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Welcome everyone uh to our first ever fundamentals of intestinal stoma care webinar. My name is Lillian Reza. I am the Dukes Club president, which is the trainee section of the Association of Cht of Great Britain and Ireland. We're really glad to have everyone on board and I can see everyone's piling in slowly. Um just to start off with some housekeeping uh points, you will see a um a message box towards your right and on there, it's quite clear that if you're joining this, this platform, the best way to use it is by joining on Chrome edge or Five Fox. If you're having trouble, please u use one of those browsers or message me privately if it's, if it's another it issue and I'll see what I can do to help. Um If you have questions that you'd like to ask the speakers, please use the message function again to ask your questions. We'll try to answer them during the Q and A's live. Um And with that, I'm going to hand over to our first speakers, Nicola Yardley and A, a. Hello, everybody. Good morning. My name is a A, I'm the vice president and CPD coordinator for the Nigerian Society for Correct Disorders and on behalf of society, I'd like to welcome you to this very important webinar. Um Before we start, I'd like to give us a background on why we're here. So, uh Nigeria is a representative of what we see in Sub Saharan Africa. We have a very large population over 220 million individuals. And in that population, we have lots of patients with common colorectal disorders. The creation of intestinal stoma is one of the commonest colorectal disorders that has been done in our setting. And for a population of over 220 million people, we will have less than 12 trained stomach care nurses who are dedicated to taking care of this patient. Of course, you agree with me that this is quite insufficient. In addition, many of our patients do have access to adequate stoma appliances. Less than 5% of our patients actually have access to stoma bags and adequate s and in my own practice, I see that as a marker of socioeconomic status. This is very, very sad and we are very sore statistics and we thought it and nice to have this kind of webinar where we would have a discussion to try to train healthcare providers in the global north and global itself on how to manage this kind of patients. Before. Now, most of the patients who have stomach disorder and stomach surgeries are being cared for by doctors, but there has to be a shift where stomach lost care is what we need to be done to, to lead them to care for these patients. And so we thought it would be best to have this kind of webinar for that. We have this um engagement to enlighten our audience. I'd like to hand out to nuclear to give up more information. Thank you, Ade Oler. Um So I'm delighted that we're able to um er join with um the Nigerian Society of Colorectal Disorders. Um um I'm a consultant colorectal surgeon er at the Countess of Chester Hospital, which is in the northwest of England, er, and I am chair of the um Education and training Committee of the Association of Coot of Great Britain and Ireland. Um I'm delighted to be able to um be at this event where we've got six talks from um er speakers from across the UK and it is fantastic that we've got over 70/700 registrations from over 17 different countries. So that's fantastic that so many people are interested in stoma care and improving outcomes for our patients. So, as Lillian has er said in her introduction, um please make sure that you're using the correct browser um that will give you the best um er um er audio visual experience with the meal platform and please keep an eye on the chat box. Please ask questions uh via the chat box and then we will put those to the faculty during the question and answer sessions at the end of each talk. Um the talks have been prerecorded in order that we can get the best quality er audio visual experience for you all the recorded talks, use less bandwidth and we're fully aware that the internet access may not be the best for er er for many of you. So um the talks are recorded but the question and answers will be live. Um I'd like to say thank you very much to our faculty for taking the time out to prepare the talks. And on that note, I'll hand back over to Ade Moler to introduce our first speaker. Thank you Nicola. So our first speaker is Mr Sanjay. He'll be talking about his structure and function of the gut. I'm sure we will all agree with me that this will set it tone for the webinar. He's Mr is very special to me and I'm I have the privilege of introducing him to us. So Sanjay was appointed as a consultant Corrector surgeon at University of Leicester in 2009. He commented on the very medical education and surgical training from the armed forces, Medical College, University of Pune. And he served his commission with the Indian Navy from 1987 to 1998. This includes service of warships, neighbor hospitals, as a medical officer and a surgical specialist. He is international representative for ACP GBI and a member of the Course studies committee of E SCP. His favorite roles include the record of surgeons to at his hospital. I met Sanjay in 2018 as a, as a fellow in Leicester and my time with him was very amazing. He, one of his interests includes system education and preoperative patient education. So definitely we all agree with me that he's very ideal to start off with this right now. So without further ado, let's hear from apologies for the lack of audio, we will um er just er, deal with, er, deal with that. Bear with us for the um er er technical issue. We've had a er um er, a rehearsal with this and it's all worked er, very well but um er, I'm guessing that's technology for you whilst um Lilian's sorting the er, audio on the um er the first talk. Um er, I'm not sure whether many of you are um er aware of the medal platform and whether you've used it before. Um but it is a free um er er to use open access um er medical education platform with the aim of um er sharing medical education opportunities er far and wide. So, the Dukes Club and ACP GBI have been utilizing the platform along with many other um societies in the UK to try and get medical education um accessible to all and it normally works very well. Ok. As a solution, Sanjay would you like to actually, uh, present your talk live as you're here? Just a second. I'm just trying to see if I should, uh, kind of just run the prerecorded talk. Let me just get to talk up and running. Can, can everyone hear me? Yes, bye. Just waiting for powerpoint to load. It's good to see so many people joining on a Saturday morning. Apologies for this. We can try once more if you like Andre. Yep, I will stop. And if it doesn't work, greetings, every one of you who was logged into a so education event today, my talk is about the structure and function of the gut. I'm Sanjay Chaudhary, a collector consultant working in England. I work at a University Hospital in Leicester. Leicester is about an hour and a half north of London and somewhere you might recollect that Leicester a few years ago did win the Premier League. But once and we are now in the lead below. For the purpose of my talk today, I'm going to discuss the anatomy and the function of the different parts of the gut together. I'm gonna start with the mouth, pharynx and esophagus. Then talk about the stomach, the liver gallbladder and pancreas, the small and large intestine and finish with the rectum anus. The mouth consists of the tape, jaw muscles and tongue, the food. Once it's eaten is chewed and mixed with saliva. This starts the process of digestion, the pharynx of the throat is a muscular tube connecting the mouth, both with the respiratory and digestive systems. Mhm. The main functions of the esophagus are to transport food and fluids from the pharynx to the stomach. It prevents reflux of gastric contents into the esophagus. There is a low esophageal sphincter that prevents the actual reflux. The esophagus also has a role in expelling the contents of the stomach. Once the vomiting reflex has been activated, stomach is a muscular organ that comprises the fundus body antrum and pylorus. The pylorus opens and closes to allow gastric contents into the small bowel. The contractions within the stomach along with the relaxation helps to combine saliva, food and gastric juices for the digestion of proteins. The stomach produces acid that kills bugs in the food and helps with the absorption of vitamin B12. It essentially stores food temporarily and slows down the release of food into the small intestine, the liver gallbladder and pancreas. The liver is a large organ and I'm going to discuss its function with respect to digestion. It produces bile, this is stored in the gallbladder and released into the duodenum. Once food enters the duodenum from the stomach oil essentially is like a detergent. It, it breaks down fats to help with the absorption of fat and fat soluble vitamins. Talking about the pancreas. I'm going to discuss the exocrine function of the pancreas here rather than the endocrine function, which is the hormones, the pancreas produces pancreatic juice consists of alkaline fluid and enzymes such as strypsin lipase amylase. And these are responsible for digestion of the protein fat and carbohydrates in the food. The alkaline fluid in the duodenum neutralizes the acid content of the acidic ph of the chime. That is the digestive food that comes out of the stomach. It fall into stain consists of the duodenum, the jejunum and the ilium. It measures about 5 to 6 centimeters in length. The duodenum is the widest part of the small intestine, measuring about 25 centimeters in length. This is where the bile and pancreatic juices meet with the food that comes out of the stomach to help with digestion. The jejunum is about 2/5 of the length of the small intestine and is largely located in the middle of the abdomen. In the jejunum, the peristaltic movements are rapid and vigorous and that helps with the digestive process. The terminal ilium or the ilium is narrower. It is located in the lower abdomen and it's walls are thinner with slow peristaltic movements. The small intestine is the powerhouse of where most of the digestion of our food takes place. The lining of the small intestine mucosa is very specialized because it has forms that are called vila and microvilli, which help with the digestion and absorption of nutrients. These microscopic finger like projections like you can see in this image here help to increase the surface area and the more surface area. There is the better the absorption these together the vili and the microvilli amplify the small intestinal surface area by about 60 to 120 times. So if you were to measure the entire absorptive capacity of the small bowel, it is about 30 m square. By the time food has left the small intestine, about 90% of nutrients have been extracted from the food that entered the small bowel. The large intestine or the colon is about a meter and a half long. It comprises the ascending, transverse, descending and sigmoid colon. Here, absorption of water and electrolytes takes place. And colonic bacteria complete the process of chemical digestion. The contents within the column are pushed back and forth by contractions and antiperistaltic contractions to such time feces are finally pushed towards the anal canal by mouse movements. There are bacteria in the colon which produce some B vitamins and Vitamin K The rectum and anus. The rectum is about 15 centimeters in length. It is the last part of the bowel just above the anal canal and it produces mucus and stones feces. This mucous it produces helps with the lubrication of feces through the rectum. The anus is the last three or four centimeters and it has specialized sphincter muscles that are responsible for our continents. The rectum has stretch receptors and nerves that work together with the anus that help to expel feces. I think this is a very important slide understanding water absorption is very important, particularly when one considers stoma and their management. If diagram helps understand that every day, about 2 L of fluid is what people would drink between one and 2 L. You have a liter of salivary gland secretions up to 2 L produced by the stomach. Almost a liter of bile, just over a liter of pancreatic juices and small intestine secretions of about 2 L. So if you add this all up, there is a large amount of water that is going through the bowel to help with the process of digestion. I can give you a simple comparison. This is something like a washing machine where you have a lot of water that helps to dissolve and mix with the food and help digestion. 90% of this water is absorbed in the small intestines by osmosis. And it's important to understand that water can actually move into the body through the small intestine or out of the body through the small intestine depending on osmotic gradients in the colon. Absorption of water is mainly in the ascending colon. Though you do continue to absorb water as stool goes through the bowel. And this is of relevance when you're thinking about a patient having an ileostomy or a colostomy. An ileostomy is performed towards the last part of the small bowel, which is the terminal ilium slightly away from the ileocecal valve. It's important to realize that the exact location of the bowel of the stoma in the small bowel will have different outputs because of the water absorption. Normally an IOST would produce about a liter every day. But this could be more in the early post operative period. Whilst the bowel takes time to adjust or the body takes time to adjust to the creation of a stoma. It's very important to understand the drinking more water can increase the output from an ileostomy. And the reason for this is that, as I mentioned in the slide earlier, that water absorption in the small bowel is controlled by the salt or the osmotic gradients. And if you drink a lot of water, there is more salt in the body, less salt in the water or no salt in the water, you find salt from the body would leave and enter into the small bowel lumen and you would lose water. So it's important that patients understand that they require some extra salt in their diet or if they are feeling dehydrated because of a high stoma output, they should have isotonic fluids, eye water with a bit of salt in it, not water alone because this will not help with water absorption. At times. We might also use drugs like loperamide that slow the passage of food through the small bowel by reducing its mobility and allows more time for water absorption or reabsorption. If you b create an A jejunostomy or a stoma much higher up in the bowel, that will be more irritating to the skin. And uh a colostomy usually produces about 200 to 600 mL of more form stool. But this would vary depending on, on how high up in the colon has the colostomy been placed. If a colostomy is created on the right side of the bowel or the transverse colon, the output would be more than when created on the left side within the descending or sigmoid colon. This is because as I mentioned, water absorption continues in the right colon. Patients with the stoma who have their lower bowel in place, continue to have some bowel movements with mucus. Sometimes this is because that bit of the bowel is still alive and continues to produce secretions. Patients with a stomach can have some inflammation in that lower bit of bowel called divergent colitis or proctitis. And this might mean that the patient complains of passing some blood and mucus like discharge from the rectum now and again, full stop. These patients might require some medication for this. Well, hopefully, I provided you some understanding of the structure and function of the gi tract and I'm now happy to take any questions. So I think um thank you for that er Sanjay. Um I think we've now got uh uh Fatima Mohammed who is um er coming to lead the the question and answer session. Um and the rest of the faculty can join us if they wish. So, um uh Fatima is a ward sister on the gastroenterology ward at the Queen Elizabeth, the Queen Mother Hospital, Margate Kent in the UK. Thanks. Thank you so much, Nicola. And thank you Sanja for that very, very informative presentation. I mean, it kind of sets the tone for what we're going to be discussing today. We know that anatomy is quite important. And if we get a hang of how the anatomy of the gut works, it's easier to um navigate stoma and stoma complications. So we got a couple of questions. Um The first question is from Malka. It says ileostomy can make skin irritation. How can how can we manage these complications? Sorry for that. Uh Someone had the hoover on in the background. Could you say that again? Fatima? OK, Sanjay. Um Someone is asking about how we can manage skin irritation as a complication of having a stoma. So I'm sure we'll address this later on in the talk. But the aim of, of uh when you create an ileostomy is number one. When you create an ileostomy, you try and spout it. And the idea being is by creating a spout, you are preventing or you're trying to help the