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Statistical survey of problems in patients with colostomy or ileostomy
Statistical
Survey
of Problems
with Colostomy HENRY
J. BIERMANN,
M.D., ALFRED
in Patients
or Ileostomy*
M. TOCKER,
M.D., AND LILIA RODRIGUEZ
TOCKER,
M.D.,
Wichita, Kansas
From the Departments of Medicane and Surgery, St. Francis Hospital, Wichita, Kansas. This research project was carried out by the Colostomy and Ileostomy Association of PTichita, Kansas, and was supported by grants from the American Cancer Society and the Leo McGuire Research Foundation, TTiichita,Kansas.
A
may see the surgery attended with forensic complications. Patients desiring additional information obtained it from sources listed in Table I.It is noteworthy that 8 per cent of the ileostomates gained additional information from the nurse whereas 53 per cent of them additional information from other gained ileostomates. This indicates that the nursing must become informed about profession ileostomy care particularly. Three times as many ileostomates as colostomates believed nursing care in the hospital was inadequate. Likewise, more ileostomates were discharged from the hospital without full knowledge of self care. Many of the colostomates replied that they had to revamp habits and ideas taught them while in the hospital. Ostomy complications ranged from none to one or more. (Table II.)The ileostomates had by far the more frequent and serious complications. This impressive list of complications and the high percentage of patients affected signifies that creation of a ventral “anus” is no simple solution in itself. Twenty-three per cent of the colostomates and 68 per cent of the ileostomates required subsequent hospitalization for complications. Interestingly, the complications appeared within the first three months after surgery, declining until about twelve months had elapsed, after which there was a second rise in the incidence of complications (Fig. 1.) Skin problems affected 47 per cent of the colostomates and 74 per cent of the ileostomates. Diarrhea was a problem to 58 per cent of the colostomates and 41 per cent of the ileostomates (whose dejecta is always
STANDARD QuESTlONNAIRE Was Sent t0 250 “ostomates” by the Colostomy and
Ileostomy Association of Wichita, Kansas. Those contacted were members of seven colostomy clubs and lived in sixteen states. and one hundred “colostomates” Ninety-two and seven “ileostomates” replied. The survey concerned patients’ viewpoints and solutions of the psychologic, functional, and physical problems attending their operations. COMPARISON BETWEEN COLOSTOMY ILEOSTOMY
AND
As one would expect, the majority of colostomates were older than the majority of ileostomates at the time of surgery. This resulted from the fact that most colostomies are necessitated by malignant lesions in the distal part of the bowel which occur more in the elderly patient and that most ileostomies are necessitated by ulcerative colitis and multiple polyposis which occur more in the younger patient. An appalling (12 to 14 per cent) percentage of patients were not informed, or did not understand, that the operation would put their “bowels on the outside.” Over two thirds of those replying believed they should have been told more about the impending surgery. In view of recent precedents, such dereliction of dutifully informing the patient
Vol.
* [‘resented at
the
112,Novembw
1966
Eighteenth Annual Meeting of the Southwestern Surgical Congress, Las X’egas, Nevada, April B-21, 1966. 647
648
Biermann,
Tacker.
and Tacker
TABLE I SOURCE
OF OSTOMY
TABLE
INFORMATION
OSTOMY
Source
tomate (per cent)
Ileostomate (per cent)
Nurse Other ostomate Books and pamphlets Other sources (friends, magazines, and the like) None
30 30 30
8 53 35
Colos-
7 30
35
NOTE: The percentages are over 100 per cent because many respondents gave more than one answer.
fluid anyway) ; 56 per cent of the colostomates and 70 per cent of the ileostomates had gas. Constipation was a concern of 34 per cent of the colostomates and of occasional concern to 6 per cent of the ileostomates. Since colostomates and ileostomates are incomparable in certain aspects, a part of the questionnaire sent to patients in each category was devoted purely to the aspects peculiar to their group. Frequently, the patients added helpful suggestions or facts which will be mentioned. COLOSTOMY
Eighty-four per cent of the colostomates had the stoma on the left side. Thirty-eight per cent wore an appliance at all times. Seventyseven per cent continue to use the first appliance recommended. Approximately one half the appliances used are permanent and one half are disposable. In 90 per cent of the cases, the physician advised irrigation. This is in
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14
MONTHS FIG. 1. Time-incidence interval between surgery and complications requiring hospitalization. Complications after ileostomy are represented by broken line, complications after colostomy are indicated by straight line.
