J Wound Ostomy Continence Nurs. 2015;42(2):155-161. Published by Lippincott Williams & Wilkins
EVIDENCE-BASED REPORT CARD
Does Colostomy Irrigation Affect Functional Outcomes and Quality of Life in Persons With a Colostomy? Dea J. Kent
Mary Arnold Long
Carole Bauer
■ ABSTRACT
■ Introduction
BACKGROUND: Colostomy irrigation may be used by patients with colostomies to regulate bowel evacuations by stimulating emptying of the colon at regularly scheduled times. OBJECTIVE: This Evidence-Based Report Card reviews the effect of colostomy irrigation on frequency of bowel evacuation, flatus production, odor, and health-related quality of life. SEARCH STRATEGY: We systematically reviewed the literature for studies that evaluated health-related quality of life in persons aged 18 years or older with colostomies of the sigmoid or descending left colon. A professional librarian performed the literature search, which yielded 499 articles using the search terms “colostomy,” “colostomies,” “therapeutic irrigation,” “irrigation,” and “irrigator.” Following title and abstract reviews, we identified and retrieved 4 studies that met inclusion criteria. FINDINGS: Colostomy irrigation reduces the frequency of bowel evacuations when compared to spontaneous evacuation and containment using a pouching system. Regular irrigation is associated with reductions in pouch usage. This change in bowel evacuation function frequently results in absence of bowel evacuations for 24 hours or longer, enabling some to discontinue ongoing use of a pouching system. Subjects using CI report reductions in flatus and odors associated with presence of a colostomy. One study was identified that found persons using CI reported higher health-related quality of life than did those who managed their colostomies with spontaneous evacuation using the Digestive Disease Quality of Life-15, but no differences were found when health-related quality of life was measured using the more generic instrument, the Medical Outcomes Study: Short Form-36. CONCLUSION: Instruction on principles and techniques of colostomy irrigation should be considered when managing patients with a permanent, left-sided colostomy. KEY WORDS: colostomy irrigation, colostomy management, evidence-based
Colostomy irrigation (CI) is the process of instilling fluid into the colon via the stoma to stimulate peristalsis and promote bowel elimination. When performed routinely, CI may result in little or no stool passage between irrigations, thus allowing the individual to achieve a level of continence. The best candidates for CI are those patients whose colostomy is in either the descending or sigmoid colon because the left side of the colon can store stool for approximately 24 to 48 hours.1 Nevertheless, not all people with a left-sided stoma may benefit from CI. The following factors should be assessed when evaluating a patient for routine CI: vision, manual dexterity, and mental alertness. Relative contraindications for CI include irritable bowel syndrome, peristomal hernia, postradiation damage to the bowel, diverticulitis, and Crohn’s disease. Persons living with a colostomy may experience multiple functional issues associated with presence of an ostomy including the need for ongoing stoma pouching, peristomal skin problems, odor control, and leakage.1-3 The presence of a colostomy may impair health-related qualityof-life (HRQOL) factors related to social function such as sleep, sexual activities, working, and going out. Other psychosocial conditions have also been linked to the presence of a colostomy, including depression and anxiety.