contents of the ileostomy fall away from the skin into a bag or a suitable sto appliance. And as I mentioned that because at the end of the day, food is being digested, you've got food, you know, acid et cetera. Now, the normal small bowel is protected against this, but skin isn't. So you've got to be careful that your stoma appliance is well fitting. And, uh, you've got an appropriate stoma bag. Once you do get skin irritation, then you've got to use some kind of a protective barrier on the skin to try and, uh, help the skin. Give it a chance to heal. Ok. All right. There's another question it says, can you explain the difference between a mucous fistula and other types of a stoma like end or loop? Yes. So normally what happens is if you imagine the bowel to be a continuous pipe running through the body, if you bring, divide the bowel because you're moving a bit of the bowel or you're trying to protect something lower down, divert the contents of the bowel. Then what you can do is you can either bring it out as a loop where both the ends are available on the skin surface or you can close one end off and bring out the proximal end into what is called an end ileostomy. Or you could actually put them at separate places whereby you have one end that comes out as an end ileostomy and the other end is connected to the skin. So that, that becomes what we call a mucous fistula. And the idea being is that if at any stage, you're worried that may be some obstruction further down, you don't want to cause what we call a closed loop obstruction, hopefully later on, we will be able to show you some diagrams that would explain this better. OK. Um Someone is asking if there's any dietary advice for patients with STOMA. I mean, these are some of the things we're going to cover on later, but I think people are quite eager with questions. So I think I'd leave this question for later on because there are lots of experts here who have a lot of experience amongst the faculty on managing stoma. So I'm going to leave this for later. OK. So there's one more question that says, um you mentioned about a spout on an ileostomy. What size should the spout be ideally when you surgically form it? Well, you're trying to get a spout of roughly about 4 to 5 centimeters. But it might not be possible in every patient depending on number one, the their abdominal wall. Uh you know, depending on how uh uh what their subcutaneous uh layer looks like. Number two, at times in some patients, the bowel mesentery may not be so sort of pliable and easy to get a spout. But you're trying to get a spout of roughly sort of between 3 to 5 centimeters, I would say, OK, thank you very much, Sanj. Um Just out of curiosity, an Iost toy and a colostomy, which one has more output? Because that's something that we um people usually differ on. Do you expect more output in an Iost toy? Than you would in a colostomy. Yes. So as I mentioned to you, the ileostomy is created on the small bowel and as you start off, so if you were to do a jejunostomy halfway up the small bowel, your output might be 3 L and you may be struggling to manage the patient's load balance as you move towards the small bowel, what's left is less. So you would that the ileostomy output would be about a liter, a liter and a half towards the end of the small bowel. Once you go into the colon, most of this water has been absorbed. And if you do a colostomy on the left side, you probably get about half a liter in terms of fluid output from your stool. Ok. Um, thank you very much, Sandy. I don't think we have any questions any more questions for you now. Um, so in the absence of none, we'll be moving to the next presentation which will be by Jenny Burch and it's on understanding the stomach appliances, fitting and supplies. Jenny is a nurse working in Saint Mark's Hospital. She's formerly a Stoma nurse specialist. However, she's now the head of gastrointestinal nursing education over to you guys. Hi. My name is Jenny and I'd like to speak to you about stoma kits, appliances, fittings and supplies. Thank you. The aims and objectives of this session are to explore stoma supplies, discuss the potential use of stoma supplies and show examples of what's available worldwide. The Stoma appliances, stoma appliances can be called stoma bags, stoma pouches, uh just bags, they can be drainable or they can be closed. And this depends on the type of stoma that the person has and they can be one piece or two piece. And I'll explain a bit more about this in a moment with some images on the right. You'll see a table with the common companies that are available in the UK that supply and manufacture stone appliances. And there are the websites for these companies and they often have really useful information on the websites which again, I'll show you later. So when we're thinking about appliances, they're made of two separate parts, there's the adhesive part and this has many names including flange, skin barrier, skin wafer, and the adhesive part is designed to adhere to the abdominal wall, not on the stoma but around the stoma. And the adhesive part is usually made of something that's very skin friendly such as a hydrocolloid. There's also the collection part and this is the the bag part of the appliance. It's made of different types of plastic and not always but often it's covered in a fabric type covering so that it is less sweaty on the skin. There is usually a filter to let out wind flater from the fecal output appliances and they're available as either opaque or transparent. Often transparent is used in the immediate time after the operation so that the stoma can be checked for color and for output. And the opaque ones are used in the longer term. And you'll see they all look slightly different and I'll explain these different types here in a moment. So if we think about a closed appliance, this is where it is closed and sealed all of the way around the outside. And this is because it's used with a colostomy, which as you know, has a thick fecal output, which is too thick, generally to drain out of unusual an appliance. And you'll see this is an example of a, on the left is an example of a two piece appliance where the collection part and the adhesive part are separate. And the little insert here shows how they click together. And this is a one piece appliance. You can see they're different shapes, different colors and this is a patient putting on their appliance onto their Colostomy trainable appliances. Most people think of drainable for feces, but there's also drainable for urine. I'll talk about that in a moment and you can see here on the bottom there are different ways of doing it the, the product up because obviously you want it to be drainable but secure and able to collect the feces. So this one's got roll up tags. This one's got a separate plastic clip. This is a one piece example. This is a two piece example. And here is a Urostomy appliance where the output is drainable. But because the output is urine, it is thinner and obviously liquid and therefore it needs a thinner bone type appliance. Whereas the drainable appliances on the left of the screen are for people with an ileostomy where the output is more loose feces. So as I've already mentioned, one piece, they come in different colors, different sizes, different shapes and this is where the adhesive or the flange is physically joined onto the collection part. The appliances on the left are closed and these are for Colostomy with thick feces. The appliances in the middle are drainable and therefore, ileostomies where there is uh looser feces and where the appliances on the right hand side are urostomy appliances or Ileal CHD appliances where you can't see it, but there is a tap or a bang. And as I say, this is somebody putting their appliance on. You can see they're quite flexible and stick directly around the stoma, the two piece appliances very similar. But the flange as in the picture on the left or here in the middle is separate and you can see there's no way of adhering the appliance to the abdomen until you use the two separate parts. So um there's benefits and um drawbacks of each type and this is somebody on the right cutting the hole to the size of the stoma in the flange. So a colostomy as you know, is formed usually from the sigmoid or descending colon. So the output is reasonably thick as all we've lost here is the rectum and the anus. So, as I've mentioned, the feces are thick, usually they will be passed in the same amount as they were passed before the stoma was formed. So as you know, that's once or twice a day, that's what it is for my patients. So they need a closed appliance because the, um, feces are thick and possibly a two piece appliance is cheaper because you can leave the adhesive on and just change the appliance as and when needed. And you can see somebody here changing their appliance and there are so many different shapes and looks of stoma appliances. You'll see a, a small one here on the left. This is a cap and this in the UK, we tend to put over the stoma to collect any mucus during sex or during, um, sport if we were sure that this would only be useful for a colostomy if we were sure that nothing much would come out in that period. Ok. So here you can see a similar appliance on an adult looks the right size, whereas on a baby, they really are quite big and there aren't many different products available for Children because although we know that Children do have stomas if they're born with an imperforate anus or a malformation, but actually there aren't, they don't always have it for their life. So there aren't many small products available. Ileostomy appliances, as you know, ileostomies are, um, when the stone is formed from the end of the small bowel or the ileum and it's either due to the colon and rectum being removed or it can be due to some of the colon and, or rectum being removed and a temporary stoma to allow healing. Now, the feces is very loose in the first few days, but in the longer term, as you know, ileostomy outputs are loose feces and the output can really vary anything from 3 to 800 mils per day of feces is normal, which is obviously a lot more volume than from a colostomy. So therefore, you would need a drainable appliance that is fastened at the bottom, similar possibly to the the product shown on the right hand bottom corner. And here is an ileostomy appliance with feces in and you can see it's looser, this will be in hospital as you know, it will often get thicker and I don't know how well you can see this image. But here is the stoma. This is a transparent appliance. Sorry, here is the stoma, this is the filter that lets species out. This is obviously the the loose ileostomy output, but this appliance is actually cut too big because I can see skin here in between the stoma, the red area here and the the appliance here and I can see skin showing. So actually this needs to be cut a little bit smaller, there will be discussions on ostomy care later in the sessions. But ideally, you want the whole in the appliance cut to the same shape and maybe 1 to 3 millimeters larger to allow for variations in cutting and placing because none of us are perfect doing that as you know, urostomy or ileal chondro are much more rare. Um, they're usually used when somebody has a bladder tumor and then a little part of the ileum is used to transfer the urine from the kidneys. And because of that, we therefore need a drainable appliance with either a little tap or a bung on the bottom. So that the urine can be let let out of the appliance at regular intervals. Of course, the urostomy will pass urine but there will also be some mucus from the little part of the small bowel cony used depends how much is drunk and what is eaten. But the output should be above a liter a day, similar volume to what is passed by somebody in normal situations because we're only rerouting. And as I mentioned, already, drainable 4 to 6 times a day is common for um, an urostomy appliance to be drained. And here are some other appliances and sometimes the appliances can be in different sizes. So maybe a, a child or a woman might want a smaller appliance and a man might want a, a larger appliance. And here's the fastening and the output for the urine, the outlet for the urine. Now, obviously, it's important when you're changing appliance to have all the right equipment and this is what we would recommend for people in hospital in the UK. A little pot with water. It doesn't need to have soap, it would be water that is suitable for drinking. We use uh plastic bags to throw the rubbish away in and scissors to cut out the, the shape and the size needed. We do have a plastic measuring guide. You can see with lots of different circles to help guide the size as you know, not all stoma are uh round, but most of them are and then some cleaning cloths as well, cleaning and drying. So the appliance is removed and I always look at the back of the appliance and see how well it has stuck. So this is a healthy stoma. You can see this is um, immediately after surgery, sometimes there's discoloration around the edge of the stoma on the stoma appliance. And here there's just a little bit of fecal seepage. So this is an area I'd want to keep an eye on to make sure it was cut properly and adhered properly. You can see the patient is cleaning around the stoma. It's important to wash away any residue from the output of the stoma as well as occasionally, um, especially if it's hot, the the appliance adhesive can remain tacky on the skin. So, even though the appliance is removed, there might be adhesive tack on there. We then we need to work out, which is the right size and not to have too much skin visible, cut it, you can see there, there's either a paper or a plastic film that's stuck onto the adhesive part and you pull that away so you can stick it onto the abdomen and the size and the shape are important. So you can see here the stoma and the flange and this is a two piece flange, uh very, very close in size and you would cut it with a pair of scissors. And you can see here you want the stoma to be exactly the same size or just a tiny bit smaller the stoma than the aperture that's cut. There are other ways to manage um stomas such as Colostomy irrigation, not suitable for stomas other than a colostomy. You can see this person has a stoma. Here they are inserting this cone and this tubing has uh water that is suitable for drinking to insert in there. The, the water will then flush pieces through the colon and it will come back out. And this plastic is um like a sleeve on a, a garment and the feces and the water will drop down into the, the toilet when the irrigation cone is removed. Ok? There's not just the products that I've talked about, but there's additional stoma supplies available that we use commonly in the UK. This is not a very clear image but there's stoma powder and this is a stoma, this is the Stoma powder bottle or container and you can see here there's whiter areas. The stoma powder is off in color and you might use it on skin where there is skin damage that has caused the skin surface to be broken and the powder is put onto the broken areas so that it absorbs any moisture and helps the appliance to stick. However, as you can imagine, if you put too much powder on the appliance will only stick to the powder not to the skin and that won't be good. So you only need a tiny, tiny bit of stoma powder. If you do have skin that is wet and oozing something that can be used in um stoma care, especially if the skin isn't even is something called a seal or a washer. And these are round in shape made of hydrocolloid. Usually they can either be broken as in here in the image so that you can make them different shapes or they're put around in a circle around the stoma to help with adhesion because they're hydrocolloid. So they are skin friendly and they're adhesive. They can help in, in people with high output stromas. If the uh the output of the ileostomy is corrosive and damaging the skin or if there is an uneven skin surface, they're examples of when you might use a Stoma Sele I mentioned earlier there were lots and lots of different company websites. Coloplast is one and if you look on them, they will have links that you can look on the internet for stoma bladder and bowel wound, urostomy, et cetera. There's also Comtech, they're all and D Azac and they might show you uh different products, they might show you information for patients and they might show you information for clinicians. You sometimes have to register with your email address to gain this information. But that is absolutely possible. And that can be sources of what you can look up. So many, many different company sites. And here is a picture from the internet of different products that have been used in the past. So this is a product that used to be used before hydrocolloid appliances were used. You can see there is an an opening here generally that was much, much larger than the stoma, which meant that the skin around the stoma would become damaged, held on by an elastic belt with um a collection part for