2008 marks the 40th anniversary of the Wound, Ostomy and Continence Nurses (WOCN) Society. The leadership of the WOCN is working on the collection of historical data regarding the birth of the specialty as well as ongoing history. Our hope is to share the historically significant events with the membership first at the 40th Annual Conference in Orlando, and then by archiving the data in a permanent location.
To illustrate the significance of archiving our history, I would like to share with you an important historical publication from 1970, cowritten by Edith Lenneberg and John Rowbotham. Edith Lenneberg was a pioneering president of the then North American Association of Enterostomal Therapists. The Ileostomy Patient: A Descriptive Study of 1,425 Persons1 reported findings on ostomy patient research conducted between the years 1958 and 1962, and is a major historical contribution of ostomy care knowledge. What follows is a brief synopsis of the findings of Lenneberg's and Rowbotham's research. "What is it like to live with an ileostomy?" was the research question asked from 2500 patients in the United States and Canada. The focus was to learn directly or indirectly about the patient's "retrospective view of the crisis" (Lenneberg and Rowbotham's description), current functioning, and possible relationships between these variables.
In the introduction, the authors note: "If all stomas were successful surgically, if all ileostomists(sic) had a smoothly contoured abdomen, had technology already produced the perfect universal appliance, and had all people easily governable emotions, an ileostomy would not represent an insult greater than an appendectomy. The ileostomy patient's task is learning a new method of handling a basic bodily function which previously was automatic." The authors point out the issues that our ostomy patient population deals with today: uneven pouching surfaces, a variety of pouching systems, and the emotional component of learning to live with a stoma.
The data were self-reported by the patients who had their ileostomy from several weeks to 28 years. Seventy percent of the patients reported having 2 to 5 ileostomy-related complications. The authors classified the complications into 2 main groups: direct complications of the surgery (classified as serious surgical complications) and pouching system issues (classified as difficulties related to the appliance) (Tables 1 and 2). Below is a synopsis of their findings:
Serious Surgical Complications
* Six hundred ninety-three patients (52%) reported having obstruction. One third of the patients with obstruction underwent surgery for correction of the condition.
* Two hundred forty-six respondents (18%) had abdominal abscesses.
* Three hundred fourteen patients (24%) reported stenosis. One hundred fifteen of these patients required surgery.
* One hundred seventy-three patients (13%) reported prolapse, almost one-half of those with prolapse needed surgical correction.
* One hundred fifty-six patients (12%) reported encountering retraction.
Complications Related to Appliances
* Granulations (sic) tissue or "proud flesh" was reported by 361 respondents (27%).1 The authors noted that the surgeon expected the granulation tissue to bridge the gap between skin and mucosa; the granulations were the foundations of scar tissue. They reported that "proud flesh" was not a complication of surgery but a naturally occurring phenomenon, which is often viewed as a difficulty by patients because it interferes with adherence of the appliance.
* Fistula formation between the ileum and skin was reported by 381 respondents (30%). Interestingly, the authors stated, "the usual cause of fistula is irritation of the skin or stoma by the appliance. This leads to erosion with secondary infection, which burrows between the skin and outer stoma to the lumen of the bowel. A proper fitting appliance worn correctly and changed at proper intervals will help prevent fistulae."1
* Skin trouble, appliance trouble, and odor were listed as ileostomy difficulties directly related to the appliance. Seven hundred thirty-six patients (55%) reported skin trouble, 533 (40%) reported some to a lot of appliance trouble, and 636 (48%) patients noted odor as a problem.
The authors noted "it is hoped that an awareness of the extent of these complications will encourage surgeons to continue perfection of techniques in order to avoid or diminish the number of obstructions-stenosis, prolapse, retraction-all of which cause repeated and continuing physical disability. The great number of responses regarding skin trouble, odor, appliance problems, and fistula attests to the need for prosthetic progress." While there was no discussion about surgical techniques, the authors did speak to the "principles of the prosthesis and definition of failure." They stated that "the prosthesis' must do the following: (1) contain all fecal drainage, whether soft, bulky or watery, and permit no soilage, (2) contain all gases, and (3) prevent discharge from touching the skin, which will be digested away by the discharge if contact is permitted for more than one hour."1
The authors reported on patterns in appliance changing: "successful fit of an appliance is usually gauged by the number of days it will stay on the body without falling off or permitting fecal matter to touch the skin."1 The authors ended with the following suggestions for future research: (1) improved methods of promoting psychological adaptation to ileostomy, (2) prosthetics, (3) case-finding methods of ulcerative colitis patients for referral to rehabilitation agencies, and (4) incidence and prevalence of ileostomy (complications, adjustment).
Almost 40 years later, the practice of ostomy care continues to look at many of the issues that Lenneberg and Rowbotham reported. Their landmark study provides us with incidence and prevalence data of ileostomy complications (defined by the authors as serious surgical complications) as well as peristomal complications (defined by the authors as appliance complications). The incidence and prevalence of stomal and peristomal complications have been reported by a few clinicians but still remains difficult to determine.2-7 In order to understand the scope of the problems our patients encounter as well as plan interventions to potentially decrease these complications standardized data collection on stoma and peristomal complications is critical.8 In addition, Lenneberg's and Rowbotham's data further illustrate the need for universal definitions of stomal and peristomal complications as well as validated interventions to provide an evidence-based practice to our patients undergoing ileostomy surgery.9
It is of interest to note that the Lenneberg and Rowbotham study states that successful fit of an appliance is usually gauged by the number of days it will stay in place and provide skin protection. This concept of a minimal and predictable wear time is a principle that the WOCN Society further developed and refined in the National Ostomy Consensus Meetings. Lenneberg and Rowbotham suggested that this principle be adapted in 1970!!
Edith Lenneberg and her colleague John Rowbotham examined issues related to successful ostomy rehabilitation. It is now 40 years later and we must continue to build on Lenneberg and Rowbotham's work. Knowledge of our history allows us to understand where our specialty of ostomy care has been, what is currently known, and where we need to be in the future. As a society, we need to look at the historical underpinnings of our tri-specialty. We are actively looking for historical documents and encourage our members to seek these out and share them by contacting our national office. Please take time to look at information you may have or you know that your colleagues might have and share that information with all of us!!
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