Influencing Factors Associated With Peristomal Skin Complications After Colorectal Ostomy Surgery: A Systematic Review and Meta-Analysis

Peristomal skin complications (PSCs) are the most common problem faced by ostomy patients, encompassing moisture-related dermatitis, mechanical dermatitis, allergic dermatitis, etc.¹ Studies have shown that the incidence of peristomal skin complications ranges from 11.0% to 60.0% internationally and from 16.3% to 58.3% in China, with most cases occurring within 3 months post-surgery.^2-4 The onset of PSCs not only causes secondary trauma for ostomy patients⁵ but also increases the likelihood of readmission, impacts their quality of life, raises medical costs, and places added strain on their families.⁶

The occurrence of PSCs can be attributed to various factors, including the patient’s overall health, stoma condition, self-care abilities, and stoma-related education.^7-8 Identifying the risk factors for PSCs is essential in preventing their occurrence and reducing their severity.⁹ While some studies have focused on identifying influencing factors for the prediction and prevention of PSCs, the results have not always been consistent. Shiraishi et al¹⁰ reported that smoking and type of ostomy were the influencing factors for PSCs, while Ayik et al¹¹ identified ileostomy, body mass index (BMI) greater than 24.9 kg/m², and temporary ostomy as associated variables. Chinese studies have also reported varying risk factors for PSCs, showcasing the complexity of this issue.^12-14 Various researchers have different focuses on PSCs, which creates challenges for clinical caregivers and researchers when it comes to efficiently grasping the influencing factors of PSCs. The objective of this review was to systematically identify and analyze the factors that influence the occurrence of PSCs in adult patients with colorectal cancer (CRC) and to offer insights for the prevention and management of PSCs.

This review was registered on PROSPERO, the international prospective register of systematic reviews (registration number CRD42023455552) and was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol (PRISMA-P).¹⁵

Objectives and research question

This work aimed to conduct a systematic review of original studies focusing on the factors influencing the occurrence of PSCs in adult patients with CRC. The incidence of PSCs was analyzed, existing studies were summarized and analyzed, and research methods were systematically evaluated to provide insights for the prevention and care of PSCs. This review was aimed at answering the research question: what factors are associated with PSCs among adult patients with CRC?

Information source and search strategy

A search was conducted in multiple databases, including PubMed, Embase, Web of Science, Cochrane Library, Wanfang, CQVIP (Weipu VIP), China National Knowledge Infrastructure (CNKI) and SinoMed. The search strategy was: ((((((("Enterostomy") OR ("Ileostomy")) OR ("Colostomy")) OR ("Ostomy")) OR (intestinal stoma)) OR (stoma)) AND ((("skin injuries") OR (" complications")) OR (dermatitis))) AND (((("Risk Factors") OR (factors)) OR (relevant factor)) OR (influencing factor)). The articles were limited to those published or e-published online from the databases’ inception to October 31, 2023.

Eligibility criteria

Literature inclusion criteria were (a) study subjects: patients with ostomies after CRC surgery (age ≥18 years); (b) study type: randomized controlled trial (RCT), experimental study, case-control study, cohort study (including prospective and retrospective) and cross-sectional study; (c) exposure factors: all factors associated with PSCs; and (d) outcome measures: incidence of PSCs. Literature exclusion criteria were (a) repeated published literature (the most comprehensive one retained); (b) non-Chinese and non-English literature; (c) overall analysis of PSCs but unable to extract the data related to PSCs alone; (d) raw data information too limited to use; (e) review, abstract, comment, letter reply, unpublished data, or case study.

Data collection extraction

Two researchers independently searched and extracted data information from the included literature, and inconsistency was discussed and resolved by the 2 researchers; if agreement could not be reached, the final decision was made by the third researcher. The Newcastle-Ottawa Scale¹⁶ was used for quality evaluation of articles, including the study population (4 points), comparability between groups (2 points), and outcome measures (3 points). Extracted information included name of the first author, year of publication, country of source, study design, number of study subjects, number of PSCs, incidence of PSCs, and reported influencing factors.