loose feces or um solid feces. This was a, a more modern version where you had a rubber um that was held on in the same way which could then be washed out. But obviously after time, these can be smelly. These are big um appliances that I would use for really problematic wounds such as an intracutaneous fist, which hopefully you don't see very much. But this would be a normal ST stoma size as would this will be a small one and this will be a normal urostomy size. And there are lots and lots of different products. These are the seals I showed you before. Different companies make them in different ingredients. Here are some different stoma powders and there are many different products. They're not all available in all countries and of course, some of them are very expensive, obtaining supplies, often you need to buy them and the pouching system isn't always available. It's for example, some interviews were undertaken in Nigeria and they said that the appliances would be available, but they weren't. So they used nylon bags and that's not always comfortable for the skin. Ok. There are some support groups available, here's some in Asia and South Africa. So in summary, many stoma supplies are available, however, they are expensive. But you can always, if you have access to online information on the internet, you can look and see what's available. Thank you very much. Any questions. Um Can you join us? Yeah, you go with us now. Um So we got uh something like eight minutes for, for the for the questions first, I'm I'm Mohammad Abi. I'm the past president of the S club and um I can see that we have a good attendance uh with us this morning. Um So the first question, we go to the questions here. What about new needs? And if you have any advice about what can be used for that age group. So, neonates obviously have very fragile skin. They're obviously a lot smaller. The stone is smaller, the skin surface is smaller. So sometimes it's not appropriate to use a stoma appliance because the, there's more risk of damaging the skin and it can be more appropriate just to protect the skin around the stoma and use something like a diaper. Er, Caroline. Would you like to add anything? And then angie? Yeah, I think, um, you're right there, Jenny, we have to be very cautious of their fragile skin. I think that's also, particularly when we're using things such as adhesive remover or skin barriers. We have to be a little bit more cautious with the ones that we use with neonates as well. Thank you. And uh, another question about the order and if there's any supplies that can reduce or help with the order and do you want to answer that one? Yeah, sure. Most of the, um, more common products that are available, um, commercially do have, um, a filter integral to the product. Um, and that filter contains something called activated charcoal which does actually absorb some of the odors. Um, and most of the bags are now, um, designed and have so much research and development within them that the, er, materials that are used are actually, um, er, very odor proof so that if the product is put on correctly there are no wrinkles or creases in the, the base plate, the flange, the part that's actually adhered to your skin and the, the tail end where the pouch is drainable and that is all clean, then there shouldn't actually be any odor from the product. The only odor that you would get would be when you would be emptying or changing the pouch itself. Yeah. And, uh, I think part of the question was about if you're not using the, the, the, you know, the stoma bags, would something else be helpful um that people can, you know, in, in, in some, in some countries with a shortage of stomach bags. Um you know, people struggle to get the, you know, the stomach bags and they may use plastic bags and stuff like that. Anything else that um you've seen people using practicing? I think so long as the p the skin around the stoma is protected. Mohammed, that is the important aspect. But you're right, there isn't as much access to stoma products in certain countries and if there is access, they're incredibly expensive. So uh that's why I put the slide up on irrigation so that if people have a colostomy, they can think about maybe washing the feces out. Although of course, the Colostomy irrigation equipment is still difficult to source. Um We're hoping that these thing, er these products would be more available but Caroline or Angie, have you um any ideas about products that could be used instead. Um The only other thing is sometimes we have um, deodorizing drops available. Um They're not commonly used in the United Kingdom now. Um, but they are available. Um, sometimes they can be added into the stoma pouch. So if you're using a pouch that maybe doesn't have a charcoal filter or isn't as secure to um contain the odor. Some deodorizing drops could be used. I'm also conscious that sometimes these are um put into a, a little bit of warm water into a bowl. Um maybe on the side if um someone has a very uh malodorous wound or, or a stoma, so it could be that there's just something in the air to try and remove some of the odor as well. Thanks. Um I got another question here from Lisa about, I'm sorry, II The um I was saying we have, we have a quite a difficult um pan pancaking is quite a difficult um complication to deal with. Um And I think I don't know how Jenny and Caroline feel, but often if patients describe pancaking to me, my, my heart sinks a little bit because it is quite a challenging complication. Um And obviously causes quite a lot of distress because this is where the stool collects around the opening of the stoma becomes quite flattened and then causes leak issues. Um The way that we would um tackle this complication would be if a patient is wearing an appliance. Um I would often ask them to perhaps put in a crunched up tissue or a small bit of cotton wool to try and keep the layers of the pouch apart. Because we um believe through some research that the pancaking is caused by a negative v occurs within the pouch itself. Um So trying to keep the layers apart so that the the back layer of the um er er plastic and the front layer trying to keep them apart and create a little bit of air space within that um does actually help sometimes putting a small bit of like cooking oil on, on the front layer so that the stool when it, when the colostomy does action, it slips down into the bottom of the bag or some um liquid soap or anything that's oily can sometimes help um drop. Um the stool down. There are also some um um special um products that are commercially available, but obviously at at additional expense, I don't know if Caroline or Jenny want to add anything else, Jen? Yes, sir, please. Uh you muted. Uh Janet. Sorry about that. Thank you Mohammed for pointing that out. Uh It can also make a difference if you can change the consistency of the feces because um I if you make it a little bit looser or a little bit firmer that can also help with problem outputs with a colostomy and help them to, to move better. Thank you. And the only other thing that I can think to add to that, um, sometimes it's where the air comes out of the filter too much. So, maybe putting a cover over the filter may just, um, keep some of the air in the bag as Angie says, it keeps the front and the back plastic, um, separated a little bit as well. Thank you. It's interesting. I haven't, I haven't heard the word pancaking of the colostomy before. And, uh, it's, it's good to know that, but why was it called pancaking? What, why, what's the, um, what's the rationale behind the name? It's a bit like the food pancake. It's sort of flat and it, um, it sticks six together. Ok. Hi. Um, we've got a question as well about infection around the sto man. And you advice about how you, when there's a skin infection. Uh, and I think skin infection, skin irritation, I don't know whether we treat it in the same way or we treat it frequently. So it really depends what the infection is in hot countries. It's more likely to be a fungal infection. In which case, any fungal treatment can work. Um, if it's a, a wound infection, then obviously, antibiotics are needed. But if people clean the skin around the stoma and it's ca carefully maintained in a healthy manner, actually, infections are not that common, which is really good because they can be a problem to manage. Ladies. Have you anything else to add. No, not really. I think it is quite rare to get an infection around the stoma. Um Sometimes I think sore red skin can be thought of as an infection, but as Jenny says, if it's kept clean um with water, then it is more rare to get an infection around it. Thank you very much. Um I think it's time to move to the next talk. So I'd like to thank Jenny Caroline and, and you for, for the um excellent talk and the um the answers for the questions and um, hopefully we'll catch up with the time, but if any questions more can come in the chat and we can answer them there as well. So, thank you all. So I would like to uh introduce uh our next um talk. Um, and uh, it's uh by Helen Evans and Helen is a lead specialist, uh nurse in stomach care and a clinical nurse specialist in surgical inflammatory bowel disease at a Park uh hospital. And the talk will be uh about uh preparing uh patient to um having a stoma and the different aspect of that. Uh, so if can bring the presentation. Thank you. Hello. Thank you for inviting me to speak today. My name is Helen Evans and I'm a clinical nurse specialist in Stoma Care in Wirral in the northwest of England. And I'd like to talk to you today about preparing the patient for stoma surgery. I'd like to just do a quick reminder about the different types of stomas that we're talking about today. Firstly, I want to talk about colostomy. I want to talk about an end colostomy. Initially, here you can see a photograph of a pink, healthy, uh nicely formed end colostomy. En Colostomies are normally formed from the sigmoid colon, although it can be from any other part of the Coulon, but the output from this is normally soft or formed And the patient wears a closed bag which they change when it gets half full. So that would be two or three times a day. Now, I'm going to look at loop colostomy. This is a loop, colostomy and loop of the bowel has been brought out and you can see two lumens of the bowel there. This is a loop of bowel and it's sometimes from the sigmoid colon, sometimes from the transverse colon. And it depends where in the colon that piece of bowel has been brought out as to what the function will be like. You can see that the stones are pink and healthy and that's how they should look. So, operations that will result in a colostomy are firstly, we've got abdominal perineal excision of rectum. This is where the anus rectum um are removed and a permanent end colostomy will be formed normally done for a cancer. Hartman's procedure. This is where the rectosigmoid bowel is removed and an end colostomy formed often for diverticular disease and sometimes temporary stomas and a defunctioning colostomy. This is where an end or a loop colostomy would be brought out. This is to defunction, the bowel either prior to surgery or for treatment or because of diseased bowel. Now, we're going to look at ileostomies. Ileostomies are formed from the small bowel here. You can see a picture of an end ileostomy and you can see that the bowel is pink and healthy as it should be. But the sto is actually more spouted than the colostomy that we saw the end colostomy. So the end ileostomy is spouted. And that's because the output from an ileostomy is more watery than a colostomy. And that allows it to drop to the bottom and that helps prevent skin soreness. I'm going to look at a loop iost toy a loop of IE which brought out and that would be to protect an anastomosis or to allow the bowel to heal again, that pink and healthy parasal stable skin is in excellent condition. Operations which would result in ileostomy formation include panproctocolectomy. This is where the anus rectum and colon is all removed and the patient would have a permanent end ileostomy. This would be for uh cancer, ulcerative colitis or sometimes for Crohn's disease, sub type of Colectomy. This involves a portion of the colon to be removed. It sometimes can end up with a patient can have an IOST. Also anti resection is where they, there's a sigmoid resection, anastomosis and the loop ileostomy is performed upstream and that's to allow the anastomosis to, to heal. Also a defunctioning loop ileostomy. This would be brought out above an obstruction or a diseased part of the bowel or to allow treatment, patient assessment. All of our active patients are seen referred to as preoperatively and we offer them a home visit. The benefit of a home visit is that the patient feels more relaxed in their own home and more likely to take in what we say and are more likely to ask questions. We ring them beforehand and we all arrange the visit and we also invite them to ask another family member or a friend to be present. If this is what they require prior to the visit, the nurse needs to have all the necessary information about the patient. This is not just about what surgery they're having and what stoma they will have, but any comorbidities they may have or anything that means that they are going to struggle to manage the stoma. We run a holistic service. We want to look at our patients as a whole. This is the first time we've met the patient. So it's really important to build a rapport. This has to be done fairly quickly. We would introduce ourselves and our role and find out how they're feeling. We would ask what they're expecting for the meeting and ascertain what they already know, that's what their main concerns are. And in fact, if they've heard of stones before, do they know anybody who's had a stoma? We live in a small peninsula and often people know of other people who have a stoma. This is reassuring for them if the person they know is that they know is continuing with their life. As before, there are 1200 people on the world with a stoma. And I say to the patients that I meet lots of these people out of hospital and nobody else knows they've got a stoma. Generally they're managing very well. We would discuss with the patient, the type of operation they're having done, they will already have spoken to the surgeon. They were seen the anesthetist, they have seen the at hand recovery nurse and they may have actually met a Atan nurse as well. So these people will have explained the operation to them, but it's important that we go over them over it again. We would explain about the stoma, describe the stoma. Often these people have no idea what their bowel looks like. So we would describe that, use photographs, use booklets and leaflets to describe the stoma. We would discuss how the er, will function would be, what the consistency would be, how they would manage it. We would show stoma bags demonstrate the type of stoma bags that we were talking about. All patients come back from theater with a clear drain will bag on and we would tell them, tell them that also we would advise about the support in hospital. The benefit of us seeing them is that we will also see them when they come into hospital. That's nice for them to have a familiar face. We would talk through the process of teaching them how to change the bag. M maybe initially just actually taking the bag off and having a look at the stoma. But eventually we want them to be independent and manage it. The stoma themselves. We discuss the support in the community. We cover the hospital and community. So we'd also see them at home after the surgery and we'd talk to them about getting back to normal activities. We'd talk about the stoma products and we'd show them appropriate stoma bags. There are many, many different types of stoma bags and the patient can choose what's appropriate for them. We would show them a variety of bags so they could see that there was lots of to choose from. We would explain how to apply them. We would show how to empty the drainage part. We would talk to them about filters, talk about different types of bags. We'll explain depending on what surgery they are having done, how many times they would need emptying or changing the bag. We would also advise about disposing the products. We would talk about how they'd obtain supplies. We'd give them plenty of supplies to go home with them on they were discharged from hospital. And once they were seen at home within the first week after discharge, we would organize for them to get supplies on a monthly basis. With all of this, we have a practice pack which has a pretend stomer in it. This practice pack we would use to demonstrate how to apply the bag and how to remove it and make them feel perhaps a little bit better about being able to manage. We give advice about when they go home about hernias, parastomal hernias and support garments. We would check at this point if they want to discuss sexual function. This can be very, very difficult for people to discuss, but it's important that we're open about it and that they do have the chance