Effect of enterostomy on quality of life in spinal cord injury patients

Colostomy and quality of life after spinal cord injury: systematic review

BACKGROUND

Spinal cord injury (SCI) has a significant impact on the quality of life (QoL) of affected patients. The aim of this review was to determine whether colostomy formation improves QoL in patients with SCI.

METHODS

The Cochrane Register, MEDLINE, Embase and CINAHL were searched using medical subject headings. The search was extended to the reference lists of identified studies, ClinicalTrials.gov and the WHO International Clinical Trials Registry. All clinical trials that included spinal injury and QoL, time spent on bowel care, and patient satisfaction with stoma were assessed.

RESULTS

A total of 15 studies were found (including 488 patients with a stoma), of which 13 were retrospective cross-sectional studies and two were case-control studies, one of which was prospective research. Nine of 11 studies focusing on QoL reported that patients' QoL was improved by the stoma, whereas the remaining two studies found no difference. Time spent on bowel care was significantly reduced in all 13 studies that considered this outcome, with patients reducing the average time spent on bowel care from more than 1 h to less than 15 min per day. All 12 studies assessing patient satisfaction with their stoma reported high patient satisfaction.

CONCLUSION

Stoma formation improves QoL, reduces time spent on bowel care, and increases independence. Stoma is an option that could be discussed and offered to patients with spinal cord injury.

Outcomes following stoma formation in patients with spinal cord injury

AIM

The formation of a diverting stoma of the bowel in patients with spinal cord injury (SCI) is a useful option in managing problems associated with prolonged bowel care, pressure ulcers and neurogenic bowel. This descriptive study examines surgical outcomes and the effect on an individual's health-related quality of life (HrQoL) in this complex group of patients.

METHODS

Data were retrospectively collected in all patients with SCI who underwent a diverting stoma at Prince of Wales Hospital, Sydney, between January 2013 and January 2018 via a self-report questionnaire developed specifically for the study.

RESULTS

Forty-three individuals were identified of whom 26 responded. 73% were men with a mean age of 45 years. The reasons for stoma formation included sacral pressure ulcer (50%), prolonged bowel care (35%), faecal incontinence (19%), constipation (8%), autonomic dysreflexia (8%), carer difficulties (8%) and haemorrhoids (4%). 76% of patients reported an improvement in HrQoL with 72% scoring their satisfaction with a stoma ≥ 8/10.

CONCLUSION

While stoma formation is often seen as a treatment of last resort, our study has shown that it is an effective management option for a number of conditions post-SCI. It can improve HrQoL and has a high level of satisfaction amongst patients. Ideally, patients who could potentially benefit from a stoma should be identified early and receive appropriate education and counselling to help facilitate informed and timely decision-making and reduce adverse bowel related impact on quality of life and adjustment post-SCI.

Neurogenic bowel management after spinal cord injury: a systematic review of the evidence

STUDY DESIGN

Randomized-controlled trials (RCTs), prospective cohort, case-control, pre-post studies, and case reports that assessed pharmacological and non-pharmacological intervention for the management of the neurogenic bowel after spinal cord injury (SCI) were included.

OBJECTIVE

To systematically review the evidence for the management of neurogenic bowel in individuals with SCI.

SETTING

Literature searches were conducted for relevant articles, as well as practice guidelines, using numerous electronic databases. Manual searches of retrieved articles from 1950 to July 2009 were also conducted to identify literature.

METHODS

Two independent reviewers evaluated each study's quality, using Physiotherapy Evidence Database scale for RCTs and Downs and Black scale for all other studies. The results were tabulated and levels of evidence assigned.

RESULTS

A total of 2956 studies were found as a result of the literature search. On review of the titles and abstracts, 57 studies met the inclusion criteria. Multifaceted programs are the first approach to neurogenic bowel and are supported by lower levels of evidence. Of the non-pharmacological (conservative and non-surgical) interventions, transanal irrigation is a promising treatment to reduce constipation and fecal incontinence. When conservative management is not effective, pharmacological interventions (for example prokinetic agents) are supported by strong evidence for the treatment of chronic constipation. When conservative and pharmacological treatments are not effective, surgical interventions may be considered and are supported by lower levels of evidence in reducing complications.

