SACS 2.

0
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?

- Any compromise in the integrity of peristomal skin (definition)

- Wide range of incidence rates:
- 10,2 40% (review of 7 studies)1
- 18 55%2
- Lack of consensus concerning stomal and peristomal complications does not allow for comparison of
prevalence rates
SCARPA ET AL (2007)
ST. CYR ET AL. (2012) COLWELL ET AL. (2001) Rod in loop ileostomy: just an
An evaluation of the The state of the insignificant detail for ileostomy-
canadian assessment guide sandard diversion related complications?
44% 56% 61%

BOSIO ET AL. (2007) ANTONINI M, MILITELLO G (2013)

A proposal for classifying peristomal skin The incidence of Stomal and Peristomal
disorders: results of a multicenter Complications in Italy: results of a pilot study
observational study 56%
52%
1. Salvadalena G. Incidence of complications of the stoma and peristomal skin among individuals with colostomy, ileostomy, and urostomy: a systematic review. J Wound Ostomy Continence Nurs.
2008;35(6):596-607.
2. Bosio G, Pisani F, Lucibello L, Fonti A, Scrocca A, Morandell C, Anselmi L, Antonini M, Militello G, Mastronicola D, Gasperini S. A proposal for classifying peristomal skin disorders: results of a multicenter
observational study. Ostomy Wound Manage. 2007;53(9):38-43.
3. 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.
 REVIEW OF THE LITERATURE

Incidence of complications of the

stoma and peristomal skin
among individuals with
colostomy, ileostomy, and
urostomy: a systematic review.
Salvadalena G. Journal Wound
Ostomy Continence Nurs. 2008
Nov-Dec;35(6):596-607; quiz 608-9.

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?

- An evidence-based instrument developed out of a clinical need

- 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

- An objective classification system to document the incidence of peristomal skin lesions

 ORIGINAL SACS CLASSIFICATION
L1 Erythematous lesion
(peristomal erytheme without
loss of substance

L2 Erosive lesion with loss of

substance as far as and non
beyond the basal membrane

L3 Ulcerative lesion beyond

the basal membrane

L4 Ulcerative
fibrinous/necrotic lesion

LX Proliferative lesion
(neplasia, granulomas, osalate
deposit)
The SACS 2.0 Study: objectives

1. Completion of the classification to include an additional

level of severity (L5)

2. Classification of all types of peristomal skin changes

present, eliminating the notion of most serious lesion
Beginning of the
SACS 2.0 Study
(January 2013)

End of the SACS 2.0 Coming soon..

Empoli Study
(December 2014) WCET Journal
Prato

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

SACS 2.0 Classification

 The SACS 2.0 Study: Results
Peristomal Skin Disorders

LX: Proliferative lesion 18

PATIENTS ENROLLED L5: Ulcerative involving planes beyond the

13
fascia

L4: Ulcerative with fibrin/necrotic lesion 66

L3: Ulcerative lesion 23

L2: Erosive lesion 74

Peristomal Skin
Skin Integrity Incidence
Disorders L1: Erythematous lesion 61
171 59,86%
255
0 10 20 30 40 50 60 70 80
Ostomy Types
Gender Colostomy Ileostomy Urostomy

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)

L1 Erythematous lesion L2 Erosive lesion with loss of

(peristomal erytheme without substance as far as and non
loss of substance beyond the basal membrane

L3 Ulcerative lesion beyond L4 Ulcerative

the basal membrane fibrinous/necrotic lesion

L5 ULCERATIVE LESION INVOLVING

LX Proliferative lesion
PLANES BEYOND THE MUSCOLAR
(neplasia, granulomas, osalate
FASCIA (WITH OR WITHOUT FIBRIN,
deposit)
NECROSIS, PUS OR FISTULA)
 THE SACS STUDY: TOPOGRAPHY (T)

TOPOGRAPHY (T) Patient standing in front of the

HCP

- I = Upper Left Quadrant

- II = Upper Right Quadrant
- III = Lower Right Quadrant
- IV = Lower Left Quadrant
- V = All the Quadrants
Perspective of the HCP

The order of the quadrants around the stoma

starts in the Upper Left corner (TI) and ends
in the Lower Left corner (TIV) clockwise.
Objective n.1: Completion of the classification to include an additional level of severity (L5)

We therefore proposed the

sole inclusion of the condition
relating to the detection of a
new non-classifiable lesion (L5)
even though it has a low
presence in our study (5%)

L5 ULCERATIVE LESION INVOLVING PLANES BEYOND THE

MUSCOLAR FASCIA (WITH OR WITHOUT FIBRIN, NECROSIS, PUS OR
FISTULA)

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.

CLASSIFICATION OF THE LESIONS IN THE PHOTO (EXAMPLE):

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
picture of a lesion such as L5 and the possibility to
classify any lesion present in the peristomal
quadrant makes the classification more precise for
the health professional.
CONCLUSION
We have maintained the basic characteristics of
the original SACS Study, on the basis of which it is
objective, reproducible and easy to use.
This upgrade tool offers, at all clinicians, a
complete guideline for a correct interpretation and
diagnosis of skin disorders, characteristics not
present in other types of classification.
The use of the SACS instrument is important in
terms of determining and documenting skin
lesions, that it would contribute to the exact
measurement of the prevalence and incidence of
skin lesions, and that it would provide assistance in
clinical decision making.
The low rate of lesion L5 is a limitation of this study, but only for
the numerosity of the sample. However, the numerosity of this
type of lesion is strongly influenced by risk factors such as:
Abdominal operative procedure, operative time, emergency
procedure and clean wound classification.
Consequently the need to implement the existing classification
with a type of clinical picture that interested the abdominal
structures beyond the dermis.
FUTURE STEPS
The study group is currently working on a NEW
DIAGNOSTIC PROPOSAL FOR EACH L CONDITION,
which, in all likelihood, we will refer to as LD
(LESION DIAGNOSIS) and to which will necessarily
correspond a TOPICAL OR SYSTEMIC THERAPEUTIC
PROPOSAL referred to as R (RESOLUTION).
 THANK YOU
FOR YOUR
ATTENTION

ANTONINI Mario
Ostomy and Wound Care Specialist Local Healthcare Toscana Centro - Empoli
Professor at University of Florence
mantonini11@alice.it