Strengths and Limitations of CI A number of descriptive studies provide insights into the potential strengths and limitations of CI among persons Dea J. Kent, MSN, RN, NP-C, CWOCN, DNP(c), Community Health Network, Indianapolis, Indiana. Mary Arnold Long, MSN, RN, CRRN, CWOCN-AP, ANCS-BC, DNP(c), Riverview Hospital, Wound Ostomy Continence Center, Noblesville, Indiana. Carole Bauer MSN, RN, ANP-BC, OCN, CWOCN, Riverview Hospital, Wound Ostomy Continence Center, Noblesville, Indiana. The authors declare no conflict of interest. Correspondence: Dea J. Kent, MSN, RN, NP-C, CWOCN, DNP(c), Riverview Hospital, Wound Ostomy Continence Center, 395 Westfield Rd, Noblesville, IN 46060 ([email protected]). DOI: 10.1097/WON.0000000000000121
Copyright © 2015 by the Wound, Ostomy and Continence Nurses Society™
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with left-sided colostomies. Four cross-sectional, descriptive studies found that persons who perform CI stated that it exerts a positive influence on stoma-specific issues such as odor, leaking, and peristomal skin problems.1-3 Respondents also reported that CI alleviates psychological problems such as anxiety, depression, and uncertainty; social challenges such as going out; and maintaining or forming intimate relationships, spiritual challenges, and occupational challenges. They also report CI as having a positive effect on sleeping, eating, and traveling. A survey of 100 persons with end ostomies of the sigmoid colon found that CI was perceived as assisting them to engage in social and occupational activities.4 Another descriptive study found that persons with colostomies who used CI reported less need to wear an ostomy pouch, and some were able to remain continent between irrigation episodes.5 Terranova and associates6 interviewed 340 subjects living with a left colostomy for at least 1 year; their research compared respondents’ recall of stoma-related factors (evacuation regularity, odor and gas, and peristomal skin issues) in persons performing CI versus those relying on spontaneous evacuation with pouching. Half of their patients who did not perform CI reported problems with gas and odor as compared with 20% of irrigators, and 18% of those who did not perform CI reported peristomal skin problems compared with 0% of irrigators. They also found that 92% of irrigators achieved continence; 71% of irrigators irrigated every other day, 21% daily. Seventy-two percent of irrigators spent 40 minutes or less performing CI. Sanada and coworkers7 evaluated economic and psychosocial issues in 30 age-matched pairs (N = 60) of individuals who managed their colostomies using either CI or spontaneous evacuation. Subjects who performed CI reported fewer peristomal skin problems, less sleep disturbance, less distress associated with bathing, and less odor than did subjects who managed their colostomies using spontaneous evacuation. They also reported using fewer pouches and spending less money on pouching supplies. Persons who managed their colostomies with CI also reported improvements in their ability to engage in outdoor and occupational activities. The primary limitation associated with performance of CI was the time required for irrigation. Seargant8 evaluated satisfaction with CI and its contribution to a sense of normalcy in 165 persons with colostomies. Most patients (151/165; 91.5% of respondents) who regularly irrigated stated they were satisfied with CI and believed it aided them in living a “normal life.” Karadag˘ and Baykara3 described a case in which CI aided a patient to live a more normal spiritual life. They described a case of a man practicing the Islamic faith; this patient was able to use CI to achieve sufficient continence and eliminate flatus to participate in spiritual activities, while adhering to the traditions and requirements of his religion.
■ March/April 2015
Existing research also reveals limitations of CI. For example, irrigation requires the individual to instill fluid and then wait for evacuation of the colon, a process that can take up to 2 hours.2,4,6,8 While complications are rare following changes in the original design of irrigating equipment, a single severe complication of thermal injury to the colon associated with infusion of an irrigating solution was reported, which resulted in permanent colon damage.9 Other adverse side effects include a transient fall in blood pressure-associated with dizziness and stricture of the colon.1,2 Considered collectively, findings from these studies provide proof of concept that CI is a feasible and safe management option for persons with left-sided colostomies. Results also suggest that patients who perform CI are satisfied with this management option, and many report that irrigation reduces the frequency of stool passage from the colostomy, odor, and flatus. Irrigation is also reported to improve psychosocial factors associated with psychosocial benefits including social activities outside the home and sexual activities. While these findings are encouraging, they are not sufficient to determine whether CI improves functional outcomes (frequency of passage of stool from the colostomy, frequency of fecal leakage, odor, and passage of flatus) and psychosocial outcomes associated with maintaining an optimal HRQOL when compared to management with spontaneous bowel evacuation.
Question Does regular CI improve colostomy function (frequency of bowel evacuation, flatus production, odor) and HRQOL in adults aged 18 years or older with a permanent left-sided colostomy compared to spontaneous evacuation and containment using a pouching system?
■ Methods The literature was systematically searched using the key terms “colostomy,” “colostomies,” “therapeutic irrigation,” “irrigation,” and “irrigator” by a professional librarian using CINAHL and PubMed electronic databases (Table 2). Inclusion criteria were any patient with a leftsided colostomy living with a colostomy. Randomized controlled trials and nonrandomized comparison studies were included. Descriptive studies, individual case studies, case series, and cross-sectional studies were excluded, as were studies published in languages other than English. No studies were excluded based on publication date. Refer to the article by Gray and colleagues10 for a detailed description of methods used to generate Evidence-Based Report Card and taxonomies for Levels of Evidence and Strength of Recommendations for Treatment (SORT) statements. The initial search returned 499 articles, which was narrowed to 477 citations after removal of duplications. Abstract review narrowed our search to 71 articles.