to discuss it. It may be that they don't discuss it at this point, but at least if we've opened up those lines of communication, they may come back to it at a later date. We also talk about sleep. People worry very much about sleep, but they'll be able to sleep in their usual position. Within the first few weeks, people tend to sleep on their back when they've had a stoma, but eventually they should be able to sleep in any position. We also asked them if they have any particular sports, they enjoy any hobbies and we'd be able to discuss with them that we would hope that to be able to get them back to those hobbies, give doctor advice the most often question we get is about diet and what people can and can't eat. We would suggest that most people need a modified fiber diet for the first six weeks, post surgery and then they can gradually introduce all kinds of foods into their diet. They may find foods that they have to avoid. But we would suggest that they try them in small amounts. If it has a detrimental effect, then to leave it out for a few weeks and try it again. We have lots of leaflets, diet sheets and recipe books for patients. We talked to them about returning to work. What type of job do they do? And what does it involve? Are they entitled to sick pay? And we can signpost them for benefits advice. It's important that we uh p patients understand that within the realms of their disease. If they want to return back to work, they should do. We also talk about accessible toilet facilities unless they work in a very small workplace, then they're entitled to ask for accessible toilet facilities. And we talk to them about this and about the radar key which allow them access to these toilets. We talk about the Stoma Care Support Group, the national support groups. We talk about the Colostomy Association, the Ileostomy Internal Patch Association, and also the Urostomy Association. Although we haven't talked about Urostomy today, we also have a number of local support groups. Patients can feel better. I in, in a group, if they know it's not just them with a stoma that there are other people out there managing. I want to talk now about citing, citing is a really very important part of our role. Most patients can manage the stoma. But if it's in a place that they can't see it difficult to reach or if the bag leak and then increase, then it's really difficult. So poorly positioned stones are very difficult to manage. That's one of the reasons that sighting is very important. We would assess their abdomen overall. We'd sight within the rectus muscle. We'd avoid any skin creases or overhangs. We'd avoid old scars, we'd avoid the waistline and it's in a position that patients can see to do this. We have the patient lying, standing and sitting, we have them wear their normal clothes so we can see where the waistline is. It can just take some time sighting because it's important to write. We agree the site with the patient and then we leave a pen with the patient because although it's a permanent marker, it may be that they, it fades a little bit before the surgery and we leave them to go over it. We'd encourage the patient or family members to ask any questions. There's an awful lot of information, sorry. This is an awful lot of information for the patient to take in and we do leave booklets with them and practice packs and they can read those in their own time and we do give them our contact number. So if they have any queries at any point, they can give us a ring. Thank you. Ok. We're moving into the UN A session now with Lisa Gibbs. Thank you for that um, talk call. Have we got Lisa here to um uh join the Q and A session? Um And uh Helen, are you available with your camera on so we can ask you? Fantastic. We've got Caroline and perhaps a few of the others back if um we can't get um Helen and Lisa in, we can um we can ask a few questions to uh the rest of our faculty. OK. So um perhaps I will ask a few questions um whilst we're waiting for Lisa to join us. Are you there, Lisa? We can't hear you or see you Lisa's microphone off. I looks like she's got problems. There's a error sign on her microphone. OK. OK. So, um so we can start asking a few questions whilst we're waiting for um uh Lisa if that's OK. So um uh Helen, there's a question here from uh Jenny Helen, you mentioned about exercise. When is it safe to exercise? And what, what kind of exercise can people do? Do we have to tell them to be careful in the early days? Do they allowed to go and do what they like? Do they have to worry about the pouches? Um If Helen can't join us and Caroline or Jenny. I see that you're there. Are you able to answer that? Yeah, I'm very happy to answer that. Um, we try to encourage people to become, um active after stoma surgery as soon as possible. Um, we often now, uh speak to people preoperatively about abdominal core exercises. Um That's a very key aspect for us because uh we know that if people strengthen their abdominal core, um particularly around the stoma area, this will help to reduce the risk of parastomal hernias, which can cause problems um for our patients. So we're very focused on abdominal core exercises, but also about fitness. Um, people don't stay in hospital very long nowadays, uh very early discharges. We need to make sure that they're able to um look after themselves confidently when they're at home. So it's about getting people um out of bed, um, building the strength in their muscles. Um, so that they are um, feeling uh confident about walking around and they're at less risk of falls. We have a number of programs um in the UK that are built around um, exercise and movement after stoma surgery and the Association of Stoma Care Nurses is currently working on a big project um, of that, which I'm sure we'll hope to share with everyone as well. Thank you. Um, Caroline. Um, now, yes, we've got uh Helen and Lisa. So thank you, er, Lisa. Ok. So I think we've already answered all the questions. Um but very kindly, thank you so much and Helen thank you so much for a very informative talk. Er, one question um is have you had any patients that did not want any pre information? Yes, we definitely have patients that don't want any information. Um Helen, are you able to go a little bit closer to your microphone? We're struggling to hear you a little bit closer to what? Sorry, we're struggling to hear you a little bit. Can you get a little bit closer to your microphone? Ok. So can you hear me now? Shout, Helen. Can you hear me now? Quiet, quiet, right? Well, that's definitely not like me. So yes, we have definitely had patients who haven't wanted to have the information. Um We'd give them a second chance and ring them again another time to see if they've changed their mind. Um It, they're entitled to not have the information if they don't want it. Thank you. And another question that somebody's asked is, is the fiber diet ideal for both pediatrics and adult patients with stomas? Sorry, I missed a little bit of that. Um Is the fiber diet ideal for both pediatrics and adult patients with stomas, both having a if an adult or a child have had surgery, we would definitely have a modified fiber diet for both of them, right? We want to reduce their five after surgery initially. Um And another question is somebody's had, has is the stoma triangle still utilized in sighting of stomas. Oh, we're looking at the triangle from your umbellus to your eye at crest and down probably is still used. But it's not something that I use. Does everybody else use it? I've seen it used in papers from Italy. It certainly is one way of doing it. It's not my personal choice. Yeah. Uh Another question somebody's asked is, is, can a stoma cause any psychological problems for patients? Yes. And how do you manage that? He, it de it depends though. It depends on the patient. Depends on what psychological problem it's causing, depends on the skills and resources they've got to manage it. It's a, that would be a whole talk on its own, I would say. Um but certainly supporting the patient, the most important thing is getting the bag to fit and getting the bag. So it doesn't leak cos if the bags leaking, that's going to cause psychological problems. But if you can get a bag that doesn't leak, then that will hopefully reduce some of the issues that they have. And a thank you. And as you have many years in um the field of stoma care Helen, sorry to bring that up. But have you as a stoma nurse noticed any changes in what patients expect regarding having stomas formed these days? Yes, I would say definitely it, it does depend on the patient, but patients are much more aware now of what's available. They're more aware of what they're entitled to. They've all watched, um, youtube videos about how to manage a stoma. So that, so they're much more aware, most patients are much more aware, I would say. Great. Ok, that's probably answered most of the questions that are actually sort of, um, geared towards your topic. Helen. There is other questions on there whether, um, we want to go through some of those before we break for, um, for our, er, short break. Um, I don't know whether the rest of the panel want to help answer some of these questions with Helen. But, er, we have, um, somebody's put, could we have a single stoma device with a dumbbell shaped opening to fit a double barrel or d divine colostomy? So it depends on far, how far apart those two stomas are, if they're next to each other, then it could fit into a large oval bag. It depends on how far apart they are. Great. Anybody else on it? And that, and then one of the other questions was, um, how can one prevent stoma site infection or rash in a patient with a stoma bag? Ok. So I think like we said before keeping it, have you clean, making sure the bag fits neatly, making sure they don't have leaks. And another question one of our listeners has, has, has asked, is that how long can a colostomy bag be in place before it's changed? Like how frequently do my patients need to change it? Wow. Anybody got any thoughts about that personally? In the UK, we change our appliances very regularly. We're very lucky that, um, for most people, products are free in America. They leave them on for 7 to 14 days. But of course, you have to be careful of skin integrity around the, the stoma. If you leave the appliance in that long, if it's, it's a colostomy bag that's sealed around the outside, it can only be left in situ until there's feces in it. If you can't empty it, then obviously it will eventually fill up. But with the ileostomy bag, we in the UK, change it every day, every couple of days, but it can be left on for longer so long as it's well adhered and the skin is well protected, but careful checking that the skin is intact. Uh Angie, would you have anything to add to that? Actually, the ne the next presentation that everyone's gonna see will go through looking at how long products um and, and bags are left in, in situ and how often we change them. And also there'll be a little video about how you actually change a bag and things like that. Patients actually changing a bag. So I think, um you know, a lot of the questions that people are asking are really, really brilliant questions and hopefully they'll all get answered in in subsequent sessions if they haven't been already, I've got one final question. Um And somebody's asked is heavy lifting or any similar heavy exercises prohibited from the fear of stoma prolapse. Uh I'm happy to answer this. Um II would say no. Um But as mentioned earlier, we need to ensure that our patients um follow um abdominal core exercises to strengthen their abdominal uh abdominal muscles and then build up gradually. Um so that they can get back to lifting heavy weights. We, we see people doing weightlifting, we see people working out in the gym, but it's a process. You wouldn't want to have your surgery and then suddenly be fit and well and go out to the gym. You want to build up that adominal core muscle. So it does support the stoma so that there's less risk of herniation or prolapse. Thank you very much, everyone. Um I think we probably can conclude this session. Uh I think we're gonna take a break now and we're returning at 1045 UK time. Ok, thanks. Hi. Hello. And I hope you're all back. Um, and had a good break. Um, our next talk is um, routine care for the stoma and the patient, the basics and that's going to be delivered by Angie Perin. Good morning. My name is Angie Perin. I'm the Clinical Education Lead for Salts Health Care in the UK. And I've been a stomach care nurse for about 28 years. I'm going to be talking to you this morning with regards to postoperative stomach care, just the basics. So on returning to the ward following surgery, it's really important that the stoma are observed carefully and regularly. The stomas should appear pink and moist. What you can see here is that the top image is a colostomy and the bottom image is an ileostomy. Both appear well perfused and look extremely healthy. Obviously, if they differ from this and perhaps are more of a purple tinge or slightly blue, then this needs to be alerted to the doctors immediately and documented accordingly. All stoma should feel slightly warm to touch and the patient will have or should have a clear transparent bag on that with the filter covered over, maybe putting a small bit of micropore tape over the filter so that the filter doesn't detract from observations because we would also be wanting to record any output that comes from the stomas and this includes flatus. Um often the output that we first see in the first few hours, post surgery would be hemo fluid or just some very watery fecal output. Um But occasionally we do see a certain amount of flu too or this, this perhaps is not um for the until the first two or three days on day one after surgery, the stoma care nurse will carry out a thorough and detailed clinical assessment of the stoma. Following this assessment, she will devise a comprehensive care plan for the nurses on the ward and the patient themselves. The teaching, the care plan will consist of a teaching plan showing the patient and um advising the nurses how to empty the bag and how to change the bag. During the first few days after surgery, the stomach care nurse will also spend a lot of time with the patient, talking through their thoughts and feelings about having recent surgery and how they feel about the change in body image that they have experienced. It's so important that the patient is given the opportunity to discuss these things. In the first few days after surgery, the stomach care nurse will usually have got to know the patient really well and will have met them several times preoperatively. And so we will understand their lifestyle needs, but it is important once the stone has been formed to continue the discussions with regards to work, any cultural considerations, the hobbies and the exercise that the individual has and does here we have a diagram of the colon, the large bowel. And as you can see here, the colostomy is situated on the left hand side which is in the sigmoid colon. A colostomy itself is usually situated on the left hand side of the abdomen and, and a sigmoid colostomy would be in the left iliac fossa. Although we may see a transverse colostomy, slightly higher, higher up above the umbilicus. In general, a colostomy is a lot larger and a lot flatter in appearance than some of the other stomas and the output especially it is a sigmoid. Colostomy is pretty much a form stool very similar to someone who would pass from the anus. Um, a colostomy is relatively active, it acts about 1 to 3 times a day, obviously, depending on what you, what someone has eaten during that day. And a colostomy can be temporary or permanent as well as it could be an end colostomy or a loop colostomy, which we will discuss in the later slides. And some patients actually choose to irrigate an end colostomy as a form of management. When explaining the difference between an end and a loop colostomy. I always ask my patients to envisage the colon as one long hosepipe and um to create the end colostomy, the hosepipe itself would be cut in half and one end would be brought up to skin surface to create the functioning part of the, the colostomy. And the other end would probably be left inside the abdomen. However, to create a loop colostomy, I would again ask the patient to envisage the hosepipe, but this time the hosepipe would be just cut three quarters of the way through and then folded in half and brought up to create two ends. As you can see in the diagram on the right hand side of your screen, you can see two ends of the colon situated in the transverse codon at the top of your screen. One of the ends is a proximal end, which would be the end that produces the feces and the flatus. On the other end, the distal end would lead down to the remaining colon or rectum and that retained rectum or colon would continue to produce mucus. So it is important that the patients are aware if they have a loop colostomy, that they may feel the need to open their bowels using their anus. And this is this can be quite