Complication
Obstruction Abscesses Granulations Hernia Stenosis Prolapse Retraction Adhesiorrs Other None
II
COMPLICATIOSS
COlOStOIIXkte
(per cent)
Ilcostomate (per cent)
18 10 7 5 3 2 2 1 1 52
32 19 19 7 7 8 6 3 4 16
marked contrast to the situation in Europe where irrigation is hardly ever practiced. Most of the colostomates irrigated the stoma daily and the majority required up to one hour for irrigation. The average amount of liquid used for irrigation was about 2 quarts. Many of the colostomates used a rubber baby bottle nipple as a part of their irrigating armamentarium. (Fig. 2.) A small hole is cut in the end of the nipple and the lubricated catheter passed through the nipple which is held firmly against the stoma. This prevented premature reflux of the irrigant liquid, and once the desired amount of this liquid was taken, the catheter and nipple could be removed. Dilatation was advised by the doctor in 56 per cent of the patients, 44 per cent of whom dilate the stoma daily. ILEOSTOMY
It is generally accepted that a patient with a newly formed ileostomy should not leave the operating room without an adherent bag attached to the stoma, be it permanent or temporary in type. Two thirds of the ileostomates were wearing a permanent bag within one month after formation of the stoma. The first permanent appliance for the ileostomate was fitted by a physician in 42 per cent of the patients with ileostomies, by a club member in 18 per cent, by a nurse in 14 per cent, by a surgical supply representative in 9 per cent, and by others in 17 per cent. The appliances are either one or two piece. and are made of rubber, Neoprene, or plastic. The two piece appliance is more popular because the bag used is often disposable and since a new bag is reapplied, there is no retained odor. Also, American
Jouvnal
of Surwy
Problems in Patients with Colostomy and Ileostomy is easier to center the ring around the stoma without having the ring press against the bud. Such pressure commences ulceration, and this leads to formation of a fistula which will never heal and a new bud will need to be formed. Neoprene bags are popular because they do not retain odor. However, the black Neoprene rubs off and discolors clothing, a situation which can be avoided by making a cloth bag to go around the Neoprene bag. The survey definitely indicated that once a type of appliance is selected, the patient retains that type regardless of new developments or what other ostomates might be using. The presence of odor and its control was a significant problem. Odor is generally caused by either foods or bacteria [I]. The bacteriacaused odors are the greater offenders. Fresh discharge from an ileostomy generally is not unpleasant, mainly because the bacteria have not had time to multiply. Many of the patients countered bacterial growth by placing chlorine tablets, sodium benzoate tablets, or even aspirin tablets in the pouch. All patients had to be watchful of certain foods if they wanted to minimize odor. Beans, onions, and the foods in the cabbage family were mainly avoided. Also, eating a few sprigs of parsley, spinach, or lettuce, or swallowing tablets of chlorophyll or activated charcoal helped to deodorize the ileal dejecta. A majority of patients believed that diet was not important, other than for odor control. This is contrary to numerous articles [Z-5] which stress avoidance of such high residue foods as string beans, celery, asparagus, mushrooms, and unpeeled apples, especially during the first six weeks after surgery. The coexistence of a pemanent ileostomy with a happy life is greatly contingent upon avoidance of stoma1 complications, These are mainly strictures and peristomal skin excoriation. Strictures are less often seen since surgeons immediately “maturate” ileostomies at the time of surgery, either by a mucosal graft, after the method of Crile and Turnbull [6] or by a full thickness turnback of bowel and direct skin to mucosal anastomosis as described by Brooke [7]. Eighty-nine per cent of those with skin problems used a powder on the excoriation, and in nearly all cases the powder was karaya gum. Karaya, produced in India, Pakistan, and Africa, is the gum obtained from Sterculia urens Roxb. and other it
Vol. 112, November 1966
I
FIG. 2. Method colostomy.