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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J WOCN
■ Volume 42/Number 2
Databases Search Yielded 499 Ref erences with Abstracts Duplicates Removed by Librarian = 22 Abstracts Screened for Eligibility = 477
Abstracts Excluded After Initial Screening = 401
Full text articles Assessed for Eligibility = 76
Full Text Articles Excluded = 64 Reasons = foreign language, education for healthcare staff on procedural issues, surgical procedure education, or unclear abstract leading to non-related articles
Full Text Articles Reviewed for EBRC = 4
FIGURE 1. Flow chart describing the numbers of articles included and excluded at each step of the EBRC review process.
A review of the full text of these articles was then undertaken. Forty-six studies were excluded because they were not published in the English language, focused on procedural education or the effects of various surgical approaches, or they were not pertinent to this topic. Following this review, we identified 4 studies that comprise this EBRC (Figure 1).
■ Findings CI Versus Spontaneous Evacuation: Effect on Colostomy Function We identified 4 studies that met inclusion criteria.5,11-13 Three compared CI to spontaneous bowel evacuation with containment via a pouching system and 1 compared CI and spontaneous elimination to bowel stimulation using a foam-based enema (Table 1).5,11-13 One study compared HRQOL, using 2 generic and more condition-specific instruments.13 Doran and Hardcastle11 enrolled 20 persons with colostomies created 1 to 4 years prior to study participation, and who were not performing CI in a prospective randomized cross-over trial. They compared CI using tap water, stimulation using a foam enema with a 50-ml solution containing 1% dioctyl sodium sulfosuccinate, and evacuation via spontaneous bowel elimination. Colostomy irrigation significantly reduced the frequency of weekly bowel elimination events compared to spontaneous evacuation (mean ± standard error of the mean: 17 ± 2 vs 6 ± 1; P < .001) and more than management using the foam enema (10 ± 1 vs 6 ± 1; P < .01). Seventeen out of 20 participants (85%) reported that CI reduced odor and flatus compared to spontaneous evacuation and 18 out of 20 (90%) reported satisfaction with CI and elected to continue
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the procedure following the end of data collection. The researchers did not report differences in ostomy pouch usage when managed by CI or spontaneous evacuation (Table 1). Williams and Johnston5 reported results of a prospective, randomized controlled trial of 30 subjects with permanent colostomies following abdominoperineal resection. They used a cross-over design to compare CI with water versus spontaneous fecal elimination into a pouching system. Specifically, participants performed CI for 3 months and then returned to their baseline (spontaneous evacuation into a pouch) for 3 months. Subjects kept a daily recording of stool evacuation. Eight of the 30 subjects stopped CI prior to the end of the 3-month trial period; stated reasons for discontinuing were difficulty or inability to insert the cone into the stoma or other technical difficulties (n = 5), and objections related to nature of the procedure (n = 3). Findings revealed no significant differences in the time required to manage their colostomy on a daily basis (mean ± standard error of the mean; 45 ± 9 minutes per 34 hours vs 53 ± 9 minutes per day; P = NS). Irrigation significantly reduced the mean number of stool evacuations from the colostomy when compared to spontaneous actions (6 ± 1 vs 13 ± 2). The frequency of irrigation varied from 1 to 3 days, half reported daily irrigations, 7 (31%) irrigated every other day, and 4 (18%) irrigated every 3 days. Four patients reported bowel eliminations between irrigations, and 4 reported leakage of mucus from the colostomy between irrigations. The remaining 14 reported no bowel elimination episodes between irrigations, and 7 discontinued regular use of the colostomy pouch in favor of a small pad used to cover their stoma. Subjects were asked to provide a global assessment of flatus production as having increased, decreased, or remained unchanged during CI; 20 (90%) stated flatus production and expulsion decreased while performing CI and 2 (9%) responded it remained unchanged. Leong and Yunos12 reported results of a prospective cross-over study of 26 subjects with permanent colostomies following abdominoperineal resection. They enrolled 2 subjects in 2 groups; 10 subjects were enrolled who had lived with a colostomy for less than 1 year, and the second group comprised patients who were older than 1 year but younger than 4 years following colostomy creation. Subjects irrigated with water for 1 month and crossed over to management with spontaneous action for 1 month.7 Subjects in both groups were taught CI using tap water by a stoma therapist, subjects with new colostomies were also taught pouching principles by the same clinician. Outcomes were measured via a 9-item questionnaire; responses were ranked using a Likert scale and based on recall of their experiences over the previous month. All subjects reported achieving continence for 24 to 48 hours when managing their colostomy with CI. The authors performed a cost analysis of pouch usage based on ostomy supply cost in 1999. It revealed that the use of CI created
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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Aim/ Study Design
Compared foam enema to CI using tap water Randomized controlled trial with cross-over design
To determine preferred method of ostomy management (colostomy irrigation using tap water vs spontaneous evacuation). Randomized controlled trial with cross-over design.