normal, but it's important that the patient is aware of this because it can in my experience lead to patients experiencing some anxiety thinking that there has been something gone wrong with their surgery. So in terms of the products that the patient may choose, um that are appropriate for someone who has a colostomy, they would either choose what we call a one piece system or a two piece system. And it really is as simple as it sounds, a one piece system is a completely integral product so that the bag and the wafer is all is all in one piece and a two piece system comes as a separate base plate, flange or wafer, whatever you choose to call it and a separate bag, both products are completely suitable and it is really patient preference as to which one they choose to use. The pouch is generally designed, whether it be a one piece system or a two piece system is designed to be changed. Probably you know, two or three times a day depending on how frequently they have a bowel movement. Um, but if they're using a two piece system, um, the face plate or the wafer can actually stay in situ for a number of days and is often just changed two or three times a week. In terms of diet. For someone who is living with a colostomy. There isn't any specific dietary advice that we would give to a colostomy because they are using pretty much all of their gut. But we do try and install with a patient that everyone is different and certain foods that suit some people may not suit someone else. So it is a bit of a trial and error. When it comes to diet, we would suggest that they always chew, chew their food really, really well and perhaps avoid fizzy drinks as this obviously can produce um excessive wind for, um for someone with a colostomy. Um And it's important for us to educate our patients so that they are aware that someone with a colostomy can equally get as get constipated the same as someone with an intact gut. So again, making sure they drink plenty of fluids and um are taking um a well balanced high fiber diet, um, is so, so important just to ensure that they are living healthily. Um And also make sure that they are aware that they equally can with a tummy upset which may cause them to have some loose stool. So it's always advisable for a patient who is living with a colostomy just to have a couple of drainable bags in their, in their cupboard just in case they eat something or perhaps catch a tummy bug from a friend. Um Just so that they have got something to so that they are able to empty the bag. Should they experience any episodes of loose stool? In this diagram? We can see how an ileostomy is created using a pace of the small intestine otherwise known as the ilium. What we can see here is an ileostomy. An ileostomy is usually formed on the right hand side of the abdomen in the right iliac fossa. And ideally because the output from an ileostomy because it is small bowel is relatively liquid, then we would prefer the ileostomy to be well spouted. We would hopefully want it to be sticking out of the abdomen by about 2 to 3 centimeters. As you can see in the image here, someone has no control over when the ileostomy works and it will function throughout the day and the night. And the consistency itself can range considerably between a very, very watery output to a semi solid consistency. A bit like porridge. Again, an ileostomy can be formed in either an end or a loop and can equally be temporary or permanent. What you can see here in the top two images is an example of an end ileostomy which is as is usually made from the terminal ilium, the end part of the ilium and is brought up onto the surface of the abdomen in the right iliac fossa. And a loop ileostomy is usually created to divert feces away from a surgical joint or possibly an obstruction. Um The loop ileostomy is again made from just a small section of ilium brought to the skin surface where you will have a proximal end which will produce the feces and the flatus, you will have the distal end which is connected to the residual colon and the rectum. So you can see quite clearly here in the, in the image that you have both what we call the proximal end and the distal end. And in terms of the products that someone would use, if they have an ileostomy, again, it can be either a one piece or a two piece drainable system. If someone chooses to use the one piece system where there's the integral wafer and bag, then that would generally be changed every other day or some people, certainly in the UK choose to change it every day. I think this very much depends on country to country. Because of the insurance schemes in some countries, often they are not able to change it every day because their accessibility to products is slightly reduced. Um But in general, if someone is using a drain ball pouch, then that would be emptied probably about 5 to 6 times a day, which sounds a lot, but it's probably the, a similar number to how someone would use, um, use the bathroom to urinate. Um, and if someone is using a two piece system very similar to someone who has a colostomy, they would have a base plate and a wafer that would be changed two or three times a week and they would be wearing a drainable pouch onto that wafer. And that wafer is either a click together mechanism, um a bit like an old Tupperware system or a um adhesive coupling system which you can see here in the image. Um And the bag is just, is changed again a bit like a one p emptied, sorry a bit like the one piece system about 5 to 6 times a day. However, when it comes to diet, it is a little bit more challenging for someone who has an ileostomy. Um There, there are a few um alterations they would need to make to their diet and certain things that they need to be aware of. Um However, in the first instance, it's important to reiterate that someone living with an IOST toy must eat and drink very regularly. However, they are more likely to have a blockage than someone who has a colostomy. So to try and avoid blockages, it's important for the patient to chew their food really, really well and perhaps avoid some of the high fiber foods which are not broken down too easily. Things like nuts, coconut celery mushrooms and sweetcorn are big culprits. And patients also need to be really, really cautious and avoid things with pits and stones, which can obviously cause blockages when it comes to diet. It's important to be aware of the things that how different foodstuffs affect our output. So things like carbohydrates will firm up any liquid output. So things like bread, potatoes and rice will really, really thicken the stool. Whereas a lot of fruits and vegetables may make it a little bit more liquid. So it's possibly not a case of avoiding all these foods, but it's about combining things together. So that one complements the other. Interesting. And as you could imagine, a lot of spices, eggs and onions will cause um excessive odor along with fizzy drinks and beans and pulses can cause a certain amount of flatus. Um and also chewing, chewing gum, smoking and vaping also increases win production. And as a consequence will cause excessive flatus to come into the bag. So just to recap, the difference is between a colostomy and an IOS toomy. The colostomy, the output is formed and will function just 1 to 3 times a day that a patient would wear a closed pouch and generally change that pouch after each bowel movement. Whereas the ileostomy, the output is a lot more liquid. It will vary between a very watery output to more of a porridge like consistency. It works continuously So a drainable pouch needs to be worn so that this can be emptied throughout the day and it will be emptied probably about 5 to 6 times a day. And it changed every 1 to 3 days before we think about changing the bag. It's important that we are to note that we are cutting the correct size. The size in the bag should be cut to fit snugly around your stoma. I always say to patients a bit, it's a bit like your foot fitting into your shoe. It shouldn't be too tight and it certainly shouldn't be too baggy. It's so so important that this template is the correct size. If it's too big, then the patient will experience leaks and sore skin. So if the stoma is oval, the template and the bag need to be cut to exactly the same oval shape, we're all different. We've all got different size hands and different size feet. So believe it or not, we're all going to have some a different size stoma. And so it needs to be specific, it needs to be individualized and it needs to be the correct shape and size to suit and to match that individual. What we can see here in the top image is where the template size has been cut too big. So in the top image, we can see a certain amount of skin which has been exposed. Consequently, this had some feces leaked onto it and has resulted in some very sore skin which you can see on the image on the right hand side of the screen. Whereas the template at the bottom of the screen with the green tick is the correct size. It fits snugly around the stoma and that's what we should all be aiming for. So when it comes to changing the stoma pouch, I've listed here, the equipment that the patient should be advised to get ready before they um even start changing the bag. So I would advise them to get some warm water, some dry wipes, um a little sack or a nappy sack to put the um dirty bag into get the clean stoma pouch ready. Um And also any other additional items that they may need such as an adhesive remover or a barrier wipe. Obviously, as a nurse, we, we would be wearing gloves, but the patient themselves don't need to if the patient has a drainable product or if they have an Iost toy, I would ask them to empty their pouch before changing and then to start um by gently removing the pouch from the top, supporting their skin very carefully. With the other hand, as they um remove the pouch, slowly dispose of the soiled pouch into the, the nappy sac. And then using um a dry wipe initially to clean the excess and then use a wet wipe, a wet wipe to clean the stoma. Um making sure that you've removed all the excess species. And once that's clean, it's really important that you dry the skin thoroughly, having checked the template to ensure that it is the correct size and all the skin immediately around the stoma is protected, you would then remove the protective film from the adhesive and place that over the stoma. Some patients will fold the bag in half and do an up and over approach. Others may look through the bag if it's clear or through a clear window to help them with positioning. Some certain top tips is if there are any dips or rolls or crinkles on the tummy, just try and make sure that you're sticking the pouch onto the flat surface as possible. Once you've got the bag stuck in, in um in situ, I then use my hand over the bag itself because then the warmth of the palm of your hand will actually help to um help, will help the adhesive to stick. Um And obviously, if the bag is drainable, please, please please make sure that the tail um is done up securely. Now we'll see a short video demonstrating how to change a sto about. So today I'm gonna run you through my, so today I'm gonna run you through my typical bag change routine. In terms of storing my supplies, I have a larger cabinet in the house where I store my monthly SUPP bag and then I keep this toiletry bag in my bathroom with about a week's worth of supplies in and I change day to day and take out and about just washing my hands before we get started. Just, I've had my stoma for just over eight years now. So I'm fairly as in my routine here, I'm just packing on everything I need for the change, which includes a decent remover, spray, some dry wipes. Black side for pre scissors for pre cutting. Good morning. My name is Angie Parry. I'm the clinical education lead and in terms of the products that someone would use if they. So today I'm gonna run you through my. So today I'm gonna run you through my. So today I'm gonna run you through my typical bag change routine. In terms of storing my supplies, I have a larger cabinet in the house where I store my supplies per bag. And then I keep this toiletry bag in my bathroom with about a week's worth of supply and I'm changing day to day and take it out and about just washing my hands before we get started. Just, I've had my stoma just over eight years now. So I'm fairly as in my routine here, I'm just prepping everything I need for the change, which includes an a decent remover spray, some dry wipes, a black sack for the waist, a curved scissors for pre cutting the bag. And of course the bag itself, my routine is fairly straightforward since switching to using the confidence be bags. About five years ago, I've had very few issues, the need for minimal additional products. I also cut the bags myself because my stoma size can fluctuate a little depending on my activity levels. My stoma is currently measuring about 23 mils and I use a soft convex bag. Oh, and a quick surprise appearance. Um So now I'm just wetting a couple of dry wipes before I get started. Personally, I tend to change my bag every 1 to 2 days. Again, personal preference. I have an Ileostomy. So I've emptied my bag before changing and then going in with the adhesive remover spray to help remove my bag with little skin damage. I always have some dry wipes to hand at this stage too just in case of any leakage or if my stoma starts to function. My most recent surgery was just over a year ago and so I don't have any additional wounds or fistulas, uh, et cetera that I need to dress and care for. So, although I've sped up these clips slightly, my bag change routine generally only takes a few minutes. So I've just popped the old bag into the black sack and then grabbed the wipes that I previously wet as well as a couple of dry wipes to clean and dry the area and then go in with a new bag that I've pre and double check the size of the f before removing the back in and applying the bag from the box over again. Once I've applied the bag, I tend to use the window to double check that I placed it properly and that everything is looking comfortable and snug because I have an ileostomy. I use a drainable bag. So I'm just holding it and securing that drainable tail before popping any remaining bits that I used in the sack and then taking that fresh bag in, popping my drains back on, ready for the day, popping the blacks back in the bin and then putting my supplies back ready for tomorrow. Thank you for listening and I'm happy to take any questions. Thank you so much, Angie for that presentation. Apologies. We had a little glitch with our audio but it soon resolved as we went forward, we have a couple of questions. Um The first one is that apart from infection, what is another complication that may arise from not taking good care of a colostomy or a stoma? Um I think by taking not taking good care of the colostomy, obviously leakages, um is probably one of the most common things that can occur if you're not careful in your um cleaning routine and your change routine. It's so so important in, in the first instance to make sure that you're cutting the exact size and shape of the stoma if you don't. I think that's probably one of the very, very, um biggest reasons that we see. Um, patients experience leakages Um So it's important right from the word go that we educate our patients to follow the exact change routine that is prescribed by their stomach care nurse and to get the products to suit them. Um some patients do find it easier to use a one P system or a two P system and it's really important that we spend time with our patients to make sure that they are using the products that suit them. Yes, thank you very much. Um Another question is as regards um adhesion, adhesion of the bag to the skin. Someone said that in the experience the person has, there's always an issue with the bag adhering to the skin. Are there any tips to help with that? Making sure that the skin is clean and dry and really, really thoroughly dry is, is probably the the first um thing to consider. Um if and obviously, what we are wanting to do is to adhere the bag to the flattish part of the skin. Um So as we saw in the video, it might be necessary for the patient to stretch up the abdomen and pop the bag on. So they're adhering it to the flatt surface that they possibly can um and making sure that the bag actually molds to any creases um that we have or if there are any creases present to perhaps um fill those creases with some um additional items such as a stoma paste or a seal. That we saw earlier in Jenny's presentation. Um And then once and there are some other additional items such as some of the barrier wipes that we use. They also do contain, um, they're quite tacky and so can actually promote adhesion as well. I don't know if Jenny or Caroline have got any additional comments. No, I don't think I've got anything. Um, else to add to that, Angie. You've covered everything, Jenny, you're on. Thank you, Caroline Fatima. Um One tip can be if the stoma is quite an active stoma change it first thing in the morning so that there's less activity