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a review of the original SACS scale
and a proposal of a new classification
ANTONINI Mario
Ostomy and Wound Care Specialist Local Healthcare Toscana Centro - Empoli
Professor at University of Florence
mantonini11@alice.it
The Peristomal skin should be
intact with no evidence of
redness, loss of epidermis or
sensations such as itchiness,
warmth or pain
Colwell J, Beitz J. Survey of wound ostomy and continence (WOC) nurse clinicians on stomal and
peristomal complications: A content validation study. J Wound Ostomy Continence Nurs.
2007;34(1):57-69.
WHAT IS A PERISTOMAL SKIN DISORDERS?
NO DESCRIPTION OF
Number of participants in each NO DEFINITIONS OF
phase of the analysis.
Different length of the studies. THE ASSESSMENT OF
SKIN DISORDERS.
THE SKIN LESIONS.
Complications
Time OSTOMY COMPLICATIONS PERISTOMAL COMPLICATIONS Cutaneous signs
Immediate post-operative Oedema Contact Allergic Dermatitis (CAD) Cutaneous alterations
complications (0 72 hrs)
Ischaemia and necrosis Candidiasis Infection
Intra and peristomal haemorrage Folliculitis or other bacteria
Malpositioning Pseudo-verrocous lesion Proliferation
Poor creation of a stoma Oxalates deposit
Late post-operative complications Retraction Neoplasia
Prolapse Mucocutaneous detachment Ulcer
Fistula Pressure Ulcers
Stenosis Contact Irritative Dermatitis (CID)
Hernia Pyoderma Gangrenosum
Trauma Trauma
Pseudo-inflammatory polypse Dermatitis Artefact
Psoriasis Dermatological disease
Eczema
Seborrheic dermatitis
WHAT IS THE SACS INSTRUMENT?
- A systematic literature review revealed that no universal system existed to objectively classify peristomal
lesions according to type and location
- The SACS Instrument was developed to help establish a standard language for the assessment and
classification of peristomal lesions
- Provides operational definitions for the consistent interpretation of peristomal skin lesions
L4 Ulcerative
fibrinous/necrotic lesion
LX Proliferative lesion
(neplasia, granulomas, osalate
deposit)
The SACS 2.0 Study: objectives
Rimini
Catania
Ostomy Patient
ENROLLMENT
S.A.C.S. 2.0
Study
ASSESSMENT
Time frames
T0 T1 T2 T3 T4 T5 T6
7 DAYS 6 MONTHS
14 DAYS 3 MONTHS
1 MONTH 2 MONTHS
Consensus
Conference
17%
47%
53% 43%
40%
Males Females
SACS CLASSIFICATION 2.0
Objective n.1: Completion of the classification to include an additional level of severity (L5)
4. Sandy-Hodgetts K, Carville K, Leslie GD. Determining risk factors for surgical wound dehiscence: a literature review. Int Wound J 2015;12:265-75.
5. Dealey C. The management of patients with acute wounds. In: Dealey C. The Care of Wounds: A Guide for Nurses. Fourth edition. Hoboken, NJ: John Wiley & Sons; 2012.
L5 ULCERATIVE LESION INVOLVING PLANES
BEYOND THE MUSCOLAR FASCIA (WITH OR
WITHOUT FIBRIN, NECROSIS, PUS OR
FISTULA)
L5, TI-III-IV
Objective n.2: Classification of all types of peristomal skin changes present, eliminating the notion of most
serious lesion
WHEN USING THE SACS 2.0 INSTRUMENT:
- Document each lesion observed
- Document the topographical location(s) for each lesion observed
The sole classification of the prevailing sign (most serious lesion) is reductive in most cases
and not explanatory for the health professional. For example, redness may exist as a
single lesion (simple redness - L1) or co-exist together with an ulcerative fibrinous/necrotic
lesion (L4) as a sign of inflammation/infection, but may also not be present in an
ulcerative lesion (L3) as it is in the healing phase. In literature such situations may be
referred to as primary skin lesions present at the onset of the disorder or as secondary
skin lesions as a result of modifications over time caused by the progression of the
disorder, manipulation, medications or the healing process5. During the course of the
development of consensus it was thus decided that each lesion present in the peristomal
quadrant should be classified.
L2, TV: EROSIVE LESION WITH SUPERFICIAL LOSS OF SUBSTANCE - L2, TV (lesions 1,2 and 3)
(LESIONS 1, 2 AND 3); L4, TII-III-IV FIBRINOUS/NECROTIC - L4, TII-III-IV (lesions 5 and 6)
ULCERATIVE LESION (LESIONS 5 AND 6); LX, TIII-IV - - LX, TIII-IV (lesion 4)
PROLIFERATIVE LESION (LESION 4)
5. Dealey C. The management of patients with acute wounds. In: Dealey C. The Care of Wounds: A Guide for Nurses. Fourth edition. Hoboken, NJ: John Wiley & Sons; 2012.
L2, TV: erosive
LX, TIII-IV -
lesion with
proliferative
superficial loss
lesion
of substance
L4, TII-III-IV
fibrinous/necr L2, TV: EROSIVE LESION WITH SUPERFICIAL LOSS OF SUBSTANCE
otic ulcerative L4, TII-III-IV FIBRINOUS/NECROTIC ULCERATIVE LESION
LX, TIII-IV - PROLIFERATIVE LESION
lesion
The inclusion of an additional descriptive clinical The low rate of lesion L5 is a limitation of this study, but only for
picture of a lesion such as L5 and the possibility to the numerosity of the sample. However, the numerosity of this
classify any lesion present in the peristomal type of lesion is strongly influenced by risk factors such as:
quadrant makes the classification more precise for Abdominal operative procedure, operative time, emergency
the health professional. procedure and clean wound classification.
Consequently the need to implement the existing classification
CONCLUSION
with a type of clinical picture that interested the abdominal
We have maintained the basic characteristics of structures beyond the dermis.
the original SACS Study, on the basis of which it is
objective, reproducible and easy to use.
ANTONINI Mario
Ostomy and Wound Care Specialist Local Healthcare Toscana Centro - Empoli
Professor at University of Florence
mantonini11@alice.it