Annals of the Royal College of Surgeons of England (1990) vol. 72, 175-176
Colostomy: past and present H Brendan Deviin
MD FRCS
Consultant Surgeon
North Tees General Hospital, Stockton-on-Tees, Cleveland
Key words: Stoma; Colostomy
Sir Hugh Lockhart-Mummery had two abiding interests in colorectal surgery. His first was how to avoid a colostomy and, if a stoma was inevitable, his second was how to make the patient's life tolerable. His technical excellence allowed him to undertake restorative surgery in the 1960s and 1970s when less skilled surgeons would have been content with abdominoperineal excision, which was the norm for rectal cancer at that time (1). Lockhart-Mummery had been documenting the practice in St Mark's over the same period (2) and had demonstrated the shift to restorative resection without any deterioration in outcome, a fact that was always uppermost in his thinking. This surgical counsel, to avoid the abominable colostomy, took root in all those registrars who were trained and influenced by Lockhart-Mummery. At first we strove for lower and lower hand-sewn anterior resections and then the staple gun appeared (3). The extent of this widespread practice of anterior resection can be observed if we review the surgical management of rectal cancer on a regional basis. If we look at data for the Northern Region since 1973, this revolution is well displayed (Fig. 1) (4). Rectal cancer remains a surgical challenge;- the 5-year survival rate has not changed in 30 years. The improvement to date has been the reduction in the rate of abdominoperineal excision and the improvement in the quality of life for those who have avoided a permanent colostomy. No longer can surgery involving the formation of a permanent stoma be considered a 'gold standard', yet surgeons in the past have repeatedly denied the downside of stoma surgery. J P Lockhart-Mummery, Sir Hugh's father, believed that patients with a colostomy could enjoy golf and everday life (5), and this may have been so if you were upper middle-class and treated at a centre of excellence. For those who could afford the appliances and were able to
Correspondence to: Mr H B Devlin MD FRCS, Consultant Surgeon, North Tees General Hospital, Stockton-on-Tees, Cleveland TS19 8PE
ask for the best, life could be tolerable, but this applied to few patients. In 1968, with encouragement from Sir Hugh, a former administrator of St Mark's, a ward sister from St Thomas' and I set out to quantify the social and psychological aftermath of rectal cancer surgery (1). We compared the social status of those who had restorative surgery with those who had abdominoperineal excision and colostomy. Each living patient was followed up, examined physically, and taken through a semi-structured questionnaire about their social and psychological life. The results in those patients with a colostomy were depressing. One-third suffered continuous colostomy diarrhoea, onethird never went out, they were prisoners of the lavatory and socially isolated, and one-third were pathologically depressed requiring psychiatric help. Surgery may have cured these patients' cancer but at what price? Our results needed independent corroboration and Eardley et al. in Manchester soon published a similar study with the same discouraging 'quality of life' measurements (6). As a result of these papers, surgeons became more aware of the problems of a stoma and especially of the n
1000
COLOSTOMY
800
_
, , ~~~~~~~~~~~~~~~~~~~~~~
600
400o
200[
SPTU
E EA
LEOSTOMY
1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 [year]
SPTU=lntroduction of 'Russian' staple
gun
EEA=Introduction of 'American' staple gun 1. Figure The changing incidence of abdominoperineal operations with permanent colostomy in the Northern Region: 19731986; population, 3.2 million.
176
H B Devlin
disadvantages of poor technical surgery resulting in inappropriately sited, retracted, prolapsed or herniated stomas. Any of these technical failures added an immeasurable extra burden to the harassed colostomate. The appliance manufacturers, too, became aware that appliances were not all they were cracked-up to be. Better appliances and new systems for colostomy irrigation were developed. Specialisation in stoma nursing began. So much for the past. What about the colostomy patient today? The technical problems of creating a permanent colostomy still remain. When we reviewed our results at North Tees for the decade 1974-1983 we found a surprising incidence of problems, 18% of patients developing a technical complication. Paracolostomy hernias occurred in 5-10%. Revisional surgery was needed in 6%, retraction and stenosis being the main indications
(7). Although appliances have improved, stoma nurses have been trained and public awareness of disability has increased, the diminished psychosocial status of colostomates is still being recorded. McDonald et al., in 1982, surveying South London colostomates, found little changed since 1970 (8), and Wade, in 1989, recorded the same sorry story (9). Colostomates are generally elderly and, apart from the rectal cancer and any residual complications of their surgery, 80% of these patients have at least one chronic ailment, the most common being rheumatoid arthritis and rheumatism; 20% are disabled and this is enhanced by increasing age, female sex and often widowhood. Colostomy patients contrast dramatically with the younger ileostomy patients who have experienced a disabling disease and are delighted with the relief that surgery brings to them. The ileostomy is a small price to pay (10). In contrast, rectal cancer and abdominoperineal excision is often unassociated with ill-health; 30% of these patients present as emergencies with no prodromal illness and, after operation, the elderly patients cast their minds back to youthfulness without a colostomy. Colostomy management is often haphazard. Diet and drugs are widely employed to regulate stoma function but these regimens often fail and even with the best of modern appliances accidents still occur. Only 60% of patients claim an adequate, unrestricted social life. Sexual problems due to nerve damage during the pelvic dissection and psychological overlay are frequent. Unless the patient has a strong and stable relationship at the time
of surgery, an abdominoperineal excision is usually the end of an active sex life. The impact the caring services have made on the welfare of colostomates is debatable. Less then 50% of general practices have a regular structured follow-up system for colostomates and 54% of general practitioners state they lack the confidence to deal with appliance and stoma problems. Hospital clinics and surgeons are not perceived by the patient as a major source of help; indeed only 5% of colostomates turn to their surgeon for advice (9,11). Self-help groups have made little impact as have visits by colostomy visitors (9). Stoma nurses have not fulfilled all original expectations. While they have undoubtedly improved the patient's awareness of appliances they do not seem to have raised the levels of psychological or social function of colostomates. The quality of life of the colostomate remains ambiguous. The problem is back to the surgeon. We must develop better treatment modalities, improve our skills and go back to Lockhart-Mummery's original premise that the best management of a colostomy is its avoidance.
