Colorectal surgery in Sweden and Ethiopia : stoma issues and covid-19 consequences

Abstract

Creation and reversal of an ostomy are common procedures in colorectal surgery, and problems related to these surgeries are still in many aspects unsolved and affect people’s everyday life. Ostomy problems are closely related to perioperative care and outcomes after colorectal surgery, since many patients receive an ostomy at the time of surgery, and even more in an emergency- or a resource-constrained setting. Ostomy issues are also connected to late cancer diagnosis.

A hernia at the stoma site is a known complication after ostomy reversal. The best method for closing the abdominal wall is not known. Other problems relate to the nipple and peristomal skin, impaired adhesion of stoma bags, leakage rates and quality of life.

Surgery for colorectal conditions includes the important and common diagnoses of colon and rectal cancer, but also benign conditions like inflammatory bowel disease, diverticular disease, and trauma. Colorectal cancer is the third most common cancer form worldwide, and it is known to increase in lowand middle-income countries (LMIC), where mortality is also much higher than in high-income countries.

According to the World Health Organization (WHO) there is a huge lack of surgical care worldwide and basic research is needed to be able to move towards the globally agreed development goal for 2030: improved health for all. Much effort has been expended in recent years to shed light on the lack of cancer service and basic surgical care in Sub-Saharan Africa, but there is limited research on detailed perioperative management. Ethiopia has no nationwide registries for colorectal cancer or perioperative care, and there are few studies on the subject. The quality of life for patients with stoma has not been evaluated in comparison to that in other settings.

In this thesis we wanted to study current issues related to the creation or reversal of a stoma, effects on perioperative care, and outcomes after colorectal surgery, in Sweden and Ethiopia, and during the COVID-19 pandemic, when health care was under heavy pressure all over the world.

The aim of the first study was to evaluate the hernia incidence in patients at three surgical centers in Stockholm after loop ileostomy reversal 2010-2015. This retrospective cohort study with chart evaluation was done in 2018. Apart from the chart review, computer tomography (CT) scans and magnetic resonance imaging (MRI) pictures were re-evaluated, and patients were contacted with a questionnaire and asked for symptoms. The study showed a cumulative hernia incidence of 7.4%. This was lower than in some other studies, but hernia was still substantially underdiagnosed in the patient’s chart, while the reevaluation of the radiology provided more information. Most patients with hernia also had symptoms. In connection with this study, we started a randomized controlled trial to evaluate whether mesh reinforcement in the abdominal wall during stoma reversal could lower hernia incidence. This study is currently ongoing with around 110 patients included.

The aim of the second study was to evaluate surgical management during the most intense period of the COVID 19 pandemic, March 1 to August 31, 2020, compared to the same period the year before. This was a population-based cohort study including all patients from the Stockholm-Gotland region. The patients included were those diagnosed with colorectal cancer during the study period. The study showed that the time to surgery and complications remained the same between study periods. However, during the pandemic, the number of patients receiving an ostomy almost doubled (absolute risk +13% (95% CI 6.8-20)), compared to the year before and residents participated to a lesser extent in colorectal cancer procedures.

The third study sought to describe the management and perioperative care of patients undergoing advanced colorectal surgery at Tikur Anbessa Specialized Hospital (TASH), in Ethiopia from September 12 to December 11, 2022. The study was a prospective cohort study. Main outcomes were short-term complications and length of stay. The study showed a median (Interquartile Range, IQR) age of the patients of 45 years (25-60); most (91%) were healthy and classified as American Society of Anesthesiologists (ASA) class I or II. Many had anemia (45%). The proportion receiving thromboprophylaxis was 40%. Complications (26%) and median length of stay after surgery (6 days) were in the range of those in other settings, but there was room for improvements in perioperative care, preoperative assessment and treatment of anemia and malnutrition. In addition, better access to investigations and minimal invasive surgery, increased use of thromboprophylaxis and less use of postoperative antibiotics were also recognized as desired areas for improvement.

The fourth study aimed to evaluate the quality of life and the stoma-specific quality of life in stoma patients in Ethiopia and Sweden. This cross-sectional study undertook data collection between October 2022 and January 2023. Sixty-six patients were included. The quality of life for the stoma patients in Ethiopia differed significantly more to the national quality-of-life level than did the Swedish patients’. Of the patients with temporary ostomy in Ethiopia, 88% had a home-made stoma bag. Using the validated questionnaire Stoma QoL, 16 of the 20 items had significantly worse outcomes for the Ethiopian patients. The largest problems were related to social interactions and pouch-related issues. In the overall Stoma QoL score, the Ethiopian patients scored 48 of 100. This is the lowest score in published studies from different countries in Africa, Asia, and Europe. Better access to stoma material and training of stoma nurses is imperatively needed in Ethiopia.