Patient-Reported Outcome After Ostomy Surgery for Chronic Constipation

The Impact of Colostomy on Inpatient Outcomes Following Primary Total Knee Arthroplasty

Introduction The inpatient postoperative outcomes of patients with colostomies following primary total knee arthroplasty (TKA) have not been well studied in the literature. The purpose of this study was to analyze how colostomy impacts the immediate postoperative outcomes of TKA. Our null hypothesis is that after correcting for common variables, a colostomy does not predispose patients undergoing TKA to surgical site infections (SSIs) and periprosthetic infections. Methods The National Inpatient Sample database was used to retrieve information on colostomy patients and patients without a colostomy who had undergone primary TKA from 2016 to 2019. Patients with colostomies were matched to a cohort of non-colostomy control groups in a 1:1 propensity score algorithm by age, sex, race, and pertinent comorbidities. Patient demographic characteristics, comorbidities, length of hospital stay (LOS), total hospital charges, and inpatient complications were compared. Results Following propensity score matching, 399 patients with colostomies were compared to 385 patients without a colostomy (control). The colostomy group had a prolonged LOS (3.15 ± 2.67 vs 2.44 ± 3.15 days, p<0.001) compared to the control group. Also, the colostomy group had significantly higher incidences of acute kidney injury (AKI) (6.02% vs 1.56%, odds ratio (OR): 4.04, 95% confidence interval (CI): 1.63-10.00, p<0.001), blood loss anemia (20.55% vs 13.25%, OR: 1.69, 95% CI: 1.16-2.48, p=0.008), and blood transfusions (4.01% vs 0.26%, OR: 16.04, 95% CI: 2.12-121.56, p<0.001). There was no difference in periprosthetic infection, superficial SSI, or deep SSI. Conclusion Patients with colostomies face a notably higher risk of experiencing AKI, blood loss anemia, and blood transfusion requirements during the immediate postoperative period following primary TKA. Despite the perceived risk of postoperative infection in colostomy patients, this patient population is not at an increased risk of developing periprosthetic infection, superficial SSI, or deep SSI following TKA.

CE: Nursing Care for Patients After Ostomy Surgery

ABSTRACT

When patients who undergo ostomy surgery do not have access to an ostomy care nurse, staff nurses must assume responsibility for providing ostomy care and educational support. However, many staff nurses may lack the necessary knowledge and skills to provide this type of care. This article details the basics of pre- and postoperative care and patient education for nurses who encounter patients with two of the most common types of ostomy surgery of the bowel: colostomy and ileostomy. It covers the care of a new stoma and provides information about emptying and changing the pouch, nutritional and lifestyle considerations, and possible complications.

Depression after stoma surgery: a systematic review and meta-analysis

BACKGROUND

Depression is the leading cause of global disability and can develop following the change in body image and functional capacity associated with stoma surgery. However, reported prevalence across the literature is unknown. Accordingly, we performed a systematic review and meta-analysis aiming to characterise depressive symptoms after stoma surgery and potential predictive factors.

METHODS

PubMed/MEDLINE, Embase, CINAHL and Cochrane Library were searched from respective database inception to 6 March 2023 for studies reporting rates of depressive symptoms after stoma surgery. Risk of bias was assessed using the Downs and Black checklist for non-randomised studies of interventions (NRSIs), and Cochrane RoB2 tool for randomised controlled trials (RCTs). Meta-analysis incorporated meta-regressions and a random-effects model.

REGISTRATION

PROSPERO, CRD42021262345.

RESULTS

From 5,742 records, 68 studies were included. According to Downs and Black checklist, the 65 NRSIs were of low to moderate methodological quality. According to Cochrane RoB2, the three RCTs ranged from low risk of bias to some concerns of bias. Thirty-eight studies reported rates of depressive symptoms after stoma surgery as a proportion of the respective study populations, and from these, the median rate across all timepoints was 42.9% 42.9% (IQR: 24.2-58.9%). Pooled scores for respective validated depression measures (Hospital Anxiety and Depression Score (HADS), Beck Depression Inventory (BDI), and Patient Health Questionnaire-9 (PHQ-9)) across studies reporting those scores were below clinical thresholds for major depressive disorder according to severity criteria of the respective scores. In the three studies that used the HADS to compare non-stoma versus stoma surgical populations, depressive symptoms were 58% less frequent in non-stoma populations. Region (Asia-Pacific; Europe; Middle East/Africa; North America) was significantly associated with postoperative depressive symptoms (p = 0.002), whereas age (p = 0.592) and sex (p = 0.069) were not.