as in if you, if you've got a urostomy or an ileostomy that is quite active, then if you change it before you eat and drink or when you haven't eaten and drunk for a while, there's less chance of the, the output coming through as you're doing a change. Like that young lady in your video mentioned she always has a wipe just in case there's a bit of unexpected output from the feces. Mhm. Thank you so much. I think that every stoma is different and with time you get to know what the stoma likes and what the stoma doesn't like. So I think that sometimes over a period of time you learn what to do and what not to do. There's another question about drinking of alcohol because we're getting a lot of younger people having stomas. Are there any considerations as regards alcohol consumption, II think um in the first instance, I would remind um young individuals that um drinking alcohol is going to make their out from an ileostomy, certainly that much more liquid. Um But I think young people you can't stop them, they have to continue to, to live their life. Um But obviously everything in moderation, but I also also suggest that perhaps um a carbohydrate loading meal might be advisable Um the um prior to, to drinking alcohol. And there are also some additional products that we can use um some little sachets or that we can actually pop into the bag itself if the bag is drainable. Obviously, they've got an ileostomy. So they may be using a, they are most likely using a, a drainable bag and there are some little sachets that we can buy that the patient can use to actually put in their bag. And actually, then when the output from the ileostomy works as the contents hit the little sachets, the output then becomes a lot thicker which will ultimately reduce the risk of leakages occurring. Thank you very much. Um The next question that's probably the advice that I would give. Is there anything Jenny or Caroline want to add about that? Um No, I think just referring back to Angie's presentation about um fizzy drinks. Um Just thinking about the type of alcohol you're you're um consuming if it's something that's very fizzy, maybe just let it stand for a little while before you, um, drink it. Um, but again, just think about the types of, uh, drink you're taking. Ok. I think we earlier spoke about control in adults. Oh, sorry, Jenny, you can go. That's all right. I was just gonna add that. Obviously you can use medication so you can use medication that slow down the gut to help with people with either a high output or if they wanted to go and drink alcohol and they wanted not to be emptying it as much, slowing down the gut as well as eating carbohydrates. As Angie said, all of that can help to, to manage how they, how they cope. Ok. But they would need to take that about 30 minutes or 60 minutes prior to eating or drinking so that the gut has time to slow down before they then start putting um, fluids or, or food into their gut. So, uh yeah, that's a good point, Jenny. I forgot that. Thank you. So, are there examples of medications because some people have questions around what medications can be used to reduce the stomach output? And do they have to be prescribed or they can be bought over the counter? For example, someone's asking about loperamide if that's suitable to help manage high output. Sorry, Fatima, I'm really, really struggling to hear. I think that it's all breaking up a little bit for, for me. But I think one of the most common um er, antimotility drugs we'd be using. Is loperamide. Yes. Ok. And does that have to be prescribed or can it be bought over the counter? Yeah. In many countries it can be bought. Fatima. Um, in fact in the UK, it's hard to get it. There's a slight lag and I've answered for you. Thank you very much. I think. Um, we're having some, uh, so someone is asking about if there are indications for refashioning an ileostomy or a colostomy. Um I'll answer, I think Angie's having some um technical issues. So, yeah, there can be cases when uh we would fashion refashion the stoma. Um that maybe, um because maybe it's retracted, so it's back inside the abdomen or pulled back in, um, and particularly with an ileostomy. If you're struggling, you've got no spout, you're getting a lot of leakage or um with a colostomy, maybe the output's not coming out very easily. And um, uh the patient's having um trouble, um, evacuating their bowels. So we might refashion it. Um Sometimes if people have a parastomal hernia, if the hernia has been repaired, sometimes we need to refashion the stoma at the same time. Um So yes, there are indications and it's usually if people are having difficulties managing their stoma appliance, we try to avoid going back to surgery at any cost. Um And we will look to use appliances and additional items to try and solve a problem, but sometimes it is necessary to refashion it. All right. Thank you. I think that kind of answers the question because someone was asking if it's possible for a stoma to accidentally be pushed back and if a suture is needed to probably hold it outside the body. So I think yes, it's possible for it to be pushed back. And as, as you have stated, refashion in it will be the next step. So the last question, it's about how to increase confidence in people that have stomas as regards leakages and all of the complications surrounding having a stoma. Oh, I think that's a very, very big question to ask. I think it's really important to try and maintain constant or regular communication with the patient so that the patient feels that they're supported in their lifestyle. Um There's a lot of availability on social media at the moment with different groups. Um And I think we've already several, several sessions have already spoken about the importance of support groups and how you can find a lot of support um and encouragement and reassurance from, from your peers and from others that have a stoma formed. Um But I think in the first instance, having a relationship with your stoma care nurse is equally important and actually to highlight any, any issues that the patient may have, whether that be physical with bak leakages, or whether it's psychological, whether they're struggling with coming to terms with the formation of the stoma. So I think all these sorts of things are better spoken about. Um, and it's important that certainly in he's presentation and earlier in mine that, you know, it's important that patient is given the time to actually talk some of these issues through. Thank you very much. Anything to add Caroline or Jenny. Yeah, I, I've got some discussion in the next slide about that. Yeah. Yes. Um, so Jenny is going to be taking us through what to do when things go wrong, especially in the managing of the stoma uh as we stated earlier, thank you so much. And Caroline, as you said that earlier, Jenny is a nurse in Saint Mark's Hospital and um she's currently the head of gastrointestinal nurse education and she's going to be talking to us on what to do when things go wrong. Hi, my name is Jenny Burch and I'm here to talk to you for the next 20 minutes or so about what to do when things go wrong with the stoma. When I look at things such as how to assess stoma complications, identify causes of complications and discuss treatment options and find that I will explore psychological issues and support. So when we're undertaking an assessment and there's a problem with the skin or the stoma, we need to think what is happening with the skin, what is happening with the stoma, what is different, what is the same, what might have caused this and what might we use to manage the problem. If for example, something's changed, maybe diet's changed or exercise has changed, that can make a difference. What has somebody already tried to do to help? What do they think the cause of their problem is? And what treatment options exist? So, these are the things you'll be thinking about when you look at somebody and you think. Oh, goodness. There's a problem here with the stoma or the skin now in the UK. I have lots of treatment options. You've seen some of these pictures earlier. There's lots of different appliances and one of the common problems we have in the first few months of having a stoma is that when you have a stoma formed, as you know, there can be edema uh with the size and the shape of the stoma being enlarged and as the swelling goes down as well as the abdominal swelling. So does the stomach shrink in size? Sometimes it doesn't change much. It just sound like, ok, just first time they forgotten how to do their bag change. And they used to take off the parts nice and care and maybe they're whipping it and rushing it. Maybe they're rushing. Placing the bag on when you place the bag on the hydrocolloid blue stronger after it warms up. So once it's been on the body for 5, 10 minutes, the adhesion is stronger. But if they don't place it on and hold it on for the 1st 30 to 60 seconds, then potentially if the stone is active, that can cause problems. And then if there are problems, you might want to try some of the things I mentioned earlier. The powder paste, you can have paste that will help um adhere the appliance to the, to the skin. There can be the seals that I showed you earlier in the picture on the right and there can be protective sheets if there's big problems with the skins that are stuck onto the abdomen. One of the most common problems you'll see has many different names on pale skin tones. This is what it looks like. The skin looks damaged, it looks red, maybe there are areas of white where there is maceration. It can be called contact dermatitis. It can be irritant, contact dermatitis or skin irritation. And you can see this stoma is swollen, this is a postoperative stoma and the swelling is still visible and you can see it's been leaking downwards and to the side and there can be lots of things that you need to think about. You need to think about the things we mentioned just now. What does it look like? What does the stoma look like? What's the output look like? What caused this problem? How long has the problem been happening? Almost certainly the cause for this problem is the feces coming from the stoma has damaged the skin and the treatment could be as simple as cleaning it drying it and making sure there's a good seal and cutting it to the right size. But people report when they have problems, things like the skin around the stoma used to itch a lot, especially from the feces leaking from the bag. The itching is usually intense and painful and I imagine that would be quite painful. Trauma is another problem that can occur under the white gauze is the stoma and you can see marks on the skin where it's darker and you can see slight bleeding. And what can happen is that as I mentioned, you take the appliance off nice and gently at the top. And then the last bit that stuck on at the bottom where you can't see it so well, you pull it and with repeated pulling, the skin can get, the top layers of skin can get removed and bleeding can occur. And then you can see how the skin tone has changed because of the scarring. And that will be easily remedied by saying, ok, when you take the appliance off, you take it off slowly, you take it off gently, you look after it, your skin carefully prolapse. Hopefully, prolapse is not something you see very often. This is a prolapse that is taking up much of the stoma appliance. And what you'll see here is that the the healthy red bowel is absolutely fine, but this is a plastic hard clip, you need to make sure it doesn't clip onto the end of the stoma because so much of the bowel is out of the body, it could get damaged by leaning on it, by clothes, pressing on it. So looking after the, the, the mucosa of the bowel is really important. Plus there isn't now much empty space in the appliance. So that when the food comes through, there's a potential that it will need emptying much more often with a prolapse. It is possible that the prolapse will go back in the body, particularly if um somebody is lying down, but it might not if there's a cancer recurrence and there's um metastases in the abdomen or, and I'll show you some pictures with Children later. So if the prolapse will easily go back in the body, you can wear a strap around the stoma once it's in to keep it in, obviously not so tight that the feces doesn't er drop down into the appliance, but you do need to be careful of prolapses. Keeping an eye on the color looking for bruising ulcers, rubbing any changes to the outside of the mucosa necrosis. Hopefully, this is not something you will see very often. You can see this is a swollen stoma, it's newly formed and the blood supply has been damaged leading to a darkness instead of pink or red. There is dark mucosa. Usually if you shine a light on it or a bright light, you can see some healthy mucosa below. And if that happens, then no real intervention is usually needed. Just careful observation to make sure it stays warm. But if when looking at it with a bright light, there's no obvious pink edema, then obviously that's a surgical emergency and the surgeon needs to review it as the star carrier um loosens it can be quite smelly, it can look quite distressing to the patient. So it's worthwhile explaining that the top surface will come off and it will look different and just make them aware. So they have expectations of this surface moving. But then what happens afterwards is instead of having a nicely formed stoma, the stoma might be flushed instead of spouted, the stoma might be recessed instead of above the skin level, which can then make subsequent management difficult. You don't often see parastomal hernias as big as this one. But you can see this gentleman has a very pronounced hernia. If somebody does have a hernia and the hernia is bowel in the wrong places. Um, pushing often in this area around the stoma causing a bulge, then keep an eye that the stoma a works that the um, the bowel doesn't twist on itself that the stoma looks healthy and that the color is staying pink or red, but it can be supported by um, an elastic or a firm belt around the abdomen to hold the weight of the hernia that will make it feel more comfortable. Unfortunately, the hernia belt, when it's hot can feel a bit constricting on the abdomen. But they will, for most people, when the hernia is a little bit bigger and maybe not even as big as this, they will find it more comfortable than disturbing to have the belt on Children with stomas. Luckily, they're reasonably rare. But the little image on the right where there's two stomas that are both prolapsing, that's very common for stomas to prolapse in Children because they're coughing, crying and, and that can weaken the stoma formation. As I mentioned before, the stoma appliances on small Children look awfully big. You don't have to have an appliance. You can have a pad so long as the output from the stoma isn't too corrosive, but it's difficult to stop the Children, putting their fingers inside and um scratching if the skin becomes irritated. This is hopefully something you won't see very often. I just wanted to show you this for interest in my hospital. We do really extensive operations where the person would end up with a colostomy as in the top image and a urostomy in the bottom image, they'll have a big abdominal wound, they'll have two stomas close together, they'll have um as I say, the wound very close to the stone as often. And because our patients who have this operation have it for cancer, they've often had radiotherapy and chemotherapy. So their wound healing is often slow and the wounds are prone to break down just making things a bit more awkward. You can see around the urostomy. There's a little bit of detachment as well as in the midline that the wound has the hi. But within about seven weeks, these weeks are about, these pictures are about seven weeks apart. You can see how much the healing has occurred. So if we think about problems such as a high output stoma and that can be defined as a stoma with an output of 1.5 L or more of feces a day. And if we think what a normal output is, that's aa normal output. There can be many causes for a high output. It can be an infection. Um In which case, antibiotics may be necessary if there's been a blockage and all the feces has backed up behind the blockage. Once the blockage has been removed, then there can be all the passage of the feces which seems to go on for a lot of, for many days or a postoperative eyes, a paralytic eyes where the peristalsis action stops. Then after when things start to work, uh there can often be a high output for a few days or a few weeks. Medication can be used to resolve it. But medication can also cause a high output such as chemotherapy diet, a very high fiber diet in somebody who has an ileostomy might mean that their output increases to over a liter, possibly even a liter and a half per day. So how might you recognize a high output? The patient might report that they feel thirsty if they're in hospital, you might notice their urine output is lower or they might report that their urine output is darker in color and they go to the