Bowel Dysfunction and Management

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.

Elective stoma formation is a safe and effective treatment for significant neurogenic bowel management problems and perianal pressure ulcers in persons with SCI, and greatly improves their quality of life.

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
  1. Creation of an ostomy in selected patients provides equivocal or superior quality of life outcomes when compared to conservative bowel management
  2. Both colostomy and ileostomy surgery significantly reduces the amount of time required for bowel management (Level of Evidence: 3).
  3. Patients who undergo ostomy surgery tend to be satisfied with their surgery, and a significant portion report a desire to be counselled about this option earlier.
  4. There are no clear advantages when functional, clinical, or quality of life outcomes associated with colostomy are compared to those seen in SCI patients undergoing ileostomy (Level of evidence: 4).

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.
  1. Participants reported experiencing bowel difficulties for a mean (SD) time of 10 (10) years before surgery. 11% would’ve preferred surgery a year earlier, 28% up to 5 years earlier, 30% up to 10 years earlier and 32% earlier still. None suggested stoma formation was too early.
  2. Participants reporting an ileostomy were significantly more likely to need assistance than those with a colostomy.
  3. Laxative use was reduced from 58 to 31% and dietary manipulation to assist bowel care was reduced significantly.
  4. 83 (70%) reported they felt very positive about their stoma, whereas 2 participants felt others avoided them due to the stoma.
  5. For 23%, there was impact on personal relationships; 9 reported positive impact, 6 negative and 3 neutral.
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.
  1. 10 participants had a stoma for perineal wounds
  2. Average time spent on bowel care per week decreased from 5.95 hr prior to stoma formation to 1.5 hr after
  3. Of the 10 patients, 3 reported cutaneous irritations and 1 reported detachment of the pocket
  4. Of the 10 patients, 9 reported having much easier bowel care since the stoma formation, and 6 felt that the stoma had given them greater independence.
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
  1. 13/18 reported significant reduction of time required for bowel management, none reported increase of time
  2. 17/18 reported better bowel management after colostomy, and would prefer not to reverse the colostomy if given the choice.
  3. 15/18 are not concerned about bowel management after colostomy when they travel long distances
  4. 16/18 are not dependent on easy access to toilets after colostomy when not at home
  5. 9/18 reported positive social influence; 8 reported no change
  6. 12/18 had GITT within normal range after colostomy, 2 had GITT over normal range by less than 12h
  7. 2/18 reported both leakage & skin issues post colostomy. One reported odour problems; the other reported cosmetic issues & pain
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.
  1. No statistically significance differences were found in the demographic distributions for cases and controls.
  2. No statistically significant differences were reported between the cases and the matched controls for any of the bowel care outcomes or bowel-related quality of life. Both groups reported low incidence of accidental/unplanned bowel movements and falls related to bowel care.
  3. Mean responses to the quality of life items were generally very high; however, a large number of respondents continue to express dissatisfaction with bowel care. The cases had a much higher percentage of responses (55.7%) in the “very dissatisfied” category than did the controls (41.7%).
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
  1. The average time spent on bowel care per week decreased significantly from 10.3 hours to 1.9 hours after the colostomy.
  2. 18/31 participants felt the colostomy gave them greater independence.
  3. 25 participants wished they had been offered a stoma earlier.
  4. No participants wanted a stoma reversal.
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
  1. Colonic transit time was significantly longer in the right side colostomy compared to the left side colostomy and the ileostomy.
  2. In all groups, quality of life increased (RC: 49 to 79, LC: 50 to 86, IL: 60 to 82 min) and bowel care time decreased (RC: 102 to 11 min, LC: 123 to 18 min, IL: 73 to 13 min).
 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
  1. Quality of life improved significantly after colostomy.
  2. All 27 patients were satisfied, 16 very satisfied
  3. Colostomy reduced the number of hospitalizations caused by chronic bowel dysfunction by 70.4%.
  4. After colostomy, the average amount of time spent on bowel care was reduced significantly from 117.0 min/day to 12.8 min/day.
  5. Significant improvements were recorded in the areas of physical health, psychosocial adjustment, and self-efficacy.
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.
  1. No significant difference in the group with a colostomy compared to the group without a colostomy in regard to their general well-being, emotional, social or work functioning.
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
  1. Colostomy participants (N=12): mean time spent on bowel care per week before stoma formation was 8.8 h (0.6-12.2) compared with 1.4 h (0.3-3.5) after; 50% of these patients were independent in bowel care before, 92% independent after; 10 patients claimed that the colostomy had a beneficial effect on their quality of life
  2. Illeostomy patients (N=2): mean time spent on bowel care per week before ileostomy was 17.5 h and this was unchanged after ileostomy formation. 1 subject decreased the time he spent on bowel care from 28 h to 14 h; the other developed complications and his time increased from 7 h to 21 h.
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.
  1. All seven participants who had colostomy performed as an adjunct to the treatment of perianal pressure ulcers successfully healed their ulcers.
  2. The amount of time spent on bowel care decreased dramatically in the patients with prolonged bowel care.
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.
  1. Bowel care frequency increased from a median 3 times/week (range 2-7) before enterostomy to a median 7 times/week (range 4-14) after enterostomy.
  2. Bowel care duration diminished from a median 6 hours/week (range 0.7-14 hours) before enterostomy to a median 1 hour/week (range 1.3-7 hours) after enterostomy.
  3. The number of patients affected by bowel care related complaints pre- vs. post-operatively, respectively, were as follows: abdominal pain in 10 vs. 2, fecal leakage in 8 vs. 0, anorexia in 7 vs. 2, flatus in 9 vs. 4, sweating in 4 vs. 2 and odour in 4 vs. 5.
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