremely obese or thin, have been able to mold the wafer to fill in and adapt to the irregularities. We instruct both the staff and the patient to use it like a round flat piece of clay and to be creative in employing the material to solve difficulties. The edges of the Colly-Seel can be vulnerable to water, and the wafer can itself deteriorate, dripping its decomposition to the skin below. This can be prevented by using waterproof tapings all around the edges of the appliance. Some patients have been able to keep the appliance in position by this means for a week or more, even when swimming and showering daily. Neutral nail polish on the Colly-Seel rim edge also waterproofs. Ointments of many kinds, together with a belt, have been used in the past for those who could tolerate none of the adhering substances. However, this method usually leads to slipping of the appliance and to curling of the material covering the face plate. If one has to do without any of the adherent materials, it is better to do without the ointments, we believe, and to use gauze or linen, plus a lotion (e.g., Tincture of Benzoin, Cherry Resin, etc.). It is also to be noted here that the "post-op" sheaths applied in the operating room are also of two types-one using adhesive backing (such as the Atlantic or Marsan pouch) and others (such as the Hollister) using Karaya gum doughnuts for adherence.
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Belts For many years, a belt was wom with every type of appliance. In recent years, the cement on devices has been used without belts by many, with the employment of reinforcing adhesive tapes instead. Some surgeons avoid the use of belts and do not even allow for the belt position in choosing a location for the stoma. However, a belt is frequently needed for the non-cement appliances, and many patients feel insecure without its presence on any appliance. At some of the club meetings in various sections of the country, we have discovered that the majority of people employ belts. This is particularly true for men. Many women who do not use belts wear girdles over the appliance. If one uses a belt, it is wise to have several so that if one becomes wet, a dry one is available. For those who go swimming, having a second belt in reserve is a great convenience. Some of the belts are rubberized; others are of nonelastic materials. They attach to the appliance either by fastening to a flange or by means of hooks which fit into an opening. Another kind of belting attaches to a metal ring which fits over the face plate.
Accessories WASHERS. In order to cover the rim of skin exposed at the base of the stoma, a washer of some kind is necessary to protect against the ileal contents. A popular kind of protector, long in use, is a rubber dam square with a center hole which is approximately the size of the stoma. The hole has several slits put in the rim in order to adapt to the stomal diameter. The dam is cemented to the appliance and then -to the skin. Another old fashioned washer is the half-moon of double-backed adhesive which is usually placed on the skin at the base of the stoma before the appliance is put in place. Still another makeshift washer which some find superior to others consists of a doughnut of absorbent cotton which is saturated with a simple protective ointment or Karaya powder. The most popular and useful protector at the present time is the Karaya gum gasket. It is easy to apply and can be stretched or cut to make a snug fit. On the body it becomes soft and jelly-like, serving to protect the skin and the stoma from abrasion against the edge of the hole in the face plate. A foam rubber disk of the same diameter as the face plate can be cemented to the face plate. A hole is cut (either by the patient or the manufacturer) in the foam rubber so that it can fit snugly against the stoma. When the face plate together with its foam rubber pad is cemented to the abdomen, the rim of skin which would have been left uncovered is thus completely covered by the foam rubber. If the stoma later shrinks in diameter over a period of time, only the hole size in a new foam rubber pad has to be made smaller, while the old face plate can continue to be used~ The Colly-Seel wafer has been described under "Adherents." SKIN PROTECTORS. Tincture of Benzoin as a first application on the skin dries the surface and allows better adhesion. Some have advised against the use of Compound Tincture of Benzoin lest it cause reaction in
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people who are hypersensitive but we have found allergic response rare. However, if one has misgivings, the plain Tinture of Benzoin may be used. Some find that the Colly-Seel and Karaya gum washers do better without underlying Tincture of Benzoin. Karaya gum powder is sometimes dusted over the entire surface of the skin that is to be occupied by the face plate. Of course, when the Colly-Seel is used, the entire skin surface is also protected. A method used in the past, and now also sometimes effective for people who cannot tolerate Colly-Seel, cement, or adhesives, is to place tissue paper on the skin, wet it with water, and then impregnate with Karaya powder by dusting heavily. Sometimes several layers of the wetted paper and the powder may be applied. The appliance is then fitted over these layers and held with a belt. Another type of crusting has also been produced, especially in those with irritated skin, by a mixture of cod liver oil powder (e.g., Desitin Powder) and Tincture of Benzoin. In fact, many different kinds and combinations of Karaya, powders, and antacid gels have been used as bases on the skin beneath the face plate for those who have acute irritative problems. Although the management of skin and appliance difficulties is not the subject of this paper, it should be mentioned that some people regularly use hydrocortisone, antifungal and antibiotic powders, lotions, and ointments because of past skin rashes resulting from bacterial and fungal infections. ADHESIVE TAPES. Many ileostomates use reinforcement tapes along the circumference of the face plate after the appliance is in place. Virtually every kind of adhesive tape has been found useful but it would appear that those which at the present time cause the least skin reaction are the Micropore, Cleartape, and waterproof adhesives. An adhesive tape manufactured in England (Downs) also has marked adhering and water-protective qualities. However, a few people have developed sensitivities and this possibility should be kept in mind. CovERS. Because the bag portion of the appliance may rub against the lower portion of the abdominal wall, causing skin rashes and macerations, cloth or felt coverings can be worn over the bag. These not only serve as protectors of the skin but also have a cosmetic value when brightly colored or flowered cloth is used. Many women wear panties over the appliance and some have even split the lower portion of the panties for use during sexual activity. The bikini type of panty also protects against rubbing by the pouch of the appliance.
