Assessment of Embarrassments to Safety Aspects of Life of Patients after Performing Colostomy Operations , in Two Egyptian Societies

Background: Stoma operations have been shown to be associated with a lot of body life style and emotional alterations which affect the safety aspects of life of patients after performing colostomy. Colostomies or ileostomies are performed to people of different ages ranging from infants to the elderly for different causes. Whether the stoma is permanent or temporary, it is difficult to adjust patients and their partners. This study is carried out among those who had stoma, and focused on their understanding the frustrations and fears of the patients. Objectives: The primary aim of this study was to study patients' perspective positive aspects of practicing colostomy. The study will also help to answer the stoma patients' worrying questions and identify the most frequent problems that affect their safety aspects of life negatively. Methods: The study enrolled 75 adults and old adult patients who performed colostomy operation. They included both sexes attending outpatient clinics of the two study settings. Patients were taken from two hospitals in Alexandria and one hospital in El-Menia . A structured questionnaire interview was done to obtain information on patients. Stoma examination was done to assess the lumen mucosa and its functions and the skin around the stoma. Altered sexual life and its psychological responses were assessed by asking the patients directly. Results: The results revealed that half of the patients (50.8%) were old adults ( 40 years) with mean score 37.81±13.13. Married patients constituted 54% while unmarried were 29 (46%) with mean score of 2.38±0.02. Illiterate and read and write patients collectively represented half of the patients(30.2% and 20.6% respectively). The relationship between diagnosis, types of colostomy and pouching system and gender was not statistically significant. Similarly, the relationship between diagnosis, types of colostomy pouching system, educational level and setting was not statistically significant. All aspects of sexual & psychological alteration and gender showed highly statistically significant difference. Conclusion: 53.3% of ostomy operations were done for male cancer and 46.7% for females. Postoperative sexual dysfunction was common in both sexes due to presence of stoma, stress, difficulty to reach orgasm, dryness, erectile dysfunction and infertility. These alterations lead to a negative impact on patients' safety and quality of life.


INTRODUCTION
Colostomy is a surgically created opening in the abdominal wall through which digested food passes.It may be temporary until the bowel rests or heals, or it may be permanent, when the disease affects the end of the colon or rectum. (1)Colostomy is a life saving surgery that enables the patient to enjoy a full range of activities.
Thousands of people annually undergo ostomy surgery for various reasons and return to their healthy functioning lifestyle. (2)(5) Ostomy patients usually suffer from many alterations associated with presence of the stoma itself.These alterations could be resulting from poor care of those patients, or life-style and emotional disturbances which usually affect the quality of life and safety of the patients.Furthermore, the trans-cultural aspect plays a very serious role in occurrences of these complications. (6,7)A study of operative risks in patients with colorectal cancer, reported that the placement of a diverting colostomy yielded a 13% mortality and that most colostomies were performed in the emergency settings. (8)e number and proportion of older patients undergoing surgical procedures are increasing as a result of increased life expectancy. (8,9)Older patients have a natural physiological decline that may impair the ability to compensate appropriately for the added stress of complicated surgery.However, the presence of significant comorbid conditions is the most important determinant of surgical outcome. (10)Clearly, surgeons will increasingly be confronted with older patients undergoing operations that involve Abdel Ali & El-Rahman 461 the consideration of creating a fecal ostomy with more older patients being subject to ostomies.It is important to evaluate the risk of these procedures in patients of advanced age. (11)though patients were managing their colostomies, including males and females with a median age of 67 years, (12)  In planning reversal procedures, the quality of life and social impairments associated with an ostomy must be considered for patients who have difficulties in proper managing stoma, which affect their psychological well being. (16)Thus, the caregivers must be trained on how they can manage those patients safely minimizing their complaints through a holistic and comprehensive plan of care.To integrate with the community centers, as well as to construct guidelines for stoma patients to fulfill the arising need or their partners' needs for considering safety. (17,18)IM OF THE STUDY: The main aim of the study was to assess the patient's perspective positive aspects of practicing colostomy through: 1. Assessment of the main causes of colostomy operations.
2. Assessment of post operative problems and sexual dysfunctions.
3. Assessment of embarrassments to practice colostomy.

SUBJECTS AND METHODS
A prospective study was carried out in

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Table 5 shows that most of Alexandria patients (84.6%) used pouching system compared to only 15.4% of El-Menia patients.

1-Distribution of patients according to frequency of changing of stoma bags
Figure 1 showed that about half of the sample (>40%) never used stoma bagswhile 25% were changing the bags at improper time and about 10% of them were changing the bags at proper time.