Meta-analysis and statistical analysis

Data analysis was conducted using the software Review Manager Software (RevMan 5.4, Microsoft, Redmond, WA) to calculate the combined incidence of PSCs and its 95% confidence intervals (CI). The odds ratio (OR) and 95% CI of PSCs in patients with ostomies from the literature analysis were utilized as the effect size statistics. Heterogeneity of the combined data was assessed primarily through I², if I² ≤ 50% and P > .1, which indicated no significant heterogeneity among studies. A fixed-effects model was adopted for analysis. If heterogeneity was present (I² > 50% and P < .1), a random-effects model was adopted for analysis. Due to the limited number of included case-control articles (less than 10), no publication bias analysis was performed.

Literature search and screening results

After conducting an initial search across various databases, a total of 211 articles were found. After removing 86 duplicate articles with Endnote X9 software for reference management, 125 articles were retained. Subsequently, a detailed screening of titles and abstracts led to the exclusion of 84 articles that did not meet the inclusion criteria, resulting in 41 articles being selected for further review. Upon thorough examination of the full texts, 29 additional articles were excluded for not meeting the inclusion criteria, leaving a total of 12 articles for qualitative synthesis. Two more articles were excluded due to incomplete data (Yang et al., Yun et al).^17-18 Eventually, 10 studies were enrolled in the meta-analysis^{3-4,10-13,19-22} (Figure 1).

Characteristics and quality equality evaluation of the included literature

A total of 10 studies published between 2010 and 2023 were included in this analysis, comprising 1 randomized clinical trial, 6 cohort studies, and 3 cross-sectional studies. The collective participation of 3753 patients with ostomies revealed that 981 individuals experienced PSCs, with the incidence ranging from 15.5% to 47.7%. The studies were conducted in various countries, including China (5), Italy (1), Japan (1), Turkey (1), Korea (1), and the United States, Canada, and Europe (1).

The literature identified 34 influencing factors related to PSCs, which can be categorized into 3 types: (a) fixed factors (demographics and clinical history), including age, sex, type of ostomy (colostomy versus ileostomy), temporary or permanent ostomy, emergent operation (operation time), type of stoma, stoma duration, malignancy, diabetes, psoriasis, comorbidities; (b) changeable factors (varied with time or treatment), including stoma height, chemotherapy, stoma profile, radiotherapy; and (c) manageable factors (intervenable factors), including diet type, remover, powder, type of device, hydrocolloid plaque, gauze for cleansing, low pH detergent, excretion status, self-care ability, telephone follow-up, weight, enterostomal therapist instruction, smoking, BMI, self-care knowledge of stoma, self-care skill of stoma, stoma education, preoperative stoma positioning, and stoma care products. After extracting influencing factors that appeared in 2 or more articles, 7 influencing factors (stoma duration, type of ostomy, diabetes, age, type of stoma, self-care knowledge, chemotherapy) were found. After further analysis, 4 influencing factors (type of ostomy, diabetes, self-care knowledge, chemotherapy) were extracted (P < .05) in Table 1 and Table 2.

Outcome analysis

Type of ostomy 

Six studies^{3,8,10-11,13,22} identified the type of ostomy as the influencing factor for PSCs. Using a random-effects model, the analysis demonstrated heterogeneity (I² = 87%, P < .00001). The results indicated that type of ostomy was an influencing factor for PSCs (OR=2.37, 95% CI [1.06，5.32], P = .0008) in Figure 2.  

Diabetes 

Three studies^4,21-22 indicated that diabetes was the influencing factor for PSCs. The analysis, using a random-effects model, showed significant heterogeneity (I² = 88%, P = .0003). The findings revealed that diabetes was a significant influencing factor for PSCs (OR = 2.58, 95% CI [1.23, 5.42], P = .01), as depicted in Figure 3.

Self-care knowledge 

Two studies^3,13 reported that self-care knowledge was the influencing factor for PSCs. Using a random-effects model, the analysis showed heterogeneity (I² = 69%, P = .07). The result showed that self-care knowledge was the influencing factor for PSCs (OR=0.41, 95% CI [0.22,0.75], P = .004) in Figure 4.

Chemotherapy 

Three studies^3-4,19 reported that chemotherapy was the influencing factor for PSCs. Using a random-effects model, the analysis showed heterogeneity (I² = 69%, P = .07). The results showed that chemotherapy was the influencing factor for PSCs (OR=4.03, 95% CI [2.24, 7.26], P < .00001) in Figure 5.

