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Chapter 30 Long-term Results After Fecal Incontinence Surgery
Philipps RKS (1998) Colorectal surgery.Saunders,London
Pickrell KL,Broadbent TR, Masters FW, Metzger JL (1952) Construction of a rectal sphincter and
restoration of anal continence by transplanting the gracilis muscle: a report of four cases in
children.Ann Surg 139 : 853–863
Pinho M, Ortiz J, Masatosha O et al (1992) Total pelvic floor repair for the treatment of neuro-
pathic fecal incontinence.Am J Surg 163:340–343
Rockwood TH, Church JM, Fleshman JW et al (1999) Patient and surgeons ranking of the sever-
ity of symptoms associated with fecal incontinence: the fecal incontinence severity index.Dis
Colon Rectum 42: 1525–1532
Rockwood TH, Church JM, Fleshman JW et al (2000) Fecal incontinence quality of life scale:
quality of life instrument for patients with fecal incontinence.Dis Colon Rectum 43 :9–17
Rongen MJGM,Uludag Ö,El Naggar K et al (2003) Long-term follow-up of dynamic graciloplas-
ty for fecal incontinence.Dis Colon Rectum 46 :716–721
Rosen HR, Novi G, Zoech G, Feil W, Urbarz C, Schiessel R (1998) Restoration of anal sphincter
function by single-stage dynamic graciloplasty with a modified (split sling) technique.Am J
Surg 175: 187–193
Rosen HR, Urbarz C, Holzer B,Novi G,Schiessel R (2001) Sacral nerve stimulation as a treatment
for fecal incontinence.Gastroenterology 121: 536–541
Rothbarth J, Bemelman WA, Meijerink WJHJ et al (2000) Long-term results of anterior anal
sphincter repair for fecal incontinence due to obstetric injury.Dig Surg 17 :390–394
Sangalli MR, Marti MC (1994) Results of sphincter repair in postobstetric fecal incontinence.
J Am Coll Surg 179:583–586
Setti-Carraro P, Kamm MA, Nicholls RJ (1994) Long-term results of postanal repair for neuro-
genic faecal incontinence.Br J Surg 81: 140–144
Scott A,Hawley PR, Phillips RK (1989) Results of external sphincter repair in Crohn’s disease. Br
J Surg 76: 959–960
Sielezneff I, Malouf AJ, Bartolo DC,Pryde A,Douglas S (1999) Dynamic graciloplasty in the treat-
ment of patients with faecal incontinence.Br J Surg 86: 61–65
Simmang C, Birnbaum E, Kodner IJ et al (1994) Anal sphincter reconstruction in the elderly:
does advancing age affect outcome? Dis Colon Rectum 37 :1065–1069
Slade MS, Goldberg SM,Schottler JL et al (1977) Sphincteroplasty for acquired anal incontinence.
Dis Colon Rectum 20: 33–35
Soffer EE, Hull T (2000) Fecal incontinence: a practical approach to evaluation and treatment.
Am J Gastroenterol 95:1873–1880
Sonnino RE, Reinberg, O,Bensoussan AL,Laberge JM, Blanchard H (1991) Gracilis muscle trans-
position for anal incontinence in children:long-term follow-up.J Pediatr Surg 26: 1219–1223
Vaizey CJ, Kamm MA, Gold DM, Bartram CI, Halligan S, Nicholls RJ (1998) Clinical, physiologi-
cal, and radiological study of a new purpose-designed artificial bowel sphincter. Lancet 352:
105–109
Vaizey CJ, Carapeti E, Cahill JA, Kamm MA (1999) Prospective comparison of faecal incontinence
grading systems. Gut 44 : 77–80
Van Tets WF, Kuijpers JHC (1998) Pelvic floor procedures produce no consistent changes in anat-
omy or physiology. Dis Colon Rectum 41 :365–369
Wexner SD, Baeten C,Bailey R et al (2002) Long-term efficacy of dynamic graciloplasty for fecal
incontinence.Dis Colon Rectum 45 :809–818
Williams NS, Patel J, George BD, Hallan RI, Watkins ES (1991) Development of an electrically
stimulated neoanal sphincter.Lancet 338 :1166–1169
Womack NR, Morrison JF,Williams NS (1988) Prospective study of the effects of postanal repair
in neurogenic faecal incontinence.Br J Surg 75: 48–52
Wong WD, Jensen LL, Bartolo DCC, Rothenberger DA (1996) Artificial anal. Dis Colon Rectum
39: 1345–1351
Wong WD, Congliose SM, Spencer MP et al (2002) The safety and efficacy of the artificial bowel
sphincter for fecal incontinence. Results from a multicenter cohort study. Dis Colon Rectum
45: 1139–1153
Young CJ, Mathur MN, Eyers AA, Solomon MJ (1998) Successful overlapping anal sphincter re-
pair.Relationship to patient age, neuropathy, and colostomy formation. Dis Colon Rectum 41:
344–349
Yoshioka K, Keighley MRB (1989) Critical assessment of the quality of continence after postanal
