A two-piece ostomy bag is one of the two types of ostomy appliances available; the other is the one-piece bag. The main difference between both options is the part that attaches to the peristomal skin. In the one-piece bag, the adhesive baseplate skin barrier, flange, or wafer) is part of the bag. In the two-piece, the bag is a detachable part independent of the wafer.
“A one-piece system has the pouch and solid skin barrier attached as one unit. The two-piece system consists of the solid skin barrier wafer with body-side adhesive and a top-side flange that accepts the pouch. The pouch can be changed as required without disturbing the skin barrier seal. This allows wearing a shorter pouch for certain activities (e.g. swimming) and substitution of a standard size pouch for ‘normal’ wear time. The shorter pouch is snapped on the adhesive wafer for the activity and then popped off and replaced.”1
A patient using the two-piece system can remove and replace the bag without removing the wafer. An adhesive surface or a press-on-click mechanism attaches the bag to the wafer. Users can buy this ostomy appliance as a kit or separately.
“A two-piece colostomy appliance is composed of a pouch and a separate adhesive faceplate. The faceplate is left in place for a period of time, usually 2 to 5 days. During this period, when the colostomy appliance requires changing, only the bag needs to be replaced. There are two main types of two-piece appliance: those that ‘click’ together and those that ‘adhere’ together. The clicking Tupperware-type joining action provides extra security as there is a sensation when the appliance is secured, which the patient can feel.”2
Changing a Two-Piece Pouching System
“The time between changes of the pouching system varies by type of stoma, type of drainage, body shape, patient activity level, skin moisture, and patient preference. Some pouching systems are made to be changed daily, and others every 3 to 7 days.
Follow the same basic principles regardless of the system: Remove the skin barrier gently to prevent skin trauma. Applying warm water may help. Use an adhesive remover only if the patient’s skin has a lot of adhesive residues. (The adhesive remover itself can leave a residue on the skin that interferes with adherence of the skin barrier.) Wash the skin gently with warm water and a washcloth or soft paper towels—soap isn’t needed. Avoid products that contain alcohol and premoistened wipes or towelettes (which also can interfere with skin barrier adherence).
Be very gentle when cleaning the peristomal skin and stoma. Because the stoma contains few or no nerve endings, it’s easy to cause trauma without the patient being aware. The stoma also is very vascular, so even minimal trauma can cause bleeding. If you use a skin sealant or barrier film, let it dry completely before applying the pouching system. Once you’ve cleaned and prepped the skin, apply the skin barrier, then apply the pouching system.”3
Advantages of a Two-Piece Ostomy System
- Users can remove the ostomy bag without detaching the skin barrier, reducing the incidence of skin irritation, inflammation, and infection, which are frequent with one-piece bags. “Irritant dermatitis of the skin results from contact with a chronic irritant, such as stool or chemicals. This may be due to poor stoma construction causing effluent to be in contact with the skin or from a poor technique in appliance care. Effluent may come in contact with the skin if the appliance is not the appropriate size, has not been applied appropriately, or has been left in place too long. Also, if the stoma is located in a poor location or is poorly constructed, this may contribute to leakage and dermatitis. Too many products used on the skin under the ostomy appliance may cause increased interaction of product ingredients, resulting in the development of sensitivity to products. Skin damage correlates with the area that is exposed to the irritant. […] Treatment is directed at identifying and eliminating the cause. The goal is to protect damaged skin and avoid other irritants. The appropriate pouching system provides a secure, predictable wear time and protects the peristomal skin from effluent.”4
- The user or the caregiver discards the one-piece system with every pouch change, whereas the wafer in the two-piece system can outstay over one pouch change before disposal.
- You can switch bags to suit different occasions. For example, using a smaller pouch during exercises or intimacy.
- The stoma is easily visible during flange placement.
- The bag can rotate.
- The system is compatible with single-use pouch liners.
- The system suits people with impaired dexterity and vision.
- The easier bag exchange facilitates travel, the use of public restrooms and active social life.
Disadvantages Of a Two-Piece Ostomy System
- The system is bulkier, firmer and visible under the clothes, a problem for patients seeking discretion or tight clothes.
- The bag and the wafer is more prone to detachment and cause accidental leaks. “Regardless of the type of appliance used, a skin barrier is essential to protect the skin from irritation and excoriation. To maintain skin integrity, a skin barrier or leaking pouch is never patched with tape to prevent the accumulation of urine under the skin barrier or faceplate.”5
- The wafer requires staying clean between changes, difficult for those with low dexterity.
- The system has a higher chance of stomal discharge accumulation behind the flange, increasing the risk of irritations.
- “When a two-piece pouch is used, an elongated or prolapsed stoma can be pinched within the plastic flange when the two pieces of the pouch are connected, causing a laceration. Alternately, a prolapsed stoma can hang over the plastic flange of a two-piece pouch and sustain a laceration if the stoma is pinched between the clothing and the flange. Change to a one-piece pouch may be required.”6
- The system is more expensive. “Another factor you need to consider when you are choosing your ostomy system is cost. When choosing an appliance, make sure you take into account whether or not you can afford that particular system for the length of time that you will have your stoma. Some systems can be quite expensive. The coverage of ostomy supplies varies between countries, with some covering all the cost and others covering none. Find out what government or private plans are available where you live.”7
Set an appointment with an ostomy nurse before hospital discharge and follow-up reviews are important in selecting a suitable system.