of using
rubber
I
nipple
to
irrigate
species of sterculia. It exerts a protective and healing influence upon a raw weeping skin surface. At least three companies [7] now market a soft pliable karaya gum washer which may be purchased or trimmed to fit precisely around the base of the stoma. The pouch is prepared with cement or a doublesided adhesive disc, a moistened washer is put into position over the stoma and pressed firmly to the skin, and the pouch is put on in the usual manner. Those ostomates with stomas x to 1% inches long were for the greater part the most satisfied with their stoma. Fifteen per cent were not satisfied with the length of their stomas which were g to 2 inches in length. SUMMARY
A survey was made of ninety-two colostomates and one hundred and seven ileostomates. Only those subjects pertinent to the physician’s care of the patient are presented in this paper. Outstanding among the replies is the fact that two thirds of these patients believed that the doctor should have better informed them about their impending operation. After surgery, ostomy care was relegated to hospital and surgical supply house personnel who often were inadequate to the task. Ten per cent of the physicians said nothing to the patient about irrigating the colostomy, and almost one half (44 per cent) said nothing about dilating the colostomy. Nearly two thirds (61 per cent) of the physicians did not prescribe a diet, not even postoperatively, for the ileostomates. Local ostomy clubs were a source of great technical assistance and psychological encouragement to new ostomates.
Biermann,
650
Tacker,
REFERENCES
1. Report on a brief study of the control of odors in ileostomy appliances. Q T Monthly Bull., Boston, September/October, 1965. 2. JEANNETTEMARIE, SISTER, S.C. The ostomies: current concepts in dietary management. Hospitals, 38: 88, 1964. 3. WALKER, W. C. and PRINGLE, R. Aspects of ileostomy dysfunction: management and adaptation. Brit. J. Surg., 51: 405, 1964.
and Tacker 4. WILSON, E. The rehabilitation of patients with an ileostomy established for ulcerative colitis. M. J. Australia, 1: 824, 1964. 5. TURNBULL, R. B. Construction and care of the ileostomy. HosPital Med., 2: 38, 1966. 6. CRILE, G., JR. and TURNBULL, R. B. Mechanism and prevention of ileostomy dysfunction. Ann. Surg., 140: 459, 1954. 7. BROOKE, B. N. Management of ileostomy including its complications. Lancet, 2: 102, 1952.
A~~erican Journal
of Surgery
Survey
of Problems
with Colostomy HENRY
J. BIERMANN,
M.D., ALFRED
in Patients
or Ileostomy*
M. TOCKER,
M.D., AND LILIA RODRIGUEZ
TOCKER,
M.D.,
Wichita, Kansas
From the Departments of Medicane and Surgery, St. Francis Hospital, Wichita, Kansas. This research project was carried out by the Colostomy and Ileostomy Association of PTichita, Kansas, and was supported by grants from the American Cancer Society and the Leo McGuire Research Foundation, TTiichita,Kansas.
A
may see the surgery attended with forensic complications. Patients desiring additional information obtained it from sources listed in Table I.It is noteworthy that 8 per cent of the ileostomates gained additional information from the nurse whereas 53 per cent of them additional information from other gained ileostomates. This indicates that the nursing must become informed about profession ileostomy care particularly. Three times as many ileostomates as colostomates believed nursing care in the hospital was inadequate. Likewise, more ileostomates were discharged from the hospital without full knowledge of self care. Many of the colostomates replied that they had to revamp habits and ideas taught them while in the hospital. Ostomy complications ranged from none to one or more. (Table II.)The ileostomates had by far the more frequent and serious complications. This impressive list of complications and the high percentage of patients affected signifies that creation of a ventral “anus” is no simple solution in itself. Twenty-three per cent of the colostomates and 68 per cent of the ileostomates required subsequent hospitalization for complications. Interestingly, the complications appeared within the first three months after surgery, declining until about twelve months had elapsed, after which there was a second rise in the incidence of complications (Fig. 1.) Skin problems affected 47 per cent of the colostomates and 74 per cent of the ileostomates. Diarrhea was a problem to 58 per cent of the colostomates and 41 per cent of the ileostomates (whose dejecta is always
STANDARD QuESTlONNAIRE Was Sent t0 250 “ostomates” by the Colostomy and
Ileostomy Association of Wichita, Kansas. Those contacted were members of seven colostomy clubs and lived in sixteen states. and one hundred “colostomates” Ninety-two and seven “ileostomates” replied. The survey concerned patients’ viewpoints and solutions of the psychologic, functional, and physical problems attending their operations. COMPARISON BETWEEN COLOSTOMY ILEOSTOMY
AND
As one would expect, the majority of colostomates were older than the majority of ileostomates at the time of surgery. This resulted from the fact that most colostomies are necessitated by malignant lesions in the distal part of the bowel which occur more in the elderly patient and that most ileostomies are necessitated by ulcerative colitis and multiple polyposis which occur more in the younger patient. An appalling (12 to 14 per cent) percentage of patients were not informed, or did not understand, that the operation would put their “bowels on the outside.” Over two thirds of those replying believed they should have been told more about the impending surgery. In view of recent precedents, such dereliction of dutifully informing the patient
Vol.
