Cut to fit ostomy systems are used mainly where the stoma is irregular, and, as its name implies, it means cutting an opening on the flange that fits around your stoma.
“An ostomy can be defined as any surgical procedure resulting in the external diversion of feces and urine through a stoma. The most common ostomies are a colostomy and ileostomy for diversion of the fecal stream, and urostomy for diversion of the urinary stream. Persons living with ostomies require specialized care and management to sustain physical health and quality of life (QOL). The provision of specialized ostomy care begins preoperatively and continues throughout the postoperative and rehabilitative period and throughout the patient’s lifetime with an ostomy. Ongoing stoma and ostomy appliance sizing, the treatment of peristomal skin complications, ostomy appliance modifications, access to ostomy products and financial assistance, dietary consultation, and emotional support are just a few of the health management issues that require ongoing management following the creation of an ostomy.”1
Normally, a well-rounded and protruding stoma will need a pre-cut ostomy system; unlike stoma prolapse, where it is difficult to maintain an appliance.
“Stoma prolapse is full-thickness protrusion of bowel through a stoma that occurs in 3% of ileostomies, 2% of colostomies, and 1% of urostomies. Stoma prolapse can be classified as sliding (if it occurs intermittently with increased intra-abdominal pressure) or fixed (if it is present constantly). Prolapse occurs more frequently with loop colostomies than end colostomies and most frequently involves the efferent (distal) limb. Risk factors for stoma prolapse include patient factors such as advanced age, obesity, bowel obstruction at the time of stoma creation, and lack of preoperative site marking by enterostomal nurse. Techniques proposed to limit stoma prolapse include extraperitoneal tunneling, mesentery-abdominal wall fixation, and limiting the size of the aperture. Symptoms associated with stoma prolapse include pain, skin irritation, difficulty with maintaining an appliance and can rarely lead to obstruction, incarceration, and strangulation. Acute stoma prolapse can often be reduced at the bedside with the aid of sugar and ice to reduce bowel wall edema, allowing for an elective repair if prolapse was to recur.”2
Some of the types of stomas that are typically recommended to use a cut-to-fit system include non-circular stomas, oval stomas, and reduced/shrinking stomas.
The above stoma shapes can arise as a result of various factors. For example, the stoma can heal with scarring tissue that distorts its shape. The current contours of the abdomen can also determine the final appearance and shape of the stoma. Immediately after surgery, the stoma is usually much bigger due to the natural inflammation and swelling process. With time, the stoma size reduces until it settles on a final size once healing is complete.
A cut-to-fit system helps the patient adjust the size of the stoma flange accordingly to prevent leakage and skin irritation. Consequently, as an ostomy patient, it will be necessary to measure the size of the stoma as frequently as recommended by the ostomy nurse or health care provider, which is generally once a week.
The cut-to-fit ostomy procedure
There are two ways of doing this. The first is by using scissors and the second is by the use of a flange cutter, which is commercially available from various ostomy product manufacturers. They are much easier to use and give finer results than scissors.
The flange is placed and cut on a hard surface since a soft surface can lead to it being damaged and may result in an irregularly cut opening. The size of the opening is determined by the latest stoma measurements. It is important to cut the opening about 3-4mm larger than the stoma outline because this extra space helps to prevent stoma trauma during flange removal.
The usual skin preparation is carried out before placing the flange on the peristomal skin. “Peristomal skin disorders represent the most common post-operative complication in ostomates, the incidence of which ranges from 15–65%. It has been estimated that these events account for more than a third of stoma care clinic visits resulting in a substantial economic burden on the patient and the health care system. Peristomal skin is constantly exposed to a number of substances including urine, feces, medicaments, ostomy pouch systems, and stoma skin care products such as barrier films and adhesive paste/removers. The above can result in a variety of peristomal events, including physical skin abrasion and/or infections, dermatologic conditions (pyoderma gangrenosum, psoriasis etc.), and contact dermatitis. Bodily fluids are known to be an important cause of peristomal dermatitis. To protect the peristomal skin, medical professionals recommend applying stoma skin care products designed to prevent peristomal irritation.”3
Different professionals carry out the skin preparation procedure in particular ways, but the common goal is to prevent or reduce skin infection and irritation. Common pouching products usually include skin sealants, skin barrier pastes, powders, and solvents.
A cut-to-fit ostomy system serves the same purpose as a pre-cut ostomy type. “These are used for colostomies for people who are unable to find the right size pouch for their needs. Pre-cut pouches already have holes cut into them, which is centered on top of the stoma. Cut-to-fit is cut according to the size of the stoma. The cut-to-fit pouches are usually given after surgery because the size of the stoma will decrease as it heals.”4 This includes:
- Facilitating effective and hygienic discharge collection
- Protection of the skin around the stoma from stoma discharge. This, in turn, prevents skin irritation, inflammation, and infection.
- Prevention of bad odor
Components to a Pouching System
- “Skin Barrier: This piece of the pouch has an opening for the stoma. The opening can be pre-cut by the manufacturer or can be cut to fit by the patient. The cut to fit skin barrier is used in the initial postoperative period to adjust to the decrease in edema of the stoma.