CONCLUSIONS

Depressive symptoms occur in almost half of stoma surgery patients, which is higher than the general population, and many inflammatory bowel disease and colorectal cancer populations outlined in the literature. However, validated measures suggest this is mostly at a level of clinical severity below major depressive disorder. Stoma patient outcomes and postoperative psychosocial adjustment may be enhanced by increased psychological evaluation and care in the perioperative period.

The prevalence of anxiety and depression in patients with ostomy: A systematic review and meta-analysis

AIM

The prevalence of anxiety and depression in patients with ostomy is reported differently. The aim of this systematic review and meta-analysis is to estimate the global prevalence of anxiety and depression in patients with ostomy.

METHOD

A systematic search of Embase, Proquest, Scopus, PubMed and Web of Science (ISI) databases was conducted from January 1990 up to 5 May 2021. A total of 3392 records were retrieved and 18 studies were ultimately included. Two reviewers independently assessed full-text of articles according to predefined criteria. A random-effects model was used to estimate the prevalence of anxiety and depression and I² index was used to assess the heterogeneity of the studies. Subgroup analysis and mea-regression were conducted to explore potential sources of heterogeneity. The review protocol is registered in PROSPERO and is available online. Data analysis was performed using R software version 4.3.1.

RESULTS

In this study, the pooled prevalence of anxiety was 47.60% (95% CI, 29.94-65.26) and the pooled prevalence of depression was 38.86% (95% CI, 29.29-48.43). The subgroup analysis showed the prevalence of anxiety and depression in different regions was not significantly different (p = 0.854, p = 0.143 respectively). Nevertheless, the highest and lowest prevalence of anxiety were in Asia and the America 51.79% and 32.69%, respectively and the highest and lowest prevalence depression were in Asia with 49.80% and Europe with 26.77%, respectively.

CONCLUSION

The finding of this study showed the global prevalence of anxiety and depression in patients with ostomy is high. Therefore, all health care providers who deal with these patients should use appropriate psychological strategies, techniques and interventions to reduce anxiety and depression in these patients.

Diverting Ileostomy in Children With Functional Constipation: A Study Evaluating the Utility of Colon Manometry

OBJECTIVES

Pediatric functional constipation (FC) may require invasive evaluations [like colon manometry (CM)] and surgical interventions [including diverting ostomy (DO)]. We evaluated the utility of CM in guiding surgery after DO.

METHODS

Children with medically refractory FC undergoing an ostomy were included. Institutional Review Board approval was obtained for this retrospective study. Demographics and CM variables [high amplitude propagating contractions (HAPCs)] were recorded. Outcome measures: response to ostomy closure defined as successful if no need for further surgery after ostomy closure, and improvement on baseline CM after ostomy. A CM-guided ostomy closure algorithm was developed based on previous studies. We evaluated the association between response to ostomy closure and demographics, ostomy indication and CM improvement, and evaluated the role of CM predicting response using algorithm.

RESULTS

A total of 60 children underwent ostomy for FC (median age: 7.1 years, range 0.15-23.6 years, 50% female). Ostomy was closed in 30 patients and deemed successful in 23 of 30. CM was performed in 42 of 60 patients before ostomy and in 29 of 30 before ostomy closure. We found no association between ostomy outcome and age, gender, weight, imaging studies, follow-up time, time with ostomy, HAPCs, and CM improvement. We found an association between failed response and ostomy indication of antegrade colonic enemas (ACE) failure ( P = 0.026) and successful response when ostomy closure was guided by algorithm ( P = 0.03).

CONCLUSIONS

DO is a useful intervention in selected children with medically refractory FC, improving colon motility in most. CM can successfully guide the timing and type of ostomy closure. Larger studies are needed to further validate our findings.

The role of neuromodulation in chronic functional constipation: a systematic review

BACKGROUND

Chronic functional constipation is a highly prevalent disorder in which, when conservative measures fail to relieve symptoms, surgical interventions are sometimes indicated. In recent years, neuromodulation for the treatment of functional constipation has gained interest but its role and effectiveness are still unclear. The purpose of this review is to provide a systematic overview on the current literature on the different modalities of neurostimulation and their effect on chronic functional constipation in adults as reported in the literature.

METHODS

A search in the literature for articles concerning the effect of different types of neuromodulation on constipation was performed in PubMed using extensive search terms for the different modalities of neuromodulation. Studies and trials were checked for eligibility. For all types of neuromodulation together, 27 articles were included.