* [‘resented at
the
112,Novembw
1966
Eighteenth Annual Meeting of the Southwestern Surgical Congress, Las X’egas, Nevada, April B-21, 1966. 647
648
Biermann,
Tacker.
and Tacker
TABLE I SOURCE
OF OSTOMY
TABLE
INFORMATION
OSTOMY
Source
tomate (per cent)
Ileostomate (per cent)
Nurse Other ostomate Books and pamphlets Other sources (friends, magazines, and the like) None
30 30 30
8 53 35
Colos-
7 30
35
NOTE: The percentages are over 100 per cent because many respondents gave more than one answer.
fluid anyway) ; 56 per cent of the colostomates and 70 per cent of the ileostomates had gas. Constipation was a concern of 34 per cent of the colostomates and of occasional concern to 6 per cent of the ileostomates. Since colostomates and ileostomates are incomparable in certain aspects, a part of the questionnaire sent to patients in each category was devoted purely to the aspects peculiar to their group. Frequently, the patients added helpful suggestions or facts which will be mentioned. COLOSTOMY
Eighty-four per cent of the colostomates had the stoma on the left side. Thirty-eight per cent wore an appliance at all times. Seventyseven per cent continue to use the first appliance recommended. Approximately one half the appliances used are permanent and one half are disposable. In 90 per cent of the cases, the physician advised irrigation. This is in
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14
MONTHS FIG. 1. Time-incidence interval between surgery and complications requiring hospitalization. Complications after ileostomy are represented by broken line, complications after colostomy are indicated by straight line.
Complication
Obstruction Abscesses Granulations Hernia Stenosis Prolapse Retraction Adhesiorrs Other None
II
COMPLICATIOSS
COlOStOIIXkte
(per cent)
Ilcostomate (per cent)
18 10 7 5 3 2 2 1 1 52
32 19 19 7 7 8 6 3 4 16
marked contrast to the situation in Europe where irrigation is hardly ever practiced. Most of the colostomates irrigated the stoma daily and the majority required up to one hour for irrigation. The average amount of liquid used for irrigation was about 2 quarts. Many of the colostomates used a rubber baby bottle nipple as a part of their irrigating armamentarium. (Fig. 2.) A small hole is cut in the end of the nipple and the lubricated catheter passed through the nipple which is held firmly against the stoma. This prevented premature reflux of the irrigant liquid, and once the desired amount of this liquid was taken, the catheter and nipple could be removed. Dilatation was advised by the doctor in 56 per cent of the patients, 44 per cent of whom dilate the stoma daily. ILEOSTOMY
It is generally accepted that a patient with a newly formed ileostomy should not leave the operating room without an adherent bag attached to the stoma, be it permanent or temporary in type. Two thirds of the ileostomates were wearing a permanent bag within one month after formation of the stoma. The first permanent appliance for the ileostomate was fitted by a physician in 42 per cent of the patients with ileostomies, by a club member in 18 per cent, by a nurse in 14 per cent, by a surgical supply representative in 9 per cent, and by others in 17 per cent. The appliances are either one or two piece. and are made of rubber, Neoprene, or plastic. The two piece appliance is more popular because the bag used is often disposable and since a new bag is reapplied, there is no retained odor. Also, American
Jouvnal
of Surwy
Problems in Patients with Colostomy and Ileostomy is easier to center the ring around the stoma without having the ring press against the bud. Such pressure commences ulceration, and this leads to formation of a fistula which will never heal and a new bud will need to be formed. Neoprene bags are popular because they do not retain odor. However, the black Neoprene rubs off and discolors clothing, a situation which can be avoided by making a cloth bag to go around the Neoprene bag. The survey definitely indicated that once a type of appliance is selected, the patient retains that type regardless of new developments or what other ostomates might be using. The presence of odor and its control was a significant problem. Odor