repair for faecal incontinence. Br J Surg 76: 1054–1057
427
Chapter 31
Chapter 31 Quality of Life with a Permanent Colostomy
Quality of Life
with a Permanent Colostomy
Brigitte Holzer, Harald R. Rosen
429
31
Contents
31.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 430
31.1.1 Social Well-Being . . . . . . . . . . . . . . . . . . . . . . . 430
31.1.2 Psychological Well-Being . . . . . . . . . . . . . . . . . . 430
31.2 Preoperative Expectations . . . . . . . . . . . . . . . . . . 431
31.2.1 Influence of Age . . . . . . . . . . . . . . . . . . . . . . . . 432
31.2.2 Influence of Education . . . . . . . . . . . . . . . . . . . . 432
31.3 QoL Instruments . . . . . . . . . . . . . . . . . . . . . . . 432
31.4 Individual Factors Influencing QoL in Patients
with a Stoma . . . . . . . . . . . . . . . . . . . . . . . . . 433
31.4.1 Age and Gender . . . . . . . . . . . . . . . . . . . . . . . . 433
31.4.2 Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . 434
31.4.3 Time of QoL Evaluation . . . . . . . . . . . . . . . . . . . 434
31.4.4 Social Factors (Education, Religion) . . . . . . . . . . . . 435
31.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 437
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
430
Brigitte Holzer,Harald R. Rosen
31.1 Introduction
Since the introduction of abdominal perineal excision (APR) by Ernest Miles in 1908
and the concurrent demand for radical resection of the tumor-bearing rectum, nearly
43 years elapsed before Goligher first expressed concern regarding the sequel of surgical problems in the course of tumor resection affecting patient’s quality of life (QoL)
(Goligher 1951; Miles 1971).
Today it is widely accepted that most patients with rectal cancers or disorders that
will require surgical therapy can be treated with sphincter preservation by standardized surgical techniques (Renner et al. 1999). However, although the lowest rates of
APR and consequent permanent stoma formation have been reported to be between
9% and 10% in specialized units, observation of multicenter studies have shown significantly higher numbers of patients who undergo APR (37%–68%) (Allun et al.
1994).
A permanent colostomy may be constructed for patients with low rectal cancer, anorectal inflammatory bowel disease, persistent incontinence despite attempted surgical correction, neurological disorders or anorectal agenesis.
In the past, many publications have dealt with the sequel of APR and the presence
of a permanent colostomy, and it is widely accepted that this procedure involves a
heavy price for affected patients (Camilleri-Brennan and Steele 1998; Grumann et al.
2001; Koller et al.1996; Sprangers et al. 1995; Williams and Johnston 1983).
31.1.1 Social Well-Being
31
Social life may deteriorate after surgery for rectal cancer, although results are contradictory.A colostomy may bring a fear of being a nuisance to other people, mainly because of odor,and there may be embarrassment about the presence of a stoma.
Wiring et al. in 1975 examined a group of 214 patients who had a permanent colostomy and a group of 110 who had restorative surgery. There was significantly reduced
social contact in the colostomy group. Similarly, MacDonald and Anderson in 1985
noted that those with a colostomy tended to participate less in social activities than
those without a stoma; their interests in outdoor pursuits were significantly less.
In 1984 MacDonald and Anderson found a statistically significant worsening partner relationship in 29% of patients with a colostomy compared with 14% of those who
had a sphincter-saving resection.
31.1.2 Psychological Well-Being
There are some studies showing a high prevalence of psychological problems in patients operated for rectal carcinoma, even though the instruments used in most cases
may not be psychometrically reliable.Patients with colostomies tend to suffer most.
Devlin et al. in 1971 found that 23% of 83 patients suffered from a severe form of psychological disturbance after APR, compared with one of 37 patients who had a sphincter-saving operation.
Williams and Johnston in 1983 reported a 32% prevalence of depression following
an APR, compared with a 10% prevalence after anterior resection.