Study Citation
Doran Hardcastle (1981)11
Williams and Johnston (1980)5
Outcome Measures
Main outcome measure: Subjects: 30 persons with permanent Frequency of bowl colostomies, analysis based on 22 elimination events. persons who completed study. Subjects were selected from a single Secondary outcomes: Time clinic. required to manage the colostomy on a daily Intervention: Subjects irrigated for 3 basis. Frequency of mo, then crossed over to their irrigation. Passage of normal method of spontaneous stool between irrigations, evacuation for another 3 mo. global assessment of flatus production.
Main outcome measure: Subjects: 20 persons with wellFrequency of bowel established colostomies, who had elimination events. APR resection 2-4 y prior, and who were not previously doing irrigation. Secondary outcomes: Odor and flatus. Satisfaction Intervention: Managed with with intervention. spontaneous evacuation ×2 mo as run-in, then randomly assigned to CI with 1 L of tap water or 50-ml foam enema (1% weight/volume dioctyl sodium sulfosuccinate in a buffered solution). Data collection over a 2-mo period then crossed over to alternative intervention.
Methods
Included Studies Examining Quality of Life Associated With Colostomy Irrigation
TABLE 1.
Limitations
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Analysis of findings not Colostomy irrigation significantly based on intentionreduced the frequency of stool to-treat principles. evacuations compared to spontaneous evacuation. Sample size not based on power analysis for No significant difference in the time determination of required to manage the magnitude of effect. colostomy. Frequency of irrigation varied from Secondary outcomes not measured using 1 to 3 d with half reporting daily validated instruments. irrigation. Passage of stool between irrigations and flatus production were significantly reduced.
10 patients reported an increase in Sample size not based on power analysis for flatus with the foam enema determination of when compared to natural magnitude of effect. evacuation. 17 patients thought that CI reduced Secondary outcomes (odor, flatus, odor and flatus when compared satisfaction with to natural evacuation. intervention) not Patient’s self-reports indicated no measured using change in social activities or diet validated instruments. with any method. Patients reported a decreased use of codeine with CI and stopped taking it during the CI period. Statistically significant differences were demonstrated in: colostomy actions with CI vs NE and CI vs foam enema No statistically significant differences were found in: time spent managing the stoma
Findings
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12
Methods
Outcome Measures
Findings
Subjects: 25 subjects received general To compare health-related counseling and were taught stoma quality of life in persons irrigation using tap water. General who managed their counseling was given but irrigation stomas using CI vs was not implemented for control spontaneous evacuation. group Nonrandomized comparison All subjects managed their colostomy cohort study. with CI or spontaneous evacuation. HRQOL was measured at baseline and after 12 mo using 2 validated instruments: Medical Outcomes Study Short Form-36 and Digestive Disease Quality of Life-15. Changes were compared in HRQOL scores over time and between groups.
Main outcome measures: changes in SF-36 and DDQ-15 scores over time and between groups. Secondary Outcomes: Individual domain scores within SF-36.
Baseline DDQ-15 and SF-36 HRQOL scores did not significantly differ at baseline. DDQ-15 scores rose significantly in both groups at 12 mo. Cumulative DDQ-15 scores were significantly higher in the CI group vs the spontaneous evacuation group after the intervention at 12 mo. Comparison of changes in DDQ-15 and SF-36 domain scores did not significantly differ when measured at 12 mo.