The purpose of this meta-analysis was to evaluate types of factors associated with PSCs among adult patients with CRC. The analysis included 10 studies and identified ostomy type, diabetes, self-care knowledge, and chemotherapy as influencing factors linked to the occurrence of PSCs. Despite half of the included studies being conducted in China and some articles not being very recent, the results of this meta-analysis highlighted similarities in PSCs studies across different countries and races.

In this meta-analysis, 4 factors were identified as being associated with the onset of PSCs. Clinicians should be sensitive to fixed factors, monitor changeable factors, and pay attention to manageable factors.

Type of ostomy

Six studies^{3,8,10-11,13,22} mentioned type of ostomy as a risk factor for PSCs. Patients with an ileostomy are more likely to develop PSCs compared to those with a colostomy. This could be attributed to the fact that water absorption primarily occurs in the large intestine, leading to a higher volume of unabsorbed water in the excrement of patients with ileostomies.^17,23 Consequently, ileostomy excretions—which contain a significant amount of small intestinal fluid—can be highly corrosive, especially in the first year post-surgery when they still contain active digestive enzymes that can result in skin damage.²⁴

Diabetes 

For patients with diabetes, hyperglycemia creates an optimal environment for the growth of bacteria and fungi, increasing the risk of complications such as peripheral neuropathy, vascular lesions, skin infections, and various skin changes.²⁵ Elevated blood sugar levels pose challenges for proper skin care in these patients. Prolonged exposure to high glucose concentrations in tissues can result in decreased white blood cell count, weakened pathogen-killing ability, and reduced chemotaxis, making diabetic patients more susceptible to skin infections.²⁶ As a result, diabetes is recognized as a risk factor for PSCs.

Self-care knowledge 

Ostomy care has great reliance on patients’ self-care ability. Since the implementation of enhanced recovery after surgery programs, many patients with stoma and their families have not received sufficient education and practical training on stoma care during their hospital stay. When discharged, their knowledge and skills related to stoma care often fall short of what is needed to effectively manage their own stoma, which greatly increases the incidence of stoma-related complications. The lack of self-care knowledge has a positive connection with the occurrence of PSCs, and self-care knowledge serves as a protective factor against PSCs.^27-28

Chemotherapy 

Chemotherapy commonly leads to skin damage and associated issues such as itching, rash, and facial flushing. These adverse reactions are believed to impact the delicate skin surrounding the stoma, compromising its integrity, increasing fragility, and impeding the self-repair processes.^29-30 Moreover, excessive sweating and changes in skin accessory tissues can heighten the risk of folliculitis, fungal infections, and other skin complications.³¹ Additionally, chemotherapy-induced alterations in gastrointestinal function can lead to irregular stool shape and excretion, increasing the likelihood of leakage, contamination, bag distension, and related challenges in stoma management.^32-33 Consequently, chemotherapy represents a significant risk factor for peristomal skin complications.

The recognition of risk factors and protective factors for PSCs provide a reference for their prevention. PSCs are the most common complications after ostomy creation surgery, and in the analyzed studies patients with ostomies were affected by different influencing factors of PSCs at different periods after stoma creation. During the early postoperative period, the incidence of PSCs was high due to patients’ unfamiliarity with stoma pocket usage and concurrent radiotherapy and chemotherapy. Therefore, at the postoperative period and discharge, stoma therapists and other professionals can offer consultations, telephone follow-ups, family visits, stoma association support, and other forms of stoma management guidance to meet the needs of stoma care, ultimately enhancing ostomy adaptation and improving quality of life. Continuous professional education on stoma care can empower patients to acquire the necessary theoretical knowledge and practical skills in stoma nursing. This ongoing education helps enhance their self-care practices, leading to a decreased likelihood of peristomal dermatitis and ultimately contributing to an improved quality of life. Stoma-related education encompasses various aspects such as psychological support, adapting to surgery, dietary and exercise guidance, stoma care techniques, skin monitoring, postoperative recovery, and comprehensive education across multiple dimensions. This holistic approach aims to enhance the self-care abilities of patients with CRC and stomas.¹⁴ For patients without a positive learning attitude, it is crucial to emphasize the significant link between stoma complications and postoperative self-care. One effective approach is to provide personalized health guidance, implement purposeful and targeted health education activities, address unhealthy behaviors, enhance stoma awareness, and promote a positive attitude towards stoma care. Monitoring the impact of health education on patients with CRC and stomas, assessing their self-care abilities and knowledge levels regularly, and enhancing their stoma care knowledge and self-care skills are essential steps in improving patient outcomes.^12,14

