Problems and Rehabilitation of Filipino Stoma Patients

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ROJ@11dec20

Reynaldo O. Joson, MD

Romeo Gutierrez, MD

1979

Problems and Rehabilitation of Filipino stoma patients. J Enterosmal Therapy. September – October, 1983.

Introduction

Abdominal stomas are being constructed with increasing frequency in the treatment of various malignant, congenital, inflammatory, and traumatic conditions. It is estimated that some 80,000 abdominal stomas in the United States and more than 5,000 in Great Britain are being constructed annually. As to how many abdominal stomas are being constructed annually in the Philippines, nobody knows. The scarcity of local hospital statistics as well as the inadequacy of first-hand information on the problem of our Filipino stoma patients cloud an accurate assessment of the Philippine situation.

Abroad, the establishment of stoma rehabilitation clinic and the formation of ostomy self-help groups like the Colostomy Welfare Group and the Ileostomy Association in the United States point to the great needs of stoma patients. Here, in the Philippines, we can just imagine the magnitude of the problems of our stoma patients who are all too often left to their own devices after discharge from the hospital.

It is for this reason that since January of 1979, we embarked on the project of studying the problems of Filipino stoma patients and how we could rehabilitate them.

Methods

The first phase of the project was to make a survey on how many abdominal stomas had been done in our hospital (Philippine General Hospital) for the past five (5) years from 1974 to 1978. The types of abdominal stomas studied were colostomies, ileostomies, and ileal conduits. This retrospective chart review also determined the indications and complications of the abdominal stomas.

The second phase of the project was to conduct personal interviews with patients having abdominal stomas. The primary aim of this interview was to study the effects of stomas, especially the permanent ones, on their daily lives and to define particular problem areas of Filipino stoma patients. Thus, questions revolved around the hospital experiences surrounding the stoma surgery, stoma management at home, diet, bowel function, physical, economic, social, psychosocial, sexual, and other problems related to the stoma.

With the availability of some information on the common problems of Filipino stoma patients, the third phase of the project was to find ways and means to rehabilitate these patients.

Results and Comments

Incidence, Indications, and Complications

From 1974 to 1978, a total of 416 colostomies, 59 ileostomies, and 12 ileal conduits were done in the Philippine General Hospital (PGH) for various indications (Table 1). Fifty per cent (50%) of the colostomies and ileostomies and all of the ileal conduits done in adult patients were permanent, while all the stomas done in pediatric patients were temporary. Pediatric patients were those 14 years old and below.

Tables 2 and 3 list the indications for colostomy in pediatric and adult patients respectively. The most common indication in pediatric patients were a congenital disease causing intestinal obstruction. Imperforate anus and Hirschsprung’s disease were the most common. In adults, malignancy of the rectum and the colon was the most common indication for colostomies.

Table 4 shows the indications for ileostomy. Majority of this kind of stoma were performed in pediatric patients and these were all temporary, done mainly for complications arising from an ileal pathology such as ileal atresia, intussusception, granulomatous and non-granulomatous ileitis, and strangulated ileal obstructions secondary to adhesive bands. In adults, the few cases of ileostomy done were for colonic polyposis (4), amebic colitis (3), and trauma (1). The only indication for a permanent ileostomy in this age group was colonic polyposis.

Ileal conduits were seen only in adults and the most common indication was malignancy of the urinary bladder (Table 5).

The complications of colostomies and ileostomies are listed in Tables 6 and 7 respectively. No complication arising from ileal conduits was encountered, not that there was none, but most probably because of poor data recording, poor patient follow-up, and the limited number of cases performed.

The most common complications of colostomies were prolapse (16) and parastomal hernia (12), the former being more frequently encountered in pediatric patients and the latter in adult patients. The other complications were peristomal infection (5), retraction (4), stenosis (4), peristomal evisceration (3), malposition of colostomy (3), internal herniation (3), and gangrene of colostomy stump (5). The overall incidence of complications of colostomies was 13%.

For ileostomies, the complications encountered were prolapse (3), gangrene of stump (3), stenosis (2), and retraction (2). The overall incidence of complication was 17%.

Problems

A survey was done on 50 adult permanent colostomies who came back for follow-up at the outpatient clinic starting January, 1979. The age of these patients ranged from 18 to 74 years old, majority being in their fifth and sixth decades of life. All of these patients had their stomas done for rectal and colonic malignancies. This survey focused on patients’ viewpoints and solutions of the physical, functional, and psychologic problems attending their operations. The results of the interview are summarized below.