RESULTS

17 studies were included on SNM (sacral nerve modulation). Although multiple studies show positive results on the effect of SNM in constipation, double-blind crossover RCT's (randomised controlled trials) showed no significant effect. 3 studies were included for tSNS (transcutaneous sacral nerve stimulation), 2 for PTNS (percutaneous tibial nerve stimulation) and 2 for TTNS (transcutaneous tibial nerve stimulation). Studies and trials on these modalities of neuromodulation reported ambiguous results on statistical significance of the effect. For transcutaneous IFC (interferential current therapy) 2 studies were included, which both reported a statistically significant effect on all outcomes.

CONCLUSION

The beneficial effect of neuromodulation in chronic functional constipation remains questionable. However, neuro-modulation might be worth considering in patients refractory to treatment before turning to more invasive measures. Future research should shed more light on the effects of neuromodulation in constipation.

Chronic constipation in adults: Contemporary perspectives and clinical challenges. 2: Conservative, behavioural, medical and surgical treatment

BACKGROUND

Chronic constipation is a prevalent disorder that affects quality of life of patients and consumes resources in healthcare systems worldwide. In clinical practice, it is still considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology and Motility journal supplement devoted to the investigation and management of constipation was published (Neurogastroenterol Motil 2009;21(Suppl 2):1). In October 2018, the 3rd London Masterclass, entitled "Contemporary management of constipation" was held. The faculty members of this symposium were invited to write two reviews to present a collective synthesis of talks presented and discussions held during this meeting. The first review addresses epidemiology, diagnosis, clinical associations, pathophysiology, and investigation.

PURPOSE

The present is the second of these reviews, providing contemporary perspectives and clinical challenges regarding behavioral, conservative, medical, and surgical treatments for patients presenting with constipation. It includes a management algorithm to guide clinical practice.

Ileostomy for chronic constipation: a good idea or just asking for more trouble?

AIM

A defunctioning stoma may be an option for a small group of patients with chronic constipation who have exhausted all forms of conservative management and remain symptomatic. We investigated this group in terms of stoma-related complications and whether they regretted the intervention.

METHODS

Patients presenting to Sheffield Teaching Hospitals Pelvic Floor Unit over a 7-year period with chronic constipation unresponsive to conservative management and who had undergone a loop ileostomy for management were interviewed using the decision regret scale. Details about subsequent stoma-related surgery were recorded.

RESULTS

Thirty-seven of 38 female patients identified (median age 49 years, range 24-86) completed the decision regret scale. Median follow-up was 34 months (range 7-74). About half (49%) had no regret and a further 27% had minimal regret about the decision for a stoma. Fifty-five per cent of patients had further operations related to the stoma, some undergoing up to five operations.

CONCLUSION

A small group of patients with intractable constipation may benefit from a loop ileostomy but are likely to need subsequent surgery to the stoma. Despite this most patients who have had a stoma do not regret the decision.

Quality of life among ostomy patients: A narrative literature review

AIM AND OBJECTIVE

This study aims to identify and summarise factors related to ostomy patients' experiences and how these impact the perceived quality of life for those patients.

BACKGROUND

Ostomy formation is a common therapeutic technique used to treat different colorectal diseases such as colorectal cancer. Although surgical intervention and ostomy formation may prolong a patient's life, it may cause many problems in their daily lifestyle and affect their quality of life. The surgical creation of an ostomy has a significant impacts on a patient's quality of life from multiple perspectives, including physical, psychological, social and spiritual aspects.

DESIGN

A narrative literature review, using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline).

METHODS

This review analysis of search filters was conducted in the following databases: PubMed (MEDLINE), CINAHL, Embase, ProQuest, Science Direct, Scopus, and PsycINFO. A validation data set of 283 research articles between January 2000 and December 2019 were used to identify the impact of stoma surgery on patients' quality of life.

RESULT

Thirty-seven studies were identified as suitable for inclusion in this literature review. The results of the review indicate that quality of life (QoL) in patients who have an ostomy is influenced by many modifiable factors. Exercise, preoperative stoma site identification, family support, maintenance of social networks, education, spirituality and financial stability are all potentially modifiable factors that can improve the QOL for ostomy patients.

CONCLUSION

This review has identified multiple challenges that ostomy patients experience, which were clustered according to physical, psychological, social and spiritual challenges.

RELEVANCE TO CLINICAL PRACTICE

This study identifies issues associated with stoma creation and can help in planning and providing the required nursing care which may assist in the reduction of predictable challenges. Recommendations for future research related to nursing practice are stated.