is generally caused by either foods or bacteria [I]. The bacteriacaused odors are the greater offenders. Fresh discharge from an ileostomy generally is not unpleasant, mainly because the bacteria have not had time to multiply. Many of the patients countered bacterial growth by placing chlorine tablets, sodium benzoate tablets, or even aspirin tablets in the pouch. All patients had to be watchful of certain foods if they wanted to minimize odor. Beans, onions, and the foods in the cabbage family were mainly avoided. Also, eating a few sprigs of parsley, spinach, or lettuce, or swallowing tablets of chlorophyll or activated charcoal helped to deodorize the ileal dejecta. A majority of patients believed that diet was not important, other than for odor control. This is contrary to numerous articles [Z-5] which stress avoidance of such high residue foods as string beans, celery, asparagus, mushrooms, and unpeeled apples, especially during the first six weeks after surgery. The coexistence of a pemanent ileostomy with a happy life is greatly contingent upon avoidance of stoma1 complications, These are mainly strictures and peristomal skin excoriation. Strictures are less often seen since surgeons immediately “maturate” ileostomies at the time of surgery, either by a mucosal graft, after the method of Crile and Turnbull [6] or by a full thickness turnback of bowel and direct skin to mucosal anastomosis as described by Brooke [7]. Eighty-nine per cent of those with skin problems used a powder on the excoriation, and in nearly all cases the powder was karaya gum. Karaya, produced in India, Pakistan, and Africa, is the gum obtained from Sterculia urens Roxb. and other it
Vol. 112, November 1966
I
FIG. 2. Method colostomy.
of using
rubber
I
nipple
to
irrigate
species of sterculia. It exerts a protective and healing influence upon a raw weeping skin surface. At least three companies [7] now market a soft pliable karaya gum washer which may be purchased or trimmed to fit precisely around the base of the stoma. The pouch is prepared with cement or a doublesided adhesive disc, a moistened washer is put into position over the stoma and pressed firmly to the skin, and the pouch is put on in the usual manner. Those ostomates with stomas x to 1% inches long were for the greater part the most satisfied with their stoma. Fifteen per cent were not satisfied with the length of their stomas which were g to 2 inches in length. SUMMARY
A survey was made of ninety-two colostomates and one hundred and seven ileostomates. Only those subjects pertinent to the physician’s care of the patient are presented in this paper. Outstanding among the replies is the fact that two thirds of these patients believed that the doctor should have better informed them about their impending operation. After surgery, ostomy care was relegated to hospital and surgical supply house personnel who often were inadequate to the task. Ten per cent of the physicians said nothing to the patient about irrigating the colostomy, and almost one half (44 per cent) said nothing about dilating the colostomy. Nearly two thirds (61 per cent) of the physicians did not prescribe a diet, not even postoperatively, for the ileostomates. Local ostomy clubs were a source of great technical assistance and psychological encouragement to new ostomates.
Biermann,
650
Tacker,
REFERENCES
1. Report on a brief study of the control of odors in ileostomy appliances. Q T Monthly Bull., Boston, September/October, 1965. 2. JEANNETTEMARIE, SISTER, S.C. The ostomies: current concepts in dietary management. Hospitals, 38: 88, 1964. 3. WALKER, W. C. and PRINGLE, R. Aspects of ileostomy dysfunction: management and adaptation. Brit. J. Surg., 51: 405, 1964.
and Tacker 4. WILSON, E. The rehabilitation of patients with an ileostomy established for ulcerative colitis. M. J. Australia, 1: 824, 1964. 5. TURNBULL, R. B. Construction and care of the ileostomy. HosPital Med., 2: 38, 1966. 6. CRILE, G., JR. and TURNBULL, R. B. Mechanism and prevention of ileostomy dysfunction. Ann. Surg., 140: 459, 1954. 7. BROOKE, B. N. Management of ileostomy including its complications. Lancet, 2: 102, 1952.
A~~erican Journal
of Surgery