“People with intestinal ostomies have many ostomy equipment options. Equipment includes a skin barrier, which adheres to the abdominal skin, and a collection pouch, which connects to the skin barrier and contains the stool. Managing an intestinal ostomy requires pouch emptying from one to many times a day. People who have colostomies need to empty the pouch once or twice a day. People who have ileostomies need to empty their pouch more frequently, from a few to many times a day. Less frequently, the skin barrier or entire appliance needs to be removed from the skin and changed. Ostomy care requires time, consistent routines, the ability to see the stoma (which may be obscured by a large abdomen or a peristomal hernia), manual dexterity, and stamina. Contact with ostomy output can lead to skin complications and can result from a retracted stoma, the location of the stoma on a patient’s abdomen, or a variety of problems relating to managing the ostomy equipment. Good ostomy care can prevent leaks, rashes, skin breakdown, and the need for frequent skin barrier changes, while poor ostomy care can result in more frequent skin barrier changes and increasingly complex peristomal skincare.”8
Considerations in Using a Two-Piece System
- “Ability to change pouch without changing skin barrier (allows the user to wear a short pouch for some activities and return to a longer length for other activities)
- Ease of placement of skin barrier with flange (no pouch attached so stoma easily visualized)
- Security issues of proper flange attachment
- Profile under clothing
The pouching system framework divides pouch options into two major divisions: drainable and non-drainable. Drainable pouches include open-ended pouches, indicated for fecal drainage, and pouches with a tap indicated for drainage of urine. Drainable pouches are drained when one-third full. Non-drainable pouches are closed at the bottom and are removed and generally discarded when about one third to one-half full. A common characteristic of all pouches is odor-resistant film.”9
Specialists advise patients to experiment with one and two-piece bags and to test features from each system. You may request samples to determine what is available without having unnecessary expenses.
(1) Bayless, T. M., & Hanauer, S. B. (2011). Advanced therapy of inflammatory bowel disease: ulcerative colitis (Vol. 1). PMPH-USA. Available online at https://books.google.co.ve/books?id=KtIWZoFn_LAC&pg=PA181&dq=two+piece+ostomy+bag+can+be+switched&hl=es-419&sa=X&ved=0ahUKEwig9t6DkLTiAhWp2FkKHTILD40Q6AEIJzAA#v=onepage&q=two%20piece%20ostomy%20bag%20can%20be%20switched&f=false
(2) Lynn, P. (2010). Taylor’s Handbook of Clinical Nursing Skills. Lippincott Williams & Wilkins. Available online at https://books.google.co.ve/books?id=00x7I4hLj0IC&pg=PA664&dq=two-piece+ostomy+system+appliance&hl=es-419&sa=X&ved=0ahUKEwj375qB_rPiAhUFvlkKHS3CAiIQ6AEINjAC#v=onepage&q=two-piece&f=false
(3) Deitz, D., & Gates, J. (2010). Basic ostomy management, part 2. Nursing2018, 40(5), 62-63. Available online at https://journals.lww.com/nursing/Fulltext/2010/05000/Basic_ostomy_management,_part_2.24.aspx
(4) Fischer, J. E., Bland, K. I., & Callery, M. P. (Eds.). (2006). Mastery of surgery. Lippincott Williams & Wilkins. Available online at https://books.google.co.ve/books?id=PgUFJg_-f4YC&pg=PA1461&dq=ostomy+system+appliances&hl=es-419&sa=X&ved=0ahUKEwiuhvGXirTiAhUO2VkKHaPBAVgQ6AEIRDAE#v=onepage&q=ostomy%20system%20appliances&f=false
(5) Brunner, L. S. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (Vol. 1). Lippincott Williams & Wilkins. Available online at https://books.google.co.ve/books?id=SmtjSD1x688C&pg=PA1386&dq=ostomy+system+appliances&hl=es-419&sa=X&ved=0ahUKEwiuhvGXirTiAhUO2VkKHaPBAVgQ6AEIPTAD#v=snippet&q=ostomy%20appliance&f=false
(6) Browne, N. T., Flanigan, L. M., McComiskey, C. A., & Pieper, P. (2008). Nursing care of the pediatric surgical patient. Jones & Bartlett Publishers. Available online at https://books.google.co.ve/books?id=wRqGwrdmxCcC&pg=PA109&dq=two-piece+ostomy+system+appliance&hl=es-419&sa=X&ved=0ahUKEwjg5d-M_rPiAhXKrFkKHeNQBRoQ6AEIRTAE#v=onepage&q=two-piece&f=false
(7) Cross, A. W. My Other Bag’s a Prada: Quick and Dirty Tips for Surviving an Ileostomy. Available online at https://books.google.co.ve/books?id=xUlLDwAAQBAJ&pg=PT28&dq=ostomy+system+appliances&hl=es-419&sa=X&ved=0ahUKEwiuhvGXirTiAhUO2VkKHaPBAVgQ6AEILjAB#v=onepage&q=ostomy%20system%20appliances&f=false
(8) McMullen, C. K., Wasserman, J., Altschuler, A., Grant, M., Hornbrook, M. C., Liljestrand, P., … & Krouse, R. S. (2011). Untreated peristomal skin complications among long-term colorectal cancer survivors with ostomies: lessons from a study of family caregiving. Clinical journal of oncology nursing, 15(6), 644. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4123754/
(9) Colwell, J. C., Goldberg, M. T., & Carmel, J. E. (2012). Fecal & Urinary Diversions-E-Book: Management Principles. Elsevier Health Sciences. Available online at https://books.google.co.ve/books?id=u7x6AII_zdMC&pg=PA230&dq=changing+a+two+piece+ostomy+pouch&hl=es-419&sa=X&ved=0ahUKEwitt8PHnrTiAhVCjlkKHW5oBFAQ6AEIUTAF#v=onepage&q=two%20piece%20ostomy%20pouch&f=false