Chapter 31 Quality of Life with a Permanent Colostomy
In 1975 Writing et al. used the Heidelberg Colostomy Questionnaire in a study that
covered mainly social and psychological function in patients with a stoma. They concluded that the colostomy was associated with a significant degree of depression,
hopelessness, loneliness and suicidal thoughts.
The patients after APR studied by MacDonald and Anderson in 1984 were found to
have a statistically significantly higher incidence of low self-esteem and feelings of
stigma than those who had undergone a sphincter-saving resection.
Interestingly, there has been some controversy among surgeons about the real impact of a permanent colostomy on patient quality of life (QoL), and although most of
them consider a permanent colostomy being associated with a marked deterioration
in patient QoL, there are some data that show that a permanent colostomy may even
be more beneficial for patient QoL than a very low sphincter-preserving anterior resection (Grumann et al. 2001).
Despite such observations,it is evident that the consequences of rectal surgery have
an important bearing on a patient’s quality of life. Although differences in definition
exist, quality of life may be regarded as representing one individual’s ability to carry
out daily activities, as well as satisfaction with personal performance and with the
balance between disease control and adverse effects of treatment (Gotay et al. 1992;
Olschewski et al. 1994). However, our own experiences as well as the observations of
others indicate that QoL following the therapy of a certain disorder is influenced by
various other factors than by the treated disease alone.
31.2 Preoperative Expectations
431
Patient’s expectations in regard of the disease and the proposed operation appear to be
of major importance for his or her subjective perception of the outcome of treatment.
What does the patient expect from the operation? Apart from the primary desire to
achieve cure from the disease,other expectations on the part of the patient can only be
surmised.
In a prospective study we evaluated the patient’s preoperative expectations as objectively as possible and to describe the patient’s priorities in relation to age, gender
and socioeconomic status.
In the period from 1998 to 2001, 167 patients were given a questionnaire consisting
of 15 questions prior to surgery for colorectal cancer. The questionnaire included various aspects that were thought to influence the patient’s quality of life. Moreover, the
patients had the opportunity to rate the questions they considered most important.
The following five items were considered most important by the total group of patients: complete cure of the disease was rated most important (98%) followed by the
avoidance of a stoma (93%), undisturbed continence (90%), less pain (54%), normal
digestion (42%) and good control over bowel evacuation (41%).
In contrast, the following aspects were considered less important by the patients:
the ability to eat as desired (43%), to use public transport (29%) or to attend public
events (27%). Avoidance of adjuvant chemotherapy or radiotherapy was considered
important by 26%, being able to travel by 17%, being able to resume work as soon as
possible by 16%,and an undisturbed sexual life by 11%. The appearance of the scar was
given the least priority (8%).
31
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Brigitte Holzer,Harald R. Rosen
31.2.1 Influence of Age
Cure from the disease – rated most important by the total group – was given significantly less priority by patients older than 80 years of age compared to those younger
than 79 years of age (p=0.0065).
Having an operation without a stoma was significantly less important for patients
aged 28–50 years compared to those older than 51 years (p=0.0144).
31.2.2 Influence of Education
An evaluation of the data in relation to the education level revealed that patients who
had attended school for more than 12 years gave less importance to the question of a
colostomy (p=0.061). These patients considered it very important to avoid adjuvant
treatment (p=0.0087) and also gave more importance to the ability to resume work
early (p=0.0061).
In summary,our patients gave the highest priority preoperatively to the question of
the cure of disease, as anticipated, followed by the problems of colostomy and continence. However,we believe that factors apart from those we investigated (age,gender,
education) should be taken into account when evaluating these results.
Solomon et al. described that patients’preferences do not always accord with those
of clinicians. Unless patients’ preferences are explicitly sought and incorporated into
clinical decision making, patients may not receive the treatment that is best for them.
In a prospective study, patients undergoing curative surgery for colorectal cancer were
interviewed postoperatively to elicit their preferences compared with those expressed
by clinicians.There were significant differences between patients and clinicians.Clinicians were more willing than patients to trade survival to avoid a permanent colostomy in favor of chemoradiotherapy. Patients’strongest preference was to avoid chemotherapy, more than to avoid a permanent colostomy (Salomon et al.2003).
Furlani and Ceolim in Brazil described that their nurses should assume their roles
as patient educators in the whole preoperative process in order to facilitate improvement of quality of life for the stoma patient (Furlani and Ceolim 2002).