Hospital Experience

All the patients were informed beforehand by the surgeons of the nature of impending operation. After being told that their anus were to be excised and their bowels placed on the abdominal wall, almost all reacted with fear and depression but accepted the plan of operation in a resigned manner. There was one patient who absconded after being told of the nature of the impending surgery but who eventually returned for the operation because of intolerable anal pain and bleeding. This shows that Filipino patients with rectal and colonic malignancies would usually accept an operation which could restore them to a state of relative well-being or cure their cancer, even at the price of a permanent colostomy.

After the operation, the predominant feelings were still fear and depression. The root cause of such stemmed not so much from the cancer itself, but how they, with their abdominal stomas, could come to terms with their altered body image and cope with the daily exigencies of the lives they would have after discharge from the hospital.

The reaction observed postoperatively varied from mild anxiety to severe depression. There were at least 5 instances where depression was so marked that the patient simply refused to eat or move about so that antidepressants had to be administered.

Most patients were not critical of the treatments they had received from the hospital. When asked on the adequacy of advice given by the medical staff on how to take care of themselves after discharge, all answered positively. However, the interview also revealed that none of the patients could at least change the colostomy bags themselves on discharge. Seven (7) patients had sought further information, especially on the type and use of the newer appliances, from relatives abroad. Majority had revamped the use of commercial colostomy bag taught them while in the hospital.

Home Experience

Colostomy Control

Forty-eight (48) of the 50 stoma patients were using the natural evacuation method of control. Majority of these patients had one or two colostomy actions daily at predictable times, starting 2 months postoperatively on the average. The remaining 2 patients were using irrigation as a method to achieve colostomy control. Although they were satisfied with the result of irrigation, there were times when they neglected the procedure because a colostomy irrigation usually took an hour a day.

Appliances

All patients started with the use of commercially manufactured disposable colostomy appliances which consisted of a polyethylene bag and an adhesive in one piece (Fig. 1). This was the kind of appliance usually prescribed by the surgical staff and which all patients used postoperatively up to the time they left the hospital. After discharge, more than half of the patients, on their own efforts and/or by force of circumstances, had changed the type of bag prescribed by the staff. Those who were financially capable shopped around from one appliance firm to another. Some had even sought alternative appliance from relatives living in the United States. Majority, however, had improvised their own colostomy bags because of financial reasons. These indigent patients usually used the ordinary polyethylene bags, 100 pieces of which could be bought at the price of one commercial colostomy bags. These ordinary bags would be held in place around the stoma with a makeshift flange and belt or adhesives. Examples of improvised appliances arising from Filipino ingenuity are shown in Figures 2 to 8.

Self-care

Forty-five out of 50 patients serviced their own colostomies at the time of interview. Only 5 patients could not change their colostomy bags by themselves either because of arthritis or senility.

Disposal of Appliances

Since disposable bags were being used by the majority, these bags when filled with feces were usually wrapped in newspaper or were simply placed in covered in waste cans for disposal. This was particularly convenient for those without indoor lavatories.

Skin Irritation

Every stoma patient had complaints of skin irritation at one time or another. This maybe due to an appliance that had leaked resulting in maceration and excoriation of the skin by the body wastes. It may also be due to an allergic response to adhesive. Frequent changing of appliances, use of heat and exposure, and avoidance of appliance with adhesive were resorted to and were found effective. No patient with colostomies had skin irritations severe enough to seek medical consultation.

Odor and Flatus

Odor and flatus surprisingly were well tolerated and did not present much of a problem. Majority of the patients interviewed had accepted their colostomies as their anus and reasoned out that odor and flatus were but natural and expected consequences of such. Furthermore, these patients were found to be relatively more hygiene-conscious than average. The daily routine for cleaning and changing an appliance was an important factor in controlling odor. The minority of patients who were bothered by the odor of the stomal effluents and who could afford, used odor-proof colostomy bags.

Diet

All patients interviewed had normal diets. However, these were somehow restricted in quantity to effect only one or two bowel movements per day, as well as in quality, discarding from their diet foods which could promote foul odor and flatus such as onions and fishes. These they did on a trial and error basis until they were finally satisfied with the results.