toilet less regularly. They might as symptoms progress get muscle cramps. It might be that if they're wearing an appliance, that the appliance fills up more often and maybe the appliance leaks because they're not expecting it to fill so much. So they're not emptying it enough, particularly at night. And as symptoms get worse, they may feel faint or lethargic. And the reason this happens and the reason we give the who the World Health Organization solution is because if you think about how the body works, you can understand how things have changed. So when you eat or drink food into your mouth down through your esophagus, into your stomach, it becomes digested into a uh a, a mushy consistency thyme or chime. And as it is released from the stomach after a few hours into the duodenum, the first part of the uh small bowel, the duodenum likes to be at a certain level of concentration of sodium and that's just under 100 millimoles. And if you say you drink water, water doesn't contain salt. So if you drink water, once the water is released from the stomach into the duodenum, what you find is that this concentration of sodium is depleted. So what the body then does is it transfers sodium from the rest of the body into the gut into the duodenum to rebalance this sodium concentration. Now, that is absolutely fine if the bowel is working in the normal way and as the uh waste works its way through the body, what is needed and the sodium will be reabsorbed. However, if there's a high output and for whatever reason, things are passing through the, the gi tract, the gastrointestinal tract much faster than normal. There won't be time for reabsorption of the fluids or the sodium. So that's why we often replace sodium and restrict too much in relation to oral fluids. So we might treat a high output by replacing fluids and electrolytes. If they are in a hospital environment, this might be intravenously. If they're able to take fluids orally, then we would use the World Health Organization rehydration solution, which is a combination of glucose, bicarbonate of soda, sodium chloride and water. And that helps to increase the sodium levels, increase the fluid levels. And the glucose and bicarbonate help to transport the sodium. We can also slow down the gut using medications such as loperamide and codeine phosphate. If there is a high output, you need to be careful, um or the patient needs to be careful of their skin around the stoma because the fecal output is much more corrosive and the enzymes within the bowel output. The feces will start damaging the skin and often it's really useful to change the diet. So if somebody has a high output, a liter, a liter and a half or more a day, they should maybe increase their carbohydrates such as rice or bread and decrease fiber such as onions and beans. And this will slow down the peri spouses a little bit as well. These foods might be reintroduced in the future, being careful to chew foods really well, or it might be if it's a long term problem that the person needs to eat more rice and less fiber for the foreseeable future. So when we're thinking about coping with stoma that in relation to food, some food pro products um makes more feces than others such as vegetables. So therefore, some people choose to avoid eating the vegetables. It can be psychological issues, body image, scars from the surgery, having the stone in itself. Sexuality can be an issue. People might report feeling less attractive, they might report having physical or emotional difficulties maintaining sexual relations. Some people have reported a poorer quality of life, especially if they feel that they're lacking control, lack of control over their body, if their lifestyle is restricted or if they've got complications with looking after their stoma in Sri Lanka, there was a cross sectional questionnaire sent to 43 patients. They were quite young, median age of 48 several years since their stoma. And what made them have a better quality of life was being female if they had a colostomy, compared to an ileostomy, if they had a comfortable income, and if they felt their sexual activity was satisfactory in their perspective, but they had a worse quality of life if they felt they needed to change their clothes and the way they looked, if they were depressed and if it took them longer to learn self care, showing how important it is to become independent with care. So the people at risk of a poor quality of life tend to be younger people, possibly women. Although the other studies said women often have better quality of life if they have benign disease. If they have problems getting a job, if they have problems with their stoma or changing their diet, if there were problems being able to attend their religious ceremonies, if they were depressed or anxious, or if they were worried about their disease coming back and it will be made worse if they've got depression. As I mentioned, actually, it ways to help them cope is if they've got good social support, if they've got good support from their partner, and if they become independent with their stoma, and the way that we as healthcare professionals can help is to gain stoma independence, so they can look after their stoma themselves, maybe put them in people who put in a support group of discussion and counseling and even relaxation to try and calm them down. So one person said, having a colostomy has affected me and my girlfriend. At one point, she helped me with the bag and then she got a bit irritated with me and shouted at me. And now I don't like her and we haven't had intercourse since. Whereas another one patient said in interviews in a study once I clean myself and package myself, like, well, I can still meet and have sexual relations with. My husband may cope by either venting emotions, being acceptance, having religious and education and family support. Maybe even using humor. Uh if they start to be maladaptive, then they might have substance abuse, mental disengagement, behavioral changes, denial. Some people don't want their friends to come and visit them. They avoid going to social occasions and they don't tell people and people are different and everybody has different ways to cope. The positive factors. Help from family, chat with friends on social media, find ways to travel by changing how they eat negative coping with wellbeing and religion. So I feel upset sometimes and if my uh my nylon bursts just as I'm going for prayers, that can be really sad and I feel ashamed, take home messages, try and train your patients, help them to understand what they can do to avoid problems if problems occur. How can they help them? How can you help them and support as needed? Ok. Any questions, right? We got Sanja and Ademola to lead the Q and a session. All right, thank you, Nila. So let's start off with the, with the question on there saying can you expand on sexuality issues of patients with the stoma? I think there's no doubt that in particularly, in fact, not only in all younger patients, but it might be of more importance in younger patients. I think it is, you know, having to cope with a stoma not only impacts on a person or the patient himself, but also on their closed ones, their spouses, their families. Because, you know, if you're living together in a place, you've got to come to terms with it and it's difficult, it's really difficult because uh at times your spouse or partner may be able to sort of cope with it or at times, you know, it's something that they may force themselves to do, but they are unhappy about it and it takes years to get better or at times it may not get better. But I think if, if as a nurse, you are aware of it, you probably need to try and see how best to educate and see whether you can, you know, get them to realize that, you know, this is just natural, this is part of their body that you know, they need to appreciate. Ademola. Are you back on looking at uh George? You've got a question there saying that there's always two ostium in the stoma, the distal ostium. And uh how do you cope with the distal ostium. Well, normally speaking, if you do have a problem with the distal part of the stoma or the distal, uh, you know, the, what we call the efferent loop, it's not too much of a worry because generally speaking, there isn't much fecal contamination. But if you do have a problem, I think with any sto or necrosis, retraction or a problem, one needs to go back to the surgeon and see how best he or she can revise uh stoma for the patient. Can a woman? Yeah, there's a question here about having uh pregnancies and uh a baby. There isn't a contraindication or you know, there is nothing to stop a patient from having uh you know, a, a woman with a stoma from having a baby during pregnancy because of the increased intraabdominal pressure. You may find that you may get stoma prolapse and at times this is something which can be quite worrying for patients. But uh I don't think there's any sort of, I can ask one of my nursing colleagues if they've come across problems per se. But the main issue I'm aware of as a surgeon is that stomal prolapse is an issue, angie, anything to come in, Jenny. I think also one of the other things to remember is as the um as the abdomen increases in size as the pregnancy continues, you do need to change the size of the template. So you need to cut the bag but, um, slightly bigger because the stoma will, will undoubtedly get larger as the woman progresses through her pregnancy. So that's a really interesting, that's a really important thing to, to remember. Um, uh, in, in Stoma car so that the stoma doesn't just, you know, doesn't become, um, too restricted and doesn't, and the patient doesn't have leak problems. Um, Jenny, anything. No, I think Angie's covered it in yourself. San, thank you. So, I think also when you talk about stoma size, if you do develop a hernia or a parastomal hernia, you find, then your stoma does tend to enlarge and you may need to go back and look at your appliance, uh template and sort of resize that or look for additional support. You have products such as flanes or belts that might be helpful in such patients. Yeah, if I might hear something. Can you hear me? Yeah, great. Yes. Thank you. So, regarding stomas with complications, if it's a temporary stoma and um it's lived its purpose. If there's a complication, we actually think about reversing the stomach. I think that's one of the option to put him on the block. If it's a temporary stomach and it's sub dysfunction, we just reverse the stomach. Yeah, I II can certainly think of patients where, you know, we've had a problem with a patient postoperatively where they've had a very high output from a stoma and they've been admitted a few times. So in that case, normally, instead of, you know, waiting for about two or three months, all patients on chemotherapy waiting for six months, we have after discussion with the oncologist gone in earlier and closed the stoma to allow them to sort of restart their chemo or, you know, uh help them get over this problem. There's a question there from uh A Y saying that when it's time to bear down, how does it affect the stomach? I think anything that increases intraabdominal pressure might cause the stoma to push out a bit or prolase temporarily. But again, you know, this should not be an issue or not be a concern in a young healthy woman, I think with uh no further questions. Should we move on to uh the next session? Yes. So um I know it's been a long day, but we have one final talk. Thank you Sanjay. So our final talk today is on how to follow up the stoma patients with regards to ward discharge preparations and the role of the Stoma Nose L clinic. Follow up. Our speaker is in Caroline UDO because we are behind time. I will be able to say everything about her. I'll just give her a brief version of our introduction. So Caroline qualified that with um a first class honors in BC in nursing and also became a nurse from Bristol in 1993. And then she moved to Saint George's NHS Healthcare Trust in London. She currently works as a director of Clinical and Patient Services for the security care where she supports a team of nurses, providing care to the NHS and a team of care center personnel who manage patient prescriptions. She has published several papers contributed to book chapters and present at both national and international conferences. She's also a member of the ACN Rep committee as well as a non of B AC. So with further, further ado, let's hear from, hello and welcome to this session on patient discharge and follow up after stoma surgery. My name is Caroline Redone and I've been a stone care nurse for almost 30 years. I used to work in a large South London teaching hospital where I saw a wide range of patients from neonates, pediatrics through to adults. I saw people with bowel angiological stomas and some very complex surgery and visited patients while they were in hospital and after their discharge in their own environment at home. I currently work as the Director of Clinical and patient Services for a private company, Secure Care and Clinimed. And in this role, I have a team of nurses around the UK who also work in hospitals and community settings to support all types of patients with a stoma. The aims and objectives of this session or two fold, we're looking at inpatient preparation for discharge. So everything that we run through with the patients while they're in hospital to make sure that we plan for a safe discharge. And secondly, the follow up care pathway which we follow for people with a stoma. Once they've left hospital preparation for discharge starts, the moment a patient is admitted to hospital, we do a full assessment of the patient and identify if there are any areas where their needs aren't currently being met. This means if there are areas where we feel they will need more care. Once they're discharge, we have time to put that into place and it won't delay their discharge. The aim is to keep the hospital stay to a minimum length of time. So the patient returns to their home environment as soon as possible. This has benefits for the patient. Not many patients like being in hospital, it also reduces the risk of gaining hospital acquired infections, but there's also economic benefits for the care provider as well. And in these days, we need to be conscious of all of these aspects of a patient's care. When we're thinking about discharge, we have to think about both a practical preparation as well as a psychological preparation, practical involving how they change their stoma pouch and are they able to manage and the psychological how they're feeling after having stoma forming surgery. So when we look a little bit further into the practical preparation for discharge, there's aspects that we need to ensure that the patient is confident and competent to change their pouch before they go home. This starts with making sure they're able to empty or drain a pouch depending on the type of products they're wearing and that they can change a stoma pouch on their own or with their carer or family support. If that's what's going to happen at home, many stomach care nurses will use some documentation such as the seven steps to going home that you can see on the slide here. This is a document I use with my team of nurses and it monitors through a traffic light system. We have a red amber and green system and it starts with a patient emptying their pouch with assistance, moving on to be able to do this themselves with supervision right through to the green section where they're able to change and empty and prepare their own pouch themselves. During this time, we need to make sure that patients are familiar with the equipment that they need to change their stoma pouch. Everyone's an individual and everyone has slightly different appliances and maybe the use of other essential accessories such as washers or flang extenders or adhesive removers that may help with their stoma care requirement. We also talk to patients about preparing their pouch template. Everyone has a slightly different shaped stoma and we need to make sure that the pouch is cut to fit nice and snugly around their stoma so that their skin is not exposed to the effluent from the stoma. If there are large gaps around the pouch and the stoma, then patients will get sore skin and this can affect the adherence of their pouches. We show our patients how to cut to the template size. And we explain that the stoma will shrink in time. And as the stoma is shrinking, that they need to be able to cut the pouches smaller. We show patients the template and how to measure around their stoma so that they can see if the stoma is shrinking. Some people are able to cut their own stoma pouches out and others need support with this. And in the UK, when patients have their pouches delivered, we're, we're able to ask the delivery company to cut the pouches ready for that patient according to their own template. In the early days, we would leave the patient with a few supplies, cut and then check the stoma at set intervals so that we can make sure if it's shrinking, we're able