References I Devlin HB, Plant JA, Griffin M. The aftermath of surgery for anorectal cancer. Br MedJ3 1971;3:413-18. 2 Lockhart-Mummery HE, Ritchie JK, Hawley PR. The results of surgical treatment for carcinoma of the rectum in St Mark's Hospital from 1948-1972. Br J Surg 1976;63: 673-7. 3 Heald Rj. Towards fewer colostomies-the impact of circular stapling devices on the surgery for rectal cancer in a district hospital. Br J Surg 1980;60: 198-200. 4 Rubin GP, Devlin HB. The quality of life with a stoma. Br J Hosp Med 1987;39:300-6. 5 Lockhart-Mummery JP. Diseases of the Rectum and Colon. 2nd Ed. London: Balliere, 1934. 6 Eardley A, George WD, Davis F et al. Colostomy: the consequences of surgery. Clin. Oncol. 1976;2:277-83. 7 Burgess P, Mathew V, Devlin HB. A review of terminal
8 9 10 11
colostomy complications following abdomino-perineal resection for carcinoma. BrJ Surg 1984;71:1004. MacDonald LD, Anderson HR, Bennett AE. Cancer patients in the community: outcomes of care and quality of survival in rectal cancer. Report to the DHSS, 1982. Wade B. A Stoma is for Life. London: Scutari Press, 1989. Rubin G. Doctor's Role in Stoma Care. Royal College of General Practitioners Members Reference Book, 1987. Rubin G. Aspects of stoma care in general practice. J R Coll Gen Pract 1986;36:369-70.
Colostomy: past and present H Brendan Deviin
MD FRCS
Consultant Surgeon
North Tees General Hospital, Stockton-on-Tees, Cleveland
Key words: Stoma; Colostomy
Sir Hugh Lockhart-Mummery had two abiding interests in colorectal surgery. His first was how to avoid a colostomy and, if a stoma was inevitable, his second was how to make the patient's life tolerable. His technical excellence allowed him to undertake restorative surgery in the 1960s and 1970s when less skilled surgeons would have been content with abdominoperineal excision, which was the norm for rectal cancer at that time (1). Lockhart-Mummery had been documenting the practice in St Mark's over the same period (2) and had demonstrated the shift to restorative resection without any deterioration in outcome, a fact that was always uppermost in his thinking. This surgical counsel, to avoid the abominable colostomy, took root in all those registrars who were trained and influenced by Lockhart-Mummery. At first we strove for lower and lower hand-sewn anterior resections and then the staple gun appeared (3). The extent of this widespread practice of anterior resection can be observed if we review the surgical management of rectal cancer on a regional basis. If we look at data for the Northern Region since 1973, this revolution is well displayed (Fig. 1) (4). Rectal cancer remains a surgical challenge;- the 5-year survival rate has not changed in 30 years. The improvement to date has been the reduction in the rate of abdominoperineal excision and the improvement in the quality of life for those who have avoided a permanent colostomy. No longer can surgery involving the formation of a permanent stoma be considered a 'gold standard', yet surgeons in the past have repeatedly denied the downside of stoma surgery. J P Lockhart-Mummery, Sir Hugh's father, believed that patients with a colostomy could enjoy golf and everday life (5), and this may have been so if you were upper middle-class and treated at a centre of excellence. For those who could afford the appliances and were able to
Correspondence to: Mr H B Devlin MD FRCS, Consultant Surgeon, North Tees General Hospital, Stockton-on-Tees, Cleveland TS19 8PE
ask for the best, life could be tolerable, but this applied to few patients. In 1968, with encouragement from Sir Hugh, a former administrator of St Mark's, a ward sister from St Thomas' and I set out to quantify the social and psychological aftermath of rectal cancer surgery (1). We compared the social status of those who had restorative surgery with those who had abdominoperineal excision and colostomy. Each living patient was followed up, examined physically, and taken through a semi-structured questionnaire about their social and psychological life. The results in those patients with a colostomy were depressing. One-third suffered continuous colostomy diarrhoea, onethird never went out, they were prisoners of the lavatory and socially isolated, and one-third were pathologically depressed requiring psychiatric help. Surgery may have cured these patients' cancer but at what price? Our results needed independent corroboration and Eardley et al. in Manchester soon published a similar study with the same discouraging 'quality of life' measurements (6). As a result of these papers, surgeons became more aware of the problems of a stoma and especially of the n
1000
COLOSTOMY
800
_
, , ~~~~~~~~~~~~~~~~~~~~~~
600
400o
200[
SPTU
E EA
LEOSTOMY
1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 [year]
SPTU=lntroduction of 'Russian' staple
gun
EEA=Introduction of 'American' staple gun 1. Figure The changing incidence of abdominoperineal operations with permanent colostomy in the Northern Region: 19731986; population, 3.2 million.