26 subjects reported absence of Main Outcome Measure: Subjects: 26 persons with left-sided Comparison of CI with bowel evacuation for 24 to 48 h Frequency of bowl sigmoid or sigmoid end colostomies spontaneous evacuation when using CI. elimination events. following abdominal-perineal of stoma. resection. Duration of time living Secondary Outcomes: Cost CI had lower monthly cost than Nonrandomized, prospective with a colostomy ranged from spontaneous evacuation. analysis based on trial with cross-over immediate postsurgery to 4 y monthly pouch usage. design. More subjects reported peristomal postsurgery. Peristomal skin problems. skin problems and problems with Sleep and sexual activity. Subjects were divided into 2 groups: sleep and sexual activity when 10 with 1 but
EVIDENCE-BASED REPORT CARD
Does Colostomy Irrigation Affect Functional Outcomes and Quality of Life in Persons With a Colostomy? Dea J. Kent
Mary Arnold Long
Carole Bauer
■ ABSTRACT
■ Introduction
BACKGROUND: Colostomy irrigation may be used by patients with colostomies to regulate bowel evacuations by stimulating emptying of the colon at regularly scheduled times. OBJECTIVE: This Evidence-Based Report Card reviews the effect of colostomy irrigation on frequency of bowel evacuation, flatus production, odor, and health-related quality of life. SEARCH STRATEGY: We systematically reviewed the literature for studies that evaluated health-related quality of life in persons aged 18 years or older with colostomies of the sigmoid or descending left colon. A professional librarian performed the literature search, which yielded 499 articles using the search terms “colostomy,” “colostomies,” “therapeutic irrigation,” “irrigation,” and “irrigator.” Following title and abstract reviews, we identified and retrieved 4 studies that met inclusion criteria. FINDINGS: Colostomy irrigation reduces the frequency of bowel evacuations when compared to spontaneous evacuation and containment using a pouching system. Regular irrigation is associated with reductions in pouch usage. This change in bowel evacuation function frequently results in absence of bowel evacuations for 24 hours or longer, enabling some to discontinue ongoing use of a pouching system. Subjects using CI report reductions in flatus and odors associated with presence of a colostomy. One study was identified that found persons using CI reported higher health-related quality of life than did those who managed their colostomies with spontaneous evacuation using the Digestive Disease Quality of Life-15, but no differences were found when health-related quality of life was measured using the more generic instrument, the Medical Outcomes Study: Short Form-36. CONCLUSION: Instruction on principles and techniques of colostomy irrigation should be considered when managing patients with a permanent, left-sided colostomy. KEY WORDS: colostomy irrigation, colostomy management, evidence-based
Colostomy irrigation (CI) is the process of instilling fluid into the colon via the stoma to stimulate peristalsis and promote bowel elimination. When performed routinely, CI may result in little or no stool passage between irrigations, thus allowing the individual to achieve a level of continence. The best candidates for CI are those patients whose colostomy is in either the descending or sigmoid colon because the left side of the colon can store stool for approximately 24 to 48 hours.1 Nevertheless, not all people with a left-sided stoma may benefit from CI. The following factors should be assessed when evaluating a patient for routine CI: vision, manual dexterity, and mental alertness. Relative contraindications for CI include irritable bowel syndrome, peristomal hernia, postradiation damage to the bowel, diverticulitis, and Crohn’s disease. Persons living with a colostomy may experience multiple functional issues associated with presence of an ostomy including the need for ongoing stoma pouching, peristomal skin problems, odor control, and leakage.1-3 The presence of a colostomy may impair health-related qualityof-life (HRQOL) factors related to social function such as sleep, sexual activities, working, and going out. Other psychosocial conditions have also been linked to the presence of a colostomy, including depression and anxiety.
Strengths and Limitations of CI A number of descriptive studies provide insights into the potential strengths and limitations of CI among persons Dea J. Kent, MSN, RN, NP-C, CWOCN, DNP(c), Community Health Network, Indianapolis, Indiana. Mary Arnold Long, MSN, RN, CRRN, CWOCN-AP, ANCS-BC, DNP(c), Riverview Hospital, Wound Ostomy Continence Center, Noblesville, Indiana. Carole Bauer MSN, RN, ANP-BC, OCN, CWOCN, Riverview Hospital, Wound Ostomy Continence Center, Noblesville, Indiana. The authors declare no conflict of interest. Correspondence: Dea J. Kent, MSN, RN, NP-C, CWOCN, DNP(c), Riverview Hospital, Wound Ostomy Continence Center, 395 Westfield Rd, Noblesville, IN 46060 ([email protected]). DOI: 10.1097/WON.0000000000000121
Copyright © 2015 by the Wound, Ostomy and Continence Nurses Society™
J WOCN
■ March/April 2015 155