This meta-analysis has several limitations. First, the review included 10 articles, half of which were conducted in China, and some articles were not recent (4 adopted articles were more than 5 years old). This diversity in country of origin may provide insights into different perspectives on PSCs and highlight the need for further studies. Additionally, the quality of the included articles was not consistently high, which could impact the overall results. Second, the influence factors included in the articles vary in terminology and type, such as BMI categories, stoma product classifications, and descriptions of self-care practices, predominantly reported in China. Moreover, stoma care and self-management training methods in China may differ from those in other countries, potentially influencing the study results. Third, factors like age, sex, stoma type (loop or end), and stoma product selection remain contentious across different studies. These controversies stem from variations in study subjects, design, sample size, outcome indicator definitions, and retrospective data discrepancies. Future research should aim to conduct more studies using standardized terminologies and classifications to identify influencing factors more effectively.

It is recommended to expand the sample size for further investigation into PSCs. Existing studies primarily focus on factors such as patients’ health status, stoma status, self-management capacity, and stoma care practices, including the type of ostomy, presence of diabetes, and if the patient is undergoing chemotherapy. However, there is a lack of research on the potential correlation between changes in stoma excrement composition and bacteria with the occurrence and severity of PSCs following surgery, radiotherapy, and chemotherapy. This area presents an avenue for future research.

This meta-analysis provides a summary of the influencing factors of PSCs, offering valuable insights for clinical research and practice. Type of ostomy (OR=2.37, 95% CI [1.06,5.32], P = .0008), diabetes (OR=2.58, 95% CI [1.23,5.42], P = .01), self-care knowledge (OR=0.41, 95% CI [0.22,0.75], P = .004), and chemotherapy (OR=4.03, 95% CI [2.24, 7.26], P < .00001) were significant factors associated with PSCs. There are limitations to consider, such as the predominance of single-center cross-sectional and cohort studies, with only one RCT and multicenter study included. Some articles were not recent research, and overall quality of the literature is compromised by retrospective designs, incomplete data collection, and limited validation factors, leading to inconsistencies across studies that hinder meta-analysis. Conducting future studies, such as large-sample prospective cohort and case-control studies focusing on changes in stoma excrement composition and bacteria, may help address these limitations.

Acknowledgment: All authors contributed equally to this study.

Authors: Li-Li Ma, RN, MSc¹; Ya-Juan Zhang, RN, MSc²; Jin-Xiu Yao, RN, MSc²; Wei-Ying Zhang, RN, PhD¹; and Hui-Ren Zhuang, RN, MSc¹

Affiliations: ¹Department of Nursing, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China; ²Department of Nursing, Shanghai Sixth People’s Hospital Affiliated to Jiao Tong University, School of Medicine, Shanghai, China.

Disclosures: The authors have no financial or other conflicts of interest to disclose.

Funding: This study is funded by Important Weak Subject Construction Project Shanghai Pudong New Area Health Commission (Grant No. PWZbr2022-04).

Data Availability Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Correspondence: Wei-ying Zhang, RN, PhD, Nursing Director, Department of Nursing, Shanghai East Hospital, School of Medicine, Tongji University, Jimo Road No.150, Pudong New Area, Shanghai, China; zhangwy_cn@126.com

1. LeBlanc K, Whiteley I, McNichol L, Salvadalena G, Gray M. Peristomal medical adhesive-related skin injury: results of an international consensus meeting. J Wound Ostomy Continence Nurs. 2019;46(2):125-136. doi:10.1097/WON.0000000000000513

2. Taneja C, Netsch D, Rolstad BS, Inglese G, Eaves D, Oster G. Risk and economic burden of peristomal skin complications following ostomy surgery. J Wound Ostomy Continence Nurs. 2019;46(2):143-149. doi:10.1097/WON.0000000000000509

3. Zhang XP, Xu JJ. Analysis of factors associated with the occurrence of peristomy dermatitis in patients with colorectal cancer. Article in Chinese. Nursing Practice and Research. 2020;17(1):11-14. doi:10.3969/j.issn.1672-9676.2020.01.004.