CONCLUSIONS

Often, more than one procedure is necessary to develop an effective bowel routine. Evidence is low for non-pharmacological approaches and high for pharmacological interventions.

Neurogenic colorectal and pelvic floor dysfunction

Constipation and faecal incontinence are common symptoms among patients with spinal cord injury (SCI), myelomeningocoele (MMC), multiple sclerosis (MS), Parkinson's disease (PD) and stroke. Faecal incontinence in SCI, MMC and MS is mainly due to abnormal rectosigmoid compliance and rectoanal reflexes, loss of rectoanal sensibility and loss of voluntary control of the external anal sphincter. Constipation in SCI, MMC and MS is probably due to immobilisation, abnormal colonic contractility, tone and rectoanal reflexes or side effects from medication. In PD, dystonia of the external anal sphincter causes difficult rectal evacuation and the loss of dopaminergic neurons in the enteric nervous system probably causes slow-transit constipation. Changes after stroke remain to be studied. Though dietary adjustments, oral laxatives, suppositories and other conservative treatment modalities are commonly used, evidence for their use in patients with central neurological disorders is scarce. For patients with severe symptoms trans-anal irrigation, the Malone appendicostomy or a colostomy can be recommended.

Optimal treatment for severe neurogenic bowel dysfunction after chronic spinal cord injury: a decision analysis

BACKGROUND

When conservative management fails in patients with chronic spinal cord injury (SCI) and neurogenic bowel dysfunction, clinicians have to choose from a variety of treatment options which include colostomy, ileostomy, Malone anterograde continence enema (MACE) and sacral anterior root stimulator (SARS) implantation. This study employed a decision analysis to examine the optimal treatment for bowel management of young individuals with chronic refractory constipation in the setting of chronic SCI.

METHODS

A decision analysis was created to compare the four surgical strategies using baseline analysis, one-way and two-way sensitivity analyses, 'worst scenario' and 'best scenario' sensitivity analyses, and probabilistic sensitivity analyses. Quality-adjusted life expectancy (QALE) was the primary outcome.

RESULTS

The baseline analysis indicated that patients who underwent the MACE procedure had the highest QALE value compared with the other interventions. Sensitivity analyses showed that these results were robust.

CONCLUSION

The MACE procedure may provide the best long-term outcome in terms of the probability of improving bowel function, reducing complication rates and the incidence of autonomic dysreflexia, and being congruent with patients' preferences. The analysis was sensitive to changes in assumptions about quality of life/utility, and thus the results could change if more specific estimates of utility became available.

Colorectal motility and defecation after spinal cord injury in humans

Following spinal cord injury, colorectal problems are a significant cause of morbidity, and chronic gastrointestinal problems remain common with increasing time after injury. Although many cord-injured patients achieve an adequate bowel frequency with drugs and manual stimulation, the risk and occurrence of fecal incontinence, difficulties with evacuation, and need for assistance remain significant problems. The underlying physiology of colorectal motility and defecation is reviewed, and consequences of spinal cord injury on defecation are reported. A discussion of present management techniques is undertaken and new directions in management and research are suggested. There is need for more intervention in regard to bowel function that could improve quality of life, but there is also a need for more research in this area.

[Assessment of anorectal disorders with paraplegia]

INTRODUCTION

Functional anorectal disorders in paraplegia are frequent; few studies evaluate the effect of these disorders on quality of life.

OBJECTIVE

Assessment of the functional anorectal disorders in a homogeneous group of patients with total paraplegia in terms of quality of life.

