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Long distance to hospital is not a risk factor for non-reversal of a defunctioning stoma
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. (Clister)ORCID iD: 0000-0001-5076-7400
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. (Clister)
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. (Clister)
2019 (English)In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 34, no 6, p. 993-1000Article in journal (Refereed) Published
Abstract [en]

PURPOSE: To see if road distance to hospital influences stoma reversal rate, time from index operation to stoma reversal, and occurrence of permanent stoma.

METHODS: Data from all diagnosed cases of rectal cancer from three counties in northern Sweden were extracted from the Swedish Rectal Cancer Registry. The three counties are sparsely populated, with a population density roughly one fifth the average density in Sweden. Distances to nearest, operating, and largest hospital were obtained using Google Maps™. Matched data on socioeconomic variables were retrieved from Statistics Sweden.

RESULTS: In univariate logistic regression analysis, patients living closer to the operating hospital had a higher likelihood of non-reversal than those living farther away (OR 0.3; 95% CI 0.12-0.76). However, no difference was seen in the multivariate analysis. Of the 717 cases included, 54% received a permanent stoma and 38% a defunctioning stoma at index surgery. The reversal rate of a defunctioning stoma was 83%. At follow-up, 61% still had a stoma, 89% of these were permanent, and 11% non-reversed defunctioning stomas. Median time to stoma reversal was 287 days (82-1557 days). Of all 227 stoma reversals, 77% were done more than 6 months after index surgery.

CONCLUSIONS: Longer distance to hospital is not a risk factor for non-reversal of a defunctioning stoma. Only 23% had their defunctioning stoma reversed within 6 months after index surgery. Future studies aiming to determine reversal rate need to extend their follow-up time in order to receive accurate results.

Place, publisher, year, edition, pages
Springer, 2019. Vol. 34, no 6, p. 993-1000
Keywords [en]
Defunctioning stoma, Distance, Permanent stoma, Rectal cancer, Rural, Stoma reversal
National Category
Surgery
Identifiers
URN: urn:nbn:se:umu:diva-156475DOI: 10.1007/s00384-019-03258-6PubMedID: 30747282OAI: oai:DiVA.org:umu-156475DiVA, id: diva2:1289410
Funder
Västerbotten County Council, VLL-675981Available from: 2019-02-18 Created: 2019-02-18 Last updated: 2020-03-06Bibliographically approved
In thesis
1. Stomas from a rural perspective: an evaluation of characteristics, differences and improvement opportunities
Open this publication in new window or tab >>Stomas from a rural perspective: an evaluation of characteristics, differences and improvement opportunities
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction: Stoma-related complications are common and consequences for the individual patient may be considerable. In rural areas, competence regarding stoma-related problems is largely absent. Since the aim of a publicly funded healthcare system is good healthcare on equal terms regardless of where one lives, studies evaluating differences and possible areas of improvement in rural areas are important. An evaluation of stoma-related characteristics, geographic differences and improvement opportunities from a rural perspective has not been done previously. The characteristics and differences studied in this thesis are: stoma reversal; occurrence of permanent stoma; and quality-of-life (QoL).

Methods: Epidemiological methods applied to register data were used in Study I. Data extracted from the National Rectal Cancer Register together with socioeconomic data from Statistics Sweden were used. Study II was a cross-sectional study using surveys matched with data from the National Rectal Cancer Register. Study III was based on data from a double-blind randomised controlled trial. Patients were randomised to either a prophylactic mesh or no mesh in order to prevent parastomal hernia (PSH). Quality-of-life was assessed by grouping and comparing results of questionnaires answered by the patients included. In Study IV, a qualitative explorative method was applied to describe the quality of life of rural living stoma patients. Qualitative content analysis was used to analyse data.

Aims and Results: Study I investigated whether distance by road to hospital had an impact on the following outcomes: stoma reversal rate; time from index operation to stoma reversal; and occurrence of permanent stoma after rectal cancer surgery. Longer distance to hospital had no effect on these outcomes in a multivariate model. In the univariate logistic regression model results indicated the opposite; patients living closest to the operating hospital had a higher likelihood of no reversal (OR 0.3; 95% CI 0.12–0.76). In northern Sweden, 77 % of all stoma reversals were delayed more than 6 months after index surgery. Stoma reversal was performed up to 1557 days after index surgery, and the shortest time to reversal was 82 days (median 287 days).

Study II investigated the impact of distance to nearest hospital on the QoL of rectal cancer patients who had received a stoma at index surgery. Patients living in rural areas reported more pain and sore skin compared to those living closer. When only considering patients who still had a stoma, global QoL was reduced and stoma-related problems were also affected negatively in the rural group.

Study III Investigated whether a prophylactic mesh when creating an end colostomy affected QoL. No effect on global QoL was seen at one-year follow up. In several other QoL-parameters mesh patients scored superior compared to non-mesh patients, even when excluding those with a parastomal hernia (PSH).

Study IV investigated experiences of living with a stoma in a rural setting, how the process of seeking healthcare was experienced and the problems that occur. Results show that living with a stoma was experienced as a process; an initial sense of hopelessness, especially when suffering from stoma-related problems, progressing to the crucial acceptance of their situation. Stoma leakage was frequently described and experienced as unpleasant and unpredictable. Experiences of seeking healthcare in a rural district varied, some spoke warmly about the care given at the cottage hospital while other expressed dissatisfaction.

Conclusions: The notably high rate of delayed reversal of a defunctioning stoma in northern Sweden leads to unnecessary suffering for patients. In view of the long delay in reversal times seen, future studies must have considerably longer follow-up. Rural living rectal cancer patients who receives a stoma reported more pain than those living closer to the nearest hospital. Rectal cancer patients who still had a stoma reported an inferior quality-of-life and more stoma-related problems compared to their town counterparts. Results from the studies in this thesis show that the use of a prophylactic mesh when forming an end colostomy has no impact on subsequent global QoL. Rural living stoma patients commonly experience problems related to their stoma that affect their everyday living. Improved patient education shortly after receiving a stoma could help these patients in coming to terms with their situation.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2020. p. 57
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2067
Keywords
rural, defunctioning stoma, permanent stoma, stoma reversal, distance, quality-of-life, parastomal hernia, mesh, prophylaxis, colostomy, urostomy, ileostomy, content analysis
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:umu:diva-168717 (URN)978-91-7855-175-0 (ISBN)978-91-7855-174-3 (ISBN)
Public defence
2020-04-03, Konferenslokal Uman, Hotell Toppen, Storuman, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2020-03-13 Created: 2020-03-06 Last updated: 2020-03-09Bibliographically approved

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Näverlo, SimonStrigård, KarinGunnarsson, Ulf

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