176
H B Devlin
disadvantages of poor technical surgery resulting in inappropriately sited, retracted, prolapsed or herniated stomas. Any of these technical failures added an immeasurable extra burden to the harassed colostomate. The appliance manufacturers, too, became aware that appliances were not all they were cracked-up to be. Better appliances and new systems for colostomy irrigation were developed. Specialisation in stoma nursing began. So much for the past. What about the colostomy patient today? The technical problems of creating a permanent colostomy still remain. When we reviewed our results at North Tees for the decade 1974-1983 we found a surprising incidence of problems, 18% of patients developing a technical complication. Paracolostomy hernias occurred in 5-10%. Revisional surgery was needed in 6%, retraction and stenosis being the main indications
(7). Although appliances have improved, stoma nurses have been trained and public awareness of disability has increased, the diminished psychosocial status of colostomates is still being recorded. McDonald et al., in 1982, surveying South London colostomates, found little changed since 1970 (8), and Wade, in 1989, recorded the same sorry story (9). Colostomates are generally elderly and, apart from the rectal cancer and any residual complications of their surgery, 80% of these patients have at least one chronic ailment, the most common being rheumatoid arthritis and rheumatism; 20% are disabled and this is enhanced by increasing age, female sex and often widowhood. Colostomy patients contrast dramatically with the younger ileostomy patients who have experienced a disabling disease and are delighted with the relief that surgery brings to them. The ileostomy is a small price to pay (10). In contrast, rectal cancer and abdominoperineal excision is often unassociated with ill-health; 30% of these patients present as emergencies with no prodromal illness and, after operation, the elderly patients cast their minds back to youthfulness without a colostomy. Colostomy management is often haphazard. Diet and drugs are widely employed to regulate stoma function but these regimens often fail and even with the best of modern appliances accidents still occur. Only 60% of patients claim an adequate, unrestricted social life. Sexual problems due to nerve damage during the pelvic dissection and psychological overlay are frequent. Unless the patient has a strong and stable relationship at the time
of surgery, an abdominoperineal excision is usually the end of an active sex life. The impact the caring services have made on the welfare of colostomates is debatable. Less then 50% of general practices have a regular structured follow-up system for colostomates and 54% of general practitioners state they lack the confidence to deal with appliance and stoma problems. Hospital clinics and surgeons are not perceived by the patient as a major source of help; indeed only 5% of colostomates turn to their surgeon for advice (9,11). Self-help groups have made little impact as have visits by colostomy visitors (9). Stoma nurses have not fulfilled all original expectations. While they have undoubtedly improved the patient's awareness of appliances they do not seem to have raised the levels of psychological or social function of colostomates. The quality of life of the colostomate remains ambiguous. The problem is back to the surgeon. We must develop better treatment modalities, improve our skills and go back to Lockhart-Mummery's original premise that the best management of a colostomy is its avoidance.
References I Devlin HB, Plant JA, Griffin M. The aftermath of surgery for anorectal cancer. Br MedJ3 1971;3:413-18. 2 Lockhart-Mummery HE, Ritchie JK, Hawley PR. The results of surgical treatment for carcinoma of the rectum in St Mark's Hospital from 1948-1972. Br J Surg 1976;63: 673-7. 3 Heald Rj. Towards fewer colostomies-the impact of circular stapling devices on the surgery for rectal cancer in a district hospital. Br J Surg 1980;60: 198-200. 4 Rubin GP, Devlin HB. The quality of life with a stoma. Br J Hosp Med 1987;39:300-6. 5 Lockhart-Mummery JP. Diseases of the Rectum and Colon. 2nd Ed. London: Balliere, 1934. 6 Eardley A, George WD, Davis F et al. Colostomy: the consequences of surgery. Clin. Oncol. 1976;2:277-83. 7 Burgess P, Mathew V, Devlin HB. A review of terminal
8 9 10 11
colostomy complications following abdomino-perineal resection for carcinoma. BrJ Surg 1984;71:1004. MacDonald LD, Anderson HR, Bennett AE. Cancer patients in the community: outcomes of care and quality of survival in rectal cancer. Report to the DHSS, 1982. Wade B. A Stoma is for Life. London: Scutari Press, 1989. Rubin G. Doctor's Role in Stoma Care. Royal College of General Practitioners Members Reference Book, 1987. Rubin G. Aspects of stoma care in general practice. J R Coll Gen Pract 1986;36:369-70.