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with left-sided colostomies. Four cross-sectional, descriptive studies found that persons who perform CI stated that it exerts a positive influence on stoma-specific issues such as odor, leaking, and peristomal skin problems.1-3 Respondents also reported that CI alleviates psychological problems such as anxiety, depression, and uncertainty; social challenges such as going out; and maintaining or forming intimate relationships, spiritual challenges, and occupational challenges. They also report CI as having a positive effect on sleeping, eating, and traveling. A survey of 100 persons with end ostomies of the sigmoid colon found that CI was perceived as assisting them to engage in social and occupational activities.4 Another descriptive study found that persons with colostomies who used CI reported less need to wear an ostomy pouch, and some were able to remain continent between irrigation episodes.5 Terranova and associates6 interviewed 340 subjects living with a left colostomy for at least 1 year; their research compared respondents’ recall of stoma-related factors (evacuation regularity, odor and gas, and peristomal skin issues) in persons performing CI versus those relying on spontaneous evacuation with pouching. Half of their patients who did not perform CI reported problems with gas and odor as compared with 20% of irrigators, and 18% of those who did not perform CI reported peristomal skin problems compared with 0% of irrigators. They also found that 92% of irrigators achieved continence; 71% of irrigators irrigated every other day, 21% daily. Seventy-two percent of irrigators spent 40 minutes or less performing CI. Sanada and coworkers7 evaluated economic and psychosocial issues in 30 age-matched pairs (N = 60) of individuals who managed their colostomies using either CI or spontaneous evacuation. Subjects who performed CI reported fewer peristomal skin problems, less sleep disturbance, less distress associated with bathing, and less odor than did subjects who managed their colostomies using spontaneous evacuation. They also reported using fewer pouches and spending less money on pouching supplies. Persons who managed their colostomies with CI also reported improvements in their ability to engage in outdoor and occupational activities. The primary limitation associated with performance of CI was the time required for irrigation. Seargant8 evaluated satisfaction with CI and its contribution to a sense of normalcy in 165 persons with colostomies. Most patients (151/165; 91.5% of respondents) who regularly irrigated stated they were satisfied with CI and believed it aided them in living a “normal life.” Karadag˘ and Baykara3 described a case in which CI aided a patient to live a more normal spiritual life. They described a case of a man practicing the Islamic faith; this patient was able to use CI to achieve sufficient continence and eliminate flatus to participate in spiritual activities, while adhering to the traditions and requirements of his religion.
■ March/April 2015
Existing research also reveals limitations of CI. For example, irrigation requires the individual to instill fluid and then wait for evacuation of the colon, a process that can take up to 2 hours.2,4,6,8 While complications are rare following changes in the original design of irrigating equipment, a single severe complication of thermal injury to the colon associated with infusion of an irrigating solution was reported, which resulted in permanent colon damage.9 Other adverse side effects include a transient fall in blood pressure-associated with dizziness and stricture of the colon.1,2 Considered collectively, findings from these studies provide proof of concept that CI is a feasible and safe management option for persons with left-sided colostomies. Results also suggest that patients who perform CI are satisfied with this management option, and many report that irrigation reduces the frequency of stool passage from the colostomy, odor, and flatus. Irrigation is also reported to improve psychosocial factors associated with psychosocial benefits including social activities outside the home and sexual activities. While these findings are encouraging, they are not sufficient to determine whether CI improves functional outcomes (frequency of passage of stool from the colostomy, frequency of fecal leakage, odor, and passage of flatus) and psychosocial outcomes associated with maintaining an optimal HRQOL when compared to management with spontaneous bowel evacuation.
Question Does regular CI improve colostomy function (frequency of bowel evacuation, flatus production, odor) and HRQOL in adults aged 18 years or older with a permanent left-sided colostomy compared to spontaneous evacuation and containment using a pouching system?
■ Methods The literature was systematically searched using the key terms “colostomy,” “colostomies,” “therapeutic irrigation,” “irrigation,” and “irrigator” by a professional librarian using CINAHL and PubMed electronic databases (Table 2). Inclusion criteria were any patient with a leftsided colostomy living with a colostomy. Randomized controlled trials and nonrandomized comparison studies were included. Descriptive studies, individual case studies, case series, and cross-sectional studies were excluded, as were studies published in languages other than English. No studies were excluded based on publication date. Refer to the article by Gray and colleagues10 for a detailed description of methods used to generate Evidence-Based Report Card and taxonomies for Levels of Evidence and Strength of Recommendations for Treatment (SORT) statements. The initial search returned 499 articles, which was narrowed to 477 citations after removal of duplications. Abstract review narrowed our search to 71 articles.
