SACS 2.0 Classification

1. ANTONINI Mario
Ostomy and Wound Care Specialist – Local Healthcare Toscana Centro - Empoli
mantonini11@alice.it
SACS Score
FROM SACS TO SACS 2.0 AND BEYOND
14TH CONFERENCE OF THE EUROPEAN COUNCIL OF ENTEROSTOMAL THERAPISTS
ROMA, 23 – 26 GIUGNO 2019

2. SACS Score: From SACS to SACS 2.0 and Beyond
“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.

3. SACS Score: From SACS to SACS 2.0 and Beyond
«The rehabilitation of people living with an ostomy depends
mainly on the integrity of their peristomal skin»
«Maintaining a healthy peristomal skin is therefore the main
objective of any health care professional that takes care about
ostomates»

4. SACS Score: From SACS to SACS 2.0 and Beyond

5. SACS Score: From SACS to SACS 2.0 and Beyond
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
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.
ST. CYR ET AL. (2012)
An evaluation of the
canadian assessment guide
44%
BOSIO ET AL. (2007)
A proposal for classifying peristomal skin
disorders: results of a multicenter
observational study
52%
COLWELL ET AL. (2001)
The state of the
sandard diversion
56%
ANTONINI M, MILITELLO G (2013)
The incidence of Stomal and Peristomal
Complications in Italy: results of a pilot study
56%
SCARPA ET AL (2007)
Rod in loop ileostomy: just an
insignificant detail for ileostomy-
related complications?
61%

6. SACS Score: From SACS to SACS 2.0 and Beyond
COMPLICATIONS
Time OSTOMY COMPLICATIONS PERISTOMAL COMPLICATIONS Cutaneous signs
Immediate post-operative
complications (0 – 72 hrs)
Oedema Contact Allergic Dermatitis (CAD) Cutaneous alterations
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

7. SACS Score: From SACS to SACS 2.0 and Beyond
PREVENTION ASSESSMENT AND CLASSIFICATION TREATMENT
Therapeutic Relationship Assess and recognize skin lesions
Knowledge about Stoma Bag Types and
accessories
Stoma-siting
Use of a Peristomal Skin Disorders
Rating Score
Advanced Dressings and their Correct
Use
Stoma surgery
Knowledge about Stoma Complications
and Peristomal Skin Disorders
Knowledge about Stoma Bag Types and
accessories
Prevention Assessment and Classification Treatment

8. SACS Score: From SACS to SACS 2.0 and Beyond
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

9. SACS Score: From SACS to SACS 2.0 and Beyond
The Objectives of the Original SACS Study
1. ASSESS AND CLASSIFY PERISTOMAL SKIN DISORDERS
The Study group agreed on not taking into consideration:
• The aetiology of peristomal skin disorders
• The Therapeutical treatment
2. EVALUATE THE CORRELATION BETWEEN BOOD CHEMISTRY
AND SEVERITY OF PERISTOMAL LESIONS.

10. SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: DEFINITIONS
PERISTOMAL AREA:
The term “peristomal” is meant to include the
whole skin around the stoma even if it is not
directly linked with the stoma.

11. SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: DEFINITIONS
THE PREDOMINANT SIGN:
It was decided that the classification should only
refer to the Predominant Sign (the most serious
one) and the Topography (T) of the lesion; the
classification will include only one «L» and in
case more than one «T».

12. SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: DEFINITIONS
TOPOGRAPHY
▪ T I = Upper Left Quadrant
▪ T II = Upper Right Quadrant
▪ T III = Lower Right Quadrant
▪ T IV = Lower Left Quadrant
▪ T V = All the Quadrants
The order of the quadrants around the stoma starts
in the Upper Left corner (TI) and ends in the Lower
Left corner (TIV) clockwise.
Patient’s head
Patient’s feet

13. SACS Score: From SACS to SACS 2.0 and Beyond
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)

14. L1
HYPEREMIC LESION
Peristomal redness with intact skin
SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: CLASSIFICATION
SACS Classification
LESION (L)

15. L2
EROSIVE LESION
Open lesion NOT extending into subcutaneous tissue;
partial thickness skin loss
SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: CLASSIFICATION
SACS Classification
LESION (L)

16. L3
ULCERATIVE LESION
Open lesion extending into subcutaneous tissue and
below; full thickness skin loss
SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: CLASSIFICATION
SACS Classification
LESION (L)

17. L4
ULCERATIVE LESION
Full thickness skin loss with non-viable, dead tissue
(necrotic, fibrinous)
SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: CLASSIFICATION
SACS Classification
LESION (L)

18. LX
PROLIFERATIVE LESION
Abnormal growths present (i.e. hyperplasia,
granulomas, neoplasms)
SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: CLASSIFICATION
SACS Classification
LESION (L)

19. The Objectives of SACS 2.0 Study
SACS Score: From SACS to SACS 2.0 and Beyond
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»

20. SACS Score: From SACS to SACS 2.0 and Beyond
The Objectives of SACS 2.0 Study
Objective n.1: Completion of the classification to include an additional level of severity (L5)
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
L5 – ULCERATIVE LESION INVOLVING
PLANES BEYOND THE MUSCOLAR
FASCIA (WITH OR WITHOUT FIBRIN,
NECROSIS, PUS OR FISTULA)
LX – Proliferative lesion
(neplasia, granulomas, osalate
deposit)

21. SACS Score: From SACS to SACS 2.0 and Beyond
The Objectives of SACS 2.0 Study
Objective n.1: Completion of the classification to include an additional level of severity (L5)
L5 – ULCERATIVE LESION INVOLVING PLANES BEYOND THE
MUSCOLAR FASCIA (WITH OR WITHOUT FIBRIN, NECROSIS, PUS OR
FISTULA)
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%)
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.

22. L5
DEPTH LOSS OF
SUBSTANCE
Ulcerative lesion involving planes beyond the muscolar
fascia (with or without fibrin, necrosis, pus or fistula)
SACS Score: From SACS to SACS 2.0 and BeyondSACS Score: From SACS to SACS 2.0 and Beyond
The SACS 2.0 Study: CLASSIFICATION
SACS Classification
LESION (L)

23. SACS Score: From SACS to SACS 2.0 and Beyond
SACS 2.0 Classification
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.
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.
CLASSIFICATION OF THE LESIONS IN THE PHOTO (EXAMPLE):
▪ L1, TV: Hyperemic Lesion - Peristomal Redness with Intact Skin
▪ L2, TV: Erosive Lesion – Superficial Loss of Substance
▪ L4, TII-III-IV Ulcerative Lesion - Full thickness skin loss with non-viable, dead tissue
(necrotic, fibrinous)
▪ LX, TIII-IV Proliferative Lesion - Abnormal growths present (i.e. hyperplasia,
granulomas, neoplasms)

24. SACS Score: From SACS to SACS 2.0 and Beyond
CONCLUSION
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.
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
• Development of a Peristomal Skin Disorders
measuring System (a system to size the stoma area
affected from a wound and to assess it the severity)
• Guideline for the use of the various types of ostomy
devices based on the type of wound and associated
treatment

25. THANK YOU FOR YOUR ATTENTION
ANTONINI Mario
Ostomy and Wound Care Specialist – Local Healthcare Toscana Centro - Empoli
mantonini11@alice.it
14TH CONFERENCE OF THE EUROPEAN COUNCIL OF ENTEROSTOMAL THERAPISTS
ROMA, 23 – 26 GIUGNO 2019