METHODS

During a global follow-up consultation, patients answered questions on a systematic questionnaire about anorectal disorders and a specific quality-of-life autoquestionnaire about functional digestive disorders: Functional Digestive Disorders Quality of Life (FDDQL) questionnaire; score 0 to 100 (100 corresponding to no effect on quality of life).

RESULTS

Twenty-three patients with a mean age of 44.3 years who had been paraplegic for 10 years participated. Two had a colostomy because of bedsores. Fourteen underwent daily rectal examination, 10 with an evacuation aim; the time given to defecation was, on average, 36 minutes. One patient had clinical constipation. Twelve had had one or more episodes of incontinence. The mean global FDDQL score was 69.7. This score was not related to incontinence; only the "comfort" domain among the 8 domains was related to incontinence.

DISCUSSION

Anorectal disorders are frequent in paraplegia; the duration and the methods of defecation represent a great worry to patients. More than half of the patients already had faecal incontinence; the effect of even occasional incontinence on quality of life is significant. Since the FDDQL scale is not specific to patients with paraplegia, its interest should be checked on a greater number of patients. For certain patients, it is important not to dismiss more complex surgical treatment methods.

Which stoma works better for colonic dysmotility in the spinal cord injured patient?

BACKGROUND

The formation of an intestinal stoma is very effective in the treatment of colonic dysmotility associated with spinal cord injury (SCI). Little is known about the difference in the long-term outcome among left-sided colostomies, right-sided colostomies, and ileostomies in this patient population.

METHODS

The records of 45 SCI patients with intestinal stomas at our institution were reviewed retrospectively. Operative details and preoperative colonic transit times (CTT) were recorded. Patients who were alive and available were interviewed using a questionnaire designed to assess the quality of life (QOL), health status, and time to bowel care before and after stoma formation.

RESULTS

Between 1976 and 2002, 45 patients underwent a total of 48 intestinal stomas. A left-sided colostomy (LC) was formed in 21 patients, right-sided colostomy (RC) in 20, and ileostomy (IL) in 7. Three of the patients in the RC group ultimately underwent total abdominal colectomy and ileostomy. The indications for stoma formation and CTT were different in the three groups. Bloating, constipation, chronic abdominal pain, difficulty evacuation with prolonged CTT was the main indication in 95% of patients in the RC group, 43% of patients in the LC group, and 29% in the IL group. Management of complicated decubitus ulcers, perineal and pelvic wounds was the primary indication in 43% of patients in the LC group, 5% in the RC group, and none in the IL group. Preoperative total and right CTTs were longer in the RC group compared with the LC group: 127.5 versus 83.1 hours (P <0.05) and 53.7 versus 28.5 hours (P <0.05), respectively. Eighty-two percent of patients (37 of 45) were interviewed at a mean follow-up of 5.5 years after stoma formation. Most patients who were interviewed were satisfied with their stoma (RC, 88%; LC, 100%; IL, 83%) and the majority would have preferred to have the stoma earlier (RC, 63%; LC, 77%; and IL, 63%). The QOL index significantly improved in all groups (RC, 49 to 79, P <0.05; LC, 50 to 86, P <0.05; and IL, 60 to 82, P <0.05), as well as the health status index (RC, 58 to 83, P <0.05; LC, 63 to 92, P <0.05; IL, 61 to 88, P <0.05). The average daily time to bowel care was significantly shortened in all groups (RC, 102 to 11 minutes, P <0.05; LC, 123 to 18 minutes, P <0.05; and IL, 73 to 13 minutes, P <0.05.).

CONCLUSIONS

Regardless of the type of stoma, most patients had functional improvement postoperatively. Patients who underwent RC had longer CTT and more chronic symptoms related to colonic dysmotility, reflecting the preoperative selection bias. The successful outcome noted in all groups suggests that preoperative symptoms and CTT studies may have been helpful in optimal choice of stoma site selection.

Use or misuse of colostomy to heal pressure ulcers

PURPOSE

The purpose of this study is to evaluate the effectiveness of colostomy performed as an adjunct measure in the attempt to heal pressure ulcers by flap closure.