- Pouch: This piece of the system attaches to the skin barrier to collect the stool or urine that comes from the stoma.
- Drainable Pouch: A drainable pouching system has the ability to open at the bottom allowing the contents to be drained or emptied.
- Closed-End Pouch: A closed-end pouching system does not have an opening at the bottom of the pouch. This entire system is thrown away when full and a new system is applied.
- One-Piece Pouching System: The skin barrier and the pouch are made as one piece, they do not come apart. The entire system is removed and replaced each time a pouch change is done.
- Two-Piece Pouching System: The skin barrier and the pouch are two separate pieces that you snap, clip or stick together. The pouch can be removed and replaced while leaving the skin barrier intact on the abdomen.
Pouch Change Procedure
- When changing your ostomy pouch is to make sure you empty the pouch fully prior to pouch change procedure.
- Gather all of the supplies you will need for a pouch change:
- Face cloths
- New pouch
- Scissors if cutting out skin barrier
- Measuring guide if stoma measurement is needed
- Stoma adhesive powder, paste, and skin prep if typically used
- Plastic baggie to dispose of the old pouch into
- Sit in a comfortable position that allows visualization of the stoma.
- Remove pouch and dispose of in a plastic bag.
- Cleanse peristomal skin using warm water and face cloth.
- Apply a dusting of stomahesive powder to skin if excoriated or denuded.
- Wipe away any extra powder that does not stick to peristomal skin.
- Seal in powder with skin prep.
- Measure stoma using a measuring guide that is provided by the manufacture of the pouches.
- If pouches are not precut then trace and cut out new size of stoma opening on the skin barrier.
- Center stoma in middle of skin barrier opening and place pouch over stoma. If using a two-piece pouch this is the time to snap on, click on or stick on the pouch to the skin barrier.
- The pouch is typically changed every 3-4 days.
- If leaking of effluent is noted then pouch change should occur immediately.”5
Advantages of a cut-to-fit ostomy system
- Can be adjusted to fit the size and shape of the stoma
- It doesn’t require any skilled personnel to cut the opening after the patient has had the initial training.
- There is a reduced risk of discharge accumulation behind the flange.
- Ostomates with dexterity problems due to hand arthritis or other causes can find it difficult to cut out the opening with sufficient precision.
- There are increased chances of mistakes that can lead to poor flange placement and increased risk of leakage and skin irritation.
- It is cumbersome to perform the procedure while traveling or when in a public restroom
- It can interfere with social life owing to the time needed to perform the procedure during a pouch change.
What may happen when the ostomy equipment’s size is wrongly adjusted?
“Selecting a plate with too small size in relation to the size of the ostomy causes the necessity to cut too large an outlet in relation to its size. Then, the margin between the outlet in the plate and the plastic ring for attaching the pouch is too small. This makes it difficult to adhere the plate to the skin directly around the ostomy, i.e. where it is the most important. Correspondingly, the adhesive of the one-part pouch in which the outlet is too large, i.e. outside the margin marked on the protective paper, will not hold the skin as long and well as it should. Improper choice of the equipment’s size in proportion to the size of the ostomy can thus lead to decreased connection to the skin and a reduced time of adhering to the stomach, and can cause one of the most frequent complications, i.e. skin inflammation around the ostomy. Improper matching of the size of the equipment to the size of the fistula can be equally unfavorable as its improper cutting.”6
The caring of your stoma when using a cut-to-fit ostomy system is the same as when using other types of ostomy systems, though it is of utmost importance to practice appropriate stoma management regardless of the system.
(1) Recalla, S., English, K., Nazarali, R., Mayo, S., Miller, D., & Gray, M. (2013). Ostomy care and management: a systematic review. Journal of Wound Ostomy & Continence Nursing, 40(5), 489-500. Available online at https://nursing.ceconnection.com/ovidfiles/00152192-201309000-00009.pdf
(2) Krishnamurty, D. M., Blatnik, J., & Mutch, M. (2017). Stoma complications. Clinics in colon and rectal surgery, 30(03), 193-200. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5498161/
(3) Cressey, B. D., Belum, V. R., Scheinman, P., Silvestri, D., McEntee, N., Livingston, V., … & Zippin, J. H. (2017). Stoma care products represent a common and previously underreported source of peristomal contact dermatitis. Contact dermatitis, 76(1), 27-33. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5523875/
(4) Zulkowski, K. (2015). Ostomy terms and definitions-continued. World Council of Enterostomal Therapists Journal, 35(3), 48. Available online at https://www.wcetn.org/assets/Journal/WCET_Terms/wcet20wound20terms2020definitions203.pdf
(5) Lynch, S., Lavoie, K. (2013). Ostomy Overview: Care of the Patient with an Ostomy. Available online at https://lms.rn.com/getpdf.php/1913.pdf
(6) Muzyczka, K., Kachaniuk, H., Szadowska-Szlachetka, Z., Charzynska-Gula, M., Kocka, K., Bartoszek, A., & Celej-Szuster, J. (2013). Selected problems associated with the treatment and care for patients with colostomy–part 2. Contemporary Oncology, 17(3), 246. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934070/