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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J WOCN
■ Volume 42/Number 2
Databases Search Yielded 499 Ref erences with Abstracts Duplicates Removed by Librarian = 22 Abstracts Screened for Eligibility = 477
Abstracts Excluded After Initial Screening = 401
Full text articles Assessed for Eligibility = 76
Full Text Articles Excluded = 64 Reasons = foreign language, education for healthcare staff on procedural issues, surgical procedure education, or unclear abstract leading to non-related articles
Full Text Articles Reviewed for EBRC = 4
FIGURE 1. Flow chart describing the numbers of articles included and excluded at each step of the EBRC review process.
A review of the full text of these articles was then undertaken. Forty-six studies were excluded because they were not published in the English language, focused on procedural education or the effects of various surgical approaches, or they were not pertinent to this topic. Following this review, we identified 4 studies that comprise this EBRC (Figure 1).
■ Findings CI Versus Spontaneous Evacuation: Effect on Colostomy Function We identified 4 studies that met inclusion criteria.5,11-13 Three compared CI to spontaneous bowel evacuation with containment via a pouching system and 1 compared CI and spontaneous elimination to bowel stimulation using a foam-based enema (Table 1).5,11-13 One study compared HRQOL, using 2 generic and more condition-specific instruments.13 Doran and Hardcastle11 enrolled 20 persons with colostomies created 1 to 4 years prior to study participation, and who were not performing CI in a prospective randomized cross-over trial. They compared CI using tap water, stimulation using a foam enema with a 50-ml solution containing 1% dioctyl sodium sulfosuccinate, and evacuation via spontaneous bowel elimination. Colostomy irrigation significantly reduced the frequency of weekly bowel elimination events compared to spontaneous evacuation (mean ± standard error of the mean: 17 ± 2 vs 6 ± 1; P < .001) and more than management using the foam enema (10 ± 1 vs 6 ± 1; P < .01). Seventeen out of 20 participants (85%) reported that CI reduced odor and flatus compared to spontaneous evacuation and 18 out of 20 (90%) reported satisfaction with CI and elected to continue
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the procedure following the end of data collection. The researchers did not report differences in ostomy pouch usage when managed by CI or spontaneous evacuation (Table 1). Williams and Johnston5 reported results of a prospective, randomized controlled trial of 30 subjects with permanent colostomies following abdominoperineal resection. They used a cross-over design to compare CI with water versus spontaneous fecal elimination into a pouching system. Specifically, participants performed CI for 3 months and then returned to their baseline (spontaneous evacuation into a pouch) for 3 months. Subjects kept a daily recording of stool evacuation. Eight of the 30 subjects stopped CI prior to the end of the 3-month trial period; stated reasons for discontinuing were difficulty or inability to insert the cone into the stoma or other technical difficulties (n = 5), and objections related to nature of the procedure (n = 3). Findings revealed no significant differences in the time required to manage their colostomy on a daily basis (mean ± standard error of the mean; 45 ± 9 minutes per 34 hours vs 53 ± 9 minutes per day; P = NS). Irrigation significantly reduced the mean number of stool evacuations from the colostomy when compared to spontaneous actions (6 ± 1 vs 13 ± 2). The frequency of irrigation varied from 1 to 3 days, half reported daily irrigations, 7 (31%) irrigated every other day, and 4 (18%) irrigated every 3 days. Four patients reported bowel eliminations between irrigations, and 4 reported leakage of mucus from the colostomy between irrigations. The remaining 14 reported no bowel elimination episodes between irrigations, and 7 discontinued regular use of the colostomy pouch in favor of a small pad used to cover their stoma. Subjects were asked to provide a global assessment of flatus production as having increased, decreased, or remained unchanged during CI; 20 (90%) stated flatus production and expulsion decreased while performing CI and 2 (9%) responded it remained unchanged. Leong and Yunos12 reported results of a prospective cross-over study of 26 subjects with permanent colostomies following abdominoperineal resection. They enrolled 2 subjects in 2 groups; 10 subjects were enrolled who had lived with a colostomy for less than 1 year, and the second group comprised patients who were older than 1 year but younger than 4 years following colostomy creation. Subjects irrigated with water for 1 month and crossed over to management with spontaneous action for 1 month.7 Subjects in both groups were taught CI using tap water by a stoma therapist, subjects with new colostomies were also taught pouching principles by the same clinician. Outcomes were measured via a 9-item questionnaire; responses were ranked using a Likert scale and based on recall of their experiences over the previous month. All subjects reported achieving continence for 24 to 48 hours when managing their colostomy with CI. The authors performed a cost analysis of pouch usage based on ostomy supply cost in 1999. It revealed that the use of CI created
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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Aim/ Study Design
Compared foam enema to CI using tap water Randomized controlled trial with cross-over design
To determine preferred method of ostomy management (colostomy irrigation using tap water vs spontaneous evacuation). Randomized controlled trial with cross-over design.