Social and Sexual Problems

After the operation, an overwhelming 40 out of 50 patients either did not get back to their previous occupations or refused to seek employment even if capable. Majority attributed this to the need to retire or rest as a consequence of their getting sick. Others simply gave senility as an excuse. Those who had gone back or were forced to go back to work were mostly the younger patients and those who were breadwinners of a family. Examples of patients who had gone back to active life after the operation were a teacher, a foreman in a construction firm, a jeepney driver, a vendor, and several businessmen. These were the patients who had adjusted well to their colostomies.

Data regarding sexual problems were rather limited because our patients were generally shy in discussing this kind of a topic and also because, as we had gathered, majority of the married patients who were in their sixth and seventh decades of life no longer engaged in sexual activities at the onset or even before the onset of the disease. Those who engaged in sex postoperatively were the younger patients. We have 4 examples to cite. Two female patients in their mid-twenties resumed sexual activities with their husbands a year after the operation and reported no problem. A male patient, 28 years old, received a semblance of a foreplay from his wife who would clean his stoma and place a new colostomy bag around the stoma before each sexual intercourse. The last patient, a 60-years-old male, had a problem. After the operation, his wife left him because of his colostomy. However, despite this, the patient being well-adjusted, still managed to have an active sex life with other women.

Rehabilitation

Equipped with some data and knowledge on the problem of our Filipino stoma patients, we started to formulate a program of rehabilitation, as outlined below.

Rehabilitation for stoma patients begins before surgery. A preoperative counseling should include an explanation of the patient’s disease as well as the plan of surgical treatment and its resultant abdominal stoma. The function and importance of the stoma should be described. The patient should be given the assurance that after the operation he can live a full, active, productive life, with few, if any, meaningful limitations in the social, occupational, or sexual spheres. Any reaction of fear and depression should be dealt with before surgery. Advices from a well-adjusted veteran stoma patient invited to visit the wards may be useful and may persuade the previously unwilling patient to agree to the operation (Fig. 9).

Once a patient has accepted the proposed operation, he is prepared for surgery. A careful preoperative planning of where to cite the stoma is an important factor in the postoperative management. As a rule, the location of the stoma should be selected so that it does not interfere with the waistline, depressed scars, surgical incisions, body prominences, skin folds, and umbilicus. Preoperatively, it may be helpful to have the patient try on and be acquainted with the use of colostomy bag.

While it takes only a few minutes to construct the stoma, the patient must live with it for a lifetime. Thus, it is vital for the stoma to be managed properly from the moment of its creation. This includes proper placement of stoma, adequate protrusion of stoma for effective collection, and avoidance of technical factors that can lead to complications like prolapse, parastomal hernia, retraction, and stenosis.

Postoperatively, the patient is taught the mechanics of servicing his stoma, how to clean it, how to change a colostomy bag, and what complications to watch out for. Before the patient is discharged from the hospital, he should be able to change the colostomy bag by himself. Thus, the aim during this period of postoperative case is towared self-management and self-sufficiency.

Any emotional problem arising during this time should be handled accordingly. The primary psychologic treatment is conversation about the issue of personal importance. Every stoma patient needs to express negative feelings, doubts, fears, and anxieties, and the surgeon or a nurse should be patient in listening and responding to them. Again, a well-adjusted stoma patient may be very useful in this particular aspect of the problem.

After discharge from the hospital, the patient is advised to follow-up at the outpatient clinic. While there is as yet no formal establishment of a stoma rehabilitation clinic, the regular outpatient clinic for patients with colorectal malignancies is presently being used for this purpose. This clinic is aimed at providing primary rehabilitation for patients who have not received full instruction for their adaptation to the stoma. It also provides secondary rehabilitation for those who need a review and expansion of previous orientation in self-care. Moreover, it provides crisis care for people who, at any time, are troubled and need advice about any urgent stoma-related problem.

The clinic is being held once a week, every Friday, 2-4 pm in our hospital. Although presently, it is being manned by a surgeon and a nurse, the comprehensive management of a stoma patient will eventually be handled by a multidisciplinary team of staff coming from the various fields of surgery, medicine, urology, psychiatry, dermatology, nursing, and social work. A workable referral system of the different subspecialties will be devised.