4. Liu N, Pi HY, Zhou Jing, Li N, Guo DD, Li YK. Analysis of factors associated with the occurrence of peristoma dermatitis in patients with colorectal cancer. Article in Chinese. Chinese Journal of Modern Nursing. 2018;24(35):4252-4256. doi:10.3760/cma.j.issn.1674-2907.2018.35.009

5. Song XL, Hu NN, Wu YX, Lu HY, Jin X. Home life experience of colorectal cancer patients with a permanent colostomy: a qualitative study. Nurs J Chin PLA. 2019;39(15):3816-3821. doi:10.396/j.Issn.1008-9993.2017.01.008

6. Gao YP, Zhu Y. Research progress of family caregivers of patients with permanent colostomy. Chin J Prac Nurs. 2017;33(11):878-880. doi:10.3760/cma.j.issn.1672-7088.2017.11.020.

7. Xian XM, Shi WL, Xiang WL. Qualitative research on self-management experience for intestinal fistulization patients with complications. Nurs and Reha J. 2015(8):703-706,711. doi:10.3969/j.issn.1671-9875.2015.08.001

8. Emmanuel A, Chohda E, Lapa C, Miles A, Haji A, Ellul J. Defunctioning stomas result in significantly more short-term complications following low anterior resection for rectal cancer. World J Surg. 2018;42(11):3755-3764. doi:10.1007/s00268-018-4672-0

9. Jayarajah U, Samarasekera DN. A cross-sectional study of quality of life in a cohort of enteral ostomy patients presenting to a tertiary care hospital in a developing country in South Asia. BMC Res Notes. 2017;10(1):75. doi:10.1186/s13104-017-2406-2

10. Shiraishi T, Ogawa H, Katayama C, et al. The presurgical controlling nutritional status (CONUT) score is independently associated with severe peristomal skin disorders: a single-center retrospective cohort study. Sci Rep. 2021;11(1):18857. doi:10.1038/s41598-021-98369-y

11. Ayik C, Özden D, Cenan D. Ostomy complications, risk factors, and applied nursing care: a retrospective, descriptive study. Wound Manag Prev. 2020;66(9):20-30.

12. Huang QM, Huang LM. Analysis of risk factors and countermeasures for skin injury around the enterostomy. Colorectal and Anal Surgery. 2017;23(6):783-787. https://www.zhangqiaokeyan.com/academic-journal-cn_journal-colorectal-anal-surgery_thesis/0201233482183.html

13. Tao Y, Chen LH, Hu CW, Zhang XM. Analysis of the occurrence of dampness-related skin injury in patients with enterostomy. Article in Chinese. Chinese Journal of Practical Nursing. 2019;35(5):321-325. doi:10.3760/cma.j.issn.1672-7088.2019.05.001.

14. Liu YG, Cao QJ, Wu Yan. Systematic evaluation of factors affecting the occurrence of cutaneous complications around the enterostomy. Article in Chinese. Evidence-Based-Nursing. 2020;6(9):894-904. doi:10.12102/j.issn.2095-8668.2020.09.005

15. Moher D, Shamseer L, Clarke M, et al; PRISMA-P Group. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1. doi:10.1186/2046-4053-4-1

16. Wells G, Shea B, O’Connell D, et al. (2000). The Newcastle–Ottawa Scale (NOS) for assessing the quality of non-randomized studies in meta-analysis. 2000. Accessed January 7, 2024. https://xueshu.baidu.com/usercenter/paper/show?paperid=1x710rj0w3780cn0ts3d0gd08q453667&site=xueshu_se

17. Yang D, Meng FS. Analysis of the factors influencing the occurrence of complications after ileostomy. Article in Chinese. Nursing Research. 2013;27(25):2733-2735. doi:10.3969/j.issn.1009-6493.2013.25.018