31.3 QoL Instruments
Controversial results of the impact of a permanent colostomy on the patient’s QoL can
be partly explained by the different quality of life-instruments that were used, partly
by differences in patient populations (Audisio et al. 1997; Grumann et al. 2001) (Ta-
Table 31.1. QoL questionnaires used in patients with rectal disorders
Nottingham Health Profile General QoL questionnaire
QLQ-C30 QoL in pts with cancer (EORTC)
SF-36 General QoL questionnaire
QLQ-CR 38 QoL in pts with colorectal cancer
ASCRS FI questionnaire QoL in pts with fecal incontinence
DDQ-15 Digestive disease QoL questionnaire
Chapter 31 Quality of Life with a Permanent Colostomy
ble 31.1). An instrument should be of proven validity, that is it must measure the intended variable and not another. It must be reliable,measuring the variables accurately, and also sensitive,measuring any changes present.
Generic questionnaires such as the Nottingham Health Profile are useful and allow
the researcher to compare QoL across whole patient populations. However, they may
not be sensitive enough to measure changes in QoL that may be brought about by different types of surgery or adjuvant treatment.
On the other hand, differences in global QoL associated with different operations
may truly not exist, the benefit of surgery resulting solely from the removal of the tumor, irrespective of the surgical technique used. Questionnaires that have been designed for use in patients with cancer,such as the Rotterdam Symptom Checklist and
the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C 30
core questionnaire,may be more suitable. In addition,further questionnaires specific
to colorectal cancer are necessary. For example, the EORTC group developed a colorectal cancer questionnaire or module (QLQ-CR 38), which has been validated in the
Netherlands and is being tested in a number of international phase III trials.
In a recent multicentric trial focusing on QoL aspects in patients with a permanent
colostomy, we have modified a validated instrument for QoL measurement in patients
suffering from fecal incontinence.For this purpose,the QoL questionnaire for fecal incontinence introduced by Rockwood and co-workers for the American Society of
Colorectal Surgeons (ASCRS) was adapted by simply replacing the term “incontinence” by “colostomy”. A pilot study confirming the applicability of this instrument
was conducted at different institutions and the questionnaire proved to be easily
understandable. However, it must be admitted that there is still a lack of a validation
process for the specific use in patients with a stoma.
433
31.4 Individual Factors Influencing QoL in Patients with a Stoma
31.4.1 Age and Gender
Nugent et al. (1999) described in their study that some patients cope extremely well
with their stoma and others find them both distressing and disruptive to their lifestyles. A possible reason for this may be related to age or the patients’previous condition. Patients with an ileostomy most frequently have inflammatory bowel disease as
their underlying pathology (90% in a series of 16,470 stoma patients) and are generally unwell before stoma formation (Fleshman and Lewis 1991). This contrasts with
patients with colostomy, who are generally older, have cancer, and may be asymptomatic.
Contrary to this finding, a study be Stryker et al. examined 675 patients with ileostomies.The group of patients aged 60 years old or older fared as well or better than the
younger group (Stryker et al.1985).
Furthermore, it must be taken into account that sexual and urological problems
arising as a complication after pelvic floor surgery (and not directly related to the formation of a colostomy) will affect patients’QoL as well.
In the largest study of 16,470 American stoma patients,59% of patients with colostomy and 25% with ileostomy had problems with their sex lives (Fleshman and Lewis
1991).
The study by Awad et al. confirmed that 25% of patients with ileostomy had moderate or severe problems with their sex lives (Awad et al. 1993).
31
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Brigitte Holzer,Harald R. Rosen
An in-depth study looked at sexual concerns in 50 patients with ileostomy and
found that 24% of male patients were unable to obtain or sustain an erection; 32% said sex
was physically difficult; and 46% found sex psychologically difficult (Rolstad et al.1983).
Devlin et al. reported in 1971 that 51% of patients over 65 years old who had a colostomy felt socially isolated, in contrast to 19% of younger patients with a stoma. In this
study, women felt more socially isolated than men.
31.4.2 Counseling
In a study of Karadag and co-workers, a profoundly negative impact of a colostomy or
ileostomy on QoL was shown and they suggested that specialized counseling of these
patients by a dedicated team could improve QoL significantly (Karadag et al. 2003).
With two QoL questionnaires,43 stoma patients before and after stoma therapy were
interviewed. The results were analyzed regarding the stoma-related problems in the
subgroups of patients with irrigating colostomies (n=16), nonirrigating colostomies
(n=15), and ileostomies (n=12). After stoma therapy, the irrigating colostomy patients
had a significantly higher score than the nonirrigating colostomy and ileostomy patients. Cumulatively, all of the items improved significantly after stoma therapy, for example, getting dressed, bathing and participating in sports.