DISCUSSION
Ostomy is an artificial communication between organs or viscera and external evacuation of the intestinal contents.
According to the cause of disease, stomas can be temporary or permanent.Most patients with stoma have colorectal cancer. (19,20)cio-demographic characteristics of the study sample are shown in table 1.More than half (50.8%) of the patients were old adults (40 years).Several studies are in accordance with these findings, showing that the majority of adult stoma patients due to cancer or intestinal TB were aged45-55 years or more (21) and that there is an increased number and proportion of older patients undergoing surgical procedures. (8,9,13)The study comprised 54% of males and 46% of females (Alexandria and El-Menia).The median age of males and females with was 67 years, was mentioned in a study of positive and negative aspects of colostomy irrigation. (12)e present study showed, that 53.3% males and 46.7% females were diagnosed as having cancer, while both inflammatory bowel disease and obstruction dominates among males (Table 2).Undergoing operative intervention for colorectal cancer was reported in elderly patients. (8,22)There was a statistically significant difference between the diagnosis, types of colostomy and pouching system with the different gender.Similar, findings were reported in many studies, with more older patients being subjected to ostomies. (11,22,23)e present study clearly observed that 84.6% of Alexandria patients used pouching system, versus only 15.4% of El-Menia patients (Table 5).The study revealed highly significant differences between the two settings.Litterature review revealed that the performance of colostomies in emergency settings is necessary (8) and ensured that correct patients through experience of living with the stoma. (7,24) regards the stoma complications, this study postulated that 25% of the patients used stoma bags (Figure 1), but were changing the bags at improper time.It was reported that older patients had difficulties in properly managing stoma bags; and that the bags affect their psychological well being.have answers to every question about the operation and its results. (25)e present study illustrates that sexual act and psychological alteration of colostomy patients varies significantly due to gender.Males showed more sense of sadness and depression (42.6%) while anxiety about sexual practices was higher among females (66.7%), as well as avoidance of sexual relations (52.6%).Also 50% of each gender refused to discuss the sexual problems.The literatures mentioned that all the psychological problems, so far also affect sexual function.For instance, impotence and decreased libido may be a symptom of depression rather than the sequel of the operation. (26,27)Stoma individuals face real and symbolic losses, which bring about negative feelings in their relationships.Particularly, the mutilation and social disrepute make it difficult for patients to face this situation which can affect lifestyle and their safety. (26)There is a clear-cut need for sexual education of the health professional. (28)

CONCLUSION
The study concluded that a significant percentage of ostomy operations were due to cancer (53.3% males and 46% female).
surgical outpatient clinics of three hospitals in two different governorates, namely, Alexandria Main University Hospital, El-Moassat Hospital and El-Menia University Hospital.The study included a sample of 75 adult and old adult colostomy patients, of both sexes.Their age ranged from 20 to 70 years.The participants were selected randomly from patients at least one month postoperative.The study period extended for two years.Data were collected using a structured questionnaire, specially designed assessment sheets and personal interview with the patients who performed colostomy.Data collection were divided into two parts.A-Part one: included socio-demographic data such as age, sex, marital status, education level and area of residence.B-Part two: included examination of stoma for presence of inflammation, bleeding, stenosis, herniation, prolapse, ulceration and necrosis.Bowel observation was also carried for diarrhea, constipation, gases, leakage, abdominal cramps and presence of odor.Skin around the stoma was assessed for presence of itching, irritation, ulceration, infection and folliculitis.Psychological response and sexual alterations were assessed by asking the patients directly about the problems related to sex such as pain during intercourse, erectile dysfunction, dryness, as well as psychological response to sexual practices as fear, anxiety or avoidance of sexual practices.The preparatory phase of the study included obtaining permissions to conduct the study from the authorities of different study settings and obtaining patient approval for participation.In addition, a pilot study was conducted.to ensure applicability.Ten patients were included.Each sheet was evaluated and tested for reliability and the modifications were done accordingly.The collected data were processed using the statistical analysis (SPSS) version 16 and Minitab 15.Constrains that faced the authors included the following: seven patients refused to complete the study and five patients died before completion of the study leaving 63 patients out of the 75.The period of interview was rather longer per patient (20-45 minuntes) and sometime it was done in two visits.Data collection from 17 patients was completed by home visits.Lastly, training of the assisting staff for the accuracy of data collection was an additional stress on the researchers who interviewed patients by themselves.RESULTS The total number of observed cases was 63 patients, distributed as follows:35 patients from Alexandria Main University Hospital and El-M0aassat Hospital and 28 patients from El-Menia University Hospital.
information given empathetically and more effective care are the best ways to lead Bull High Inst Public Health Vol.41 No.4 [2011] and retractions (14%, 12% and 10% respectively).Most studies mentioned that, although nurses and enterostomal therapists may be more familiar with the practical and stomal problems, the surgeons still neglect this aspect among stoma patients.They should

Table 1 : Socio-demographic characteristics of the studied sample.
demographic characteristics of the study sample.More than half (50.8%) were old adults (40 years and more) with a mean of 37.81 ± SD 13.126 years.All males (54%) were married with a mean of 2.38 ± 0.023 SD .Females accounted for 46% of the whole study sample.Illiterate and read &

Table 6 : The correlation of study sample according to sexual and psychological alterations and the gender Sexual & psychological alterations Male n=34
* Significant ( p < 0.05)