Study Citation
Doran Hardcastle (1981)11
Williams and Johnston (1980)5
Outcome Measures
Main outcome measure: Subjects: 30 persons with permanent Frequency of bowl colostomies, analysis based on 22 elimination events. persons who completed study. Subjects were selected from a single Secondary outcomes: Time clinic. required to manage the colostomy on a daily Intervention: Subjects irrigated for 3 basis. Frequency of mo, then crossed over to their irrigation. Passage of normal method of spontaneous stool between irrigations, evacuation for another 3 mo. global assessment of flatus production.
Main outcome measure: Subjects: 20 persons with wellFrequency of bowel established colostomies, who had elimination events. APR resection 2-4 y prior, and who were not previously doing irrigation. Secondary outcomes: Odor and flatus. Satisfaction Intervention: Managed with with intervention. spontaneous evacuation ×2 mo as run-in, then randomly assigned to CI with 1 L of tap water or 50-ml foam enema (1% weight/volume dioctyl sodium sulfosuccinate in a buffered solution). Data collection over a 2-mo period then crossed over to alternative intervention.
Methods
Included Studies Examining Quality of Life Associated With Colostomy Irrigation
TABLE 1.
Limitations
Kent et al
J WOCN (continues )
Analysis of findings not Colostomy irrigation significantly based on intentionreduced the frequency of stool to-treat principles. evacuations compared to spontaneous evacuation. Sample size not based on power analysis for No significant difference in the time determination of required to manage the magnitude of effect. colostomy. Frequency of irrigation varied from Secondary outcomes not measured using 1 to 3 d with half reporting daily validated instruments. irrigation. Passage of stool between irrigations and flatus production were significantly reduced.
10 patients reported an increase in Sample size not based on power analysis for flatus with the foam enema determination of when compared to natural magnitude of effect. evacuation. 17 patients thought that CI reduced Secondary outcomes (odor, flatus, odor and flatus when compared satisfaction with to natural evacuation. intervention) not Patient’s self-reports indicated no measured using change in social activities or diet validated instruments. with any method. Patients reported a decreased use of codeine with CI and stopped taking it during the CI period. Statistically significant differences were demonstrated in: colostomy actions with CI vs NE and CI vs foam enema No statistically significant differences were found in: time spent managing the stoma
Findings
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Methods
Outcome Measures
Findings
Subjects: 25 subjects received general To compare health-related counseling and were taught stoma quality of life in persons irrigation using tap water. General who managed their counseling was given but irrigation stomas using CI vs was not implemented for control spontaneous evacuation. group Nonrandomized comparison All subjects managed their colostomy cohort study. with CI or spontaneous evacuation. HRQOL was measured at baseline and after 12 mo using 2 validated instruments: Medical Outcomes Study Short Form-36 and Digestive Disease Quality of Life-15. Changes were compared in HRQOL scores over time and between groups.
Main outcome measures: changes in SF-36 and DDQ-15 scores over time and between groups. Secondary Outcomes: Individual domain scores within SF-36.
Baseline DDQ-15 and SF-36 HRQOL scores did not significantly differ at baseline. DDQ-15 scores rose significantly in both groups at 12 mo. Cumulative DDQ-15 scores were significantly higher in the CI group vs the spontaneous evacuation group after the intervention at 12 mo. Comparison of changes in DDQ-15 and SF-36 domain scores did not significantly differ when measured at 12 mo.
26 subjects reported absence of Main Outcome Measure: Subjects: 26 persons with left-sided Comparison of CI with bowel evacuation for 24 to 48 h Frequency of bowl sigmoid or sigmoid end colostomies spontaneous evacuation when using CI. elimination events. following abdominal-perineal of stoma. resection. Duration of time living Secondary Outcomes: Cost CI had lower monthly cost than Nonrandomized, prospective with a colostomy ranged from spontaneous evacuation. analysis based on trial with cross-over immediate postsurgery to 4 y monthly pouch usage. design. More subjects reported peristomal postsurgery. Peristomal skin problems. skin problems and problems with Sleep and sexual activity. Subjects were divided into 2 groups: sleep and sexual activity when 10 with 1 but