METHODS

Twenty-seven consecutive patients who underwent colostomy for healing of pressure ulcers were studied by chart review and patient questionnaire. Fecal diversion was accomplished by colostomy in each case.

RESULTS

There were four (15 percent) deaths. Twenty-three patients subsequently underwent flap closure of their ulcer. Of 19 patients available for follow-up, only 6 (32 percent) patients had completely healed, although most patients thought their quality of life improved because of the colostomy. None of the patients underwent colostomy closure.

CONCLUSION

Our conclusions are that, although most patients will have an improved quality of life subsequent to diversion, the high mortality and low rate of pressure ulcer healing should temper enthusiasm for performing colostomy in this setting.

Quality of life after spinal cord injury: a literature critique and meta-analysis (1983-1992)

Research articles cross-indexed in Index Medicus under the subject headings "quality of life" (QOL) and "spinal cord injury" (SCI) were examined in order to compare their relative merits in terms of research design, sampling techniques and the type of QOL criteria included. Of 3,710 citations indexed for the ten year period 1983 through 1992 under "quality of life," thirty-two research articles (< 1 percent) were cross-indexed with the subject heading "spinal cord injury." The modal design was a descriptive survey or case study (n = 23 or 72 percent). None of them were randomized clinical trials. Because of limited rigor of research design and poor validity of measurements, conclusions about the ability of rehabilitative care to improve the QOL for SCI persons could not be drawn from the studies reviewed. Meta-analysis indicated that severity of injury is associated with QOL, with more severe injury being correlated with poorer quality. The critique concludes that QOL research with SCI persons needs to be better designed and should include more uniform and valid criteria.

Common complications of wound healing. Prevention and management

The culmination of any operation is a healed wound. Failure of a wound to heal increases time spent in the hospital and the expense, and may start a cascade of progressive complications. Thus, it is important to optimize as many factors as possible before operation and to have the knowledge and resources to deal with wound problems should they occur. This approach involves understanding basic wound healing with its multiple factors, including nutrition, and knowing how to deal with potential adverse factors in wound healing, such as chemotherapy, corticosteroids, and radiation.

Gastrointestinal complications of chronic spinal cord injury

Gastrointestinal problems are important in the chronic stage of spinal cord injury. We review the literature on problems of specific segments of the alimentary tract in this setting and add observations based on clinical experience. Emphasis is placed on the colon and rectum, where most clinically apparent problems occur. While bowel management programs are often successful in the near-term, long-term dysfunctions are common and difficult to treat. Studies to determine colonic transit time and rectal physiologic responses are useful to provide scientific basis of management of such patients. More information is needed on the relative roles of extrinsic and intrinsic nervous system in GI function.

The efficacy of colostomy as a bowel management alternative in selected spinal cord injury patients

Although colostomy has been used to divert the fecal stream from pressure sore sites and to deal with fecal incontinence in patients with conus/cauda level injuries, its use on an elective basis to shorten and simplify the bowel routines of SCI patients to improve their quality of life has not normally been advocated. A questionnaire and two case histories were used to gather data relating to self-care and management of elimination in order to delineate criteria for consideration of elective colostomy. The study concludes that elective colostomy may be an appropriate alternative for some SCI patients, particularly those who have failed in self-care or for whom their vocation or avocation is impaired by prolonged bowel routines.

Ostomy prolapse in paraplegic patients: etiology, prevention, and treatment

Colostomies are sometimes used to manage those SCI patients who have large pressure sores that are frequently soiled by stool. Seventeen such patients in an Acute Spinal Cord Injury Unit were reviewed to define the problem of ostomy prolapse in paraplegic patients. It was concluded that prolapse is more likely in those patients with an injury at or above the T-10 level. The two patients who had loop colostomies developed prolapse. Those ostomies that were end-sigmoid and exteriorized into an area where there was sensation and abdominal wall muscular integrity were the most successful.