Nugent et al. also described an inadequate preoperative counseling in their study.
Operating before appropriate counseling can be given is occasionally avoided, but
even in emergency situations it is desirable that a stoma therapist should visit the patient before the operation to discuss sitting and consequences of a stoma.A significant
proportion of patients felt that additional support would be helpful (Nugent et al.
1999).
However, it must still be emphasized that even in countries with a high quality of
surgical skills in coloproctology disorders, specialized stoma therapy groups are still
under-represented in comparison of the total number of patients.
A possible reason may also be the low intake of stoma support groups and other patient associations. This is in agreement with a large national survey of stoma patients
in France, where only one-third of patients with a stoma were members of a stoma
group (Baumel et al.1994).
31.4.3 Time of QoL Evaluation
In some studies, the scores of many quality-of-life dimensions were lower than baseline in the early postoperative period.Surgery also restricted the social life of these patients for the first few months. After 3–6 months, most scores had returned to preoperative values.The scores of most dimensions then remained similar to baseline.
However, although improved emotional function, mental health and future perspective reflect a positive and optimistic attitude despite disfiguring surgery,the score
of perception of body image was worse than baseline for the whole year after operation. This may have resulted from the difficulty in accepting a stoma or abdominal
scars (Camilleri-Brennan and Steele 2001; White and Hunt 1997).
In accordance with these observations, we recommend including patients in QoL
studies only after rectal surgery (colostomy or sphincter preservation), with a minimal
history of 1 year following definitive surgery (closure of a protective stoma or formation of a permanent colostomy or ileostomy, respectively)
Chapter 31 Quality of Life with a Permanent Colostomy
31.4.4 Social Factors (Education, Religion)
We felt that the patient’s social and cultural situation might strongly effect the QoL
outcome after the formation of a permanent colostomy. Therefore,we tried to evaluate
possible social and geographic factors that could have an impact on QoL of patients
following APR. In an international trial, patients operated on for low rectal cancer by
APR were evaluated using a QoL questionnaire mentioned above. The results for the
four domains of QoL (lifestyle, coping behavior, embarrassment, depression), as well
as for subjective general health were evaluated with regard to age, gender, education
and geographic origin in a univariate and multivariate analysis (Table 31.2).
Thirteen institutions in 11 countries included data from 257 patients. While the
analysis of results of general health did not reveal any significant differences,the analysis of the four domains of QOL showed a significant influence of the geographic origin (Fig. 31.1). The presence of a permanent colostomy showed a consistently negative
impact on patients in southern Europe as well as in patients of Arab (Islamic) origin.
On the other hand, age,gender and educational status did not reveal a statistically significant influence.
There are many reasons for these statistically consistent findings in our study.
Since the worst QoL results in all domains were found in patients of Islamic religion, we assume that religious factors may play a very important role. This issue has
been addressed in a recent paper by one of our study participants (M.A.K.) who described a significantly poorer outcome in patients following APR compared to patients with sphincter-preserving surgery (Kuzu et al.2002). In the APR group, a significantly greater number of patients stopped praying daily and fasting during Ramadan.
This resulted in significantly higher social isolation and affected QoL even more negatively.
435
Table 31.2. International study of QoL after stoma formation
Total 257 patients (%)
Male 149 (58%)
Female 108 (42%)
Age (median, min,max) 63.5 (17–91) years
Educational status
No high school 97 (37%)
High school 65 (25%)
College or university 71 (28%)
Missing data 24 (10%)
Geographic origin
Northern Europe (Copenhagen,Aarhus, Goeteborg) 81 (32%)
Middle Europe (Erlangen,Luebeck, Krakow, Nantes, Geneva,Vienna) 113 (44%)
Southern Europe (Barcelona, Padua, Ankara) 25 (10%)
Arab or Asian origin (Alexandria) 29 (12%)
Missing data 9 (2%)
436
Brigitte Holzer,Harald R. Rosen
31
Fig. 31.1.Results of quality of life according to geographic origin
Another aspect of the explanation for our findings may be attributed to the fact that
postsurgical stoma care varies widely throughout Europe. It is obvious that patients
who have standardized support available in hospital and (even more) at home, and
who receive repeated counseling by qualified specialists in stoma care, will overcome
daily problems arising from their colostomy much more easily than patients who are
left alone in this situation.Furthermore,the presence of well-trained stoma therapists
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