We envision that what is presently a follow-up clinic will later become an established stoma rehabilitation clinic servicing all Filipino stoma patients throughout the country. The clinic will serve both as a special resource to the surgeon and his patient during the primary rehabilitation process and as a permanent center where specially trained and interested personnel can keep abreast of the recent advances in the area and acquire expertise based on the volume of patients rarely available to the individual surgeon. While the stoma clinic will never replace the patient’s personal doctor, it will add a needed dimension to quality care and teaching.

Another plan is to have a staff-nurse or nurse-clinician trained as an enterostomal therapist. The objective is to provide a resource person to the hospital’s staff, someone who can take time to keep abreast with the current development in the field and support general nursing care with specific technical and psychological insight. At present, a nurse volunteer is undergoing training to serve this purpose (Fig. 10).

The last but an equally vital plan is to utilize the help of well-adjusted stoma patients in the rehabilitation project. They can provide moral support to each other and to new patients. They can get great consolation merely from conversation with confident well-adjusted stoma patients. They can exchange ideas and solutions to problems inherently found in Filipino stoma patients. An example is an exchange of ideas regarding innovation of appliances.

Last July 27, 1979, the Philippine Stoma Association was established and the officers were elected (Figs. 11 and12). This association of stoma patients can provide a forum for discussion, advice, and demonstration of management procedures. It can also serve as an important agent in the successful rehabilitation of Filipino stoma patients.

Summary

A project was undertaken to study the life and problems of Filipino patients with abdominal stomas, namely, colostomy, ileostomy, and ileal conduit. The physical, social, psychologic, and sexual problems among 50 adult permanent colostomies were described. A program of rehabilitation was then formulated which consisted of five (5) major aspects, namely: 1) preoperative and postoperative counseling; 2) proper construction of stoma; 3) stoma rehabilitation clinic; 4) enterostomal therapist; and 5) ostomy association.

Table 1. Incidence of abdominal stomas.

*( n ) permanent stomas

Table 2. Indications for colostomy in pediatrics.

Table 3. Indications for colostomy in adults.

Table 4. Indications for ileostomy.

Table 5. Indications for ileal conduits.

Table 6. Complications of colostomies.

Table 7. Complications of ileostomies.

Fig. 1. A sample of a commercial colostomy bag.

Fig. 2 Improvised appliance using an ordinary polyethylene bag and adhesive.

Fig. 3a. Improvised appliance using an ordinary polyethylene bag and a makeshift flange and rubber belt.

Fig. 3b. Improvised appliance placed around colostomy stoma for collection of feces.

Fig. 4. Improvised appliance with makeshift flange coming from the mouth of a plastic container.

Fig. 5. Improvised appliance using an ordinary polyethylene bag with an embroidered opening for the stoma and a garter to keep the appliance in place.

Fig. 6a. Improvised appliance with the opening for the stoma woven with a piece of clothing for support.

Fig. 6b. Two strings to keep the improvised appliance in place.

Fig. 7a. A two-to-three-layered rectangular piece of clothing and gauze used to cover the colostomy.

Fig. 7b. Improvised appliance partially dismantled.

Fig. 8. A ring cut out from a coconut shell is used to protect colostomy stoma. A piece of clothing inside the shell covers the stoma and the shell can be held in place by a makeshift belt.

Fig. 9. A colostomist visiting a candidate for stoma surgery.

Fig. 10. A nurse volunteer training to be an enterostomal therapist.

Fig. 11. First members of the Philippine Stoma Association.

Fig. 12. An abdominal stoma is the badge of membership to the Philippine Stoma Association.

References:

1. Biermann H, Tocker A, Tocker L. Statistical survey of problems in patients with colostomy or ileostomy. Amer J Surg 1966. 112:647-650.

1. Devlin, HB. Colostomy. Indications, management, and complications. Ann R Coll Surg Engl 1973. 52:392-408.

1. Fussell K. Common problems of ileostomies and colostomies. Practitioner 1976. 216:655-660.

1. Lenneberg E. Modern concepts in the management of patients with intestinal and urinary stomas. Clin Obstet Gynecol 1972: 15:542-579.

1. Lenneberg E. Role of enterostomal therapists and stoma rehabilitation clinics. Cancer. 1971. 28:226-229.

1. Rowbotham JL. Advances in rehabilitation of stoma patients. Cancer. 1975. 36:702-704.