18. Yunhong, Zhang Y, Zheng W, Yu HX. Risk factors and nursing countermeasures for fecal hydrodermatitis after prophylactic ileostomy. Article in Chinese. Chinese Electronic Journal of Colorectal Diseases. 2019;8(4):413-416. doi:10.3877/cma.j.issn.2095-3224.2019.04.018

19. Guerra E, Denti FC, Di Pasquale C, et al. Peristomal skin complications: detailed analysis of a web-based survey and predictive risk factors. Healthcare (Basel). 2023;11(13):1823. doi:10.3390/healthcare11131823

20. Salvadalena G, Colwell JC, Skountrianos G, Pittman J. Lessons learned about peristomal skin complications: secondary analysis of the ADVOCATE trial. J Wound Ostomy Continence Nurs. 2020;47(4):357-363. doi:10.1097/WON.0000000000000666

21. He D, Liang W, Yao Q, et al. The effect of stoma education class on peristomal dermatitis in colorectal cancer patients with defunctioning ileostomy-a retrospective study of 491 patients. Transl Cancer Res. 2021;10(2):581-588. doi:10.21037/tcr-20-3267

22. Sung YH, Kwon I, Jo S, Park S. Factors affecting ostomy-related complications in Korea. J Wound Ostomy Continence Nurs. 2010;37(2):166-172. doi:10.1097/WON.0b013e3181cf7b76

23. Shi J, Ro BK, Liu L. Cause analysis and care of different types of periostomy dermatitis. Article in Chinese. Journal of Nursing. 2012;27(20):40-41. doi:10.3870/hlxzz.2012.20.040

24. Gray M, Black JM, Baharestani MM, et al. Moisture-associated skin damage: overview and pathophysiology. J Wound Ostomy Continence Nurs. 2011;38(3):233-241. doi:10.1097/WON.0b013e318215f798

25. Du XM, Wang XQ, Chen JX, Zhang XN. Observation on the effect of tannin cream in relieving the pain of ileostomy irritant dermatitis. Article in Chinese. Nursing Practice and Research. 2010;7(13):49-50. doi:10.3969/j.issn.1672-9676.2010.13.026

26. Meng QX. Discussion on clinical care of 60 diabetes cases with dermatology. Journal of Aerospace Medicine. 2014;25(9):1325-1326. doi:10.3969/j.issn.2095-1434.2014.09.091 http://172.31.10.117/D/Periodical_hkhtyy201409091.aspx

27. Suo X. Effect of health belief patterns on self-care ability in patients with urostomy in bladder cancer. Nursing Practice and Research. 2017;14(18):79-81. doi:10.3969/j.issn.1672-9676.2017.18.035. http://172.31.10.117/D/Periodical_tlsjyyj201718036.aspx

28. Arumugam PJ, Bevan L, Macdonald L, et al. A prospective audit of stomas--analysis of risk factors and complications and their management. Colorectal Dis. 2003;5(1):49-52. doi:10.1046/j.1463-1318.2003.00403.x

29. Dou RX, Wang JP. The relationship of combination of preoperative radiotherapy with anastomotic leakage and low anterior resection for rectal carcinoma. China Medical Journal. 2019;54(1):10-15. http://172.31.10.117/D/Periodical_zgyk201901004.aspx

30. Huang YM, Zhong XY, Lan ML, et al. A pocket design and application for hospital bed care. Nursing Practice and Research. 2018;15(10):158. doi:10.3969/j.issn.1672-9676.2018.10.068. http://172.31.10.117/D/Periodical_tlsjyyj201810069.aspx

31. Bartha I, Hajdu J, Bokor L, Kanyári Z, Damjanovich L. Colostomás betegek életminöségének vizsgálata [Quality of life of post-colostomy patients]. Article in Hungarian. Orv Hetil. 1995;136(37):1995-1998

32. Doughty D, Junkin J, Kurz P, et al. Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges. J Wound Ostomy Continence Nurs. 2012;39(3):303-315; quiz 316-317. doi:10.1097/WON.0b013e3182549118

33. Li L, Wang H, Hu XQ, et al. Retrospective clinical analysis of hypersensitivity reactions to oxaliplatin. Article in Chinese. Chinese Clin Pharmacol. 2014;30(2):149-150. doi:10.13699/j.cnki.1001-6821.2014.02.019