APPLIANCE MAINTENANCE After the bag is emptied, while still in place on the abdomen, the inside may be rinsed by pouring water into the spout at the bottom of the appliance. For this purpose, some people carry a folded pint carton, a collapsible cup, or other kind of container so that this procedure can be accomplished easily in public as well as in private facilities. When the entire one-piece appliance or the bag portion from a two-piece appliance has been removed, some type of cleansing process is in order. Numerous tablets and solutions are sold by appliance dealers for
MECHANICAL MANAGEMENT OF THE ILEOSTOMY STOMA
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this purpose. Some people prefer a dilute Clorox solution. Others use detergents and hexachlorophene soaps. Usually the one-piece appliance or the bag of the two-piece device is first rinsed in cool water (some think that warm or hot water promotes bacterial growth), and then is scrubbed with a bottle brush and a cleansing agent. The applicance or the pouch is allowed to soak in the solution for a period of time (for 1 hour to several hours). It is patted dry and then usually hung on a hook or a coat hanger, with the walls held apart either by tissue paper or by a spreader at the mouth of the spout to allow free circulation of air. With the appliance in place on the abdomen, there are a variety of closures used for the spout. Among the more popular are the thick rubber band, the barrette, and the solid plug. A small binder clip as used on a clip board and purchasable at a stationery store also has become popular. Deodorants In general, odor is not a major problem with most ileostomates. The contents of the small intestine have a bacterial population that is different from that of the colon, and usually does not contain malodorous end-products. But foods, medicines, and lack of cleanliness of the appliance can lead to odors. Moreover, some people do seem to produce odors in their ileal emanations no matter what their diets are. Local deodorants that have been in use are many in number. For instance, several kinds of deodorant tablets sold by appliance dealers are related to the quarternary amines. Aspirin tablets placed in the appliance have been reported to be effective, as have chlorophyl concentrations. Masking perfumes are used as well as sprays and liquids which claim to be neutralizing in their effects. Several new deodorizing products show promise of being effective (e.g., Pettibone Powder). Among the deodorants taken by mouth are bismuth compounds, especially bismuth subgallate and bismuth subcarbonate. They may be taken as tablets or powders. Although the dosage varies widely, effectiveness has been reported with teaspoonful doses several times a day. Chlorophyl tablets have also found supporters (e.g., Derifil). The avoidance of specific foods (e.g., fish, garlic, some condiments, egg yolk) has sometimes been effective. Only trial and error can determine the usefulness of a deodorizing method in any one person.
MEASURING AND FITTING THE APPLIANCE Measuring Devices One may measure the diameter of a stoma with an ordinary ruler or estimate its width by eye reckoning, but it is easier to use one of the measuring devices obtainable from the appliance dealer. Some of the catalogues (e.g., Atlantic) have a variety of holes on the back cover which can be tested on the stoma until the proper sized opening is found. Other companies (e.g., United Surgical, Marsan) have separate cards with different hole widths. Also available are plastic measurers with different size rings.
