OTUCU SIMON (2018)
Despite substantial advances in surgical technique and enterostomal therapy, complications after stoma creation remain extremely common. The study was conducted to determine the pattern and short term outcomes of Intestinal stoma among patients in Mbale Regional Referral Hospital.
The study was a retrospective review of case files for patients that underwent surgery for intestinal stoma fashioning from January 2016 to December 2017 and fulfilled the inclusion criteria.
The rate of stoma specific complications in the literature varies quite widely, ranging from 10% to 70% depending on the methodology of the study, the length of follow up, and the definition of a “complication”. For example, virtually all ostomates will have at least transient episode of minor periostomal irritation and skin irritation is the most frequently reported stoma complication. (Park JJ et al 2013)
Anecdotal data from Mbale regional referral hospital indicates a high turnover of intestinal stomas being done every year. However no follow up study has been done on the outcomes
In order for an appropriate intervention to be made there is need for background information on the magnitude of the problem. This study therefore provided such information.
In cases of colostomies, the most common indication of intestinal stoma among patients in MRRH was imperforate anus 15/45(33.3%) representing increasing congenital anorectal anomalies in the region. These findings agree with those of a study done by Guaderer MWL et al 2012 which found out that congenital anomalies by far are the most common indication of intestinal stoma in pediatric age.
Hirsch sprung disease 7/45(15.6%) was the most common indication of intestinal stoma associated with intestinal obstruction. This is still in agreement with the study done by Guaderer MWL et al 2012. These findings may either reflect an increasing prevalence of congenital anomalies or increased awareness and health seeking behavior among parents.
In this study, colostomy was made in 8.9% of patients with sigmoid volvulus, 4.4% in patients with Adhesions and in 2.2% in patients with anorectal mass. A study done by Mamon et al 2012 reported similar findings. This shows that these conditions are globally occurring with slight differences in prevalence occurring in different geographical areas.
The main indication of ileostomy was penetrating injury, representing increasing violence in the region. This was in contrast with a study reported by Brand M I et al Feb 2008 in which themain indication was intestinal tuberculosis (58.4%) and enteric perforation (30.6%). The other less common indication of ileostomy in this study was carcinoma colon 1/5(20%).Sociodemographic factors definitely influence disease patterns, mode of treatment and outcomes.
This study revealed a high prevalence of stomas although most of them did not fulfill our inclusion criteria. The challenge with most retrospective reviews in Africa is because of poor methods of documentation, recording and retrieval of data. Consequently some research findings may not be a true representation of what is on ground.
In this study male to female ratio were 21:29; 1:1.4 which is in comparison with the ratio of 4.94:1 reported by Kaider-person O et al 2005, and that of the general population of Uganda. The mean age was 2.5 years with range of 0-70.Most of the patients were in age group 0-5years (50%). Imperforate anus remained the most common indication for intestinal stoma as in contrast with Kaider-person O et al in which typhoid perforation was the most common indication for intestinal stoma.
Female patients taking the highest number of intestinal stoma in this study may be a mere coincidence. However it may also be a reflection of better health seeking behaviors noted among the female population in Uganda.
Commonest stoma formed was Loop colostomy in 38/45(84.4%) patients. This was in contrast with Kaider-person O et al 2005 in which the commonest stoma formed was loop ileostomy.
Overall morbidity was higher with ileostomy as compared to colostomy. This was in contrast with Shabbir F et al 2016. Depending on the indications, an ileostomy could have been the easiest procedure to perform since most of these procedures on close inspection were emergencies and performed by junior doctors and interns who were short on experience.
Overall patients did well, with a few complications occurring in the short term. More of the complications were registered in ileostomy than colostomy which is in agreement with the study by Ratliff et al 2012 who found out that there was high morbidity associated with ileostomy than colostomy.
The most common early complications were retraction. Similar findings were reported from the study by Argumugum PJ et al 2009.There was one mortality in this study which was attributed to possible undiagnosed congenital heart or renal anomaly. The death was not related to the stoma or its complications. Park et al had strong relation of age for early complications, Mock et al 2010 depicts that morbidity and mortality increases as age increases due to co morbid conditions and poor immunity. Loop colostomy registered the highest number of complications. This is simply because it was the most performed procedure.
Emergency cases sustained more complication rate (29.6%) than elective cases .Ratliff et al 2010 who found out that irrespective of the cause and indication of surgery, the patients that are operated without formal preparation of gut and less time is given for resuscitative measures tend to suffer more complications. This is the case with emergency surgeries.
One major limitation of this study is its retrospective design that did not allow for real time follow up of cases. A more detailed and bigger prospective cohort study would be desirable in future.
- Intestinal stomas are a common procedure with the majority performed for pediatric congenital anomalies.
- Colostomies are more commonly performed than other intestinal stomas
- Most stoma cases have a good short term recover with early complications reported more in ileostomies than colostomies.
- Emergency procedures were associated with more early complications than elective procedures.
Recommendation to the Government
- Policies that encourage awareness of the condition and its management.
- Increased funding for healthcare to cater for early detection of disease processes like colon cancer
Recommendations to the hospital
- Increased training and supervision of junior intern doctors on proper techniques of stoma fashioning.
- Provision of drugs and supplies for proper resuscitation and antibiotic prophylaxis against infection
- Counseling of patients and caretakers on how to care for stoma patients and how to cope with the condition
Recommendations to the patients and care takers.
- Early seeking of health advice and treatment in case of illness
- Adhering to treatment instructions given by the healthcare service provider
Areas for further study
The Researcher suggests the following areas for further study;
A more detailed larger prospective cohort study that will incorporate other factors such as wealth index and coping mechanisms is recommended.