Colostomy and Ileostomy

A stoma is a surgically formed opening between a body cavity, such as the colon or ileum, and the external body environment, such as the outer abdominal wall. After formation of a colostomy or ileostomy, stool flows through the stoma from the colon or intestines respectively, into a collecting device attached to the abdominal wall, thereby bypassing the rectum and anus. SCI individuals who undergo elective colostomy or ileostomy have usually exhausted all other appropriate bowel management options. The most common reasons for undergoing stoma surgery include prolonged bowel management episodes, unmanageable fecal incontinence, and constipation. Autonomic dysreflexia and pain associated with bowel evacuation, difficulties finding appropriate care, perianal disease and pressure injuries close to the anus may also be reasons to choose a stoma for bowel management. Stoma for bowel management remains uncommon; one study suggested prevalence in the UK of around 2.5% (Coggrave et al. 2009). There is no general consensus as to when colostomy should be performed in people with SCI. Aging and increased duration of SCI may contribute to bowel management difficulties (Faaborg et al. 2008) and with increasing life expectancy amongst people with SCI, stoma may become a more common management choice in the future.

One systematic review examined studies that directly compared clinical, functional, QOL outcomes or satisfaction among individuals with a stoma to individuals using conservative means. The second focused on studies that investigated quality of life after colostomy formation.

Discussion

Stoma formation is a relatively safe, effective and well-accepted method of managing significant neurogenic bowel management problems in individuals with SCI. Studies report that a stoma reliably reduces the number of hours spent on bowel care (Munck et al. 2008; Branagan et al. 2003; Rosito et al. 2002; Kelly et al. 1999; Stone et al. 1990b; Frisbie et al. 1986; Bolling Hansen et al 2016; Waddel et al. 2020; Cooper et al. 2019), reduces the number of hospitalizations caused by GI problems (Rosito et al. 2002) and bowel care-related complaints (Frisbie et al. 1986), simplifies bowel care routine (Frisbie et al. 1986), may be associated with normal gastrointestinal transit times (Bolling Hansen et al. 2016), and reduces fecal incontinence.

Majority of people with SCI also report QOL improvements after a stoma formation (Coggrave et al. 2012; Munck et al. 2008; Safadi et al. 2003; Rosito et al. 2002; Kelly et al. 1999; Waddel et al. 2020; Van Ginkel et al. 2021; Cooper et al. 2019). Stomas were well-received by people and either met or exceeded their expectations (Rosito et al. 2002; Coggrave et al. 2012; Bolling Hansen et al. 2016; Van Ginkel et al. 2021). Tate et al. (2023) describes the large interplay of factors that contribute to surgery decision making, in which bleeding hemorrhoids, bowel incontinence, wounds, and ineffective management methods were the most common reasons to choose bowel-related surgeries such as colostomies, ileostomies or hemorrhoidectomies. Many SCI participants wished to have the stoma done earlier, or to have had it done earlier (Coggrave et al. 2012; Branagan et al. 2003; Bolling Hansen et al. 2016). Overall, current evidence supports the earlier education of stomas for bowel management for individuals with SCI.

Stoma increases independence, facilitates travel, elevates feelings of self-efficacy, and does not negatively affect body image (Branagan et al. 2003; Rosito et al. 2002; Bolling Hansen et al. 2016). Therefore, while research findings suggest that stoma formation be used to relieve bowel complications it may also be used to facilitate independence, and acceptance toward bowel care following SCI (Boucher et al. 2019; Waddel et al. 2020; Van Ginkel et al. 2021; Cooper et al. 2019; Tate et al. 2023).

There have been a few complications including increase in bowel times in one participant receiving an ileostomy (Kelly et al. 1999) and leakage and increased odor (Frisbie et al. 1986; Bolling Hansen et al. 2016), one participant with sigmoidoscopy reported noise as an issue, one reported cosmetic issues and pain (Bolling Hansen et al. 2016).

Conclusions

There is level 3 evidence (Boucher et al. 2019; Negosanti et al. 2020) that colostomy for people with SCI is a safe and effective option that is frequently used to treat localized bowel care complications, in which earlier surgery results in fewer later complications.

There is level 4 evidence (from seven studies; Frisbie et al. 1986; Stone et al. 1990b; Kelly et al. 1999; Rosito et al. 2002; Branagan et al. 2003, Munck et al. 2008; Bolling Hansen et al. 2016) that colostomy reduces the number of hours spent on bowel care.

There is level 4 evidence (from one retrospective pre-post study; Frisbie et al. 1986) that colostomy greatly simplifies bowel care routines and one study (Bolling Hansen et al. 2016) that this facilitated travel.

There is level 4 evidence (from one case study; Rosito et al. 2002) that colostomy reduces the number of hospitalizations caused by gastrointestinal problems and improves physical health, psychosocial adjustment, and self-efficacy areas within quality of life.

There is level 4 evidence (from one cross-sectional study; Coggrave et al. 2012) that colostomy reduces need for laxative use and dietary manipulation to assist bowel care.

There is level 5 evidence (Tate et al. 2023) that colostomy, ileostomy and hemorrhoidectomy are the main surgeries used to treat NBD in people with SCI. Surgical decision-making is influenced by multiple health, personal and social factors.

There is level 5 evidence (Bolling Hansen et al. 2016) that majority of people with SCI who undergo a colostomy require less time for bowel management and have a gastrointestinal transit time within the normal range afterwards.