to cut the pouches smaller so their skin isn't exposed. The patient always has a template left in their wash bag or holds all the supplies. So they know or while they're in hospital, any other healthcare professionals who may be supporting them to do their stoma care has a template to cut. To. Another important aspect of preparing for discharge is around the disposal of the waste product. We teach patients to empty their effluent into the toilet and then to fold the pouch over so that the effluent that's maintained in the pouch is contained. They place all of that along with wet and dry wipes into a small disposal bag that can be tied and made secure. And in the UK, this is disposed of in the normal household rubbish. We do ask patients to check because some areas may have a different plan for disposal of these products such as those for waste, uh wound care products and other countries may also have different facilities for disposing of stoma care products as well as preparing the practical of changing the pouch. We talk to the patients around identifying stoma and skin issues that they may experience. No one should have sore or red skin with their stoma, their skin around their stoma should look similar to that on every other area of their abdomen. I know from my own experience, a lot of patients do expect to get some sore skin and they may not raise that as an issue. But we try to explain that this isn't what they should expect. And if they do have any skin issues or problems with their stoma, it is out of the ordinary, they must contact their stoma care nurse as well as the practical preparation. We also think about psychological preparation. The change in body image following stoma surgery can change a person's life and the transition to adjust to having a stoma can take time and will be different for each individual person adaptation to having a stoma will depend on many factors. This may be around the illness that resulted in the patient having a stoma formed again, from my own experience, I know that a number of patients who have inflammatory bowel disease and they have been unwell for many, many years actually find having a stoma improves their quality of life. And it means that they're able to go out again without having to look for toilets or be restricted on where they can go. Patients who have been diagnosed with cancer may see a stoma very differently. Some people feel that having the stoma may have cured them from their cancer and see it as a positive aspect. But others, it reminds them that they had cancer or that they may still have cancer and they're going through treatment and they may see it as a negative. So again, their time to adjust to having a stoma can vary. It can also take time for people to think about the fact that their body functions in a slightly different way now. And it also depends whether their stoma may be permanent or temporary and how they adjust to it factors such as how people perceive their own body, image, the relationships, they have their sexuality and the support they get from family and friends can also affect how quickly they adapt to having a stoma. We also have to be aware of any cultural or religious issues which may influence how someone perceives having a stoma or how they are perceived by their family and friends. Now they have a stoma. There may be different practices that they undertake and we need to be able to support them in this and make sure we're aware of all of their concerns. Patients will have many concerns about having a stoma and the stoma care nurse needs to be open and comfortable to address all areas of body image and sexuality and allow the patient's time to talk and raise their own concerns. It's also important that we talk to them about the support that's available when they're discharged. They always have the stomach care nurses number and they know that they can always call us when they need anything and any support, we can introduce them to stomach hair associations in the UK. We have the Colostomy Association, the Ileostomy Association and the Urostomy Association as well as many others that are available. And these often provide good levels of support for people because they're able to talk to someone else who has had the same type of stoma as themselves and may be experiencing or may have experienced some of the anxieties or concerns that the newer patient is now feeling they're able to give them some very practical advice, but also talk about their feelings as well. And as a STAIC care nurse, it's important that we also recognize our own limitations. If a patient is struggling with having a stoma and may be finding that their emotional needs or more than we can provide, then we must identify this and refer them on to counseling services so that they can get the provision that they need in order to go and live their normal life with a stoma. So when we've gone through these preparations and our patient is ready for discharge and they're able to change and empty their pouch and manage it and they're competent at changing and, and managing their stoma. We need to go through a simple checklist. We need to check that they have sufficient supplies to take home with them until their first order of stoma equipment arrives. The patient needs to have knowledge about how they order their supplies and also what equipment that they require. So if they're using a pouch, if they're using an adhesive remover or any additional items, we leave them a list of what these items are and code numbers. So they know what's being ordered in the UK. Patients obtain their supplies on prescription and the prescription can either be redeemed at a pharmacy or chemist or they can be delivered to the patient at home via a dispensing appliance contractor. There is also the option for these dispensing appliance contractors and some pharmacies to cut pouches to the right size. So we also make sure that we have a copy of the template and we're able to send it off for the patient if they need their supplies, cutting out, we make sure they have the appropriate literature throughout their time in hospital. We'll have gone through many aspects of care with them. And it's nice to have some written information that they can refer back to. In particular. She may talk about nutrition and how to return to their usual diet prior to having a stoma. Or if there are any adaptations that they may need to make, whether that be short term or long term with their type of stoma. We've often also spoken to them about a breathing and movements type of program and there's various programs around these are around ensuring that people keep active after having stomach care surgery that they're fit and able to return to their usual activities. But also we talk about abdominal core exercises to ensure that they're not more at risk of having a parastomal hernia and that we hopefully reduce the risk of this by ensuring that their abdominal core stays strong as well as the literature. We provide them with a copy of their discharge letter. This will tell them about the surgery they've had and also give them a list of their stoma equipment. So if they have any issues, once they've been discharged prior to coming back to see the stomach care nurse, and they have to seek assistance maybe from their GP or another healthcare professional while they're at home, they have um all the details that they need to share with that healthcare practitioner to ensure they receive the appropriate care. We also talk to the patient about what follow up care they'll have when they're likely to receive a phone call from us. And when we'll see them, we like to see patients face to face and that might be at home or it might be in a hospital clinic and we always make sure they have our contact details and who to contact when we're not available. So maybe overnight or at weekends also contact details of where they are getting their prescription and stoma equipment from. So they know who to contact. Should they have any queries about that? I also always remind my patients to take home their hold all or wash bag with all their stones supplies in, I know in the past sometimes when patients are packing up their own belongings to take home, they think that the hold all belongs to the hospital and that that should be left with the hospital. So I always remind them to take that home because otherwise they're going to have difficulty if they need to change their stayer bag. So what follow up care do we offer to patients after they've had stoma surgery? We do a predischarge assessment and I know a lot of nurses do this. They'll follow something similar to the stoma scoring thermometer that you can see on your screen. And this just goes through not only the seven steps to discharge to make sure people are confident at changing their pouch. It also checks that they're fit and well, it also gives a list of, are they having any chemotherapy? Are they having any leakages? Are they having any loose stool? And maybe a little bit more about how the patient's feeling? It means that they've got an assessment so that if the nurse seeing them at home is a different nurse to the nurse that's seen them in hospital, they have an assessment and a baseline of how the patient was feeling prior to going home. Some stoma nurses provide both hospital and community care. So it may be the same nurse or team of nurses that a patient's seeing. But in other areas, it will be a different nurse. And then we must make sure that we give a good referral to the community team so that they know everything that's happened and going on with that patient, all the appliances they're using how well they're getting on and that we provide their baseline assessment, we send a letter to their GP and any other relevant healthcare professionals so that they know the types of um appliances that they're using because they'll be asked to prescribe them. In some areas. It's the GP that prescribes stoma appliances. But in others, patients may have a prescribing cub and it may be a Stoma care nurse that does the prescribing. Once the patient's gone home, we tend to phone them two or three days after discharge, this gives them a chance to settle in at home and then when we speak to them, they can let us know if they're managing well or if they're having any issues. We can also check that they've received their first order of supplies. Obviously, if the patient's having trouble prior to our telephone call, they know that they can call us and they have our contact details during this phone call, we talk to them about when we'll see them, we like to have face to face contact with them so that we can observe them in their own home or in a clinic setting, making sure that they are still coping with changing their appliance. And we can also check the size of their stoma and whether they need their template resizing after this visit, we may plan a second visit and that depends on how the patient's getting on. If they're managing really well, if they may be looking to get back to work, they may not want us to visit them at home and they may not want to come into clinic. But we'll always offer a virtual review or a telephone review. If patients require more visits, we'll see them more frequently. It's a very individual process. And once the patient's managing and independent with their care, we will always remind them to contact us if anything happens that they're not sure of. And finally, we must always make sure throughout this process that we document all the care on all the planning and all the preparation for discharge. So that that's available for any other healthcare professional who may be involved in their care. Thank you very much for listening. Thank you er Caroline, another excellent talk. Um So we have a couple of questions. Um I'm gonna keep this um er Q and A session relatively short um As we're, we're running out of time. Um But we've got a couple of questions. One can a patient benefit from irrigation if they've got a blocked stoma? Um Yes, they can if it's a colostomy, um we wouldn't irrigate an ileostomy, but with a colostomy, um we can irrigate it. Um Probably um I would say we would introduce some sort of um laxative as well to try and soften the stool um so that they're less likely to get con uh constipated. And then when we have another similar question, um er can the patient benefit from an enema when they're having impacted stools? And are there any instruments that can be used bedside to assist um and provide relief if a compacted stool causes obstruction. Yes. Um We do introduce sometimes suppositories and sometimes an enema um for those patients with a colostomy that have um impacted stools um with suppositories, you do need to replace a bag over um the colostomy and maybe I always ask my patients just to keep their hand over it so that the suppositories don't, um, come out straight away into the, er, bag. Um, we can use an enema and sometimes, um, we would use maybe a soft, um, urethral catheter, um, to go further back into the, um, colon so that you can insert the enema higher up. So it has more of an impact on that stool. I don't know if there's anything else you'd like to add to that Jenny as well? Thank you, Caroline. But obviously it depends why they're um impacted and why they've got constipated. We just need to make sure it's not a tumor or something that's blocking the lumen. But yeah, all of those things are really tricky to do. You know, you make them sound really simple. Caroline suppositories tend to pop back out the fluid from the um, er, Irri. Irri not irrigation enema tends to come back out. So it, it's not quite as simple as that, but yes, they certainly are really effective. Thank you. Ok, thank you. So, I am going to um er end the um, er, questions there. I'm going to do one final poll. Um And that is to ask the audience whether they'd be interested in um, er, um attending a dedicated Q and A session um that we might perhaps organize in the New Year. So the Q and A session seems to be quite popular and I suspect people have lots of questions about patients and problems that they've seen and might value um the experience of some experienced do nurses. So if you could answer that question, that would be great. So I'd like to um sort of start the close of the session and the final wrap up by thanking our faculty for taking time out to um create the presentations. Um Thank you for recording them so that they took up less bandwidth. So hopefully there were less internet connectivity issues. Thank you to all of the delegates for joining us. Um And if you can complete the feedback form that's available in the chat um or via email, then you will get a CPD um an attendance certificate with um three CPD points. Um I would like to um advertise an event that the Association of Color Proctology are doing in the New Year. It's in March and it's free for those to attend from low and middle income countries. So many of the delegates here today will be able to attend that course free of charge. Um So um feel free to, to have a look at that and share it with any colleagues that you think might be interested in it. So I'm going to hand over to Ade Moler and um Fatima to um conclude the event. Thank you Nicola for, for this. Uh I don't know if Fatima is still on. If not, I would, I said ladies first, but we're behind time. So I will just go ahead and crack on this. So again, I like to appreciate um Nicolas said uh resource persons, the delegates a more important part to the societies and that support us the ACP GBI. We got a lot of support from the president talking the disorders. Thank you again for the, our president, Doctor Ade and the board of trustees. Thanks to the Do Club, a lot loss of support from um Mo who was in the past president, who is the current president of Do Club also through me platform for technology, as well as um the stomach who have been so wonderful in giving all this uh support without all of this, this would have not been possible. And last but not the least. I want to thank him, my mentor, my friend, my birthday mates and Mr Sanjay Cud. He was the one who sparked this idea in me that brought this patient today. And uh we very grateful for you for this opportunity and privilege. We really look forward to many more um similar webinars in the future and we have sure that we will have great things to say about us. So uh FASA any closing thoughts, um not really just to say thank you to everyone that has contributed to the success of this study day. I mean, you don't, I don't think we know the magnitude of how much change we have sparked. Um I did a study and I realized with the help of Ademola, we did a study and we realized that there is really a lot of challenges faced by healthcare providers who are providing stoma care to patients. And we have sort of tackled some of the issues that you know, healthcare providers face on a day to day basis. So thank you very much for everyone that has been a part of this. All right, thank you so much again. So I just like to us very happy and nice weekend and see you soon. Bye. Thank you. Bye. Thank you.