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 ulcers close to the anus may also be reasons to choose a stoma for bowel management. Stoma for bowel management remains uncommon; one study suggested a 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 individuals. 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.
Discussion
Stoma formation is a relatively safe, effective and well-accepted method of managing significant neurogenic bowel management problems in individuals with SCI. Research findings suggest that 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. 1990; Frisbie et al. 1986), 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), reduces fecal incontinence and improves quality of life (Coggrave et al. 2012; Munck et al. 2008; Safadi et al. 2003; Rosito et al. 2002; Kelly et al. 1999). 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). Stoma was well-received by patients and either met or exceeded their expectations (Rosito et al. 2002; Coggrave et al. 2012). Many SCI subjects wished to have the stoma done earlier (Coggrave et al. 2012; Branagan et al. 2003). There have been a few complications including increased in bowel times in one subject receiving an ileostomy (Kelly et al. 1999) and increased odor in one subject receiving an enterostomy (Frisbie et al. 1986). Overall current evidence supports the earlier education of individuals with SCI regarding the option of stoma for bowel management.
Conclusions
There is level 4 evidence (from six studies: Frisbie et al. 1986; Stone et al. 1990; Kelly et al. 1999; Rosito et al. 2002; Branagan et al. 2003; Munck et al. 2008) 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.
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.
Authors; Country
Date included in the review Total Sample Size Types of Articles Score |
Methods
Databases Level of Evidence |
Conclusions |
---|---|---|
Hocevar and Gray 2008;
USA Reviewed published articles from January 1960 to November 2007 N= 6 n=203 SCI
Types of Articles: 2 case-control 3 interviews 1 cross-sectional survey AMSTAR: 3 |
Methods: literature search for prospective and retrospective studies that directly compared clinical, functional, quality of life outcomes or satisfaction among patients with intestinal diversions to patients managed by conservative means.
Databases: MEDLINE, CINAHL, Cochrane Database for Systematic Reviews, Google Scholar
Level of Evidence: No formal validity assessment was described |
|
Author Year; Country
Score Research Design Total Sample Size |
Methods | Outcome |
Coggrave et al. 2012;
UK Retrospective self-report survey N=92 |
Population: 26 cervical (15 complete, 10 incomplete, 1 unknown), 61 thoracic (49 complete, 10 incomplete, 2 unknown), 1 missing data on level of injury; 64M:28F; Age: mean (SD) 56(9)yrs; duration of injury: mean (SD) 26(13)yrs; 91% colostomy, 9% ileostomy.
Treatment: Retrospective analysis of a self-report postal survey of individuals with SCI who had a stoma for bowel management issues (five UK spinal centres) Outcome Measures: Tennessee Self-Concept Scale, Satisfaction with Life Scale, Hospital Anxiety and Depression Scale, 3 simple rating scales for satisfaction, ability to live with bowel dysfunction, and how much bowel care restricts life. |
|
Munck et al. 2008;
Belgium Case-series N = 23 |
Population: 23 SCI participants who had a colostomy in the digestive surgery department of Brugmann Hospital between Jan 1996 and Dec 2005 (age range 22-72). Level of injury: 13 dorsal, 7 cervical, 3 lumbar.
Treatment: Colostomy Outcome Measures: Demographic information and medical information on the stoma formation and complications, collected from participants’ medical records; quality of life questionnaire. |
|
Bølling Hansen et al. 2016
Denmark Cross-sectional N=18 |
Population: N=18 (12M, 6F) with SCI and post-SCI colostomy
Mean (range) age 49.9 (37-72) Mean (range) time post SCI 20.9 (3-56) years Mean (range) time since colostomy 6.9 (0.5-20) years 8 tetraplegia, 10 paraplegia 8 cervical, 10 thoracic AIS-A/C/D: 15/2/1 17 had sigmoidostomy, 1 had transverse colostomy Treatment: Post-SCI colostomy Outcome Measures: Gastrointestinal transit time (GITT), SF-36, bowel management questionnaire |
|
Luther et al. 2005;
USA Cross-sectional N=370 |
Population: SCI participants in 6 centers that were selected to be representative of the 23 Veteran Affairs SCI centers. Survey respondents with colostomies were matched to controls based on age, year of injury, classification of paralysis and marital status by calculating propensity scores. Comparison of 74 patients with a sample of 296 matched controls without colostomies.
Treatment: Colostomy Outcome Measures: Bowel care-related items; quality of life. |
|
Branagan et al. 2003;
UK Retrospective chart review N=32 |
Population: 10 participants with cervical SCI, 18 with thoracic, and 3 lumbar; Age at injury: average 28.9 yrs; Duration of injury: mean 17.1 years
Treatment: Medical records were reviewed for participants who had a previous colostomy. Outcome Measures: Results of surgery |
|
Safadi et al. 2003;
USA Retrospective chart review N=45 |
Population: 21 tetraplegics, 24 paraplegics; 44M 1F; Mean age 55.9yrs,
Treatment: 20 right side colostomies (RC), 21 left side colostomies (LC), 7 ileostomies (IL) Outcome Measures: quality of life, colonic transit time, bowel care time |
|
Rosito et al. 2002;
USA Case series N=27 |
Population: Level of injury: C4-L3 (17 complete, 10 incomplete); mean age: 62.9 yrs; 26M 1F; Duration of injury: 25.8yrs
Intervention: Colostomy Outcome Measures: Quality of life questionnaire with 5 domains: physical health, psychosocial adjustment, body image, self-efficacy, and recreation/leisure |
|
Randell et al. 2001;
New Zealand Case-control N=52 |
Population: 26 participants with colostomy: 10 with cervical SCI, 16 with lumbar/lower thoracic SCI; age: 22-87yrs, matched with 26 participants without colostomy.
Treatment: Colostomy Outcome Measures: Burwood Quality of Life Questionnaire: 5 areas: systemic symptoms, and emotional, social, work and bowel function. |
|
Kelly et al. 1999;
UK Retrospective chart review N=14 |
Population: Level of injury: C4-L2 (3 cervical, 10 thoracic, 1 lumbar); 12M 2F; Age at time of operation: mean (range) 54.8 (20-65) yrs; time from injury to stoma formation: mean (range)15 (2-37) yrs
Treatment: 12 participants underwent left iliac fossa end colostomy and 2 participants right iliac fossa end ileostomy Outcome Measures: Time spent on bowel care per week; independence in bowel care; quality of life |
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Stone et al. 1990;
USA Case Series N=7 |
Population: Level of injury: C4-T10; Age: mean 51.6yrs; Duration of injury: mean 15.7 years
Treatment: Medical records were reviewed for participants who had undergone a colostomy Outcome Measures: Efficacy of colostomy. |
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Frisbie et al. 1986;
USA Cross-sectional N=20 |
Population: Level of injury: 9 cervical, 11 thoracic; 19M 1F; Age: median (range) 55 (27-75) yrs. Duration of the enterostomies at time of interview was, median (range): 11 months (3 months to 14 yrs).
Treatment: A total of 24 enterostomies were carried out in 20 participants: 17 sigmoid colostomies, 5 transverse colostomies, and 2 ileostomies. Outcome Measures: Bowel care time, bowel care frequency, bowel care related complaints, quality of life. |
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