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Postoperative Pouches The adhesive-backed pouches should have a hole cut to fit before the paper or other backing is removed. This tailoring should be done in the operating room at the completion of the operation. The hole should be large enough to accommodate the stoma together with a rim of skin of about 1/16 inch showing (i.e., a diameter 1/8 inch larger than the stoma). This allows for good adherence. If the hole is too small, in addition to its chance of rubbing against the ileostomy limb, it will also lead to inadequate adherence at the base of the stoma and allow seepage beneath. If the hole is too large, too much skin will be exposed and a washer of some kind will have to be applied. If there is to be any error in cutting the hole size, or in ordering from the manufacturer, the error should be in the direction of largeness rather than tightness-in any type of appliance, temporary or permanent. The Karaya gum gasket pouches (e.g., Hollister) can hug the stoma without harm because the Karaya doughnut is soft and becomes jelly-like when in contact with body heat. Permanent Appliances Any time between 5 days and 3 weeks after operation, the permanent appliance can be ordered. Generally, the earlier this is done the better. But if the stoma is edematous, or one wants to-observe it, the postoperative pouch can be worn for long periods. However, whenever possible the patient should leave the hospital with the appliance in place that he is to wear permanently. The size of the opening in the face plate will depend somewhat on the type of appliance chosen. The same general principles prevail for the more permanent as for the temporary postoperative pouches. The width of the face plate can also be chosen. For the average patient, a diameter of 3 to 5 inches is usually suitable. Children and patients with small abdomens require smaller face plate disks. This can be determined by measuring in the same way that one measures for the location of the stoma in the preoperative period. Here too it is principally the anterior superior spine and the level of the waist fold which are the most important landmarks to consider. Some people indicate preference for the wider face plates in the belief that a wide application adheres best. Others use a relatively small disk and find it adequate. The total diameter of the face plate desired should be reported to the manufacturer or dealer when ordering the permanent appliance.
TEACHING THE PATIENT The statement of a few basic principles may be in order. It is well to start the instruction of the patient as early as possible. Let him watch all the manipulations so that he becomes accustomed to them. Get some one to visit him in the early postoperative period who knows how to manage a stoma-an enterostomal therapist, an ileostomy club member, or a knowledgeable nurse or house staff member. Urge him to participate in all the procedures, even if he is only ready enough to give mild assistance. The
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earlier he is willing to consider the stoma as a part of himself, rather than as some distant, strange and disgusting mechanism, the quicker he is apt to adjust to its presence. Keep the instruction simple. Do not try to inform him of all the varieties of appliances or of the many possibilities in management until he has learned to master one. It can also be mentioned here that while the skin and appliance are being prepared, a wick of cotton or gauze can be applied to the tip of the stoma or can be wound around the ileostomy to absorb interfering emanations. Most people can learn to choose a time for changing the appliance which coincides with the period when their ileostomy function is least active. The application may be performed in any position. Some prefer standing before a mirror; others like to be semi-reclining; and still others find sitting the most comfortable. The patient may shower or bathe with the appliance in place or removed. Preferences vary. Explicit directions are given to each of our patients, emphasizing the logical sequence of applying the unit. Some, but not all require written reinforcement.
Ileostomy Clubs1 Much of what surgeons, nurses, and stomal therapists have learned, has been obtained from the ileostomy clubs'~-either by attendance at meetings or by watching visiting committees at work. Anyone who performs operations that lead to ileostomy should have knowledge of the presence of ileostomy groups in his area, and would do well to attend some of the meetings. The membership is always delighted and flattered to receive members of the medical profession either as observers or as speakers. One of the reasons that a single article on the management of ileostomy is of limited usefulness is that information on management is ever changing. A number of manuals (e.g., Boston Q.T. Ileostomy Club Manual) are more comprehensive. To keep abreast of the changing methods and ideas, subscription to the United Ostomy Quarterly'~'' is strongly suggested. This journal and other manuals are published by the United Ostomy Association,''** a loose federation of approximately a hundred affiliated local stoma groups. Enterostomal Therapists For many years the visiting committees of the ileostomy clubs were the only expert assistance available. A few nurses were also knowledgeable, but only in a few institutions, and they were relatively scarce. In recent years, the enterostomal therapist has come upon the scene. Lay people, nurses, and ileostomates trained in stomal care have become invaluable additions to the teamwork. The first reported clinic organized for training of stomal therapists was begun in Cleveland under the direc*Earliest reported club-QT Ileostomy Association of New York, 152 West 42nd Street, Suite 536, New York, New York 10001 *''Each Ostomy Quarterly contains a directory of all clubs in the United States and abroad. ''*''United Ostomy Association, 1111 Wilshire Boulevard, Los Angeles, California 90017
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tion of Tumbull. Others (e.g., in Harrisburg, Pennsylvania) are now in operation and more are in the process of formation. In our institution, we make use of a specially trained nurse-clinician. Therefore, the patient now has available for aid and instruction on ileostomy management, his surgeon, the nurse-clinician or enterostomal therapist, and the ileostomy club with its visiting committee. In some regions, the distributor and manufacturers representatives have been quite helpful in the fitting of appliances and even in helping to solve problems in management. Some of them charge for this aid. Others consider the assistance as part of their service. A few go beyond what could be expected of them in a spirit of dedication. The wise surgeon will make use of assistance wherever he can find it and will include himself actively in helping the patient to achieve rehabilitation.
REFERENCES 1. An Ileostomy club. J.A.M.A., 150:812, 1952. 2. Lyons, A. S.: Technique of ileostomy. Surg. Clin. N. Amer., 45:1211-1223, 1965.
Dr. Albert S. Lyons 1050 Park Ave. New York, N.Y. 10028